Understanding Abnormal Behavior

Biological Dimension Genetics, Brain Anatomy, Biochemical Imbalances, Central Nervous System Functioning, Autonomic Nervous System Reactivity, etc.

Sociocultural Dimension Race, Gender, Sexual Orientation, Religion, Socioeconomic Status, Ethnicity, Culture, etc.

MENTAL DISORDER

Psychological Dimension Personality, Cognition, Emotions, Learning, Stress-Coping, SelfEsteem, Self-Efficacy, Values, Developmental History, etc.

Social Dimension Family, Relationships, Social Support, Belonging, Love, Marital Status, Community, etc.

Multipath Model of Mental Disorders The multipath model describes how four major dimensions—biological, psychological, social, and sociocultural—contribute to the development of mental disorders. It operates under several assumptions: • No one theoretical perspective is adequate to explain the complexity of the human condition and the development of mental disorders. • There are multiple pathways and causes to any single disorder. It is a statistical rarity to find a disorder due to only one cause. • Not all dimensions contribute equally to a disorder. • It is guided by the state of research and scientific findings as to the relative merits of a proposed cause. • The multipath model is an integrative and interactive one. It acknowledges that factors may combine in complex and reciprocal ways so that people exposed to the same factors may not develop the same disorder and that different individuals exposed to different factors may develop a similar mental disorder.

Understanding Abnormal Behavior David Sue Western Washington University Derald Wing Sue Teachers College, Columbia University Stanley Sue University of California—Davis

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b r ief con t en t s

Features xv Preface xvi About the Authors xxiii

1 Abnormal Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 Models of Abnormal Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3 Assessment and Classification of Abnormal Behavior . . . . . 66 4 The Scientific Method in Abnormal Psychology . . . . . . . . . . . . 93 5 Anxiety Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 6 Dissociative Disorders and Somatoform Disorders. . . . . . . . 149 7 Stress Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 8 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 9 Substance-Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 10 Sexual and Gender Identity Disorders . . . . . . . . . . . . . . . . . . . . . 264 11 Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 12 Suicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 13 Schizophrenia: Diagnosis, Etiology, and Treatment . . . . . . . 359 14 Cognitive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 15 Disorders of Childhood and Adolescence. . . . . . . . . . . . . . . . . . 412 16 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 17 Legal and Ethical Issues in Abnormal Psychology . . . . . . . . . 474 Glossary G-1 References R-1 Credits C-1 Name Index I-1 Subject Index I-13

iii

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con t en t s

Features xv Preface xvi About the Authors

1

xxiii

Abnormal Behavior

2

The Concerns of Abnormal Psychology Describing Abnormal Behavior Explaining Abnormal Behavior Predicting Abnormal Behavior Controlling Abnormal Behavior

3

Reversion to Supernatural Explanations (the Middle Ages) 17 The Rise of Humanism (the Renaissance) 19 The Reform Movement (Eighteenth and Nineteenth Centuries) 20

7

Causes: Early Viewpoints

3 4 4 5

Determining Abnormality Distress 8 Deviance 8 Dysfunction 8 Dangerousness 9

Contemporary Trends in Abnormal Psychology

The Frequency and Burden of Mental Disorders

12

Stereotypes About the Mentally Disturbed

14

The Drug Revolution in Psychiatry 23 The Push by Psychologists for Prescription Privileges 24 The Development of Managed Health Care 24 An Increased Appreciation for Research 25 The Influence of Multicultural Psychology 26 CRITICAL THINKING: I Have It, Too: The Medical Student Syndrome 28

Historical Perspectives on Abnormal Behavior

16

Implications

Contextual and Cultural Limitations in Defining Abnormal Behavior

9

CONTROVERSY: Is Mental Illness a Myth and a

Political Construction?

12

Prehistoric and Ancient Beliefs 16 Naturalistic Explanations (Greco-Roman Thought) 16

2

21

The Biological Viewpoint 21 The Psychological Viewpoint 22

Summary

28

29

Models of Abnormal Behavior One-Dimensional Models of Mental Disorders

32

Using Models to Describe Psychopathology 33

A Multipath Model of Mental Disorders

34

Dimension One: Biological Factors

36

The Human Brain 37 Biochemical Theories 38 Genetic Explanations 40 Biology-Based Treatment Techniques 41 Multipath Implications of Biological Explanations 43

23

30 Dimension Two: Psychological Factors

44

Psychodynamic Models 44 Behavioral Models 47 Cognitive Models 51 Humanistic and Existential Models 53 Multipath Implications of Psychological Explanations 55

Dimension Three: Social Factors

56

Social Relational Models 56

v

vi

C O NT E N T S

CONTROVERSY: Problems in Using Racial and Ethnic

Family, Couples, and Group Perspectives 56 Social-Relational Treatment Approaches 57 Criticisms of Social-Relational Models 57

Dimension Four: Sociocultural Factors

58

Gender Factors 58 Socioeconomic Class 59 Race/Ethnicity: Multicultural Models of Psychopathology 59

3

Implications Summary

64

65

Assessment and Classification of Abnormal Behavior Reliability and Validity

67

The Classification of Abnormal Behavior

The Assessment of Abnormal Behavior

68

Diagnostic and Statistical Manual of Mental Disorders (DSM) 83 DSM-IV-TR Mental Disorders 85 Evaluation of DSM Classification System 85 Objections to Classification and Labeling 90

Observations 68 Interviews 69 Psychological Tests and Inventories 71 CONTROVERSY: Should the Rorschach Be Used in

Making Assessments? 74 Neurological Tests 80 The Ethics of Assessment 81 CRITICAL THINKING: Can We Accurately Assess the Status of Members of Different Cultural Groups? 82

4

Group References 60 Criticisms of the Multicultural Model 61 CRITICAL THINKING: Applying the Models of Psychopathology 62

Implications Summary

CRITICAL THINKING: Attacks on Scientific Integrity

96 97

Characteristics of Clinical Research 97 CONTROVERSY: Repressed Memories: Issues and Questions 99

Experiments

100

The Experimental Group 101 The Control Group 101 The Placebo Group 102 Additional Concerns in Clinical Research 102

Correlations

92

CRITICAL THINKING: Researcher Allegiance:

A “Wild Card” in Comparative Research 105

Analogue Studies

106

Field Studies

107

Single-Participant Studies

108

The Case Study 108 The Single-Participant Experiment 109

Biological Research Strategies The Human Genome Project 110

110

93

Genetic Linkage Studies 110 The Endophenotype Concept 110 Other Concepts in Biological Research 111

Epidemiological and Other Forms of Research

112

Ethical Issues in Research

113

Implications Summary

103

83

91

The Scientific Method in Abnormal Psychology The Scientific Method in Clinical Research

66

114

115

vii

C ONT ENT S

5

Anxiety Disorders Understanding Anxiety Disorders from a Multipath Perspective

117 119

Biological Dimension 119 Psychological Dimension 122 Social and Sociocultural Dimensions 123

Phobias

124

Social Phobias 125 Specific Phobias 127 Etiology of Phobias 128 CONTROVERSY: Fear or Disgust? 129 Treatment of Phobias 131

Panic Disorder and Agoraphobia

133

Panic Disorder 133 Agoraphobia 134 Etiology of Panic Disorder and Agoraphobia 134 Treatment of Panic Disorder 136 CRITICAL THINKING: Panic Disorder Treatment: Should We Focus on Internal Control? 138

Generalized Anxiety Disorder

138

Etiology of Generalized Anxiety Disorder 139 Treatment of Generalized Anxiety Disorder 140

Obsessive-Compulsive Disorder

141

Implications

Obsessions 142 Compulsions 142

6

Etiology of Obsessive-Compulsive Disorder 143 Treatment of Obsessive-Compulsive Disorder 146 Summary

147

147

Dissociative Disorders and Somatoform Disorders Dissociative Disorders

150

Somatoform Disorders Somatization Disorder 164 Conversion Disorder 164

CRITICAL THINKING: Factitious Disorder and Factitious

Order by Proxy 165 Pain Disorder 167 Hypochondriasis 167 Body Dysmorphic Disorder 168 Etiology of Somatoform Disorders 169 Treatment of Somatoform Disorders 172

Dissociative Amnesia 150 Dissociative Fugue 153 Depersonalization Disorder 153 Dissociative Identity Disorder (Multiple-Personality Disorder) 154 CRITICAL THINKING: Culture and Somatoform and Dissociative Disorders 156 Etiology of Dissociative Disorders 157 CONTROVERSY: “Suspect” Techniques Used to Treat Dissociative Identity Disorder 160 Treatment of Dissociative Disorders 161

Implications Summary

162

149

173

174

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7

CO N T E N T S

Stress Disorders Acute and Posttraumatic Stress Disorders

175 176

Diagnosis of Acute and Posttraumatic Stress Disorders 176

Etiology of Acute and Posttraumatic Stress Disorders

177

Biological Dimension 178 Psychological Dimension 179 Social Dimension 180 Sociocultural Dimension 180

Treatment of Acute and Posttraumatic Stress Disorders

Etiology of Psychophysiological Disorders

181

CRITICAL THINKING: The Hmong Sudden Death

Syndrome 183 Characteristics of Psychophysiological Disorders 183 Coronary Heart Disease 183 Hypertension 184

Treatment of Psychophysiological Disorders

Implications Summary

199

200

201

Diagnosing Personality Disorders

203

Disorders Characterized by Odd or Eccentric Behaviors

205

CONTROVERSY: Impulse Control Disorders

Implications Summary

210

Antisocial Personality Disorder 210 Borderline Personality Disorder 212 Histrionic Personality Disorder 215 Narcissistic Personality Disorder 216

217

Avoidant Personality Disorder 217 Dependent Personality Disorder 218 Obsessive-Compulsive Personality Disorder 219

Multipath Analysis of One Personality Disorder: Antisocial Personality Disorder Biological Dimension 221

Psychological Dimension 224 Social Dimension 225 Sociocultural Dimension 226

Treatment of Antisocial Personality Disorder 227

Paranoid Personality Disorder 205 CRITICAL THINKING: Is There Gender Bias in Diagnosing Mental Disorders? 207 Schizoid Personality Disorder 208 Schizotypal Personality Disorder 208

Disorders Characterized by Anxious or Fearful Behaviors

197

Relaxation Training 197 Biofeedback 198 Cognitive-Behavioral Interventions 198

Personality Disorders

Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors

192

Biological Dimension 192 Psychological Dimension 194 Social Dimension 196 Sociocultural Dimension 196

Physical Stress Disorders: Psychophysiological Disorders 182

8

Migraine, Tension, and Cluster Headaches 186 Asthma 188 Stress and the Immune System 190 CONTROVERSY: Can Laughter or Humor Influence the Course of a Disease? 191

221

230

231

228

ix

CONT ENT S

9

Substance-Related Disorders Substance-Use Disorders

235

Depressants or Sedatives 236 Stimulants 241 Hallucinogens 244

Etiology of Substance-Use Disorders

246

Biological Dimension 247 Psychological Dimension 249 CONTROVERSY: Is Drug Addiction a Disease? 250 Social Dimension 252 CRITICAL THINKING: Is Drug Use an Indicator of Disturbance? 253 Sociocultural Dimension 254

10

232 Intervention and Treatment of Substance-Use Disorders Pharmacological Approach 255 Cognitive and Behavioral Approaches 257 Self-Help Groups 258 CONTROVERSY: Controlled Drinking

Implications Summary

265

CONTROVERSY: Is Compulsive Sexual Behavior

262

262

270

Sexual Desire Disorders 271 Sexual Arousal Disorders 273 Orgasmic Disorders 275 Sexual Pain Disorders 275

Etiology of Sexual Dysfunctions

276

288

Rape

296

Implications Summary

280

Biological Interventions 280 Psychological Treatment Approaches 282

Homosexuality

283

Aging, Sexual Activity, and Sexual Dysfunctions

284

Gender Identity Disorder

286

Etiology of Gender Identity Disorder 287 Treatment of Gender Identity Disorder 288 Is GID a Valid Psychiatric Diagnosis? 288

Paraphilias

Effects of Rape 298 Etiology of Rape 299 Treatment for Rapists 299 CRITICAL THINKING: Why Do Men Rape Women? 300

Biological Dimension 278 Psychological Dimension 278 Social Dimension 279 Sociocultural Dimension 279

Treatment of Sexual Dysfunctions

264

Paraphilias Involving Nonhuman Objects 290 Paraphilias Involving Nonconsenting Persons 291 Paraphilias Involving Pain or Humiliation 293 Etiology and Treatment of Paraphilias 294

an Addiction? 267 The Study of Human Sexuality 268 The Sexual Response Cycle 268

Sexual Dysfunctions

259

Multimodal Treatment 259 Prevention Programs 260 Effectiveness of Treatment 261

Sexual and Gender Identity Disorders What Is “Normal” Sexual Behavior?

255

301

301

x

CO N TE N T S

11

Mood Disorders

303

Unipolar Depression

304

Symptoms of Unipolar Depression 304 Diagnosis and Classification of Depressive Disorders 307 CONTROVERSY: When Is One Depressed? 308 Prevalence of Unipolar Depression 309

Bipolar Disorders

Etiology of Unipolar Depression

310

Biological Dimension 310 Psychological Dimension 313 Social Dimension 317 Sociocultural Dimension 319

Treatment for Unipolar Depression

322

Biomedical Treatments for Depressive Disorders 323 CRITICAL THINKING: Should We Increasingly Turn to Drugs in the Treatment of Depression? 324

12

Suicide 335

CRITICAL THINKING: Why Do People Kill

Themselves? 336 Facts About Suicide 337

A Multipath Perspective of Suicide

343

Biological Dimension 343 Psychological Dimension 344 Social Dimension 345 Sociocultural Dimension 346

Victims of Suicide

347

Children and Adolescents 347 Elderly People 349

Preventing Suicide

350

Clues to Suicidal Intent 351 Crisis Intervention 351 Suicide Prevention Centers 353

The Right to Suicide: Moral, Ethical, and Legal Issues CONTROVERSY: Do People Have a Right to Die?

Summary

327

Symptoms and Characteristics of Bipolar Disorders 327 Classification of Bipolar Disorders 328 Prevalence of Bipolar Disorders 329 Comparison Between Depressive and Bipolar Disorders 329

Etiology of Bipolar Disorders

329

Treatment for Bipolar Disorders

330

Implications Summary

331

332

333

Correlates of Suicide

Implications

Psychotherapy and Behavioral Treatments for Depressive Disorders 324

357

358

354 356

xi

CONT ENT S

13

Schizophrenia: Diagnosis, Etiology, and Treatment The Symptoms of Schizophrenia

359

361

Positive Symptoms 361 CONTROVERSY: Should We Challenge Delusions and Hallucinations? 364 Negative Symptoms 366 Cognitive Symptoms 367 Cultural Issues 367

Types of Schizophrenia

368

Paranoid Schizophrenia 369 Disorganized Schizophrenia 369 Catatonic Schizophrenia 369 Undifferentiated and Residual Schizophrenia 370 Psychotic Disorders That Were Once Considered Schizophrenia 371 Other Psychotic Disorders 371 CONTROVERSY: Delusional Parasitosis or Physical Disease? 373

The Course of Schizophrenia

The Treatment of Schizophrenia CONTROVERSY: Balancing Prevention and Harm

373

Long-Term Outcome Studies 374

Etiology of Schizophrenia

374

Biological Dimension 375 Psychological Dimension 378 Social Dimension 379 Sociocultural Dimension 381

14

Implications Summary

389

389

390

The Assessment of Brain Damage

392

Types of Cognitive Disorders

393

Dementia 393 Delirium 394 Amnestic Disorders 395 Traumatic Brain Injury 396 Aging and Disorders Associated with Aging 398 Alzheimer’s Disease 400

385

Psychosocial Therapy 385 Interventions Focusing on Family Communication and Education 388

Cognitive Disorders

Etiology of Cognitive Disorders

383

Antipsychotic Medication 383

Cerebral Tumors 406 Epilepsy 406 Use of Psychoactive Substances 408

Treatment/Prevention Considerations 395

Medication 408 Cognitive and Behavioral Approaches 409 Lifestyle Changes 409 Environmental Interventions and Caregiver Support 410

CRITICAL THINKING: Moderators and Mediators:

Implications

What Causes What? 402 Other Diseases and Infections of the Brain 404

Summary

410

411

408

xii

15

CO N T E N T S

Disorders of Childhood and Adolescence CONTROVERSY: Are We Overmedicating Children?

Pervasive Developmental Disorders

412

414

414

Autistic Disorder 415 Other Pervasive Developmental Disorders 417 Etiology 419 Prognosis 421 Treatment 421

Attention Deficit/Hyperactivity Disorders and Disruptive Behavior Disorders

422

Attention Deficit/Hyperactivity Disorders 422 Oppositional Defiant Disorder 426 Conduct Disorders 427 CRITICAL THINKING: School Violence: A Sign of

the Times? 429

Elimination Disorders

431

Enuresis 431 CRITICAL THINKING: Child Abuse

432

434

Etiology 434 Treatment 435

16

Implications Summary

442

442

Eating Disorders Eating Disorders

443 444

Anorexia Nervosa 446 CRITICAL THINKING: Anorexia’s Web 448 Bulimia Nervosa 449 Binge-Eating Disorders 451 Eating Disorder Not Otherwise Specified 453

Etiology of Eating Disorders

Treating Anorexia Nervosa 464

Treating Bulimia Nervosa 466 Treating Binge-Eating Disorder 466

Obesity

467

Etiology of Obesity

469

Biological Dimension 469

454

Biological Dimension 454 Psychological Dimension 455 Social Dimension 456 Sociocultural Dimension 457 CRITICAL THINKING: Is Our Society Creating Eating Disorders? 462

Treatment of Eating Disorders

435

Diagnosing Mental Retardation 436 Etiology of Mental Retardation 437 Programs for People with Mental Retardation 440

Encopresis 433

Learning Disorders

Mental Retardation

CONTROVERSY: Are the BMI Index Standards

Appropriate? 470 Psychological Dimension 470 Social Dimension 471 Sociocultural Dimension 471

Treatments for Obesity Implications

464

Summary

472

472

471

C ONT ENT S

17

Legal and Ethical Issues in Abnormal Psychology Criminal Commitment

xiii 474

478

The Insanity Defense 478 Competency to Stand Trial 481

Civil Commitment

482

Criteria for Commitment 483 Procedures in Civil Commitment 484

Rights of Mental Patients

485

CRITICAL THINKING: Predicting Dangerousness: The Case

of Serial Killers and Mass Murderers 486 Right to Treatment 486 Right to Refuse Treatment 488 CONTROVERSY: Court-Ordered Assisted Treatment:

Coercion or Caring? 489

Deinstitutionalization

490

The Therapist-Client Relationship

492

Confidentiality and Privileged Communication 492 The Duty-to-Warn Principle 493 Sexual Relationships with Clients 494 Glossary G-1 References R-1 Credits C-1 Name Index I-1 Subject Index I-13

Cultural Competence and the Mental Health Profession Implications Summary

496

496

494

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Feat ur es

Critical Thinking

Controversy

I Have It, Too: The Medical Student Syndrome, 28 Applying the Models of Psychopathology, 62 Can We Accurately Assess the Status of Members of Different Cultural Groups? 82 Attacks on Scientific Integrity, 97 Researcher Allegiance: A “Wild Card” in Comparative Research, 105 Panic Disorder Treatment: Should We Focus on Internal Control? 138 Culture and Somatoform and Dissociative Disorders, 156 Factitious Disorder and Factitious Disorder by Proxy, 165 The Hmong Sudden Death Syndrome, 183 Is There Gender Bias in Diagnosing Mental Disorders? 207 Is Drug Use an Indicator of Disturbance? 253 Why Do Men Rape Women? 300 Should We Increasingly Turn to Drugs in the Treatment of Depression? 324 Why Do People Kill Themselves? 336 Moderators and Mediators: What Causes What? 402 School Violence: A Sign of the Times? 429 Child Abuse, 432 Anorexia’s Web, 448 Is Our Society Creating Eating Disorders? 462 Predicting Dangerousness: The Case of Serial Killers and Mass Murderers, 486

Is Mental Illness a Myth and a Political Construction? 12 Problems in Using Racial and Ethnic Group References, 60 Should the Rorschach Be Used in Making Assessments? 74 Repressed Memories: Issues and Questions, 99 Fear or Disgust? 129 “Suspect” Techniques Used to Treat Dissociative Identity Disorder, 160 Can Laughter or Humor Influence the Course of a Disease? 191 Impulse Control Disorders, 228 Is Drug Addiction a Disease? 250 Controlled Drinking, 259 Is Compulsive Sexual Behavior an Addiction? 267 When Is One Depressed? 308 Do People Have a Right to Die? 356 Should We Challenge Delusions and Hallucinations? 364 Delusional Parasitosis or Physical Disease? 373 Balancing Prevention and Harm, 385 Are We Overmedicating Children? 414 Are the BMI Index Standards Appropriate? 470 Court-Ordered Assisted Treatment: Coercion or Caring? 489

Disorder Charts Anxiety Disorders, 119 Dissociative Disorders, 151 Somatoform Disorders, 163 Personality Disorders, 206 Substance-Related Disorders, 235 Sexual Dysfunctions, 272 Paraphilias, 289 Mood Disorders, 305 Schizophrenia, 368 Cognitive Disorders, 391 Pervasive Developmental Disorders, 418 Attention Deficit and Disruptive Behavior Disorders, 423 Learning Disorders, 435 Mental Retardation, 436 Eating Disorders, 445

xv

p r efa ce

A

bnormal behaviors both fascinate and are of concern to scientists and the general public. Why people exhibit abnormal behaviors, how they express their disturbances, and how such behaviors can be prevented and treated are questions that continue to intrigue us. We now know that all human beings are touched in one way or another by mental disturbance in their lives, either directly through their own struggles to deal with mental disorders or indirectly through affected friends or relatives. Over the years, major research discoveries in genetics, neurobiology, and psychology have made unprecedented contributions to our understanding of abnormal behaviors. This is clearly evident in the Human Genome Project, where scientists have mapped the location of all genes in the human nucleus. The hope among mental health professionals is that the “map of life” will allow for increased understanding of mental disorders and their subsequent treatments. In addition to this tremendous biological breakthrough, we also know that psychological forms of intervention are effective in treating abnormal behaviors. The move to identify empirically supported treatments has taken the profession by storm. Finally, research has revealed the great cultural variations in abnormal behaviors and what other cultures consider effective treatments. In the Ninth Edition of our book, we examine all of these areas. In writing and revising this book, we have sought to engage students in the exciting process of understanding abnormal behavior and the ways that mental health professionals study and attempt to treat it. In pursuing this goal, we have been guided by three major objectives: • To provide students with scholarship of the highest quality, • To offer an evenhanded treatment of abnormal psychology as both a scientific and a clinical endeavor, giving students the opportunity to explore topics thoroughly and responsibly, and • To make our book inviting and stimulating to a wide range of students. In each edition, we have strived to achieve these objectives, working with comments from many students and instructors and our own work in teaching, research, and practice. The Ninth Edition, we believe, builds on the achievements of previous editions and surpasses them.

Our Approach

x vi

We take an eclectic, multicultural approach to the field, drawing on important contributions from various disciplines and theoretical stances. The text covers the major categories of disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), but it is not a mechanistic reiteration of DSM. We believe that different combinations of life experiences and constitutional factors influence behavioral disorders, and we project this view throughout the text. These combinations of factors are demonstrated in our multipath model, which is a way of looking at the causes of disorders new to the Ninth Edition. There are several elements to our multipath model. First, the contributors to mental disorders are divided into four dimensions: biological, psychological, social, and sociocultural. Second, factors in the four dimensions can interact and influence each other in any direction. Third,

PR EFA CE

different combinations within the four dimensions may cause abnormal behaviors. For instance, assume that a person has severe depression. That depression may be caused primarily by a single factor (e.g., death of a loved one) or by an interaction of factors at different dimensions (e.g., caused by child abuse occurring in early life and stressors in adulthood). Thus, a disorder such as depression may be caused by different factors and different combination of factors. Fourth, many disorders appear to be heterogeneous in nature. Therefore, there may be different types or versions of a disorder (a spectrum of the disorder). Finally, different disorders may be caused by similar factors. For example, anxiety as well as depression may be caused by child abuse and interpersonal stress. In fact, anxiety and depression often occur concurrently in people. Sociocultural factors, including cultural norms, values, and expectations, are given special attention. Because we are convinced that cross-cultural comparisons of abnormal behavior and treatment methods can greatly enhance our understanding of disorders, cultural and gender phenomena are emphasized. Indeed, Understanding Abnormal Behavior was the first textbook on abnormal psychology to integrate and emphasize the role of multicultural factors, and although many texts have since followed our lead, the Ninth Edition continues to provide the most extensive coverage and integration of multicultural models, explanations, and concepts available. Not only do we discuss how changing demographics have increased the importance of multicultural psychology, but we also introduce multicultural models of psychopathology in the opening chapters. As with other models of psychopathology (such as psychoanalytic, cognitive, behavioral, biological), we address multicultural issues throughout the text whenever research findings and theoretical formulations allow. For example, cultural factors as they affect assessment, classification, and treatment of various mental disorders are presented to students. Such an approach adds richness to our understanding of mental disorders. As psychologists (and professors), we know that learning is enhanced whenever material is presented in a lively and engaging manner. We achieve these qualities in part by providing case vignettes and clients’ descriptions of their experiences to complement and illustrate research-based explanations. Our goal is to encourage students to think critically rather than merely assimilate a collection of facts and theories. As a result, we hope that students will develop an appreciation of the study of abnormal behavior.

Special Features The Ninth Edition includes a number of new features as well as features that were popularized in earlier editions and, in some cases, have been revised and enhanced. These features are aimed at aiding students in organizing and integrating the material in each chapter. • As previously noted, our new multipath model provides a framework through which students can understand mental disorders. The model is introduced in Chapter 2 and applied throughout the book. • New and updated Critical Thinking boxes provide factual evidence and thoughtprovoking questions that raise key issues in research, examine widely held assumptions about abnormal behavior, or challenge the student’s own understanding of the text material. • New Controversy boxes deal with controversial issues with wide implications for our society. These boxes stimulate critical thinking, evoke alternative views, provoke discussion, and draw students into issues that help them better explore the wider meaning of abnormal behavior in our society. • New and updated Myth and Reality discussions challenge the many myths and false beliefs that have surrounded the field of abnormal behavior and also helps students realize that beliefs, some of which may appear to be “common sense,” must be checked against scientific facts and knowledge.

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• New Did You Know? margin boxes found throughout the book provide fascinating, at-a-glance research-based tidbits for students. • New Implications sections end each chapter, synthesizing the multipath model implications of the chapter material. • Chapter outlines and Focus Questions, appearing in the first pages of every chapter, provide a framework and stimulate active learning—with questions in mind, students begin thinking about the concepts they are about to explore within the chapter. • Integrated chapter Summaries keyed to the Focus Questions provide students with a concise recap of the chapter’s most important concepts and with tentative answers to the chapter opener’s Focus Questions. • New and updated case studies and examples make issues of mental health and mental disorders “come to life” for students and instructors. Many of the cases are taken from actual clinical files, and all are clearly designated within the text’s design. • Streamlined disorder charts provide snapshots of disorders in an easy-to-read format. • Key terms are highlighted in the text and appear in the margins.

New and Updated Coverage of the Ninth Edition Our foremost objective in preparing this edition was to update thoroughly and present the latest trends in research and clinical thinking. This has led to updated coverage of dozens of topics throughout the text, including the following: • The growing ethnic and cultural diversity in the United States and its implications for mental health research, theory, and practice. • Expanded and balanced coverage of the biological perspective and the latest research strategies and findings on genetic factors in mental disorders. • Integrated coverage of the growing prevalence of psychoactive drug use in U.S. society. • New developments concerning the implications of managed health care on mental health services and the use of evidence-based treatments. • Research findings concerning the rates of each mental disorder and the prevalence of disorders according to gender, ethnicity, and age. • Updated suicide coverage. • Coverage of date rape and reasons for why men rape. • Expanded coverage on eating disorders and obesity. • Expanded coverage of learning disorders. • Identification of psychotherapies and treatments that are likely to increase or decrease in use in the future. • Ethical and legal issues raised by recent cases involving insanity pleas, courtroom testimony by psychologists, and assisted suicide. • Integrated coverage of culture-specific therapeutic strategies for treating African American, Asian American, Latino American, and Native American clients. The design of the book has been revamped to present the content in the clearest, most accessible way. As in the previous edition, the Ninth Edition contains an abundance of tables, illustrations, figures, and photographs that graphically show research data, illustrate comparisons and contrasts, and enhance the understanding of concepts or controversies in the field. In addition to updating the book’s coverage, its look, and its special features, we have maintained a streamlined organization of the book, as described next.

P REFA C E

Organization of the Text To make covering the book’s contents over the course of a quarter or semester more manageable, the text is seventeen chapters long, in keeping with feedback from users of the book. Long-time users of our text will immediately notice that we continue to offer features that have been helpful, that we continue to have a chapter on eating disorders (Chapter 16), and that we provide coverage of mental retardation in the chapter on childhood disorders (Chapter 15). In addition, all of the chapters have been thoroughly revised and updated with an eye toward balancing research findings with clinical implications. Chapters 1 through 4 provide a context for viewing abnormal behavior and treatment by introducing students to definitions of abnormal behavior and historical perspectives (Chapter 1), the key theoretical perspectives used to explain deviant behavior (Chapter 2), methods of assessment and classification (Chapter 3), and the research process involved in the study of abnormal behavior (Chapter 4). Especially noteworthy is our new multipath model discussion found in Chapter 2. The bulk of the text, Chapters 5 through 16, presents the major disorders covered in DSM-IV-TR. In each chapter, disorders are viewed through a multipath perspective that focuses on symptoms, etiology, and treatment. Our disorders charts include not only the definitions of disorders but also their prevalence, onset, and course, so, at a glance, students are able to gain an important overview of the disorders. Highlights of the coverage in this part of the book include an entire chapter devoted to suicide (Chapter 12), which was deemed important because of its increasing visibility in the mental health professions and our society. In addition, major contemporary issues involving the right to die, assisted suicide, and our aging population have thrust it into the public limelight as well. This chapter presents information on the reasons for suicide and also on its moral, legal, and ethical implications. Chapter 16 still provides thorough coverage of eating disorders and now includes an expanded discussion of obesity and its possible inclusion in DSM-V. Research now links eating disorders to situational factors, biological proclivity, and other interlocking mental disorders. The fact that the majority of those who suffer from eating disorders are women is also a powerful statement of how the images society portrays to them may result in unhealthy behaviors. Chapter 17 concludes the book with a look at the legal and ethical issues in psychopathology, including topics such as the insanity defense, patients’ rights, confidentiality, and mental health practices in general. In our earlier edition, a separate chapter was devoted to therapy, but we have chosen to discuss treatment approaches in each of the chapters on disorders instead, allowing students closure in covering particular disorders. The therapeutic intervention chapter from previous editions is still available online for those instructors who would like to use it. The text is therefore manageable for a one-semester class. While research findings and knowledge in the field of psychopathology have grown considerably, we have tried to provide the most important and significant developments in the field without sacrificing the scholarly and comprehensive nature of the book.

Ancillaries This text is supported by a rich set of supplementary materials designed to enhance the teaching and learning experience. Several new components make use of new instructional technologies.

For Instructors • Instructor’s Resource Manual: The Instructor’s Resource Manual includes an extended chapter outline, learning objectives, discussion topics, classroom exercises, handouts, and list of supplementary readings and multimedia resources.

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The Instructor’s Resource Manual is available on the instructor Web site, www .cengage.com/psychology/sue, and is also available in print. Please consult your sales representative for further details. Test Bank: The Test Bank is a static test bank in Word that contains 100 multiple-choice and three essay questions (with sample answers) per chapter. Each question is labeled with the corresponding text page reference as well as the type of question being asked for easier test creation. The Test Bank is available on the Diploma Testing CD-ROM and in print. Please consult your sales representative for further details. Diploma Testing CD-ROM: The Diploma Testing CD-ROM—powered by Diploma—is a flexible testing program that allows instructors to create, edit, customize, and deliver multiple types of tests via print, network server, or the Web on either the MAC or WIN platform. It contains 100 multiple-choice and three essay questions (with sample answers) per chapter. Each question is labeled with the corresponding text page reference as well as the type of question being asked for easier test creation. New! PowerLecture with JoinIn: This one-stop digital library and presentation tool includes preassembled Microsoft® PowerPoint® lecture slides that highlight the major topics in abnormal psychology. In addition to a full Instructor’s Resource Manual and Test Bank, PowerLecture also includes JoinIn™ Student Response System, offering instant assessment and better student results. With JoinIn, instructors can perform on-the-spot assessments and gauge students’ understanding of a particular concept or question, while students receive immediate feedback on how well they understand concepts covered in the text and where they need to improve. PowerLecture also houses all of your media resources in one place, including an image library with graphics from the book itself, video clips, and more. Instructor Web site: Instructors can access a variety of resources at any time via www.cengage.com/psychology/sue. The instructor’s Web site includes the complete Instructor’s Resource Manual, presentation materials, video guides, and more. New! CengageNOW with Cengage Learning eBook: CengageNOW™ is an online teaching and learning resource that gives you more control in less time and delivers better outcomes—NOW. CengageNOW offers all of your teaching and learning resources in one intuitive program organized around the essential activities you perform for class—lecturing, creating assignments, grading, quizzing, and tracking student progress and performance. CengageNOW provides students access to an integrated eBook, as well as interactive tutorials, videos, animations, and more that help students get the most out of your course. WebTutor on Blackboard and WebCT: Jumpstart your course with customizable, rich, text-specific content within your Course Management System. Whether you want to Web-enable your class or put an entire course online, WebTutor™ delivers. WebTutor offers a wide array of resources, including media assets, quizzing, weblinks, and more! Visit webtutor.cengage.com to learn more. Abnormal Psych in Film DVD/VHS: The Abnormal Psych in Film® DVD/VHS is a hybrid product that contains clips from popular films such as The Deer Hunter and Apollo 13 that illustrate key concepts in abnormal psychology, as well as thought-provoking footage from documentaries and client interviews. Each clip is accompanied by overviews and discussion questions to help bring the study of abnormal psychology alive for students.

For Students • Study Guide: The Study Guide, available on the student Web site and in print, provides a complete review of the chapter with chapter outlines, learning objectives, fill-in-the-blank review of key terms, and multiple-choice questions.

P REFA C E

Answers to test questions include an explanation for both the correct answer and incorrect answers. • Student Companion Site: This text-specific Web site contains additional study aids, including quizzes, online study guide, interactive Critical Thinking exercises, and multimedia tutorials—all designed to help students improve their grades while learning more about abnormal psychology. All Web resources may be accessed by logging onto the Web site at www.cengage.com/psychology/sue. • Passkeys: Passkeys for protected assets are available with every new copy of the text. Students who have bought a used textbook can purchase access to the student Web site separately. • New! CengageNOW with Cengage Learning eBook: CengageNOW™ is an easyto-use online resource that helps students study in less time to get the grade they want—NOW. A diagnostic study tool featuring the Cengage Learning eBook and Personalized Study, CengageNOW gives students access to valuable text-specific resources that help them focus on just what they don’t know and learn more in less time to get a better grade. If the textbook does not include an access code card, students can go to www.ichapters.com to get CengageNOW with Cengage Learning eBook. • Case Studies in Abnormal Psychology: Case Studies in Abnormal Psychology, by Clark Clipson, California School of Professional Psychology, and Jocelyn Steer, San Diego Family Institute, contains sixteen studies and can be shrink-wrapped with the text at a discounted package price. Each case represents a major psychological disorder. After a detailed history of each case, critical-thinking questions prompt students to formulate hypotheses and interpretations based on the client’s symptoms, family and medical background, and relevant information. The case proceeds with sections on assessment, case conceptualization, diagnosis, and treatment outlook, and is concluded by a final set of discussion questions. • Abnormal Psychology in Context: Voices and Perspectives: Abnormal Psychology in Context: Voices and Perspectives is a supplementary text, written by David Sattler, College of Charleston; Virginia Shabatay, Palomar College; and Geoffrey Kramer, Grand Valley State University, that features forty cases and can be shrink-wrapped with the text at a discounted package price. This unique collection contains first-person accounts and narratives written by individuals who live with a psychological disorder and by therapists, relatives, and others who have direct experience with someone suffering from a disorder. These vivid and engaging narratives are accompanied by critical-thinking questions and a psychological concept guide that indicates which key terms and concepts are covered in each reading.

Acknowledgments We continue to appreciate the critical feedback received from reviewers and colleagues. The following individuals helped us prepare the Ninth Edition by sharing with us valuable insights, opinions, and recommendations. Julia C. Babcock, University of Houston Betty Clark, University of Mary-Hardin Irvin Cohen, Hawaii Pacific University & Kapiolani Community College Lorry Cology, Owens Community College Bonnie J. Ekstrom, Bemidji State University Greg A. R. Febbraro, Drake University Kate Flory, University of South Carolina David M. Fresco, Kent State University

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Jerry L. Fryrear, University of Houston, Clear Lake Michele Galietta, John Jay College of Criminal Justice Christina Gordon, Fox Valley Technical College George-Harold Jennings, Drew University Robert Hoff, Mercyhurst College Kim L. Krinsky, Georgia Perimeter College Brian E. Lozano, Virginia Polytechnic Institute and State University Jan Mohlman, Rutgers University Sherry Davis Molock, George Washington University Rebecca L. Motley, University of Toledo Gilbert R. Parra, University of Memphis Kimberly Renk, University of Central Florida Mark Richardson, Boston University Alan Roberts, Indiana University Daniel L. Segal, University of Colorado at Colorado Springs Tom Schoeneman, Lewis & Clark College Michael D. Spiegler, Providence College Ma. Teresa G. Tuason, University of North Florida Theresa A. Wadkins, University of Nebraska, Kearney Susan Brooks Watson, Hawaii Pacific University Fred Whitford, Montana State University We also wish to acknowledge the continuing support and high quality of work done by Shannon LeMay-Finn and Laura Hildebrand, Development Editors; Henry Cheek, Associate Editor; Jane Potter, Senior Sponsoring Editor; Aileen Mason and Bob Greiner, Senior Project Editors; and Laura Collins, Editorial Assistant. We also thank text designer Susan Gilday, art editor Laura Brown, photo researcher Marcy Kagan, copy editor Elaine Lauble Kehoe, proofreader Mary Kanable, and indexer Leoni McVey. D. S. D. W. S. S. S.

a bout t he aut h or s

David Sue is Professor Emeritus of Psychology at Western Washington University, where he is an associate of the Center for Cross-Cultural Research. He has served as the Director of both the Psychology Counseling Clinic and the Mental Health Counseling Program. He and his wife recently completed the book Counseling and Psychotherapy in a Diverse Society. He received his Ph.D. in Clinical Psychology from Washington State University. His research interests revolve around multicultural issues in individual and group counseling. He and his wife are proud grandparents of two grandsons (twins).

Derald Wing Sue is Professor of Psychology and Education in the Department of Counseling and Clinical Psychology at Teachers College, Columbia University. He has written extensively in the field of counseling psychology and multicultural counseling/therapy and is author of a best-selling book, Counseling the Culturally Diverse: Theory and Practice. Dr. Sue has served as president of the Society of Counseling Psychology and the Society for the Psychological Study of Ethnic Minority Issues. He received his doctorate from the University of Oregon and is married and the father of two children. Friends describe him as addicted to exercise and the Internet.

Stanley Sue is University Distinguished Professor of Psychology and Asian American Studies at the University of California, Davis. He received his B.S. from the University of Oregon and Ph.D. from UCLA. He was Assistant and Associate Professor of Psychology at the University of Washington (1971–1981) and Professor of Psychology at UCLA (1981–1996). His research interests lie in the areas of clinical-community psychology and ethnicity and mental health. His hobbies include working on computers, which has resulted in an addiction to the Internet, and jogging with his wife.

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Abnormal Behavior

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chapter outline The Concerns of Abnormal Psychology

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Determining Abnormality

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Contextual and Cultural Limitations in Defining Abnormal Behavior

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The Frequency and Burden of Mental Disorders

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Stereotypes About the Mentally Disturbed

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Historical Perspectives on Abnormal Behavior

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Causes: Early Viewpoints

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Contemporary Trends in Abnormal Psychology

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IMP LIC AT IONS

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n April 16, 2007, college student Seung Hui Cho used two semiautomatic handguns on the Virginia Tech campus to kill twenty-seven students and five faculty members, wound twenty-five others, and commit suicide with a shot to his head. The incident was the deadliest mass shooting in modern U.S. history and left many grief-stricken, horrified, and baffled at Cho’s actions. To the public, the mass killings immediately brought to mind the 1999 Columbine High School massacre in which Eric Harris and Dylan Klebold killed twelve students and one teacher before committing suicide. The Virginia Tech rampage began in the early morning hours, when Cho shot a female student and male resident assistant in a dormitory. Approximately two hours later, he went to Norris Hall, where classes were in session, and chained shut the building doors to prevent easy escape. There he fired some 174 rounds, killing and wounding many students and professors as he moved from classroom to classroom. While the second attack lasted only nine minutes, to those trapped in the building, it must have seemed like an eternity. Chaos ensued as students fled for their lives. Some jumped from second-story windows to escape, and others attempted to barricade the classroom doors. There were multiple reports of heroic actions by professors and students to save others, but it often resulted in their own deaths (summarized from the Virginia Tech Review Panel, August 2007).

CONTROVERSY Is Mental

Illness a Myth and a Political Construction?

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CRITICAL THINKING I Have It, Too: The Medical Student Syndrome 28

2

In an attempt to make sense out of an apparently “senseless” act, many questions were asked. What could have motivated Cho to carry out such a heinous deed and take so many innocent lives? Why did he commit suicide? Was he deranged, a psychopathic killer, or high on drugs? Were there warning signs that he was homicidal or suicidal? Did he suffer from a mental disorder? Would therapy or medication have helped him? Did his race, culture, and immigration status play any role in his actions?

FOCUSQUESTIONS

1 What is abnormal psychology? 2 What criteria are used to determine normal or abnormal behaviors?

3 How do context and cultural differences affect definitions of abnormality?

4 How common are mental disorders?

1 6 How have explanations of abnormal behavior changed over time?

7 What were early viewpoints on the causes of mental disorders?

8 What are some contemporary trends in abnormal psychology?

5 What are some common misconceptions about the mentally disturbed?

These questions are extremely difficult to answer for a number of reasons. First, we do not know enough about the causes of abnormal behavior and especially mental disorders to arrive at a definitive answer. It appears that psychopathology, or abnormal behavior, is not the result of any singular cause but an interaction of many factors. Most mental disorders have multiple contributors, a fact that we discuss in the next chapter. Second, Cho is no longer alive so that we could ascertain his state of mind. As a result, we must rely on secondary sources such as health or school records, observations by peers, family, and acquaintances, and any other available data (suicide notes, essays, pictures, and media communications) to construct a portrait of his state of mind. Sad to say, the Virginia Tech massacre illustrates how complex the study of abnormal psychology becomes in real life. In a sense, the purpose of this book, Understanding Abnormal Behavior, is to help you answer such questions. To do so, however, requires us first to examine some basic aspects of the study of abnormal behavior, including some of its history and emerging changes in the field. Periodically, we use the Cho case to illustrate the many complex interacting mental health issues in the field.

SEUNG HUI CHO PHOTO SENT TO NBC ON DAY OF THE MASSACRE Was Cho mentally disturbed? At college, he became known as the “question mark kid” because he would only put down a question mark for his name. He would not respond when greeted, sat for hours in his dorm room staring out the window, and referred to an imaginary girlfriend by the name of “Jelly,” a supermodel who lived in outer space. At one time, he informed a roommate that he was vacationing with Vladimir Putin, the president of Russia.

The Concerns of Abnormal Psychology Abnormal psychology is the scientific study whose objectives are to describe, explain, predict, and control behaviors that are considered strange or unusual. Its subject matter ranges from the bizarre and spectacular to the more commonplace—from the violent homicides, suicides, and “perverted” sexual acts that are widely reported by the news media to such unsensational (but more prevalent) behaviors as depression, ulcers, and anxiety about examinations.

Describing Abnormal Behavior The description of a particular case of abnormal behavior must be based on systematic observations by an attentive professional. These observations, usually paired with the results of the person’s psychological history, become the raw material for a psychodiagnosis, an attempt to describe, assess, and systematically draw inferences about an individual’s psychological disorder.

a term clinical psychologists use as a synonym for abnormal behavior

psychopathology

abnormal psychology

the scientific study whose objectives are to describe, explain, predict, and control behaviors that are considered strange or unusual an attempt to describe, assess, and systematically draw inferences about an individual’s psychological disorder

psychodiagnosis

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For example, Cho was taken to a mental health agency in Virginia, where a psychiatric evaluation was undertaken. Because we have limited access to these records, the precise nature of the therapist’s observations is tentative. Usually, however, mental status exams are conducted by mental health professionals to ascertain the degree to which clients are in contact with reality, whether they suffer from hallucinations or delusions, and whether they are potentially dangerous. Based on clinical observations, analysis of his history, and possibly psychological testing, the therapist concluded that Cho was of “imminent danger to self or others,” “mentally ill,” and in need of hospitalization. The precise psychiatric diagnosis is unknown because of confidentiality laws. Unfortunately, instead of commitment to a mental institution, a court magistrate ordered only outpatient treatment. As we now know, Cho never complied with the order to seek therapy.

Explaining Abnormal Behavior

Did You Know?

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ho’s behavior motivated his mother to seek help from churches in northern Virginia. One Presbyterian congregation felt that Cho was afflicted by a demonic power and needed spiritual deliverance. Others speculated that Cho was the epitome of evil. Although claiming that he was possessed by supernatural forces might appear far-fetched, such explanations of bizarre behavior were once common.

To explain abnormal behavior, the psychologist must identify its causes and determine how they led to the described behavior. This information, in turn, bears heavily on how a program of treatment is chosen. One popular explanation of Cho’s behavior was that he was high on drugs. An autopsy, however, revealed no evidence of alcohol or drugs present in his system. Nevertheless, Cho’s background suggests many other possible causes for his rampage: • As a child, Cho was described by family members as mute, cold, and shy. His mother speculated that he was “autistic,” a condition associated with social isolation, delayed speech, and repetitive behavior and believed to have a strong constitutional component. Some relatives say that he was different from birth and suggest that his problem was biological in nature. • Cho was often the subject of teasing and cruel taunts by classmates, probably because of his unusual behaviors. He was often bullied, called names, mocked, and told to “go back to China.” Although he seldom showed anger, rumors abounded that he kept a “hit list” of students he wanted to kill. Could such malicious actions from peers account for his homicidal and suicidal actions? • Cho was a twenty-three-year-old South Korean citizen with U.S. permanent resident status in Virginia. He immigrated to this country at age eight with his parents and sister. Some believe he never adequately adjusted to his new life in the United States and encountered culture conflicts. He felt isolated, alone, and alienated from others. Unable or unwilling to make connections with people, Cho had difficulty distinguishing between fantasy and reality. • Cho came from a very poor background and lived in a three-room basement with his family in Korea. His father was a self-employed secondhand bookstore owner who made little money and moved his family to the United States to improve their financial state. Cho appeared very self-conscious about being poor and resented “rich kids,” materialism, and hedonism. His writings and video recordings sent to NBC News contained extremely hostile statements toward those “with money.” In these snippets of Cho’s life, it is clear that many explanations for his rampage could be offered. There was something biologically wrong with him from birth; he could not tolerate the merciless teasing and bullying; his alienation from a new culture created social isolation and resentment; and his poverty made him envious and angry toward more affluent students. Depending on your viewpoint, some explanations may appear more valid than others. As we will see in the next chapter, no one explanation is sufficient to explain the complexity of the human condition; normal and abnormal behaviors result from a combination of factors.

Predicting Abnormal Behavior If a therapist can correctly identify the source of a client’s difficulty, he or she should be able to predict the kinds of problems the client will face during therapy and the symptoms the client will display. Many believe that there was sufficient evidence to predict that Cho was likely to take the lives of others and his own based on a number of reported events:

The Concerns of Abnormal Psychology

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INTERVENING THROUGH THERAPY Group therapy is a widely used form of treatment for many problems, especially those involving interpersonal relationships. In this group session, participants are learning to develop new and adaptive social skills in coping with social problems rather than relying on alcohol or drugs to escape the stresses of life.

• Cho was involved in three stalking incidents on the Virginia Tech campus. All three involved female students in whom he developed brief but intense interest. His contacts were made through instant messaging on his computer. He sent them annoying messages, made an uninvited appearance at one student’s dorm room, and left graffiti on her bulletin board. Cho was warned by campus police to cease his unwarranted contacts with them. He apparently acceded to their warnings. • Several professors reported that Cho was menacing, had a mean streak, and that his writings were often intimidating, obscene, and violent. His writings, they contend, “dripped with anger,” were graphic and disturbing, and possessed macabre violence. One professor became so fearful for her own safety and that of others that she reported Cho to the student affairs office, the dean’s office, and campus police. Each unit responded that nothing could be done if Cho made no overt threats against others. In light of these reports, why was Cho allowed to stay on campus? Why was he allowed to purchase firearms despite having a diagnosed mental condition? Why did mental health professionals not intervene more quickly? There appear to be several reasons. First, civil commitment, or involuntary hospitalization/confinement, represents an extreme decision that has major implications for an individual’s civil liberties. Our legal system operates under the assumption that people are innocent until proven guilty. Locking someone up before they commit a dangerous act potentially violates a person’s civil rights. Second, although this particular therapist proved to be correct in declaring Cho dangerous, clinicians are notoriously inaccurate in predicting dangerousness. Research shows that mental health professionals do a poor job of predicting future violence; they tend to greatly overpredict it (Buchanan, 1997).

Controlling Abnormal Behavior Abnormal behavior may be controlled through therapy, which is a program of systematic intervention whose purpose is to modify a client’s behavioral, affective (emotional), and/or cognitive state. For example, many therapists wonder whether Cho could have been helped and the mass killings prevented if he had been forced into treatment. Allowing Cho an opportunity to get in touch with and to vent his anger would reduce his chances of doing harm to others. Some mental health professionals might also recommend family therapy or social skills training. Some might even recommend hospitalization, which unfortunately was recommended but not done.

a program of systematic intervention whose purpose is to modify a client’s behavioral, affective (emotional), and/or cognitive state

therapy

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TA B L E

1.1

THE MENTAL HEALTH PROFESSIONS Clinical Psychology

Clinical psychology is the professional field concerned with the study, assessment, treatment, and prevention of abnormal behavior in disturbed individuals. A clinical psychologist must hold a Ph.D. degree from a university or a Psy.D. (doctor of psychology) degree, a more practitioner-oriented degree granted by several institutions. Their training includes course work in psychopathology, personality, diagnosis, psychological testing, psychotherapy, and human physiology. Apart from these and other course requirements, there are two additional requirements for the Ph.D. degree: students are required to complete a doctoral dissertation and usually a one-year internship. Clinical psychologists work in a variety of settings, but most commonly they provide therapy to clients in hospitals and clinics and in private practice. Some choose to work in academic settings in which they can concentrate on teaching and research. Other clinical psychologists are hired by government or private organizations to do research.

Counseling Psychology

To a great extent, a description of clinical psychology applies to counseling psychology as well. The academic and internship requirements are similar, but the emphasis differs. Whereas clinical psychologists are trained to work specifically with a disturbed client population, counseling psychologists are usually more immediately concerned with the study of life problems in relatively normal people. Furthermore, counseling psychologists are more likely to be found in educational settings than in hospitals and clinics.

Marriage and Family Counseling

A specialty in marriage and family counseling has recently emerged, with its own professional organizations, journals, and state licensing requirements. Marriage and family counselors have varied professional backgrounds, but their training usually includes a master’s degree in counseling and many hours of supervised clinical experience.

Mental Health Counseling

As of this writing, mental health counselors are recognized and licensed for clinical/counseling practice in 49 states. They work in a variety of settings, receive intensive training in personal, emotional, vocational, and human development, and have their own professional association. Mental health counselors must meet many hours of supervised clinical experience and possess master’s degrees in counseling.

Psychiatry

Psychiatrists hold M.D. degrees. Their education includes the four years of medical school required for that degree, along with an additional three or four years of training in psychiatry. Of all the specialists involved in mental health care, only psychiatrists can prescribe drugs in the treatment of mental disorders.

Psychoanalysis

Psychoanalysis has been associated with medicine and psychiatry because its founder, Sigmund Freud, and his major disciples were physicians. But Freud was quite adamant in stating that one need not be medically trained to be a good psychoanalyst. Nevertheless, most psychoanalysts hold either an M.D. or a Ph.D. degree. In addition, psychoanalysts receive intensive training in the theory and practice of psychoanalysis at an institute devoted to the field. This training includes the individual’s own analysis by an experienced analyst.

Psychiatric Social Work

Those entering psychiatric social work are trained in a school of social work, usually in a two-year graduate program leading to a master’s degree. Included in this program is a one-year internship in a social-service agency, sometimes a mental health center. Some social workers go on to earn the D.S.W. (doctor of social work) degree. Traditionally, psychiatric social workers work in family counseling services or community agencies, where they specialize in intake (assessment and screening of clients), take psychiatric histories, and deal with other agencies.

School Psychology

School psychology is the field of study concerned with the processes of cognitive and emotional development of students in educational settings. Thus it focuses on the processes of learning, remembering, and thinking and on human development as it applies to the educational process. A school psychologist may hold either a master’s or a doctoral degree. They are often employed by school districts to help with assessment and testing and with the treatment of learning difficulties.

Determining Abnormality

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Those who see Cho’s condition as caused by a chemical imbalance might rely on a primarily biological means of intervention and prescribe medication, such as antipsychotic drugs. As we shall shortly see, the treatment for abnormal behavior generally follows from its explanation. Just as there are many ways to explain abnormal behaviors, there are many proposed ways of conducting therapy and an equal number of professional helpers offering their services. Along with the demand for mental health treatment, the numbers and types of qualified helping professionals have grown. In the past, mental health services were controlled primarily by psychiatrists, psychologists, and psychiatric social workers. The list of acceptable (licensed) providers in different fields has expanded rapidly. Table 1.1 lists the qualifications, training, and workplace settings of various mental health professionals. As you can see, students desiring to enter practice can choose from a variety of professional careers.

Determining Abnormality Implicit in our discussion so far is the one overriding concern of abnormal psychology: abnormal behavior itself. But what exactly is abnormal behavior, and how do psychologists define a mental disorder? The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000a), the most widely used classification system of mental disorders, defines abnormal behavior as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. (American Psychiatric Association, 2000a, p. xxxi)

This definition is quite broad and raises many questions. First, when is a syndrome or group of behaviors significant enough to have meaning? From early descriptions of Cho in elementary school, his behavioral patterns were noticed but not considered significant (that is, not associated with pathology). He was a good student in math and English, quiet in classes, but not disliked or feared by classmates. Some teachers would even view him as a model example of compliant and appropriate classroom behavior. It was only much later that Cho’s withdrawn behaviors became pronounced. Second, what constitutes “present distress” and “painful symptoms”? We have limited access to psychiatric records, but there is little evidence that Cho was anxious or depressed. Some say that the fact that he took his own life indicates that he was depressed. However, as we will see in a later chapter, the relationship of suicide to depression is a mixed one. Certainly, however, we can speculate that his intense anger might be distressful to him. Yet is it possible to have a mental disorder without any subjective discomfort (unhappiness, distress, anxiety, and so forth)? For example, people who commit antisocial acts such as rape, murder, or robbery may not feel remorseful; rather, they may be quite contented with their acts. Third, what criteria do we use in ascertaining an “increased risk of suffering death, pain, disability,” and loss of freedom? Again, it is obvious to us that Cho met this criterion firmly because he killed himself. But Cho’s action was an extreme one, far outside normative standards. How would this last criterion apply to someone with, for example, a phobia? One could certainly make a strong case that “loss of freedom” applied; a person with a phobia about crossing bridges would be severely restricted in travel. Yet if people have only a mild phobia of snakes and seldom place themselves in an environment with them, there would be minimal restrictions on their lives. Despite problems in defining abnormal behavior, practitioners tend to agree that it represents behavior that departs from some norm and that harms the affected individual or others. Nearly all definitions of abnormal behavior use some form of statistical

abnormal behavior a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

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average to gauge deviations from normative standards. Four major means of judging psychopathology include distress, deviance (bizarreness), dysfunction (inefficiency in behavioral, affective, and/or cognitive domains), and dangerousness.

Distress

Did You Know?

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uring the Victorian era, women wore six to eight layers to conceal their bodies from the neck down. Exposing an ankle was roughly equivalent to going topless at the beach today. Taboos against publicly recognizing sexuality dictated that words avoid any sexual connotation. Victorians said “limb” instead of “leg” because the word leg was considered erotic. Even pianos and tables were said to have limbs. People who did not adhere to these codes of conduct were considered immoral.

Most people who seek the help of therapists are suffering physical or psychological distress. Many physical reactions stem from a strong psychological component; among them are disorders such as asthma, hypertension, and ulcers, as well as physical symptoms such as fatigue, nausea, pain, and heart palpitations. Distress can also be manifested in extreme or prolonged emotional reactions, of which anxiety and depression are the most prevalent and common. Of course, it is normal for a person to feel depressed after suffering a loss or a disappointment. But if the reaction is so intense, exaggerated, and prolonged that it interferes with the person’s capacity to function adequately, it is likely to be considered abnormal.

Deviance Deviance is most closely related to using a statistical average. Statistical criteria equate normality with those behaviors that occur most frequently in the population. Abnormality is therefore defined in terms of those behaviors that occur least frequently. Bizarre or unusual behavior is an abnormal deviation from an accepted standard of behavior (such as an antisocial act) or a false perception of reality (such as a hallucination or delusion). This criterion can be extremely subjective; it depends on the individual being diagnosed, on the diagnostician, and on the particular cultural context. Certain sexual behaviors, delinquency, and homicide are examples of acts that our society considers abnormal. But social norms are far from static, and behavioral standards cannot be considered absolute. Changes in our attitudes toward human sexuality provide a prime example. Many American magazines and films now openly exhibit the naked human body, and topless and bottomless nightclub entertainment is hardly newsworthy. Various sex acts are explicitly portrayed in NC-17-rated movies, and women are freer to question traditional sex roles and to act more assertively in initiating sex. Such changes in behavior make it difficult to subscribe to absolute standards of normality. Nevertheless, some behaviors can usually be judged abnormal in most situations. Among these are severe disorientation, hallucinations, and delusions. Disorientation is confusion with regard to identity, place, or time. People who are disoriented may not know who they are, where they are, or what historical era they are living in. Hallucinations are false impressions—either pleasant or unpleasant—that involve the senses. People who have hallucinations may hear, feel, or see things that are not really there, such as voices accusing them of vile deeds, insects crawling on their bodies, or monstrous apparitions. Delusions are false beliefs steadfastly held by the individual despite contradictory objective evidence. A delusion of grandeur is a belief that one is an exalted personage, such as Jesus Christ or Joan of Arc; a delusion of persecution is a belief that one is controlled by others or is the victim of a conspiracy.

Dysfunction SOCIETAL NORMS AND DEVIANCE Societal norms often affect our definitions of normality and abnormality. When social norms begin to change, standards used to judge behaviors or roles also shift. Here we see four male nurses in an overwhelmingly female occupation. In the past, being a male nurse would have brought on stereotypes about their masculinity. Role reversals in employment, hobbies, sports, and other activities are becoming more acceptable over time.

In everyday life, people are expected to fulfill various roles—as students or teachers; as workers and caretakers; as parents, lovers, and marital partners. Emotional problems sometimes interfere with the performance of these roles, and the resulting role dysfunction may be used as an indicator of abnormality. Thus one way to assess dysfunction is to compare an individual’s performance with the requirements of a role. Another related way to assess dysfunction is to compare an individual’s performance with his or her potential. For example,

Contextual and Cultural Limitations in Defining Abnormal Behavior

an individual with an IQ score of 150 who is failing in school can be labeled inefficient. (The label underachiever is often hung on students who possess high intelligence but obtain poor grades in school.) Similarly, a productive worker who suddenly becomes unproductive may be experiencing emotional stress. The major weakness of this approach is that it is difficult to accurately assess potential. How do we know whether a person is performing at his or her peak? To answer such questions, psychologists, educators, and the business sector have relied heavily on testing. Tests of specific abilities and intelligence are attempts to assess potential and to predict performance in schools or jobs.

Dangerousness Predicting the dangerousness of clients to themselves and others has become an inescapable part of clinical practice (Haggard-Grann, 2007). Ever since the California Supreme Court ruled in 1976 (Tarasoff v. Regents of the University of California, 1976) that therapists have a responsibility to assess dangerousness of clients (to themselves and others) and to protect the intended victim, psychologists have attempted to devise risk-assessment procedures and to ascertain what actions a therapist must take to comply with “a duty to protect.” Certainly, the case of Cho represents a graphic example of the need for mental health professionals to accurately assess violence risk. Yet, as we shall see in a later chapter, this is a tall order. Despite the fear of violence in persons suffering from a mental disorder, it is a statistical rarity (Corrigan & Watson, 2005). Further, predicting dangerousness is not easy, and there is no clear-cut criterion correlated with it. One of the strongest risk factors, for example, is previous violent behavior (such as suicide attempts and physical assaults). Yet, as we know, Cho evidenced neither of these in his history.

Contextual and Cultural Limitations in Defining Abnormal Behavior Nearly all criteria used to define abnormality use a statistical deviation from some normative standard. Doing so, however, presents many problems. One problem mentioned previously is that statistical criteria are static and fail to take into account differences in place, time, and community standards. Another is that statistical criteria do not provide any basis for distinguishing between desirable and undesirable deviations from the norm. An IQ score of 100 is considered normal or average. But what constitutes an abnormal deviation from this average? More important, is abnormality defined in only one direction or in both? An IQ score of 55 is considered abnormal by most people, but should people with IQ scores of 145 or higher also be considered abnormal? How does one evaluate such personality traits as assertiveness and dependence in terms of statistical criteria? Two other central problems also arise. First, people who strike out in new directions—artistically, politically, or intellectually—may be seen as candidates for psychotherapy simply because they do not conform to normative behavior. Second, statistical criteria may “define” quite widely distributed but undesirable characteristics, such as anxiety, as normal. Many psychological tests and much diagnosis and classification of behavior disorders are based in part on statistical criteria. Perhaps one of the strongest criticisms of abnormality definitions comes from the multicultural perspective. If deviations from the majority are considered abnormal, then many ethnic and racial minorities who show strong subcultural differences from the majority must be classified as abnormal. When we use a statistical definition, the dominant or most influential group generally determines what constitutes normality and abnormality. Multiculturalists contend that all behaviors, whether normal or abnormal, originate from a cultural context. Psychologists are increasingly recognizing that this is an inescapable conclusion and that culture plays a major role in our understanding of human behavior. But what is culture? There are many definitions of “culture.” For our purposes, culture is “shared learned behavior which is transmitted from one generation to another for purposes of individual and societal growth, adjustment, and adaptation: culture is represented externally as artifacts, roles, and

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DETERMINING WHAT’S ABNORMAL By most people’s standards, the fullbody tattoos of these three men would probably be considered unusual at best and bizarre at worst. Yet despite the way their bodies appear, these three openly and proudly display them at the National Tattoo Convention. Such individuals may be very “normal” and functional in their work and personal lives. This leads to an important question: What constitutes abnormal behavior and how do we recognize it?

institutions, and it is represented internally as values, beliefs, attitudes, epistemology, consciousness and biological functioning” (Marsella, 1988, pp. 8–9). Three important points should be emphasized: 1. Culture is not synonymous with race or ethnic group. Jewish, Polish, Irish, and Italian Americans represent diverse ethnic groups whose individual members may share a common racial classification. Yet their cultural contexts may differ substantially from one another. Likewise, an Irish American and an Italian American, despite their different ethnic heritages, may share the same cultural context. 2. Every society or group that shares and transmits behaviors to its members possesses a culture. European Americans, African Americans, Latino/Hispanic Americans, Asian Americans/Pacific Islanders, Native Americans, and other social groups within the United States have cultures. A strong argument can be made that hearing impaired or deaf people also possess a culture (Olkin, 1999) and that “signing” represents a language. 3. Culture is a powerful determinant of worldviews (Sue & Sue, 2008a). It affects how we define normal and abnormal behaviors and how we treat disorders encountered by members of that culture. Even racial or ethnic groups that possess many similarities may have quite different cultural constellations.

cultural universality

the assumption that a fixed set of mental disorders exists whose obvious manifestations cut across cultures the belief that lifestyles, cultural values, and worldviews affect the expression and determination of deviant behavior

cultural relativism

These three points give rise to a major problem: one group’s definition of mental illness may not be shared by another. This contradicts the traditional view of abnormal psychology, which is based on cultural universality—the assumption that a fixed set of mental disorders exists whose obvious manifestations cut across cultures (Kim & Berry, 1993; McGoldrick, Giordano, & Garcia-Preto, 2005). This psychiatric tradition dates back to Emil Kraepelin (discussed later in this chapter), who believed that depression, sociopathic behavior, and especially schizophrenia were universal disorders that appeared in all cultures and societies. Early research supported the belief that these disorders occurred worldwide, had similar processes, and were more similar than dissimilar (Howard, 1992). From this flowed the belief that a disorder such as depression is similar in origin, process, and manifestation in all societies, such as Asia, Africa, and Latin America. As a result, no modifications in diagnosis and treatment need be made; western concepts of normality and abnormality can be considered universal and equally applicable across cultures. In contrast to the traditional view of cultural universality has been cultural relativism, the belief that lifestyles, cultural values, and worldviews affect the expression and determination of deviant behavior. This concept arose from the anthropological

Contextual and Cultural Limitations in Defining Abnormal Behavior

CULTURAL RELATIVISM Cultural differences often lead to misunderstandings and misinterpretations. In a society that values technological conveniences and clothing that comes from the runways of modern fashion, the lifestyles and cultural values of others may be perceived as strange. The Amish, for example, continue to rely on traditional modes of transportation (horse and buggy). And women in both the Amish and Islamic cultures wear simple, concealing clothing; in their circumstances, dressing in any other way would be considered deviant. Swimsuits and revealing clothes are not allowed in sunbathing or swimming.

tradition and emphasized the importance of culture and diversity in the manifestation of abnormal symptoms. For example, a body of research supports the conclusion that acting-out behaviors (aggressive acts, antisocial behaviors, and so forth) associated with mental disorders are much higher in the United States than in Asia and that even Asian Americans in the United States are less likely to express symptoms via acting out (Asian American Federation of New York, 2003; Sue & Sue, 2008a; Yang & WonPat-Borja, 2007). Researchers have proposed that Asian cultural values (restraint of feelings, emphasis on self-control, and need for subtlety in approaching problems) all contribute to this restraint. Proponents of cultural relativism also point out that cultures vary in what they consider to be normal or abnormal behavior. In some societies and cultural groups, hallucinating (having false sensory impressions) is considered normal in specific situations. Yet in the United States, hallucinating is generally perceived to be a manifestation of a disorder. Which view is correct? Should the criteria used to determine normality and abnormality be based on cultural universality or cultural relativism? Few mental health professionals today embrace the extreme of either position, although most gravitate toward one or the other. Proponents of cultural universality focus on the disorder and minimize cultural factors, and proponents of cultural relativism focus on the culture and on how the disorder is manifested within it. Both views have validity. It is naive to believe that no disorders cut across different cultures and share universal characteristics. For example, even though hallucinating may be viewed as normal in some cultures, proponents of cultural universality argue that it still represents a breakdown in biological-cognitive processes. Likewise, it is equally naive to believe that mental disorders and how they are manifested are unaffected by cultural values and lifestyle characteristics of a society (APA, 2000a). A third point to consider is that some common disorders, such as depression, are manifested similarly in different cultures. A more fruitful approach to studying multicultural criteria of abnormality is to explore two questions: • What is universal in human behavior that is also relevant to understanding psychopathology? • What is the relationship between cultural norms, values, and attitudes and the incidence and manifestation of behavior disorders? These are important questions that we hope you will ask as we continue our journey into the field of abnormal psychology. In Chapter 2, we try to address these questions by presenting a multipath model that takes into consideration biological, psychological, social, and sociocultural dimensions in understanding the complexity of the human condition.

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controversy

Is Mental Illness a Myth and a Political Construction?

I

n my opinion, mental illness is a myth. People we label “mentally ill” are not sick, and involuntary mental hospitalization is not treatment. It is punishment. . . . The fact that mental illness designates a deviation from an ethical rule of conduct, and that such rules vary widely, explains why upper-middle-class psychiatrists can so easily find evidence of “mental illness” in lower-class individuals; and why so many prominent persons in the past fifty years or so have been diagnosed by their enemies as suffering from some types of insanity. Barry Goldwater was called a paranoid schizophrenic . . . Woodrow Wilson a neurotic . . . Jesus Christ, according to two psychiatrists . . . was a born degenerate with a fixed delusion system. (Szasz, 1970, pp. 167–168)

In a radical departure from conventional beliefs, psychiatrist Thomas Szasz (1987) has asserted that mental illness is a myth, a fictional creation by society used to control and change people. According to Szasz, people may suffer from “problems in living,” not from “mental illness.” His argument stems from three beliefs: 1. that abnormal behavior is so labeled because it is different, not necessarily because it is a reflection of “illness” 2. that unusual belief systems are not necessarily wrong 3. that abnormal behavior is frequently a reflection of something wrong with society rather than with the individual

According to Szasz, individuals are labeled “mentally ill” because their behaviors violate the social order and their beliefs challenge the prevailing wisdom of the times. Szasz finds the concept of mental illness to be dangerous and a form of social control used by those in power. Hitler branded Jews as abnormal. Political dissidents in many countries, including both China and the former Soviet Union, have often been cast as mentally ill. And the history of slavery indicates that African Americans who tried to escape their white masters were often labeled as suffering from drapetomania, defined as a sickness that makes the person desire freedom. Few mental health professionals would take the extreme position advocated by Szasz, but his arguments highlight an important area of concern. Those who diagnose behavior as abnormal must be sensitive to individual value systems, societal norms and values, and potential sociopolitical ramifications. For Further Consideration 1. What do you think of Szasz’s position? 2. Can you think of examples in which psychiatric diagnosis may reflect differences in culture or political beliefs?

The Frequency and Burden of Mental Disorders

the percentage of people in a population who suffer from a disorder at a given point in time

prevalence

lifetime prevalence the total proportion of people in the population who have ever had a disorder in their lives incidence the onset or occurrence of a given disorder over some period of time

A student once asked one of the authors, “How crazy is this nation?” This question, put in somewhat more scientific terms, has occupied psychologists for some time. Psychiatric epidemiology provides insights into factors that contribute to the occurrence of specific mental disorders. To address this question, some terms need to be clarified. The prevalence of a disorder indicates the percentage of people in a population who suffer from a disorder at a given point in time; lifetime prevalence refers to the total proportion of people in the population who have ever had a disorder in their lives. Incidence refers to the onset or occurrence of a given disorder over some period of time. From this information, we can find out how frequently or infrequently various disturbances occur in the population. We can also consider how the prevalence of disorders varies by ethnicity, gender, and age and whether current mental health practices are sufficient and effective. Two of the most recent, thorough, and comprehensive studies of the incidence of mental disorders in the U.S. adult population (eighteen years and older) were conducted by the National Institute of Mental Health (NIMH, 1985) and the National Comorbidity Survey Replication Study (NCS-R; Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005). The NIMH epidemiological study included a large sample of approximately 20,000 persons, while the NCS-R interviewed 9,282 people in their homes. Both used categories in the Diagnostic and Statistical Manual of the American Psychiatric Association in the construction of the research instruments. In the NCS-R study, lifetime prevalence rates for the following were found: anxiety disorders, 28.8 percent; mood disorders, 20.8 percent; impulse-control disorders, 24.8 percent; and substance use disorders, 14.6 percent. Lifetime prevalence rates across all four mental disorders were 46.4 percent.

The Frequency and Burden of Mental Disorders

Percent of group

In the NIMH study, researchers found that although men and women are equally likely to suffer from mental disorders, they differ in the kinds of disorders they experience. For example, alcohol abuse or dependence occurs in 24 percent of men but in only 4 percent of women; drug abuse is more likely to occur in men; and depression and anxiety are more likely to occur in women. Age was also an important factor. Alcoholism and depression are most prominent in the twenty-five- to forty-four-year-old age group; drug dependence in the eighteen- to twenty-four-year-old age group; and cognitive impairment in people age sixty-five and older. Phobias, however, were equally represented at all ages. Studies on even the young (children and adolescents) suggest that nearly 17 percent suffer from a serious disorder (Kessler et al., 1994; Regier et al., 1993). Figure 1.1 summarizes the rates of psychiatric disorders in various demographic categories. The cost and burden of mental disorders to our nation are indeed a major source of concern. The recognition of this problem was the impetus for Mental Health: A Report of the Surgeon General (U.S. Surgeon General, 1999) and Achieving the Promise: Transforming Mental Health Care in America (President’s New Freedom Commission on Mental Health, 2003), two comprehensive reports on the state of mental health in our nation. Their conclusions were very troubling: (1) at least 30 percent of the nation’s adults suffer from a diagnosable mental disorder; (2) 20 percent of children show signs of a diagnosable disorder in the course of a year; and (3) by the year 2020, neuropsychiatric disorders in children will increase by 50 percent and become one of the five most common forms of disability. To indicate the profound impact mental disorders have on

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LONG-TERM EFFECTS OF TRAUMA The September 11, 2001, terrorist attacks that destroyed the World Trade Center in lower Manhattan killed thousands and traumatized a nation. What are the mental health consequences of extreme disasters? How are these effects measured?

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RATES OF PSYCHIATRIC DISORDERS IN PARTICULAR GROUPS Research indicates that psychiatric disorders are present in about one-third of the U.S. population. The bar graphs in this figure illustrate the extent to which any psychiatric disorder is found in combination with other characteristics of the population, such as gender, age, ethnicity, and marital status.

Source: Data from Robins and Regier (1991).

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our health and productivity (lost years of healthy life due to disability and premature death; DHHS, 1999), mental illness ranked higher than cancer and all other malignant diseases! More frightening, however, is the point strongly made in the Surgeon General’s report that many more people suffer from “mental health problems” that do not meet the criteria for a mental disorder. These problems, the report observes, may be equally debilitating unless adequately treated. These epidemiological findings are troubling, to say the least. Clearly, mental disturbances are widespread, and many persons are currently suffering from them. What is more troubling is that two-thirds of all people suffering from diagnosable mental disorders are not receiving or seeking mental health services (President’s New Freedom Commission on Mental Health, 2003). In addition, spending on mental health services continues to decline.

Stereotypes About the Mentally Disturbed Americans tend to be suspicious of people with mental disorders. Are most of them really maniacs who at any moment may be seized by uncontrollable urges to murder, rape, or maim? Such portrayals seem to emerge from the news media and the entertainment industry, but they are rarely accurate. Indeed, the Virginia Tech incident must be seen in the context of realistic facts; Cho’s actions are a statistical anomaly. Violence in people suffering from a mental disorder is a rarity (Corrigan & Watson, 2005; Grann & Langstrom, 2007). People with mental disturbances are subject to rampant stereotyping and popular misconceptions. It is worthwhile at this point to dispel the most common of these misconceptions or myths. INCIDENCE OF ABNORMAL BEHAVIOR By all appearances, this photo seems to depict a well-functioning group of Columbia University college graduates from many facets of life. Yet studies reveal that approximately one in three persons suffers from at least one mental disorder.

Myth vs Reality Myth: Mentally disturbed people can always be recognized by their deviant abnormal behavior. Reality: Mentally disturbed people are not always distinguishable from others on the basis of consistently unusual behavior. Even in an outpatient clinic or a psychiatric ward, distinguishing patients from staff on the basis of behavior alone is often difficult. There are two main reasons for this difficulty. First, as already noted, no sharp dividing line usually exists between “normal” and “abnormal” behaviors. Second, even when people are suffering from some form of emotional disturbance, that experience may not always be detectable in their behavior. Myth: The mentally disturbed have inherited their disorders. If one member of a family has an emotional breakdown, other members will probably suffer a similar fate.

Stereotypes About the Mentally Disturbed

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Reality: The belief that insanity runs in certain families has caused misery and undue anxiety for many people. Heredity does play a role in some mental disorders, such as schizophrenia and depression, certain types of mental retardation, and bipolar disorders. However, evidence suggests that even though heredity may predispose an individual to certain disorders, environmental factors are also extremely important. This has led many mental health professionals to posit a biopsychosocial model of mental disorders in which disorders are the result of an interaction of biological, psychological, and social factors. Myth: Mentally disturbed people can never be cured and will never be able to function normally or hold jobs in the community. Reality: This erroneous belief has caused great distress to many people who have at some time been labeled mentally ill. Former mental patients have endured social discrimination and have been denied employment because of the public perception that “once insane, always insane.” Unfortunately, this myth may keep former mental patients or those currently experiencing emotional problems from seeking help. Nearly three-fourths of clients who are hospitalized with severe disorders will improve and go on to lead productive lives. Many recovered mental patients make excellent employees, and employers frequently report that they outperform other workers in attendance and punctuality. Myth: People become mentally disturbed because they are weak willed. To avoid emotional disorders or cure oneself of them, one need only exercise will power. Reality: These statements show a lack of understanding regarding the nature of mental disorders. Needing help to resolve difficulties does not indicate a lack of will power. In fact, recognizing one’s own need for help may be a sign of strength rather than a sign of weakness. Many problems stem from situations that are not under the individual’s immediate control, such as the death of a loved one or the loss of a job. Other problems stem from lifelong patterns of faulty learning; it is naive to expect that a simple exercise of will can override years of experience. Myth: Mental illness is always a deficit, and the person suffering from it can never contribute anything of worth until cured.

Did You Know?

F

amous people who have recovered from mental disorders include President Abraham Lincoln; 60 Minutes news anchor Mike Wallace; writer Art Buchwald; former vice president Al Gore’s wife, Tipper Gore; and talk show host Rosie O’Donnell.

Reality: Many persons who suffered from mental illness were never “cured,” but they nevertheless made great contributions to humanity. Ernest Hemingway, who was one of the great writers of our time and who won the Nobel Prize for literature in 1954, suffered from lifelong depression, alcoholism, and frequent hospitalizations. The famous Dutch painter Vincent van Gogh produced great works of art despite the fact that he was severely disturbed. Not only did he lead an unhappy and tortured life, but he also frequently heard voices, and he cut off a piece of his left ear as a gift to a prostitute. Others, such as Pablo Picasso and Edgar Allan Poe, contributed major works to humanity while seriously disturbed. The point of these examples is not to illustrate that madness and genius go hand in hand but that many who are less severely disturbed can continue to lead productive and worthwhile lives. The fact that people suffer from psychological problems does not mean that their ideas and contributions are less worthy of consideration. Myth: Mentally disturbed people are unstable and potentially dangerous. Reality: This misconception has been perpetuated by the mass media. Many murderers featured on television are labeled “psychopathic,” and the news media concentrate on the occasional mental patient who kills. But the thousands of mental patients who do not commit crimes, do not harm others, and do not get into trouble with the law are not news. According to the Surgeon General’s report (DHHS, 1999), there is a small elevation of risk of violence, especially among individuals with dual diagnosis (suffering from a mental disorder and substance abuse), but the risk is minimal (Eronen, Angermeyer, & Schulze, 1998; Swanson, 1994). Unfortunately, the myth persists.

a model in which mental disorders are the result of an interaction of biological, psychological, and social factors

biopsychosocial model

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Historical Perspectives on Abnormal Behavior

Did You Know?

S

ome historians do not believe trephining was a therapeutic intervention. Rather, they believe it was used to remove bone splinters and blood clots from combat blows to the head (Maher & Maher, 1985). This is consistent with findings that most trephined skulls were those of men; that the skulls possess fractures (suggesting a blow); and that the holes are usually on the left (resulting from a right-handed assailant).

In this section and the next, we briefly review the historical development of western thought concerning abnormal behavior. We must be aware, however, that our journey is necessarily culture-bound and that other civilizations (nonwestern) have histories of their own. Despite this limitation, however, it is clear that many current attitudes toward abnormal behavior, as well as modern ideas about its causes and treatment, appear to have been influenced by early beliefs. In fact, some psychologists contend that modern societies have, in essence, adopted more sophisticated versions of earlier concepts. For example, the use of electroconvulsive therapy to treat depression is in some ways similar to ancient practices of exorcism in which the body was physically assaulted. The Greek physician Hippocrates believed 2,500 years ago that many abnormal behaviors were caused by imbalances and disorders in the brain and the body, a belief shared by many contemporary psychologists. Most ideas about abnormal behavior are firmly rooted in the system of beliefs that operate in a given society at a given time. We have evolved a humanistic and scientific explanation of abnormal behavior. It remains to be seen whether such an explanation will still be thought valid in decades to come. (Much of this history section is based on discussions of deviant behavior by Alexander & Selesnick, 1966; Hunter & Macalpine, 1963; Neugebauer, 1979; Spanos, 1978; and Zilboorg & Henry, 1941.)

Prehistoric and Ancient Beliefs

trephining a surgical method from the Stone Age in which part of the skull was chipped away to provide an opening through which an evil spirit could escape

treatment method used by the early Greeks, Chinese, Hebrews, and Egyptians in which prayers, noises, emetics, flogging, and starvation were used to cast evil spirits out of an afflicted person’s body

exorcism

Prehistoric societies some half a million years ago did not distinguish sharply between mental and physical disorders. Abnormal behaviors, from simple headaches to convulsive attacks, were attributed to evil spirits that inhabited or controlled the afflicted person’s body. According to historians, these ancient peoples attributed many forms of illness to demonic possession, sorcery, or the behest of an offended ancestral spirit. Within this system of belief, called demonology, the victim was usually held at least partly responsible for the misfortune. It has been suggested that Stone Age cave dwellers may have treated behavior disorders with a surgical method called trephining, in which part of the skull was chipped away to provide an opening through which the evil spirit could escape. People may have believed that when the evil spirit left, the person would return to his or her normal state. Surprisingly, some trephined skulls have been found to have healed over, indicating that some patients survived this extremely crude operation. Another treatment method used by the early Greeks, Chinese, Hebrews, and Egyptians was exorcism. In an exorcism, elaborate prayers, noises, emetics (drugs that induce vomiting), and extreme measures such as flogging and starvation were used to cast evil spirits out of an afflicted person’s body.

Naturalistic Explanations (Greco-Roman Thought) With the flowering of Greek civilization and its continuation into the era of Roman rule (500 b.c.–a.d. 500), naturalistic explanations gradually became distinct from supernatural ones. Early thinkers, such as Hippocrates (460–370 b.c.), a physician who is often called the father of medicine, actively questioned prevailing superstitious beliefs and proposed much more rational and scientific explanations for mental disorders.

Historical Perspectives on Abnormal Behavior

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Naturalistic explanations relied heavily on observations that form the foundation of the scientific method. Their explanations denied the intervention of demons in the development of abnormality and instead stressed organic causes. Because of these factors, the treatment they prescribed for mental disorders tended to be more humane than previous treatments. Hippocrates believed that, because the brain was the central organ of intellectual activity, deviant behavior was caused by brain pathology—that is, a dysfunction or disease of the brain. He also considered heredity and environment important factors in psychopathology. He classified mental illnesses into three categories—mania, melancholia, and phrenitis (brain fever)—and for each category gave detailed clinical descriptions of such disorders as paranoia, alcoholic delirium, and epilepsy. Many of his descriptions of symptoms are still used today, eloquent testimony to his keen powers of observation. To treat melancholia, Hippocrates recommended tranquility, moderate exercise, a careful diet, abstinence from sexual activity, and, if necessary, bloodletting. His belief in environmental influences on behavior sometimes led him to separate disturbed patients from their families. He seems to have gained insight into a theory popular among psychologists today: that the family constellation often fosters deviant behavior in its own members. Other thinkers who contributed to the organic explanation of behavior were the philosopher Plato and the Greek physician Galen, who practiced in Rome. Plato (429–347 b.c.) carried on the thinking of Hippocrates; he insisted that the mentally disturbed were the responsibility of the family and should not be punished for their behavior. Galen (a.d. 129–199) made major contributions through his scientific examination of the nervous system and his explanation of the role of the brain and central nervous system in mental functioning. His greatest contribution may have been his codification of all European medical knowledge from Hippocrates’ time to his own.

Reversion to Supernatural Explanations (the Middle Ages) With the collapse of the Roman Empire and the rise of Christianity, rational and scientific thought gave way to a reemphasis on the supernatural. Religious dogma included the beliefs that nature was a reflection of divine will and beyond human reason and that earthly life was a prelude to the “true” life (after death). Scientific inquiry—attempts to understand, classify, explain, and control nature—was less important than accepting nature as a manifestation of God’s will. The Dark Ages (Fifth Through Tenth Centuries) Early Christianity did little to promote science and in many ways actively discouraged it. The church demanded uncompromising adherence to its tenets. Christian fervor brought with it the concepts of heresy and punishment; certain truths were deemed sacred, and those who challenged them were denounced as heretics. Scientific thought that was in conflict with church doctrine was not tolerated. Because of this atmosphere, rationalism and scholarly scientific works went underground for many years, preserved mainly by Arab scholars and European monks. Natural and supernatural explanations of illness were fused. People came to believe that many illnesses were the result of supernatural forces, although they had natural causes. In many cases, the mentally ill were treated gently and with compassion in monasteries and at shrines, where they were prayed over and allowed to rest. In other cases, treatment could be quite brutal, especially if illnesses were believed to be due to God’s wrath. Because illness was then perceived to be punishment for sin, the sick person was assumed to be guilty of wrongdoing, and relief could come only through atonement or repentance. During this period, treatment of the mentally ill sometimes consisted of torturous exorcistic procedures seen as appropriate to combat Satan and eject him from the possessed person’s body. Prayers, curses, obscene epithets, and the sprinkling of holy water—as well as such drastic and painful “therapy” as flogging, starving,

brain pathology

disease of the brain

a dysfunction or

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CASTING OUT THE CAUSE OF ABNORMALITY During the Middle Ages, people suffering from mental disorders were often perceived as being victims of a demonic possession. The most prevalent form of treatment was exorcism, usually conducted by religious leaders who used prayers, incantations, and sometimes torturous physical techniques to cast the evil spirit from the bodies of the afflicted.

and immersion in hot water—were used to drive out the devil. The humane treatments that Hippocrates had advocated centuries earlier were challenged severely. A time of trouble for everyone, the Dark Ages were especially bleak for the mentally ill.

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lthough the practice of exorcism is ancient, it is still recognized in Catholicism, Eastern Orthodox, and some Protestant sects. The Church of England has an official exorcist in each diocese. In general, possessed persons are not considered evil in themselves, so exorcism is seen as treatment rather than punishment.

group hysteria in which a great many people exhibit similar symptoms that have no apparent physical cause

mass madness

Mass Madness (Thirteenth Century) Belief in the power of the supernatural became so prevalent and intense that it frequently affected whole populations. Beginning in Italy early in the thirteenth century, large numbers of people were affected by various forms of mass madness, or group hysteria, in which a great many people exhibit similar symptoms that have no apparent physical cause. One of the better known manifestations of this disorder was tarantism, a dance mania characterized by wild raving, jumping, dancing, and convulsions. The hysteria was most prevalent during the height of the summer and was attributed to the sting of a tarantula. A victim would leap up and run out into the street or marketplace, jumping and raving, to be joined by others who believed that they had also been bitten. The mania soon spread throughout the rest of Europe, where it became known as Saint Vitus’ Dance. Another form of mass madness was lycanthropy, a mental disorder in which victims imagine themselves to be wolves and imitate wolves’ actions. (Motion pictures about werewolves—people who assume the physical characteristics of wolves during the full moon—are modern reflections of this delusion.) How can these phenomena be explained? Stress and fear are often associated with outbreaks of mass hysteria. During the thirteenth century, for example, there was enormous social unrest. The bubonic plague had destroyed one-third of the population of Europe. War, famine, and pestilence were rampant, and the social order of the times was crumbling. Witchcraft (Fifteenth Through Seventeenth Centuries) During the fifteenth and sixteenth centuries, the authority of the church was increasingly challenged by social and religious reformers. Reformers such as Martin Luther attacked the corruption and abuses of the clergy, precipitating the Protestant Reformation of the sixteenth century. Church officials viewed such protests as insurrections that threatened their power. According to the church, Satan himself fostered these attacks.

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By doing battle with Satan and with people supposedly influenced or possessed by Satan, the church actively endorsed an already popular belief in demonic possession and witches. To counter the threat, Pope Innocent VIII issued a papal bull (decree) in 1484 calling on the clergy to identify and exterminate witches. This resulted in the 1486 publication of the extremely influential Malleus Maleficarum (The Witch’s Hammer). The mere existence of this document acted to confirm the existence of witches, and it also outlined means of detecting them. For example, red spots on the skin (birthmarks) were supposedly made by the claw of the devil in sealing a blood pact and thus were damning evidence of a contract with Satan. Such birth defects as clubfoot and cleft palate also aroused suspicion. The church initially recognized two forms of demonic possession: unwilling and willing. God let the devil seize an unwilling victim as punishment for a sinful life. A willing person, who made a blood pact with the devil in exchange for supernatural powers, was able to assume animal form and cause disasters such as floods, pestilence, storms, crop failures, and sexual impotence. Although unwilling victims of possession at first received more sympathetic treatment than that given those who willingly conspired with the devil, this distinction soon evaporated. People whose actions were interpreted as peculiar were often suspected of witchcraft. It was acceptable to use torture to obtain confessions from suspected witches, and many victims confessed because they preferred death to prolonged agony. Thousands of innocent men, women, and even children were beheaded, burned alive, or mutilated. Witch hunts occurred in both colonial America and in Europe. The witchcraft trials of 1692 in Salem, Massachusetts, were infamous. Authorities there acted on statements taken from children who may have been influenced by the sensational stories told by an old West Indian servant. Several hundred people were accused, many were imprisoned and tortured, and twenty were killed. It has been estimated that some twenty thousand people (mainly women) were killed as witches in Scotland alone and that more than one hundred thousand throughout Europe were executed as witches from the middle of the fifteenth to the end of the seventeenth century. It would seem reasonable to assume that the mentally ill would be especially prone to being perceived as witches. Indeed, most psychiatric historians argue that mental disorders were at the roots of witchcraft persecutions (Alexander & Selesnick, 1966; Deutsch, 1949; Zilboorg & Henry, 1941). Support for the belief that many accused witches were mentally ill was based on the following evidence: (1) some witches claimed that they could do impossible acts (such as fly and cause floods) and thus must have been deluded (schizophrenic); (2) they participated in sabbats (nocturnal orgies) and must have been psychopaths or nymphomaniacs; (3) they evidenced localized sensitivity to pain in various parts of their bodies and must have been hysterics; and (4) they evidenced symptoms associated with high suggestibility, delusions, or hallucinations. Spanos (1978), however, in a comprehensive critical analysis, concluded that very little support could be found to indicate that accused witches were mentally ill. Indeed, the lines of evidence just mentioned either have no basis in fact or were misinterpreted. Sabbats, for example, seem to have existed only in the imaginations of the witch hunters. Claims of supernatural powers were obtained from the accused only after prolonged and painful torture, and trickery was often used to diminish body sensitivity. It appears that, although some accused witches may have been mentally ill, most were normal (Schoeneman, 1984).

The Rise of Humanism (the Renaissance) A resurgence of rational and scientific inquiry during the Renaissance (fourteenth through sixteenth centuries) led to great advances in science and humanism, a philosophical movement that emphasizes human welfare and the worth and uniqueness

humanism a philosophical movement that emphasizes human welfare and the worth and uniqueness of the individual

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of the individual. Until this time, most asylums were at best custodial centers in which the mentally disturbed were chained, caged, starved, whipped, and even exhibited to the public for a small fee, much like animals in a zoo. But the new way of thinking held that if people were “mentally ill” and not possessed, then they should be treated as though they were sick. A number of new methods for treating the mentally ill reflected this humanistic spirit. In 1563, Johann Weyer (1515–1588), a German physician, published a revolutionary book that challenged the foundation of ideas about witchcraft. Weyer asserted that many people who were tortured, imprisoned, and burned as witches were mentally disturbed, not possessed by demons. The emotional agonies he was made to endure for committing this heresy are well documented. His book was severely criticized and banned by both church and state, but it proved to be a forerunner of the humanitarian perspective on mental illness. Others eventually followed his lead.

DOROTHEA DIX (1802–1887) During a time when women were discouraged from political participation, Dorothea Dix, a New England schoolteacher, worked tirelessly as a social reformer to improve the deplorable conditions in which the mentally ill were forced to live.

moral treatment movement

movement instituted by Philippe Pinel that resulted in a shift to more humane treatment of the mentally disturbed

The Reform Movement (Eighteenth and Nineteenth Centuries) In France, Philippe Pinel (1745–1826), a physician, was put in charge of La Bicêtre, a hospital for insane men in Paris. Pinel instituted what came to be known as the moral treatment movement—a shift to more humane treatment of the mentally disturbed. He ordered that inmates’ chains be removed, replaced dungeons with sunny rooms, encouraged exercise outdoors on hospital grounds, and treated patients with kindness and reason. Surprising many disbelievers, the freed patients did not become violent; instead, this humane treatment seemed to foster recovery and improve behavior. Pinel later instituted similar, equally successful reforms at La Salpêtrière, a large mental hospital for women in Paris. In England, William Tuke (1732–1822), a prominent Quaker tea merchant, established a retreat at York for the “moral treatment” of mental patients. At this pleasant country estate, the patients worked, prayed, rested, and talked out their problems—all in an atmosphere of kindness quite unlike that of the lunatic asylums of the time. In the United States, three individuals—Benjamin Rush, Dorothea Dix, and Clifford Beers—made important contributions to the moral treatment movement. Benjamin Rush (1745–1813), widely acclaimed as the father of U.S. psychiatry, attempted to train physicians to treat mental patients and to introduce more humane treatment policies into mental hospitals. He insisted that patients be accorded respect and dignity and that they be gainfully employed while hospitalized, an idea that anticipated the modern concept of work therapy. Yet Rush was not unaffected by the established practices and beliefs of his times: his theories were influenced by astrology, and his remedies included bloodletting and purgatives. Dorothea Dix (1802–1887), a New England schoolteacher, was the preeminent American social reformer of the nineteenth century. While teaching Sunday school to female prisoners, she became familiar with the deplorable conditions in which jailed mental patients were forced to live. (Prisons and poorhouses were commonly used to incarcerate these patients.) For the next forty years, Dix worked tirelessly for the mentally ill. She campaigned for reform legislation and funds to establish suitable mental hospitals and asylums. She raised millions of dollars, established more than thirty modern mental hospitals, and greatly improved conditions in countless others. But the struggle for reform was far from over. Although the large hospitals that replaced jails and poorhouses had better physical facilities, the humanistic, personal concern of the moral treatment movement was lacking. That movement was given further impetus in 1908 with the publication of A Mind That Found Itself, a book by Clifford Beers (1876–1943) about his own mental collapse. His book describes the terrible treatment he and other patients experienced in three mental institutions, where they were beaten, choked, spat on,

Causes: Early Viewpoints

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and restrained with straitjackets. His vivid account aroused great public sympathy and attracted the interest and support of the psychiatric establishment, including such eminent figures as psychologist-philosopher William James. Beers founded the National Committee for Mental Hygiene (forerunner of the National Mental Health Association, now known as Mental Health America), an organization dedicated to educating the public about mental illness and about the need to treat the mentally ill rather than punish them for their unusual behaviors. It would be naive to believe that these reforms have totally eliminated inhumane treatment of the mentally disturbed. Books such as Mary Jane Ward’s The Snake Pit (1946) and films such as Frederick Wiseman’s Titicut Follies (1967) were historically important in documenting the harsh treatment of mental patients. Even the severest critic of the mental health system, however, would have to admit that conditions and treatment for the mentally ill have improved in this century.

Causes: Early Viewpoints Paralleling the rise of humanism in the treatment of mental illness was an inquiry into its causes. Two schools of thought emerged. The organic, or biological, viewpoint holds that mental disorders are the result of physiological damage or disease; the psychological viewpoint stresses an emotional basis for mental illness. It is important to note that most people were not extreme adherents of one or the other. Rather, they tended to combine elements of both. In the next chapter, we introduce a multipath model that provides an overarching umbrella to understand the multifactorial nature of mental disorders.

The Biological Viewpoint Hippocrates’ suggestion of an organic explanation for abnormal behavior was ignored during the Middle Ages but revived after the Renaissance. Not until the nineteenth century, however, did the biological or organic view—the belief that mental disorders have a physical or physiological basis—become important. The ideas of Wilhelm Griesinger (1817–1868), a German psychiatrist who believed that all mental disorders had physiological causes, received considerable attention. Emil Kraepelin (1856–1926), a follower of Griesinger, observed that certain symptoms tend to occur regularly in clusters, called syndromes. Kraepelin believed that each cluster of symptoms represented a mental disorder with its own unique—and clearly specifiable—cause, course, and outcome. He attributed all disorders to one of four organic causes: metabolic disturbance, endocrine difficulty, brain disease, or heredity. In his Textbook of Psychiatry (1883/1923), Kraepelin outlined a system for classifying mental illnesses on the basis of their organic causes. That system was the original basis for the diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the classification system of the American Psychiatric Association. The acceptance of an organic or biological cause for mental disorders was accelerated by medical breakthroughs in the study of the nervous system. The effects of brain disorders, such as cerebral arteriosclerosis, mental retardation, and senile psychoses, led many scientists to suspect or advocate organic factors as the sole cause of all mental illness. And, as we will see in Chapter 2, the drug revolution of the 1950s made medication available for almost every disorder. The issues of the therapeutic effectiveness of these drugs and of how they work, however, are still hotly debated today. The biological viewpoint gained even greater strength with the discovery of the organic basis of general paresis, a progressively degenerative and irreversible physical and mental disorder (paresis is syphilis of the brain). Several breakthroughs had led scientists to suspect that the deterioration of mental and physical abilities exhibited by certain mental patients might actually be caused by an organic disease. The work of Louis Pasteur (1822–1895) established the germ

biological view (organic view)

the belief that mental disorders have a physical or physiological basis certain symptoms that tend to occur regularly in clusters

syndromes

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theory of disease (invasion of the body by parasitic microorganisms). Then, in 1897, Richard von Krafft-Ebing (1840–1902), a German neurologist, inoculated paretic patients with pus from syphilitic sores; when the patients failed to develop the secondary symptoms of syphilis, Krafft-Ebing concluded that the patients had been previously infected by that disease. Finally, in 1905, a German zoologist, Fritz Schaudinn (1871–1906), isolated the microorganism that causes syphilis and thus paresis. These discoveries convinced many scientists that every mental disorder might eventually be linked to an organic cause.

The Psychological Viewpoint Some scientists noted, however, that certain types of emotional disorders were not associated with any organic disease in the patient. Such observations led to the psychological view—the belief that mental disorders are caused by psychological and emotional factors rather than organic or biological ones. For example, the inability to attain personal goals and resolve interpersonal conflicts could lead to intense feelings of frustration, depression, failure, and anger and to consequent disturbed behavior. EMIL KRAEPELIN (1856–1926) In an 1883 publication, psychiatrist Emil Kraepelin proposed that mental disorders could be directly linked to organic brain disorders and further proposed a diagnostic classification system for all disorders.

psychological view the belief that mental disorders are caused by psychological and emotional factors rather than organic or biological ones

Mesmerism and Hypnotism The unique and exotic techniques of Friedrich Anton Mesmer (1734–1815), an Austrian physician who practiced in Paris, presented an early challenge to the biological point of view. Mesmer developed a highly controversial treatment that came to be called mesmerism and that was the forerunner of the modern practice of hypnotism. Mesmer performed his most miraculous cures in the treatment of hysteria— the appearance of symptoms such as blindness, deafness, loss of bodily feeling, and paralysis that seem to have no organic basis. According to Mesmer, hysteria was a manifestation of the body’s need to redistribute the magnetic fluid that determined a person’s mental and physical health. His techniques for curing this illness involved inducing a sleeplike state, during which his patients became highly susceptible to suggestion. During this state, their symptoms often disappeared. Mesmer’s dramatic and theatrical techniques earned him censure, as well as fame. A committee of prominent thinkers, including U.S. ambassador to France Benjamin Franklin, investigated Mesmer and declared him a fraud. He was finally forced to leave Paris. Although Mesmer’s basic assumptions were discredited, the power of suggestion proved to be a strong therapeutic technique in the treatment of hysteria. The cures he effected stimulated scientific interest in, and much bitter debate about, the psychological view. The Nancy School About ten years after Mesmer died, a number of researchers began to experiment actively with hypnosis. Among them was Jean-Martin Charcot (1825–1893), a neurosurgeon at La Salpêtrière Hospital in Paris and the leading neurologist of his time. His initial experiments with hypnosis led him to abandon it in favor of more traditional methods of treating hysteria, which he claimed was caused by organic damage to the nervous system. Other experimenters had more positive results using hypnosis, however, which persuaded Charcot to try it again. His subsequent use of the technique in the study of hysteria did much to legitimize the application of hypnosis in medicine. Charcot’s conversion was most influenced by two physicians practicing in the city of Nancy, in eastern France. First working separately and then together, Ambroise-Auguste Liébeault (1823–1904) and Hippolyte-Marie Bernheim (1840– 1919) hypothesized that hysteria was a form of self-hypnosis. The results they obtained in treating patients attracted other scientists, who collectively became known as the “Nancy School.” In treating hysterical patients under hypnosis, they were often able to remove symptoms of paralysis, deafness, blindness, and anesthesia. They were also able to produce these symptoms in normal persons through hypnosis. Their work demonstrated impressively that suggestion could

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cause certain forms of mental illness; that is, that symptoms of mental and physical disorders could have a psychological rather than an organic explanation. This conclusion represented a major breakthrough in the conceptualization of mental disorders. Breuer and Freud The idea that psychological processes could produce mental and physical disturbances began to gain credence among several physicians who were using hypnosis. Among them was the Viennese doctor Josef Breuer (1842–1925). He discovered accidentally that, after one of his female patients spoke quite freely about her past traumatic experiences while in a trance, many of her symptoms abated or disappeared. He achieved even greater success when the patient recalled previously forgotten memories and relived their emotional aspects. This latter technique became known as the cathartic method, a therapeutic use of verbal expression to release pent-up emotional conflicts. It foreshadowed psychoanalysis, whose founder, Sigmund Freud (1856–1939), was influenced by Charcot and was a colleague of Breuer’s. Freud’s theories have had a great and lasting influence in the field of abnormal psychology. Behaviorism Whereas psychoanalysis offered an intrapsychic explanation of abnormal behavior, another viewpoint that emerged during the latter part of this period was more firmly rooted in laboratory science: behaviorism. The behavioristic perspective stressed the importance of directly observable behaviors and the conditions or stimuli that evoked, reinforced, and extinguished them. As we will see in Chapter 2, behaviorism not only offered an alternative explanation of the development of both normal and abnormal behavior but also demonstrated a high degree of success in treating maladaptive behaviors.

Contemporary Trends in Abnormal Psychology

ANTON MESMER (1734–1815) Mesmer’s techniques for treating hysteria by inducing a sleeplike state in which his patients were highly susceptible to suggestion was a forerunner of modern hypnotism. Though highly controversial and ultimately discredited, Mesmer’s efforts stimulated inquiry into psychological and emotional factors, rather than biological factors, as causes of mental disorders.

Earlier, we made the statement that our current explanations of abnormal behavior have been heavily influenced by the beliefs of the past. Much has changed, however, in our understanding and treatment of psychopathological disorders. Twentieth-century views of abnormality continue to evolve in the twenty-first century as they incorporate the effects of several major events and trends in the field: (1) the drug revolution in psychiatry, (2) the push by psychologists for prescription privileges, (3) the development of managed health care, (4) an increased appreciation for research in abnormal psychology, and (5) the influence of multicultural psychology.

The Drug Revolution in Psychiatry Many mental health professionals consider the introduction of psychiatric drugs in the 1950s as one of the great medical advances of the twentieth century (Lickey & Gordon, 1991; Nemeroff, 1998; Norfleet, 2002). Although some might find such a statement excessive, it is difficult to overemphasize the impact that drug therapy has had. It started in 1949 when an Australian psychiatrist, John F. J. Cade, reported on his successful experiments with lithium in radically calming manic patients who had been hospitalized for years. Several years later, French psychiatrists Jean Delay and Pierre Deniker discovered that the drug chlorpromazine (brand name, Thorazine) was extremely effective in treating agitated schizophrenics. Within a matter of years, drugs were developed to treat disorders such as depression, schizophrenia, phobias, obsessive-compulsive disorders, and anxiety. Large classes of drugs were developed for depression (antidepressant drugs), anxiety (antianxiety drugs), and grossly impaired thinking (antipsychotic drugs). These drugs were considered revolutionary because they rapidly and dramatically decreased or eliminated troublesome symptoms experienced by patients. As a result, other forms of therapy became available to the mentally ill, who were now more able to focus their attention on their therapy. Their stays in mental hospitals

cathartic method a therapeutic use of verbal expression to release pent-up emotional conflicts

psychological perspective that stresses the importance of learning and behavior in explanations of normal and abnormal development

behaviorism

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were shortened and were more cost effective than prolonged hospitalizations. In addition, they were allowed to return home while receiving treatment. The new drug therapies were credited with the depopulation of mental hospitals, often referred to as deinstitutionalization, which we discuss in more detail in Chapter 17. This decline can be attributed not to a decrease in new admissions but rather to shorter stays and earlier releases (Lickey & Gordon, 1991; Manderscheid & Sonnenschein, 1992; NIMH, 1995). To handle the large number of patients returning to the community, outpatient treatment became the primary mode of service for the severely disturbed. In addition to changing the way therapy was dispensed, the introduction of psychiatric drugs revived strong belief in the biological bases of mental disorders (Fox & Sammons, 1998).

The Push by Psychologists for Prescription Privileges One of the major distinguishing features between psychiatrists and psychologists has been the right to prescribe medication. Should psychologists have a legal right to prescribe medication? Within the mental health field, the opposing answers to this question have been extremely divisive (Albee, 2002; Caccavale, 2002; Hayes & Chang, 2002). Psychologists have increasingly exerted pressure on state legislatures to allow them to prescribe medication in treating the mentally disturbed. They have argued that such a move would be cost effective and benefit the American public by containing escalating health care costs (Wedding, 1995). Even though surveys suggest that most nonmedical mental health organizations favor prescription privileges for psychologists, and even though current statutes have never stipulated that only physicians can prescribe medication, the American Medical Association has adamantly opposed any such move. Although a good part of this stance may be due to psychiatry’s fears of economic losses and the blurring of boundaries between professions, other reasons are cited as well. The medical establishment has argued that granting such privileges could endanger the public because psychologists lack medical training and the expertise to recognize medical risks and potential drug-interaction effects (Tatman et al., 1997). Proponents of prescription privileges, on the other hand, present compelling reasons for approval (Foxhall, 2001; Gutierrez & Silk, 1998): (1) studies reveal that psychologists would be more cautious than psychiatrists in prescribing medication, (2) it is a logical extension of the psychologist’s role, (3) psychologists are equally if not better trained to understand mind-body relationships than their psychiatric counterparts, and (4) psychologists wishing to prescribe would be required to pass a rigorous psychopharmacology curriculum. As of this writing, several states have passed legislation allowing psychologists to prescribe medication, and statutes are being considered in others.

The Development of Managed Health Care

managed health care

the industrialization of health care, whereby large organizations in the private sector control the delivery of services

Managed health care refers to the industrialization of health care, whereby large organizations in the private sector control the delivery of services. In the past, psychotherapy was carried out primarily by individuals in solo offices or in small-group practices. Some clients paid for services out of their own pockets. Others had health plans that covered treatment, generally with minimal restrictions on the number of sessions the client could attend and usually with reimbursable treatment for a broad array of “psychological problems.” The fees, number of sessions, and types of treatment were determined by the mental health practitioner. When mental health costs rapidly escalated in the 1980s, attempts were made to contain costs via managed health care or some form of health care reform (Cummings, 1995; Hall, 1995; Sammons, 2004). This industrialization of health care has brought about major changes in the mental health professions: • Business interests are exerting increasing control over psychotherapy by determining reimbursable diagnoses, limiting the number of sessions psychologists may offer clients, and imposing other such restrictions.

Contemporary Trends in Abnormal Psychology

• Current business practices are depressing the income of practitioners. Some organizations prefer hiring therapists with master’s degrees rather than those with doctoral degrees, or they reimburse at rates below those set by the therapist. • Psychologists are being asked to justify the use of their therapies on the basis of whether they are empirically based—that is, established treatments with research support. This last point is especially important. For example, if research reveals that cognitive-behavioral forms of treatment are more successful than psychodynamic approaches for a certain form of phobia, then therapy using the latter approach might be denied by the insurance carrier. These trends have alarmed many psychologists, who fear that decisions will be made not so much for health reasons but for business ones, that the need for doctoral-level practitioners will decrease, and that the livelihood of clinicians will be threatened. Although no one can say with certainty whether these fears will be realized, recent studies suggest that managed care policies are not based on scientific foundations and that patients are being deprived of adequately skilled treatment on a massive scale (Holloway, 2004; Scribner, 2001; Seligman & Levant, 1998). As a result, lawsuits against major health-care plans over accountability, patient access, and both patient and provider rights threaten to change the managed care landscape (Holloway, 2004). A number of class-action lawsuits against some of the nation’s largest managed care providers have accused them of conspiring to reduce and delay payments to physicians.

An Increased Appreciation for Research Breakthroughs in neuroanatomy, identification of the role that neurotransmitters play in mental disorders, and increasing interest in exploring evidence-based forms of psychotherapy have produced another contemporary trend: a heightened appreciation for the role of research in the study of abnormal behavior. The success of psychopharmacology spawned renewed interest and research into brain-behavior relationships (DHHS, 1999). Indeed, more and more researchers are now exploring the biological bases (chemical and structural) of abnormal behavior. Within recent years, biological factors have been associated with many psychological disorders, such as depression, suicide, schizophrenia, learning disabilities, alcoholism, and Alzheimer’s disease (Dick & Rose, 2002; Hollon, Thase, & Markowitz, 2002). Currently, researchers are seeking insights into the most effective means of understanding and treating specific disorders through studies comparing the effectiveness of drug treatment with that of cognitive treatment and through the development of empirically based treatments (Chambless, 1993; Nathan, 1998). The move toward empirically based treatments is one of the most visible aspects of the profession’s use of research to determine the most effective forms of therapy for various disorders (Norcross, 2004; Wampold, Lichtenberg, & Waehler, 2002). The early work by the Division of Clinical Psychology Task Force (Task Force on Promotion and Dissemination of Psychological Procedures, 1995) listed treatments for various disorders as to their effectiveness; the list can be found at www.apa.org/divisions/div12/rev_est/ index.html. Although the move to evidence-based practice is accepted by the profession as important, it is not without controversy. Some claim that the call for empirically based treatments is biased against certain theoretical orientations (for example, humanistic-existential, psychodynamic). For example, studies reveal that 60 to 80 percent of those treatments identified as most effective are cognitive-behavioral treatments (Norcross, 2004). Others assert that evidence-based practice is too restrictive and does not recognize clinical intuition and the dynamic basis of therapy. Further, the majority of disorders identified are those that can be easily measured and have a discrete but narrow symptom cluster, such as phobias. What about disorders that are more global and less susceptible to precise description,

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1.2

14.4% 12.3% 68% 4.3% 1%

White American

CENSUS 2005 RACIAL/ETHNIC FIGURE COMPOSITION OF THE UNITED STATES The rapid demographic transformation of the United States is illustrated in the fact that minorities now constitute an increasing proportion of the population. Several trends are evident. First, within several short decades, people of color will constitute a numerical majority. Second, the number of Hispanic Americans has surpassed African Americans. Third, mental health providers will increasingly be coming into contact with clients who differ from them in race, ethnicity, and culture. Source: U.S. Census Bureau, National Population Estimates www.infoplease.com/ipa/A0762156.html.

Hispanic American African American Asian American Native American

such as alienation in life, feelings of meaninglessness, and so on (Messer, 2001)? Lastly, as noted earlier, some fear that managed care companies will use this information to place more restrictions on types of treatments they are willing to reimburse.

The Influence of Multicultural Psychology

multicultural psychology

an approach that stresses the importance of culture, race, ethnicity, gender, age, socioeconomic class, and other similar factors in its effort to understand and treat abnormal behavior

We are fast becoming a multicultural, multiracial, and multilingual society (see Figure 1.2). The U.S. Census reveals that within several decades, racial and ethnic minorities will become a numerical majority (Sue & Sue, 2008a). These changes have been referred to as “the diversification of the United States” or, literally, the “changing complexion of society.” Much of this change is fueled by two major trends in the United States: (1) the increased immigration of visible racial and ethnic minorities and (2) the differential birthrates among the various racial and ethnic groups in our society. The “diversity index,” which measures the probability of selecting two randomly chosen individuals from different parts of the country who differ from each other in race or ethnicity, stands at 49. In other words, there is nearly a 50 percent chance that these two individuals would be of a different race or ethnicity. Nowhere is the explosive growth of minorities more noticeable than in our public schools, where students of color now make up 45 percent of those attending. Diversity has had a major impact on the mental health profession, creating a new field of study called multicultural psychology. As noted earlier in the chapter, the multicultural approach stresses the importance of culture, race, ethnicity, gender, age, socioeconomic class, and other similar factors in its effort to understand and treat abnormal behavior. There is now recognition that mental health professionals need to (1) increase their cultural sensitivity, (2) acquire knowledge of the worldviews and lifestyles of a culturally diverse population, and (3) develop culturally relevant therapy approaches in working with different groups (American Psychological Association, 2003; Sue & Sue, 2008a). Although issues of race, culture, ethnicity, and gender have traditionally been ignored or distorted in the mental health literature, these forces are now increasingly recognized as powerful influences on many aspects of normal and abnormal human development. Four primary dimensions related to cultural diversity—social conditioning, cultural values and influence, sociopolitical influences, and bias in diagnosis—seem to explain how cultural forces exert their influence. Social Conditioning How we are raised, what values are instilled in us, and how we are expected to behave in fulfilling our roles seem to have a major effect on the type of disorder we are most likely to exhibit. Traditionally in our culture men have been raised to fulfill the masculine role, to be independent, assertive, courageous, active, unsentimental, and objective. Women, in contrast, have been raised to be dependent,

Contemporary Trends in Abnormal Psychology

helpful, fragile, self-deprecating, conforming, empathetic, and emotional. Some mental health professionals believe that, as a result, women are more likely to internalize their conflicts (resulting in anxiety and depression), whereas men are more likely to externalize and act out (resulting in drug or alcohol abuse and dependence). Although gender roles have begun to change, their effects continue to be widely felt. Cultural Values and Influences Mental health professionals now recognize that types of mental disorders differ from country to country and that major differences in cultural traditions among various racial and ethnic minority groups in the United States may influence their susceptibility to certain emotional disorders. In 1994, the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association) acknowledged the existence of “culture-bound” syndromes in other societies. Among Hispanic/Latino Americans and Asian Americans, experiencing physical complaints is a common and culturally accepted means of expressing psychological and emotional stress (Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002; Yang & WonPat-Borja, 2007). People with these cultural backgrounds believe that physical problems cause emotional disturbances and that the emotional disturbances will disappear as soon as appropriate treatment for the physical illness is instituted. In addition, mental illness among Asians is seen as a source of shame and disgrace, although physical illness is acceptable. Asian values also emphasize restraint of strong feelings. Thus, when stress is encountered, the mental health professional is likely to hear complaints involving headaches, fatigue, restlessness, and disturbances of sleep and appetite.

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Did You Know? • Minorities form a majority in onethird of the most populous U.S. counties. • Over 50 percent of California’s population is composed of minority groups. • 30 percent of New York City residents were born in other countries. • 70 percent of the population of the District of Columbia is African American. • 37 percent of the population of San Francisco is Asian American/ Pacific Islander. • 67 percent of the population of Detroit is African American. • 67 percent of the population of Miami is Latino/Hispanic American.

Sociopolitical Influences In response to a history of prejudice, discrimination, and racism, many minorities have adopted various behaviors (in particular, behaviors toward whites) that have proved important for survival in a racist society (Ridley, 1995; Sue & Sue, 2008a). Mental health professionals may define these behaviors as abnormal and deviant, yet from the minority group perspective, such behaviors may function as healthy survival mechanisms. Early personality studies of African Americans concluded that, as a group, they tend to appear more “suspicious,” “mistrustful,” and “paranoid” than their white counterparts. But are African Americans inherently pathological, as studies suggest, or are they making healthy responses? Members of minority groups who have been victims of discrimination and oppression in a society not yet free of racism have good reason to be suspicious and distrustful of white society. The “paranoid orientation” may reflect not only survival skills but also accurate reality testing. We are pointing out that certain behaviors and characteristics need to be evaluated not only by an absolute standard but also by the sociopolitical context in which they arise. Bias in Diagnosis Epidemiological studies reporting the distribution and types of mental disorders that occur in the population may be prone to bias on the part of the clinician and researcher. The mental health professional is not immune to inheriting the prejudicial attitudes, biases, and stereotypes of the larger society. Even the most enlightened and well-intentioned mental health professional may be the victim of race, gender, and social class bias. One source of bias is the tendency to overpathologize—to exaggerate the severity of disorders—among clients from particular socioeconomic, racial, or ethnic groups whose cultural values or lifestyles differ markedly from the clinician’s own. The overpathologizing of disorders has been found to occur in evaluation of African Americans, Hispanic Americans, and women (Lopez & Hernandez, 1987; Sue & Sue, 2003). It is clear that one of the most powerful emerging trends in the mental health field is the increased interest, appreciation, and respect for multicultural psychology. Understanding abnormal behavior requires a realistic appraisal of the cultural context in which behavior occurs and an understanding of how culture influences the manifestations of

AGE BIAS In making diagnoses and conducting research, clinicians and researchers must be careful to avoid age bias, as well as race, gender, and social class biases. Japanese mountaineer Yuichiro Miura set a record by becoming the oldest man to climb Mount Everest. He was 70 years old and put to shame many climbers decades younger who could not complete the trek.

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critical thinking

I Have It, Too: The Medical Student Syndrome

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o be human is to encounter difficulties and problems in life. A course in abnormal psychology dwells on human problems—many of them familiar. As a result, we may be prone to the medical student syndrome: reading about a disorder may lead us to suspect that we have the disorder or that a friend or relative has it when indeed that is not the case. This reaction to the study of abnormal behavior is a common one, and one we must all guard against. When reading about physical disorders and listening to lecturers describe illnesses, some medical students begin to imagine that they themselves have one disorder or another. “Diarrhea? Fatigue? Trouble sleeping? That’s me!” In this way, a cluster of symptoms—no matter how mild or how briefly experienced—can lead some people to suspect that they are very sick. Students who take a course that examines psychopathology may be equally prone to believe that they have a mental disorder that is described in their text. It is possible, of course, that some students do suffer from disorders and would benefit from counseling or therapy. Most, however, are merely experiencing an exaggerated sense of their susceptibility to disorders. Two influences in particular may make us susceptible to these imagined disorders. One is the universality of the human experience. All of us have experienced misfortunes

in life. We can all remember and relate to feelings of anxiety, unhappiness, guilt, lack of self-confidence, and even thoughts of suicide. In most cases, however, these feelings are normal reactions to stressful situations, not symptoms of disease. Depression following the loss of a loved one or anxiety before giving a speech to a large audience may be perfectly normal and appropriate. Another influence is our tendency to compare our own functioning with our perceptions of how other people are functioning. The outward behaviors of fellow students may lead us to conclude that they experience few difficulties in life, are self-assured and confident, and are invulnerable to mental disturbance. If we were privy to their inner thoughts and feelings, however, we might be surprised to find that they share our apprehension and insecurities. If you see yourself anywhere in the pages of this book, we hope you will take the time to discuss your feelings with a friend or with one of your professors. You may be responding to pressures that you have not encountered before—a heavy course load, for example—and to which you have not yet adjusted. Other people can help point out these pressures to you. If your discussion supports your suspicion that you have a problem, however, then by all means consider getting help from your campus counseling and/or health clinic.

abnormality. This recognition led the American Psychological Association to adopt “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” (APA, 2003). It states explicitly that the guidelines “reflect the continuing evolution of the study of psychology, changes in society at large, and emerging data about the different needs of particular individuals and groups historically marginalized or disenfranchised within and by psychology based on their ethnic/racial heritage and social group identity or membership” (p. 277).

I M P L I C AT I O N S

As you can see, the study of abnormal psychology is not only complex but also heavily influenced by the tenor of the times. As we begin our journey into attempts to explain the causes of certain disorders, we encourage you not to become rigidly locked into one system or model. It is our contention that no one model is equally applicable to all situations, problems, and populations. All have something of worth to add. And, in reality, few contemporary psychologists or psychiatrists take the extreme of adhering to just one position. Indeed, most psychologists believe that mental illness probably springs from a combination of not only biological and psychological factors but societal and environmental influences as well. It would be a serious oversight to neglect the powerful impact on mental health of family upbringing and influence, the stresses of modern society (unemployment, poverty, loss of a loved one, adapting to technological change, and so on), experiences of oppression (prejudice, discrimination, stereotyping), effects of natural disasters (earthquakes, floods, hurricanes), human-made conflicts such as wars, and our current battle against terrorism. In the next chapter, we present a multipath model to explain the complex interacting biological, psychological, social, and sociocultural factors that must all be considered in explaining and treating mental disorders.

Summary 1. What is abnormal psychology? ■ Abnormal psychology is the scientific study whose objectives are to describe, explain, predict, and control behaviors that are considered strange or unusual. 2. What criteria are used to determine normal or abnormal behaviors? ■ Nearly all definitions include statistical deviation from some normative standard. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) definition is used by most mental health practitioners. Thus abnormality is determined by four criteria: distress, deviance, dysfunction, and dangerousness.

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3. How do context and cultural differences affect definitions of abnormality? ■

Criteria used to define normality or abnormality must be considered in light of community standards and changes over time. What is considered acceptable behavior in urban environments, for example, may not be considered acceptable in rural communities. With the increasing diversity in our society, we have also become very sensitive to how culture and unique group characteristics affect the definition of psychopathology as well.

4. How common are mental disorders? ■ Over the course of a lifetime, approximately 30 percent of people suffer from mental health problems in the United States, and the human and economic costs are enormous. In addition, two-thirds of all people suffering from diagnosable mental disorders are not receiving or seeking mental health services. 5. What are some common misconceptions about the mentally disturbed? ■ Unfortunately, many myths and stereotypes have emerged regarding people who suffer from mental disorders. Beliefs that mental disorders are inherited, incurable, and the result of a weak will and that those who suffer from them will never contribute to society have caused undue worry and harm to many. The reality is that most people who have suffered from mental disorders improve, are little different from ourselves, and go on to lead normal productive lives. 6. How have explanations of abnormal behavior changed over time? ■ Ancient peoples believed in demonology and attributed abnormal behaviors to evil spirits that inhabited the victim’s body. Treatments consisted of trephining, exorcism, and bodily assaults.

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Rational and scientific explanations of abnormality emerged during the Greco-Roman era. Especially influential was the thinking of Hippocrates, who believed that abnormal behavior was due to organic, or biological, causes, such as a dysfunction or disease of the brain. Treatment became more humane. With the collapse of the Roman Empire and the increased influence of the church and its emphasis on divine will and the hereafter, rationalist thought was suppressed, and belief in the supernatural again flourished. During the Middle Ages, famine, pestilence, and dynastic wars caused enormous social upheaval. Forms of mass hysteria affected groups of people. In the fifteenth century, some of those killed in churchendorsed witch hunts were people we would today call mentally ill. The Renaissance brought a return to rational and scientific inquiry, along with a heightened interest in humanitarian methods of treating the mentally ill. The eighteenth and nineteenth centuries were a period characterized by reform movements.

7. What were early viewpoints on the causes of mental disorders? ■ In the nineteenth and twentieth centuries, major medical breakthroughs fostered a belief in the biological roots of mental illness. An especially important discovery of this period was the microorganism that causes general paresis. Scientists believed that they would eventually find organic causes for all mental disorders. ■ Mesmerism, and later hypnosis, supported another view, however. The uncovering of a relationship between hypnosis and hysteria corroborated the belief that psychological processes could produce emotional disturbances. 8. What are some contemporary trends in abnormal psychology? ■

Five contemporary developments have had a major influence in the mental health professions: (1) the drug revolution in psychiatry, which not only allowed many of the more severely disturbed to be treated outside of a hospital setting but also lent credence to the biological viewpoint, (2) the push by psychologists for prescription privileges, (3) the development of managed health care, (4) an increased appreciation for research in abnormal psychology, and (5) the influence of multicultural psychology.

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Models of Abnormal Behavior

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chapter outline One-Dimensional Models of Mental Disorders

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A Multipath Model of Mental Disorders

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Dimension One: Biological Factors

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Dimension Two: Psychological Factors

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Dimension Three: Social Factors

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Dimension Four: Sociocultural Factors

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IMPLICATIONS

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CONTROVERSY Problems

in Using Racial and Ethnic Group References

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CRITICAL THINKING

Applying the Models of Psychopathology

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teve V., a twenty-one-year-old college student, had been suffering from a crippling bout of depression. Eighteen months earlier, Steve’s friend, Linda, had broken off their relationship. However, Steve’s long psychiatric history had begun well before he first sought help from the university’s psychological services center. Steve had been in and out of psychotherapy since kindergarten and had been hospitalized twice for depression when he was in high school. His case records, nearly two inches thick, contained a number of diagnoses, including labels such as schizoid personality disorder, schizophrenia (paranoid type), and bipolar mood disorder. Although his present therapist did not find these labels particularly helpful, Steve’s clinical history did provide some clues to the causes of his problems. Steve V. was born in a suburb of San Francisco, the only child of an extremely wealthy couple. His father, who is of Scottish descent, was a prominent businessman who worked long hours and traveled frequently. On those rare occasions when he was home, Mr. V. was often preoccupied with business matters and held himself aloof from his son. The few interactions they had were characterized by his constant ridicule and criticism of Steve. Mr. V. was disappointed that his son seemed so timid, weak, and withdrawn. Steve was extremely bright and did well in school, but Mr. V. felt that he lacked the “toughness” needed to prosper in today’s world. Once, when Steve was about ten, he came home from school with a bloody nose, crying and complaining of being picked on by his schoolmates. His father showed no sympathy; instead, he berated Steve for losing the fight. His father was fond of quoting the famous Green Bay Packers coach, Vince Lombardi, “Winning isn’t everything, it’s the only thing!” In his father’s presence, Steve usually felt worthless, humiliated, and fearful of doing or saying the wrong thing. Mrs. V. was very active in civic and social affairs, and she, too, spent relatively little time with her son. Although she treated Steve more warmly and lovingly than his

FOCUSQUESTIONS

1 What models of psychopathology have been used to explain abnormal behavior?

4 What psychological models are used to explain the etiology of mental disorders?

2 What is the multipath model of mental disorders?

5 What role do social factors play in psychopathology?

3 How much of mental disorder can be explained

6 What sociocultural factors may play a role in the 1

through our biological makeup?

etiology of mental disorders?

father did, she seldom came to Steve’s defense when Mr. V. bullied him. She generally allowed her husband to make family decisions. In reality, Mrs. V. was quite lonely. She felt abandoned by Mr. V. and harbored a deep resentment toward him, which she was frightened to express. When Steve was a child, his mother had often allowed him to sleep in her bed when her husband was away on business trips. She usually dressed minimally on these occasions and was very demonstrative—holding, stroking, and kissing Steve. This behavior had continued until Steve was twelve, when his mother abruptly refused to let Steve into her bed. The sudden withdrawal of this privilege had confused and angered Steve, who was not certain what he had done wrong. He knew, though, that his mother had been quite upset when she awoke one night to find him masturbating next to her. Most of the time, Steve’s parents seemed to live separately from each other and from their son. Steve was raised, in effect, by a non-English-speaking maid whose idea of caring for him was to lock him in his room during the day. He rarely had playmates his own age. His birthdays were celebrated with a cake, but the only celebrants were Steve and his mother. By age ten, Steve had learned to keep himself occupied by playing “mind games,” letting his imagination carry him off on flights of fantasy. He frequently imagined himself as a powerful figure—Superman or Batman. His fantasies were often extremely violent, and his foes were vanquished only after much blood had been spilled. As Steve grew older, his fantasies and heroes became increasingly menacing and evil. When he was fifteen, he obtained a pornographic video that he watched repeatedly in his room. Often, Steve would masturbate as he watched scenes of women being sexually violated. The more violent the acts against women, the more aroused he became. Steve now recalls that he spent much of his spare time between the ages of fifteen and seventeen watching X-rated videos or violent movies, his favorite being The Texas Chainsaw Massacre, in which a madman saws and hacks women to pieces. Steve always identified with the character perpetrating the outrage; at times, he imagined his parents as the victims. At about age sixteen, Steve became convinced that external forces were controlling his mind and behavior and were drawing him into his fantasies. He was often filled with guilt and anxiety after one of his mind games. Although he was strongly attracted to his fantasy world, he also felt that something was wrong with it and with him. After seeing the movie The Exorcist, he became convinced that he was possessed by the devil. Up until this time, Steve had been quiet and withdrawn. In kindergarten the school psychologist had described his condition as “autistic-like” because Steve seldom spoke, seemed unresponsive to the environment, and was socially isolated. With the development of his interest in the occult and in demonic possession, however, he became

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outgoing, flamboyant, and even exhibitionistic. Against his will, Steve was hospitalized twice by his parents with diagnoses of bipolar affective disorder and schizophrenia in remission. Mr. V. often suggested that Steve had inherited “bad genes” from his wife’s side of the family because one of Mrs. V’s brothers had suffered from a history of mental illness.

What do you make of Steve? He certainly fulfills our criteria as someone suffering from a mental disorder. Yet how do we make sense of his bizarre behaviors, thoughts, and feelings? Where do they come from? Is Steve correct in his belief that he is possessed by evil spirits? Is his father correct in suggesting that “bad genes” caused his disorder? What role did his upbringing, isolation, and bullying from his father play in the development of his problems? These complex questions lead us into a very important aspect of abnormal psychology: the etiology, or causes, of disorders.

One-Dimensional Models of Mental Disorders

etiology

causes of disorders

In the previous chapter, we described how the rise of humanism influenced society’s attitude toward mental disorders. As rational thought replaced superstition in the eighteenth and nineteenth centuries, the mentally disturbed were increasingly regarded as unfortunate human beings who deserved humane treatment, not as monsters inhabited by the devil. This humanistic view gave rise, in the late nineteenth and early twentieth centuries, to two different schools of thought about the causes of mental disorders. According to one group of thinkers, mental disorders are caused primarily by biological problems, and the disturbed individual is displaying symptoms of physical disease or damage. The second group of theorists believed that abnormal behavior is essentially psychosocial, rooted not in cells and tissues but in the invisible complexities of the human mind or in stressful environmental forces. Today we realize that these two perspectives are overly simplistic because they (1) set up a false “either/or” dichotomy between nature and nurture, (2) fail to recognize the reciprocal influences of one on the other, and (3) mask the importance of acknowledging the biological, psychological, social, and sociocultural dimensions in the origin of mental disorders. In this chapter, we propose a multipath model for explaining abnormal behavior that integrates these four major dimensions. Before we begin, however, let’s look at how one-dimensional models have traditionally explained Steve’s psychopathology. • Biological Explanations Adherents to the biological perspective would say that Steve’s mental disorders are caused by some form of biological malfunctioning. Steve’s problems reside in a possible genetic predisposition to mental disorders, an imbalance of brain chemistry, or, perhaps, in structural abnormalities in his neurological makeup. The fact that he suffers from paranoid schizophrenia and a bipolar affective disorder (both disorders that have an increased probability of being present in blood relatives) seems to support such an explanation. Although biological explanations acknowledge that environmental influences are important, they are seen as secondary in the manifestation of psychopathology. • Psychological Explanations From a psychological perspective, there are a variety of ways to explain Steve’s behavior. Psychodynamic explanations would stress that Steve’s problems reside in his early childhood experiences, his inability to confront his own intense feelings of hostility toward his father (fears of castration), and his unresolved sexual longing toward his mother. Behavioral explanations would trace the roots of Steve’s problems to his behavioral repertoire. Many of the behaviors he has learned are inappropriate, and his

One-Dimensional Models of Mental Disorders

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repertoire lacks useful, productive behaviors. Other explanations might stress the development of irrational beliefs and Steve’s distorted thinking that leads to his “mind games” (misinterpretations of reality). • Social Explanations From a social or social-relational perspective, Steve’s problem resides in the family system, which is therefore the primary unit of analysis. Although Steve is manifesting the disorders, his father and mother are also suffering, and their pathological symptoms are reflected in Steve. As long as Steve is the “identified patient” and is seen as “the problem,” Mr. and Mrs. V. can continue in their mutual self-deception that all is well between them. It is obvious that the relationships between Steve and his father, between Steve and his mother, and between his father and his mother are unhealthy. The constant bullying of Steve by his father and the lack of support by his mother are the primary culprits. • Sociocultural Explanations The societal and cultural context in which Steve’s problems arise must be considered in understanding his dilemma. He is a white European American of Scottish descent, born to a wealthy family in the upper socioeconomic class. He is a male, raised in a cultural context that values individual achievement and competitiveness. One might argue, for example, that Steve’s father values American individualistic competitiveness and achievement in the extreme. He has succeeded by his own efforts, but unfortunately, his success has come at the emotional cost of his family. Further, because Steve does not live up to these benchmarks of masculinity, he is considered a failure by his father. To truly understand Steve, we must recognize that multicultural variables—race, ethnicity, gender, socioeconomic class, sexual orientation, and so on—are powerful factors. As such, they influence the types of sociocultural stressors Steve is likely to experience and the ways in which he will manifest disorders.

Using Models to Describe Psychopathology As evidenced by the preceding analysis of Steve, all four explanations seem to contain kernels of truth. But which is more accurate? Does accepting the validity of one perspective preempt the applicability of another? Is it possible that combinations of biological, psychological, social, and sociocultural factors all interact and contribute to Steve’s mental disorder? To answer these questions, let’s first examine how scientists use analogies to discuss a phenomenon that is difficult to describe or explain. A diagnosis such as “schizophrenia,” for example, is generally inferred and made more understandable by likening the phenomenon to something more concrete. A model is an analogy that scientists often use to describe a phenomenon or process that they cannot directly observe. In using an analogy, the scientist borrows terms, concepts, or principles from one field and applies them to another, as when a physician describes the eye as a “camera.” Psychologists have used models extensively to help conceptualize the causes of abnormal behavior, to ask probing questions, to determine relevant information and data, and to interpret data. For example, when psychologists refer to people as “patients” or speak of deviant behavior as “mental illness,” they are borrowing the terminology of medicine and applying a medical model of abnormal behavior. They may also describe certain external symptoms (such as snake phobia or motor tics) as being visible signs of deep underlying conflict. Again, the medical analogy is clear: just as fevers, rashes, perspiration, or infections may be symptoms of a bacterial or viral invasion of the body, bizarre behavior may be a symptom of a mind “invaded” by unresolved conflicts. Psychologists use a variety of such models, each embodying a particular theoretical approach. Hence we tend to use the terms model, theory, viewpoint, and perspective somewhat interchangeably. Most theorists realize that the models they construct will be limited and will not correspond in every respect to the phenomena they are studying (Brooks-Harris, 2008). Because of the complexity of human behavior and our relatively shallow understanding of it, psychologists do not expect to develop the definitive model.

model an analogy used by scientists, usually to describe or explain a phenomenon or process they cannot directly observe

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Rather, they use the models to visualize psychopathology as if it truly worked in the manner described. Models of psychopathology, whether they are biological, psychological, or multicultural, enable us to organize and make sense of the complexity of data related to the disturbance being studied. Models, however, can foster a one-dimensional and linear explanation of a mental disorder that limits the ability to consider other perspectives. If, for example, we use a psychological explanation of Steve’s behavior and consider his problems to be rooted in unconscious incestuous desires for his mother and ambivalent competitiveness toward his father (a psychodynamic explanation), we may unintentionally ignore all research findings pointing to powerful biological causes of certain disorders such as schizophrenia and depression.

A Multipath Model of Mental Disorders

multipath model a model of models that provides an organizational framework for understanding the numerous causes of mental disorders, the complexity of their interacting components, and the need to view disorders from a holistic framework

Nearly all texts on abnormal psychology expose students to a variety of theories that purport to explain mental disorders. For example, students may hear of how researchers have made breakthroughs in the genetics of a disorder, how the unconscious mind may influence one’s behaviors, why irrational thoughts or distorted thinking lead to pathology, or how learned inappropriate behaviors may be culprits. Because psychologists may favor one model over another, textbooks have typically presented different theories as if each alone can explain a disorder or as if each has equal validity. Research shows, however, that disorders are caused by factors that cross various theories. For instance, in the case of Steve V., genetics and brain functioning (a biological perspective) may interact with ways of thinking (a cognitive perspective) in a given cultural group (a sociocultural perspective) to produce abnormal behavior. What, then, is the “best” way to conceptualize the causes of mental disorders? We propose an integrative and interacting multipath model as a way of viewing disorders and their causes. The multipath model is not a theory but a way of looking at the variety and complexity of contributors to mental disorders. In some respects it is a metamodel, a model of models that provides an organizational framework for understanding the numerous causes of mental disorders, the complexity of their interacting components, and the need to view disorders from a holistic framework. The multipath model operates under several assumptions: (1) No one theoretical perspective is adequate to explain the complexity of the human condition and the development of mental disorders. (2) There are multiple pathways to and causes of any single disorder. It is a statistical rarity to find a disorder due to only one cause. (3) Explanations of abnormal behavior must consider biological, psychological, social, and sociocultural elements. (4) Not all dimensions contribute equally to a disorder. The model is guided by the state of research and scientific findings as to the relative merits of a proposed cause. In some cases, greater support for a biological perspective, for example, may be present, but this may evolve as research enlightens us about the contributions of other factors. (5) The multipath model is an integrative and interactive one. It acknowledges that factors may combine in complex and reciprocal ways so that people exposed to the same factors may not develop the same disorder and that different individuals exposed to different factors may develop a similar mental disorder. Let’s look at how the multipath model operates under these assumptions. First, the etiology of mental disorders can be subsumed under four dimensions, as shown in Figure 2.1: • Dimension One: Biological Factors This dimension includes genetics, brain anatomy, biochemical imbalances, central nervous system functioning, autonomic nervous system reactivity, and so forth. • Dimension Two: Psychological Factors This dimension includes personality, cognition, emotions, learning, stress coping, self-esteem, self-efficacy, values, developmental history, and so forth.

A Multipath Model of Mental Disorders

FIGURE

Biological Dimension Genetics, Brain Anatomy, Biochemical Imbalances, Central Nervous System Functioning, Autonomic Nervous System Reactivity, etc.

Sociocultural Dimension Race, Gender, Sexual Orientation, Religion, Socioeconomic Status, Ethnicity, Culture, etc.

MENTAL DISORDER

35

2.1

THE MULTIPATH MODEL Each dimension of the multipath model contains factors found to be important in explaining abnormal behavior.

Psychological Dimension Personality, Cognition, Emotions, Learning, Stress-Coping, SelfEsteem, Self-Efficacy, Values, Developmental History, etc.

Social Dimension Family, Relationships, Social Support, Belonging, Love, Marital Status, Community, etc.

• Dimension Three: Social Factors This dimension includes family, relationships, social support, belonging, love, marital status, community, and so forth. • Dimension Four: Sociocultural Factors This dimension includes race, gender, sexual orientation, religion, socioeconomic status, ethnicity, culture, and so forth. These four dimensions vary in whether a micro (narrow and within the person) or macro (broad and outside of the person) approach is taken. Within each dimension, how the multiplicity of factors are organized to explain abnormal behavior depends on a particular theoretical perspective. First, let’s take the psychological dimension as an example. Psychodynamic theories might emphasize the importance of childhood experiences in the formation of abnormal behavior; learning theories would emphasize learning and personality; and cognitive theories would emphasize cognition and thinking. Thus it is possible to have considerable differences even within a categorical dimension. Likewise, we note that some theories can be categorized in more than one dimension. TheoDIMENSION 1 ries of stress, for example, could be seen as falling Biological under the psychological or the social dimension. It is therefore best to view these four dimensions as having permeable boundaries with considerable overlap. Second, factors in the four dimensions can interDIMENSION 4 DIMENSION 2 Sociocultural Psychological act and influence each other in any direction. For example, research shows that brain functioning affects behaviors. However, research also demonstrates that engaging in certain behaviors can affect brain functioning. We also know that sociocultural factors can influence biological factors (an example DIMENSION 3 Social of a macro-level variable influencing a micro-level variable). The actual situation is much more complex because the interaction of factors may involve all four dimensions, as noted in Figure 2.2. FIGURE THE FOUR DIMENSIONS AND POSSIBLE PATHWAYS Third, different combinations within the four OF INFLUENCE Abnormal behavior can be conceptualized as arising from dimensions may cause abnormal behaviors. For four possible dimensions.

2.2

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Biological

Sociocultural

Psychological

Social

Biological

Social

Psychological

Psychological

Sociocultural

Biological

FIGURE

2.3

THE NUMBER OF DIMENSIONS THAT MAY LEAD TO PARTICULAR DISORDERS The dimensions shown are examples only because any of them can serve to influence a particular disorder.

instance, let’s assume that a woman suffers from severe depression. Her depression may be caused by a single factor (e.g., the death of a loved one) or by an interaction of factors in different dimensions (e.g., child abuse occurring in early life and stressors in adulthood). Thus a disorder such as depression may be caused by a single factor or by different combinations of factors, as noted in Figure 2.3. Fourth, many disorders appear to be heterogeneous in nature. Therefore, there may be different types or versions of a disorder (or a spectrum of the disorder). For example, schizophrenia appears to be composed of a group of different but related disorders. Likewise, there may be different types of depression that are caused by different factors. For example, severe cases of depression seem to have a stronger genetic basis than less severe cases. Finally, different disorders may be caused by similar factors. For example, anxiety, as well as depression, may be caused by child abuse and interpersonal stress. In fact, anxiety and depression often occur concurrently in people. It can be seen that finding causes of abnormal behavior is complex. Although a multipath model helps to conceptualize the complexities, the reality is that our research is currently insufficient to precisely link different dimensions of analysis for most disorders. By proposing a multipath model, we do not imply that disorders can be caused by any events or by random events. Rather, certain combinations of factors increase the likelihood of disorders. These factors often occur in different dimensions. They account for commonalities as well as uniqueness in disorders. That is, they can help predict the occurrence and nonoccurrence of disorders and provide insight into means of controlling disorders. Our task is to identify linkages in different dimensions and the meaningfulness of the linkages in explaining and controlling abnormal behaviors. The multipath model is similar to other multifactor approaches that involve biopsychosocial factors and their interaction, such as the diathesis-stress model, which we discuss later (Meehl, 1970; Rosenthal, 1970). However, the model allows for even greater complexity in conceptualizing the etiology of disorders. To aid in understanding more thoroughly the contributions of each of the four dimensions, we discuss them in the following sections.

Dimension One: Biological Factors Modern biological explanations of normal and abnormal behavior continue to share certain assumptions: (1) The things that make people who they are—their physical features, susceptibility to diseases, temperaments, and ways of dealing with stress— are embedded in the genetic material of their cells. (2) Human thoughts, emotions, and behaviors are associated with nerve cell activities of the brain and spinal cord. (3) A change in thoughts, emotions, or behaviors will be associated with a change in activity or structure (or both) of the brain. (4) Mental disorders are highly correlated with some form of brain or other organ dysfunction. (5) Mental disorders can be treated by drugs or somatic intervention (Cottone, 1992; Kolb, Gibb, & Robinson, 2003; Strohman, 2001; U.S. Surgeon General, 1999). Biological models have been heavily influenced by the neurosciences, a group of subfields that focus on brain structure, function, and disorder. Understanding biological

Dimension One: Biological Factors

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explanations of human behavior requires knowledge about the structure and function of the central nervous system (composed of the brain and spinal cord). Especially important is knowledge about how the brain is organized, how it works, and, particularly, the chemical reactions that enhance or diminish normal brain actions.

Myth vs Reality Myth: We should attempt to clearly identify those disorders that have a biological base and those that do not. Disorders that are shown to originate from biological causes warrant exclusive biological interventions. Disorders that are caused psychologically should be treated through psychological means. Reality: Although it is important to identify biological and psychological correlates of psychopathology, this dichotomous and simplistic thinking is unfortunate and has served to hinder integrated approaches to explaining and treating mental disorders. We now realize, for example, that gene activity and changes in biology are influenced by the psychological environment and vice versa. The relationship between the biological and psychological makeup of people is complex and interrelated (Plomin & McGuffin, 2003). DSM-IV-TR, for example, states explicitly that the mind-body dualism is a false one. There is much that is biological/physical in “mental disorders” and much that is mental in “physical disorders.”

The Human Brain The brain is composed of billions of neurons, or nerve cells that transmit messages throughout the body. The brain is responsible for three very important and highly complicated functions. It receives information from the outside world, it uses the information to decide on a course of action, and it implements decisions by commanding muscles to move and glands to secrete. Weighing approximately three pounds, this relatively small organ continues to amaze and mystify biological researchers. The brain is separated into two hemispheres. A disturbance in either one (such as by a tumor or by electrical stimulation with electrodes) may produce specific sensory or motor effects. Each hemisphere controls the opposite side of the body. For example, paralysis on the left side of the body indicates a dysfunction in the right hemisphere. In addition, the right hemisphere is associated with visual-spatial abilities and emotional behavior. The left hemisphere controls the language functions for nearly all right-handed people and for most left-handed ones. Viewed in cross-section, the brain has three parts: forebrain, midbrain, and hindbrain. Although each part is vital for functioning and survival, the forebrain is probably the most relevant to a discussion of abnormality. The Forebrain The forebrain probably controls all the higher mental functions associated with human consciousness, learning, speech, thought, and memory. Within the forebrain are the thalamus, hypothalamus, reticular activating system, limbic system, and cerebrum (see Figure 2.4). The specific functions of these structures are still being debated, but we can discuss their more general functions with some confidence. The thalamus appears to serve as a “relay station,” transmitting nerve impulses from one part of the brain to another. The hypothalamus (“under the thalamus”) regulates bodily drives, such as hunger, thirst, and sex, and body conditions, such as temperature and hormone balance. The limbic system is involved in experiencing and expressing emotions and motivation—pleasure, fear, aggressiveness, sexual arousal, and pain. The largest structure in the brain is the cerebrum, with its most visible part, the cerebral cortex, covering the midbrain and thalamus. The Midbrain and Hindbrain The midbrain and hindbrain also have distinct functions: • The midbrain is involved in vision and hearing and—along with the hindbrain—in the control of sleep, alertness, and pain. Mental health professionals are especially interested in the midbrain’s role in manufacturing chemicals—serotonin, norepinephrine, and dopamine—that have been implicated in certain mental disorders.

nerve cell that transmits messages throughout the body

neuron

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FIGURE

2.4

THE INTERNAL STRUCTURE OF THE BRAIN A crosssectional view of the brain reveals the forebrain, midbrain, and hindbrain. Some of the important brain structures are identified within each of the divisions.

Corpus callosum Limbic system Cerebrum

Forebrain

Thalamus Cerebral cortex Hypothalamus

Midbrain Cerebellum Spinal cord

Did You Know?

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n 2007, a thirty-eight-year-old man, mute and unconscious for five years due to a severe head injury, regained consciousness via electrical brain stimulation. Neuroscientists implanted two wire electrodes in his thalamus and passed a mild current through his brain. When the current was turned on, neuronal firing increased in the intact pathways, leading to increased arousal and awakening. Unfortunately, when the current was turned off, the patient relapsed. Nevertheless, this procedure shows promise for treatment of brain injuries (Carey, 2007).

short rootlike structure on the cell body whose function is to receive signals from other neurons

dendrite

axon extension on the cell body that sends signals to neurons, some a considerable distance away

Reticular formation

Hindbrain

• The hindbrain also manufactures serotonin. The hindbrain appears to control functions such as heart rate, sleep, and respiration. The reticular formation, a network of nerve fibers that controls bodily states such as sleep, alertness, and attention, starts in the hindbrain and threads its way into the midbrain. Because the brain controls all aspects of human functioning, it is not difficult to conclude that damage or interruption of normal brain function and activity could lead to observable mental disorders. There are, of course, many biological causes for psychological disorders. Damage to the nervous system is one: As Fritz Schaudinn demonstrated (see Chapter 1), general paresis results from brain damage caused by parasitic microorganisms. Tumors, strokes, excessive intake of alcohol or drugs, and external trauma (such as a blow to the head) have also been linked to cognitive, emotional, and behavioral disorders.

Biochemical Theories Two specific biological sources—body chemistry and heredity—have given rise to important biological theories of psychopathology. The basic premise of biochemical theories is that chemical imbalances underlie mental disorders. This premise relies on the fact that most physiological and mental processes, from sleeping and digestion to reading and thinking, involve chemical actions within the body. Support for the biochemical theories has been found in research into anxiety disorders, mood disorders (both depression and bipolar disorder), Alzheimer’s disease, autism, dyslexia, and schizophrenia (Andreasen, 2005; Lickey & Gordon, 1991; Plomin, Owen, & McGuffin, 1994). Some researchers have even claimed that our gene pool affects such characteristics as alienation, leadership, career choice, risk aversion, religious conviction, and pessimism (Colt & Hollister, 1998). To see how biochemical imbalances in the brain can result in abnormal behavior, we need to understand how messages in the brain are transmitted from nerve cell to nerve cell. Nerve cells (neurons) vary in function throughout the brain and may appear different, but they all share certain characteristics. Each neuron possesses a cell membrane that separates it from the outside environment and regulates the chemical contents within it. On one end of the cell body are dendrites, numerous short rootlike structures whose function is to receive signals from other neurons. At the other end is an axon, a much longer extension that sends signals to other neurons, some a considerable distance away. Under an electron microscope, dendrites can be distinguished by their many short branches (see Figure 2.5).

Dimension One: Biological Factors

Messages travel through the brain by electrical impulses via neurons: an incoming message is received by a neuron’s dendrites and is sent down the axon to bulblike swellings called axon terminals, usually located near dendrites of another neuron. Note that neurons do not touch one another. A minute gap (the synapse) exists between the axon of the sending neuron and the dendrites of the receiving neuron (see Figure 2.6). The electrical impulse crosses the synapse when the axon releases chemical substances called neurotransmitters. When the neurotransmitters reach the dendrites of the receiving neuron, they attach themselves to receptors and, if their “shapes” correspond, bind with them (see Figure 2.7). The binding of transmitters to receptors in the neuron triggers either a synaptic excitation (encouragement to produce other nerve impulses) or synaptic inhibition (a state preventing production of nerve impulses). The human body has many different chemical transmitters, and their effect on neurons varies (see Table 2.1). An imbalance of certain neurotransmitters in the brain is believed to be implicated in mental disorders. As discussed in Chapter 1, the search for chemical causes and cures for mental problems accelerated tremendously in the early 1950s with the discovery of psychoactive drugs. Since that time, three convincing lines of evidence have contributed to the search for biochemical causes and cures:

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Dendrites

Cell body

Axon

Axon terminals

1. Studies showed that antipsychotic drugs have beneficial effects on MAJOR PARTS OF A NEURON people with schizophrenia, that lithium is useful in controlling affec- F I G U R E The major parts of a neuron include dendrites, the cell tive disorders, and that tricyclics and monoamine oxidase inhibitors body, the axon, and the axon terminals. alleviate symptoms of severely depressed patients. 2. Biochemical studies (U.S. Surgeon General, 1999) indicate that these drugs seem to work by blocking or facilitating neurotransmitter activity at receptor sites. Most current psychiatric drugs seem to affect one of five different transmitters: acetylcholine, dopamine, gamma aminobutyric acid (GABA), norepinephrine, and serotonin. 3. Certain chemical imbalances appear to be disorder specific. Insufficient dopamine, for example, is a possible cause of Parkinson’s disease. Ironically, an excess of dopamine has been implicated in the development of schizophrenia (Lickey & Gordon, 1991; Snyder, 1986). Two hypotheses have been proposed: that people with schizophrenia may have too many postsynaptic dopamine

2.5

Sending Neuron Dendrite

Axon

Synapse

Axon

synapse minute gap that exists between the axon of the sending neuron and the dendrites of the receiving neuron

Axon terminal

Dendrites

FIGURE

2.6

Receiving Neuron

SYNAPTIC TRANSMISSION Messages travel via electrical impulses from one neuron to another. The impulse crosses the synapse in the form of chemicals called neurotransmitters. Note that the axon terminals and the receiving dendrites do not touch.

chemical substance released by the axon of the sending neuron and involved in the transmission of neural impulses to the dendrite of the receiving neuron

neurotransmitter

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Axon

Axon terminals

Neurotransmitters released by axon

receptors (a structural explanation) or that their receptors may be supersensitive to dopamine. The effect of drug therapy on receptor sites has been shown with other disorders. Drugs used to treat depression alter norepinephrine and serotonin sensitivity and receptivity at the receptor sites. Drugs used in the treatment of anxiety affect receptor reactivity to GABA. Research into biochemical mechanisms holds great promise for our understanding and treatment of mental disorders. It appears unlikely, however, that biochemistry alone can provide completely satisfactory explanations of the biological bases of abnormal behavior. Researchers should instead expect to find hundreds—or perhaps even thousands— of pieces in the biological puzzle.

Genetic Explanations Research strongly indicates that genetic makeup plays an important role in the development of certain abnormal conditions. There is strong Synapse evidence that autonomic nervous system (ANS) reactivity is inherited in human beings; that is, a person may be born with an ANS that makes an unusually strong response to stimuli (Andreasen, 2005; Baker & Binding Clark, 1990). Other studies (Carey & DiLalla, 1994; Cloninger, et al. 1986; Gatz, 1990; Plomin et al., 1994) implicate heredity as a causal factor in alcoholism, schizophrenia, and depression. To show that a particular disorder is inherited, however, researchers must demonstrate Receptor sites Nonbinding that it could not be caused by environmental factors alone, that closer genetic relationships produce greater similarity of the disorder in human Dendrite beings, and that people with these problems have similar biological and behavioral patterns (Siegel, 1990). Biological inheritance is transmitted by genes. A person’s genetic FIGURE NEUROTRANSMITTER BINDING makeup is called his or her genotype. Interaction between the genotype Neurotransmitters are released into the synapse and and the environment results in the person’s phenotype, or observable travel to the receiving dendrite. Each transmitter has a physical and behavioral characteristics. At times, however, it is difficult specific shape that corresponds to a receptor site. Like to determine whether genotype or environment is exerting a stronger a jigsaw puzzle, binding occurs if the transmitter fits influence. For example, characteristics such as eye color are deterinto the receptor site. mined solely by our genotype—by the coding in our genes. But other physical characteristics, such as height, are determined partly by the genetic code and partly by environmental factors. Adults who were undernourished as children will be shorter than the height they were genetically capable of reaching, but even the most effective nutrition would not have caused them to grow taller than their “programmed” height limit. Perhaps the greatest breakthrough in our attempt to understand the impact of genes on human life comes from the accomplishments of the Human Genome Project (HGP). In June 2000, it was announced that the locations of all genes had been mapped in the nucleus of a human cell, and approximately a year later researchers also completed its sequencing (the order of the DNA chemical subunits in each cell). Often referred to as the “map of life” or the “total body manual,” the HGP was successful in creating a basic blueprint of the entire genetic material found in each cell of the body. The human genome is composed of all the genetic genotype person’s genetic material in the chromosomes of a particular organism and is the most complex makeup instruction manual ever conceived on how the body works. Many scientists believe that the successful mapping and sequencing of the human genome will reveal phenotype observable physical life’s secrets: how our physical characteristics are determined, how we age, our and behavioral characteristics susceptibility to diseases, personality traits, and the proclivity to develop mental caused by the interaction between disorders, for example. The challenge is our inability to fully read the manual or to the genotype and the environment understand what it means. genome all the genetic material However, we have begun to accumulate scientific data that suggest the potential in the chromosomes of a particular importance of the HGP. In 1993, for example, scientists discovered the gene that organism determines the occurrence of Huntington’s disease, which causes an irreversible

2.7

Dimension One: Biological Factors

TA B L E

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2.1

MAJOR NEUROTRANSMITTERS AND THEIR EFFECTS NEUROTRANSMITTER

SOURCE AND FUNCTION

Acetylcholine (ACH)

One of the most widespread neurotransmitters. Occurs in systems that control the muscles and in circuits related to attention and memory. Reduction in levels associated with Alzheimer’s disease.

Dopamine

Concentrated in small areas of the brain, one of which is involved in the control of the muscles. In excess, dopamine can cause hallucinations. Associated with schizophrenia.

Endorphins

Found in the brain and spinal cord. Suppresses pain.

Gamma aminobutyric acid (GABA)

Widely distributed in the brain. Works against other neurotransmitters, particularly dopamine.

Norepinephrine

Occurs widely in the central nervous system. Regulates moods and may increase arousal and alertness. Often associated with mood disorders and eating disorders.

Serotonin

Occurs in the brain. Works more or less in opposition to norepinephrine, suppressing activity and causing sleep. Linked with anxiety disorders, mood disorders, and eating disorders.

degeneration of the nervous system. The genes associated with hereditary diseases such as cystic fibrosis, muscular dystrophy, neurofibromatosis, and retinoblastoma have been identified as well. Proponents of the HGP speculate that findings may offer a way of understanding the causes, prevention, and treatment for many types of sleep disorders, addictions, obesity, cancer, heart disease, and sickle cell anemia (Netting, 2001). Already, a new field called pharmacogenomics, the science of understanding the correlation between a patient’s genetic makeup and his or her response to drug treatment, has drug manufacturers poised to develop more effective pharmacological treatments.

Biology-Based Treatment Techniques Biological or somatic treatment techniques use physical means to alter the patient’s physiological state and hence his or her psychological state (Andreasen, 2005; Kolb et al., 2003; Miller & Keller, 2000). As our understanding of human physiology and brain functioning has increased, so has our ability to provide more effective biologically based therapies for the mentally ill (U.S. Surgeon General, 1999). Psychopharmacology Psychopharmacology is the study of the effects of drugs on the mind and on behavior; it is also known as medication or drug therapy. Medication is now widely used throughout the United States: more mental patients receive drug therapy than receive all other forms of therapy combined (Levinthal, 2005). The four large classes of medication are (1) antianxiety drugs (or minor tranquilizers), (2) antipsychotic drugs (or major tranquilizers), (3) antidepressant drugs (which relieve depression by elevating one’s mood), and (4) antimanic drugs (such as lithium). Many of these drugs are discussed more thoroughly in the context of specific disorders in forthcoming chapters. Antianxiety drugs (minor tranquilizers) such as propanediols (meprobamate compounds) and benzodiazepines are the preferred medications to calm and reduce anxiety in people. Researchers first developed meprobamate (the generic name of Miltown and Equanil) for use as a muscle relaxant and anxiety reducer. Within a few years, it was being prescribed for patients who complained of anxiety and nervousness or who had psychosomatic problems. Soon other drugs, such as the benzodiazepines (Librium and Valium), also entered the market. Studies suggest that the benzodiazepines work by binding to specific receptor sites at the synapses and blocking transmission (Hayward, Wardie, & Higgitt, 1989).

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Although antianxiety medications reduce anxiety in patients, they have minimal impact on the hallucinations and distorted thinking of highly agitated patients and patients with schizophrenia. In 1950, a synthetic antipsychotic drug (major tranquilizer) was developed in France called chlorpromazine (the generic name of Thorazine). It had an unexpected tranquilizing effect that decreased patients’ interest in the events around them and significantly reduced psychotic symptoms (believed to be a biochemical effect of blocking dopamine receptors). Within less than a year after its introduction, some 2 million patients used Thorazine. Thereafter, a number of other major tranquilizers were developed, mainly for patients with schizophrenia. Antidepressant drugs help individuals feel less depressed. Three large classes of the medication compounds have been identified: monoamine oxidase inhibitors, tricyclics, and selective serotonin reuptake inhibitors (a type of tricyclic). Monoamine oxidase inhibitors (MAOIs) are antidepressant compounds that are believed to correct the balance of neurotransmitters in the brain. They block the action of monoamine oxidase, thereby preventing the breakdown of norepinephrine and serotonin. More frequently used in cases of depression are the tricyclics, antidepressant compounds that relieve symptoms of depression and seem to work like the MAOIs but produce fewer of the side effects associated with prolonged drug use. The medication imipramine, a tricyclic, has been at least as effective as psychotherapy in relieving the symptoms of depression (Elkin et al., 1995). Increasingly, however, selective serotonin reuptake inhibitors (SSRIs) have become the preferred choice for treating depression. They work by inhibiting the central nervous system’s neuronal uptake of serotonin—a mechanism that appears to be extremely effective for treating unipolar depression (Seligman & Levant, 1998). SSRIs include the drugs Prozac (fluoxetine hydrochloride), Paxil (paroxetine), and Zoloft (sertraline). Antimanic drugs such as lithium are mood-controlling medications that have been very effective in treating bipolar disorders, especially mania (Klerman et al., 1994). About 70 to 80 percent of manic states can be controlled by lithium, and it also controls depressive episodes. How lithium works remains highly speculative. One hypothesis is that it limits the availability of serotonin and norepinephrine at the synapses and produces an effect opposite from that of antidepressants. Yet lithium’s ability to relieve depression appears to contradict this explanation. Other speculations involve electrolyte changes in the body, which alter neurotransmission in some manner. The use of antidepressant, antianxiety, antipsychotic, and antimanic drugs has greatly changed therapy. Patients who take them report that they feel better, that symptoms decline, and that overall functioning improves. Long periods of hospitalization are no longer needed in most cases, and patients are more amenable to other forms of treatment, such as psychotherapy. Remember, however, that medications do not cure mental disorders. Some would characterize their use as “control measures,” somewhat better than traditional hospitalization, “straitjackets,” or “padded cells.” Furthermore, medications seem to be most effective in treating “active” symptoms such as delusions, hallucinations, and aggression and much less effective with “passive” symptoms such as withdrawal, poor interpersonal relationships, and feelings of alienation. Medication does not help patients improve their living skills. Electroconvulsive Therapy Besides medication, electroconvulsive therapy (ECT) can be used to treat certain mental disorders. ECT is the application of electric voltage to the brain to induce convulsions. The patient lies on a padded bed or couch and is injected with a muscle relaxant to minimize the chance of self-injury during the convulsions. Evidence suggests that the treatment is particularly useful for endogenous cases of depression—those in which some internal cause can be determined (Klerman et al., 1994; see also Chapter 11, this volume). But how ECT acts to improve depression is still unclear. Despite its success, the use of ECT has declined significantly since the 1960s and 1970s because of potential permanent damage to the brain and the ethical objections raised by detractors.

Dimension One: Biological Factors

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Psychosurgery During the 1940s and 1950s, psychosurgery—brain surgery performed for the purpose of correcting a severe mental disorder—became increasingly popular. The treatment was used most often with patients suffering from schizophrenia and severe depression, although many who had personality and anxiety disorders also underwent psychosurgery. Critics of psychosurgical procedures have raised both scientific and ethical objections.

Multipath Implications of Biological Explanations In keeping with our multipath model, we believe that the majority of human diseases are multidimensional and multifactorial, caused by many genes interacting in a cellular environment of hormones, electrical signals, and nutrient supplies, as well as in our physical, psychological, social, and cultural environments. If the majority of mental disorders are indeed multifactorial, then any single gene or group of genes has small effects, not large ones. Our multipath model places in context our wider view of the etiology of mental disorders. First, most biological explanations implicitly assume a correspondence between organic dysfunction and mental dysfunction, with only a minimal impact from environmental, social, or cultural influences. They are one-dimensional and linear (that is, unidirectional rather than bidirectional). Muscular dystrophy, for example, was found to be traceable to a single gene. Such a relationship is often cited as evidence not only of the power of biology but also that disorders are the result of a one-way cause-effect direction. A one-to-one correspondence such as this one, however, is a rarity in behavioral genetics. Such diseases account for only 2 percent of the disease load, whereas disorders associated with the genes for bipolar disorders, cancers, and heart disease together make up 70 percent of the disease load (Strohman, 2001). Second, mental health researchers have increasingly come to reject a simple linear explanation of genetic determinism: that bad biology leads to a mental disorder, or the simple model of “one gene for one disease” (Strohman, 2001). Rather, disorders are seen as the result of complex interactive and oftentimes reciprocal processes. Such an early formulation is the diathesis-stress theory originally proposed by Meehl (1962) and developed further by Rosenthal (1970). The diathesis-stress theory holds that it is not a particular abnormality that is inherited but rather a predisposition to develop illness (diathesis). Certain environmental forces, called stressors, may activate the predisposition, resulting in a disorder. Alternatively, in a benign and supportive environment, the abnormality may never materialize. Third, gene-environment interactions appear much more complex than having a “predisposition” to develop a disorder. Research reveals that certain genes or gene combinations may actually promote an environment likely to elicit stressors that negatively affect the individual (Plomin & McGuffin, 2003; Silberg et al., 1999). In other words, in addition to conveying a predisposition for a disorder such as depression, genes may also predispose a person to seek out situations that will place them at high risk of experiencing stressors that trigger depression. Adolescent girls prone to depression, for example, may actually seek out situations that promote mood disorders (such as selecting unstable boyfriends who increase the probability of breakups). Fourth, studies reveal that different forms of the same genes, called alleles, and critical developmental periods in the life of an individual may determine whether, when, how, and what mental disturbances develop. In one longitudinal study of children from age five through their mid-twenties, researchers assessed multiple variables such as abuse, stressful life events, and depression (Caspi et al., 2003). They measured a particular gene, the serotonin transporter gene (5-HTT), in each of the participants. They identified three groups of people: (1) those with two short alleles, (2) those with two long alleles, and (3) those with one short and one long allele. Children with the two short alleles and with one short and one long allele who had been mistreated were more likely to experience depression as adults. However, those with the same gene combinations who had not been abused as children were less likely to develop

theory that holds that people do not inherit a particular abnormality but rather a predisposition to develop illness (diathesis) and that certain environmental forces, called stressors, may activate the predisposition, resulting in a disorder

diathesis-stress theory

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s it possible that what you eat can change your genes? Some scientists believe that when our ancestors changed their diets (primarily fruit and nuts) to heavy starch consumption (cereals such as wheat and barley) our brains eventually swelled to three times the size of chimpanzees’ and separated us from the lower primates. The breakdown of starches to sugar provided neural tissue with energy that changed the human genome. You are what you eat! (N. Wade, 2007).

depression. Additionally, those with the long-long combination, even when mistreated, were also less likely to develop depression. A review of studies on affective and anxiety disorders is not only consistent with these findings but also suggests strongly that gene-environment interactions that occur at early critical periods can set the stage for later behavioral phenotypes (Leonardo & Hen, 2006). It is clear that simply having a specific gene and encountering environmental stressors is not enough to predict the manifestation of a mental disorder. Rather, the configuration of the gene, the specific stressors, and the times at which they occur (critical periods) play important roles. Fifth, accumulating evidence strongly suggests that biochemical changes, brain activity, and even structural neurological circuitry often occur because of environmental influence (Gottsman & Gould, 2003; Leonardo & Hen, 2006). We know, for example, that stress-produced fear and anger cause the secretion of adrenaline and noradrenalin. Similarly, schizophrenia, rather than resulting from the presence of such chemicals as dopamine, could cause the secretion of excess amounts of the chemicals in persons with the disorder. Through brain imaging studies we also know that psychotherapeutic interventions have been found to “normalize” brain circuitry in people suffering from depression (Leuchter et al., 2002), obsessive-compulsive disorders (Baxter et al., 1992), phobias (Paquette et al., 2003), and tolerance of pain (Petrovic, Kalso, Peterson, & Ingvar, 2002). In conclusion, although biology influences the development of mental disorders, an equally powerful reciprocal influence on brain activity, brain circuitry, and biochemical production/inhibition is exerted by the environment as well.

Dimension Two: Psychological Factors

Did You Know?

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he importance of early childhood experiences, the role of the unconscious, and the use of insight continue to influence the mental health practice. One study revealed that 18 percent of clinical psychologists, 12 percent of counseling psychologists, 35 percent of psychiatrists, 33 percent of social workers, and 11 percent of counselors describe their orientation as “psychoanalytic/psychodynamic” (Prochaska & Norcross, 1999).

psychodynamic model model that views disorders as the result of childhood trauma or anxieties and that holds that many of these childhood-based anxieties operate unconsciously defense mechanism

in psychoanalytic theory, an egoprotection strategy that shelters the individual from anxiety, operates unconsciously, and distorts reality

Figure 2.1 lists a number of psychological factors that have been shown to be important in the etiology of mental disorders. Especially important for the psychological dimension are conflicts in the mind, emotions, learned behavior, and cognitions in personality formation. Like many biological explanations, psychological theories can also be prone to viewing normal and abnormal human development in a linear and one-dimensional fashion. They can also suffer from tunnel vision in explaining mental disorders as arising from psychological rather than biological, social, or sociocultural factors. Interestingly, psychological explanations of abnormal behavior vary considerably depending on the psychologist’s theoretical orientation. For example, in our chapter-opening case, Steve’s therapist might stress his client’s intrapsychic conflicts and the need to resolve and control extreme feelings of rage and hostility toward authority figures. Other psychologists might concentrate on his social isolation, being cared for by a caretaker who spoke no English and who would send him to his room when he misbehaved. As a result, Steve had few role models from whom to learn appropriate social skills that would lead to successful interpersonal relationships. Other theorists might conjecture that Steve crafted a fantasy world from his violent videos (his source of reality) because of infrequent checks and balances from his primary caretaker or parents. As a result, not only is the content of his thoughts irrational, but his thinking process has also become distorted. In this section, we briefly describe four major psychological perspectives in explaining abnormal behavior: psychodynamic, behavioral, cognitive, and existentialhumanistic. We then apply a multipath analysis to these four approaches.

Psychodynamic Models Psychodynamic models of abnormal behavior have two main distinguishing features. First, they view disorders as the result of childhood trauma or anxieties. Second, they hold that many of these childhood-based anxieties operate unconsciously; because experiences are too threatening for the adult to face, they are repressed through mental defense mechanisms—ego-protection strategies that shelter the individual from anxiety, operate unconsciously, and distort reality. As a result, people exhibit symptoms that they are unable to understand because they are manifestations of the unconscious conflicts. The early development of psychodynamic theory

Dimension Two: Psychological Factors

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is credited to Sigmund Freud (1938, 1949). Freud was convinced that powerful mental processes could remain hidden from consciousness and could cause abnormal behaviors. He believed that the therapist’s role was to help the patient achieve insight into these unconscious processes. Personality Structure Freud believed that personality is composed of three major components—the id, the ego, and the superego—and that all behavior is a product of their interaction. The id is the original component of the personality; it is present at birth, and from it the ego and superego eventually develop. The id operates from the pleasure principle—the impulsive, pleasure-seeking aspect of our being—and it seeks immediate gratification of instinctual needs, regardless of moral or realistic concerns. In contrast, the ego represents the realistic and rational part of the mind. It is influenced by the reality principle—an awareness of the demands of the environment and of the need to adjust behavior to meet these demands. The ego’s decisions are dictated by realistic considerations rather than by moral judgments. Moral judgments and moralistic considerations are the domain of the superego. The superego is composed of the conscience, which instills guilt feelings about engaging in immoral or unethical behavior, and the ego ideal, which rewards altruistic or moral behavior with feelings of pride. The energy system from which the personality operates occurs through the interplay of instincts. Instincts give rise to our thoughts and actions and fuel their expression. Freud emphasized sex (libido) and aggression as the dominant human instincts because he recognized that the society in which he lived placed strong prohibitions on these drives and that, as a result, people were taught to inhibit them. A profound need to express one’s instincts is often frightening and can lead a person to deny their existence. Most impulses are hidden from one’s consciousness; they nonetheless determine human actions. Psychosexual Stages According to psychodynamic theory, human personality develops through a sequence of five psychosexual stages, each of which brings a unique challenge. If unfavorable circumstances prevail, the personality may be drastically affected. Because Freud stressed the importance of early childhood experiences, he saw the human personality as largely determined in the first five years of life—during the oral (first year of life), anal (around the second year of life), and phallic (beginning around the third or fourth years of life) stages. The last two psychosexual stages are the latency (approximately six to twelve years of age) and genital (beginning in puberty) stages. The importance of each psychosexual stage for later development lies in whether fixation occurs during that stage. Fixation is the arresting of emotional development at a particular psychosexual stage. According to the psychodynamic model, each stage is characterized by distinct traits and, should fixation occur, by distinct conflicts. Traditional Psychodynamic Therapy Psychoanalytic therapy, or psychoanalysis, has three main goals: (1) uncovering repressed material, (2) helping clients achieve insight into their inner motivations and desires, and (3) resolving childhood conflicts that affect current relationships. Psychoanalysts traditionally use four methods to achieve their therapeutic goals: free association, dream analysis, analysis of resistance, and analysis of transference. • In free association, the patient says whatever comes to mind, regardless of how illogical or embarrassing it may seem, for the purpose of revealing the contents of the patient’s unconscious. Psychoanalysts believe the material that surfaces in this process is determined by the patient’s psychic makeup and can provide understanding of the patient’s conflicts, unconscious processes, and personality dynamics. • Dream analysis is a therapeutic technique that depends on interpretation of hidden meanings in dreams. Psychoanalysts believe that when people sleep, defenses and inhibitions of the ego weaken, allowing unacceptable motives and feelings to surface. The therapist’s job is to uncover the disguised symbolic meanings and let the patient achieve insight into the anxiety-provoking implications.

SIGMUND FREUD (1856–1939) Freud began his career as a neurologist. He became increasingly intrigued with the relationship between illness and mental processes and ultimately developed psychoanalysis, a therapy in which unconscious conflicts are aired so that the patient can become aware of and understand his or her problems.

the impulsive, pleasure-seeking aspect of our being from which the id operates

pleasure principle

an awareness of the demands of the environment and of the need to adjust behavior to meet these demands from which the ego operates

reality principle

psychosexual stages

in psychodynamic theory, the sequence of stages—oral, anal, phallic, latency, and genital—through which human personality develops psychoanalysis therapy whose goals are to uncover repressed material, to help clients achieve insight into inner motivations and desires, and to resolve childhood conflicts that affect current relationships free association psychoanalytic therapeutic technique in which the patient says whatever comes to mind for the purpose of revealing his or her unconscious

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PSYCHOSEXUAL STAGES During the oral stage, the first stage of psychosexual development, the infant not only receives nourishment but also derives pleasure from sucking and being close to its mother. Later, during the anal stage, toilet training can be a time of intense emotional conflict between parent and child, or it can be a time of cooperation.

• Analysis of resistance—a process in which the patient unconsciously attempts to impede the analysis by preventing the exposure of repressed material—is employed to interpret and uncover the repressed material. In free association, for example, the patient may suddenly change the subject, lose his or her train of thought, go blank, or become silent. The therapist can make use of properly interpreted instances of resistance to show the patient that repressed material is coming close to the surface and to suggest means of uncovering it. • In transference the patient reenacts early conflicts by carrying over and applying to the analyst feelings and attitudes that the patient had toward significant others— primarily parents—in the past. Working through transference is considered therapeutic.

Contemporary Psychodynamic Theories Freud’s psychoanalytic approach attracted many followers. Some of Freud’s disciples, however, came to disagree with his insistence that the sex instinct is the major determinant of behavior. Many of his most gifted adherents broke away from him and formulated psychological models of their own. The major differences between the various postFreudian theories and psychoanalysis lie in the emphasis that the former placed on five areas: freedom of choice and future goals, ego autonomy, social forces, object relations (past interpersonal relations), and treatment of seriously disturbed people. Some of these major theorists and their contributions are outlined in Table 2.2. Today, very few psychodynamic therapists practice traditional psychoanalysis. Most are more active in their sessions, restrict the number of sessions they have with clients, place greater emphasis on current rather than past factors, and seem to have adopted a number of client-centered techniques in their practice (Nystul, 2003).

during psychoanalysis, a process in which the patient unconsciously attempts to impede the analysis by preventing the exposure of repressed material

resistance

process by which a patient reenacts early conflicts by carrying over and applying to the analyst feelings and attitudes that the patient had toward significant others in the past

transference

Criticisms of Psychodynamic Models Psychodynamic theory has strongly affected the field of psychology, and psychoanalysis and its variations are widely employed. Nonetheless, three major criticisms are often leveled at psychodynamic theory and treatment (Joseph, 1991). First, the empirical procedures by which Freud validated his hypotheses have grave shortcomings. His observations about human behavior were often made under uncontrolled conditions and relied heavily on case studies. He also used his own self-analysis as a basis for formulating theory. His patients, from whom he drew conclusions about universal aspects of personality dynamics and behavior, tended to represent a narrow spectrum of one society. Second, his theory of female sexuality and personality has drawn heavy criticism from feminists. Phallic-stage dynamics, penis envy, unfavorable comparisons of the clitoris to the penis, the woman’s need for a male child as a penis substitute, and the belief that penetration is necessary for a woman’s sexual satisfaction all rest on assumptions that are biologically questionable and that fail to consider social forces that shape women’s behavior. A third criticism of psychoanalysis is that it cannot be applied to a wide range of disturbed people. Research studies have shown that psychoanalytic therapy is best suited to well-educated people of

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2.2

CONTRIBUTIONS OF POST-FREUDIANS AND PSYCHOANALYTIC THERAPISTS Traditional psychoanalytic theory has changed over the years due to the work of post-Freudians and others. Although most of the individuals listed here accept many of the basic tenets of the theory, they have stressed different aspects of the human condition. Some differences are listed below. 1. Freedom of choice and future goals People are not just mechanistic beings. They have a high degree of free choice and are motivated toward future goals. Alfred Adler (1870–1937) Stressed that people are not passive victims of biology, instincts, or unconscious forces. Stressed freedom of choice and goals directed by means of social drives. Carl Jung (1875–1965) Believed in the collective unconscious as the foundation of creative functioning. Believed that humans were goal directed and future oriented. 2. Ego autonomy The ego is an autonomous entity and can operate independently from the id. It is creative, forward moving, and capable of continual growth. Anna Freud (1895–1982) Emphasized the role, operation, and importance of the ego. Believed ego is an autonomous component of the personality and not at the mercy of the id. Erik Erikson (1902–1994) Perhaps the most influential of the ego theorists. Formulated stages of ego development from infancy to late adulthood—one of the first true developmental theorists. Considered personality to be flexible and capable of growth and change throughout the adult years. 3. Social forces Interpersonal relationships are of primary importance in our psychological development. Especially influential are our primary social relationships. Karen Horney (1885–1952) Often considered one of the first feminist psychologists who rejected Freud’s notion of penis envy. Stressed that behavior disorders are due to disturbed interpersonal childhood relationships.

Harry Stack Sullivan (1892–1949) Major contribution was his interpersonal theory of psychological disorders. Believed that the individual’s psychological functions could be understood only in the context of his or her social relationships. 4. Object relations The technical term object relations is roughly equivalent to “past interpersonal relations.” It refers to how people develop patterns of living from their early relations with significant others. Heinz Kohut (1913–1981) Felt it was especially important to study the mother-child relationship. Known for his work on the narcissistic personality. Otto Kernberg (1928– ) Known especially for his studies of the borderline personality. Especially interested in understanding how clients seem to have difficulty in forming stable relationships because of pathological objects in the past. 5. Treatment of the seriously disturbed Freud believed that psychoanalysis could not be used with very seriously disturbed individuals because they were “analytically unfit.” By this he meant that they did not have sufficient contact with reality to benefit from insight. Hyman Spotnitz (1908– ) Demonstrated that modern psychoanalysis could be used with severely disturbed clients. Associated with new treatment techniques that do not require clients to be intellectually capable of understanding interpretations. Techniques provide feedback that helps client resolve conflicts by experiencing them rather than understanding them.

the middle and upper socioeconomic classes who exhibit anxiety disorders rather than psychotic behavior (Corey, 2005). It is more limited in therapeutic value with people of lower socioeconomic levels and with people who are less verbal, less intelligent, and more severely disturbed (Sloane, Staples, Cristol, Yorkston, & Whipple, 1975).

Behavioral Models The behavioral models of psychopathology are concerned with the role of learning in abnormal behavior. The differences among them lie mainly in their explanations of how learning occurs (Corey, 2005; Kottler, 2002). The three learning paradigms are classical conditioning, operant conditioning, and observational learning.

behavioral models models of psychopathology concerned with the role of learning in abnormal behavior

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IVAN PAVLOV (1849–1936) A Russian physiologist, Pavlov discovered the associative learning process we know as classical conditioning while he was studying salivation in dogs. Pavlov won the Nobel Prize in physiology and medicine in 1904 for his work on the principal digestive glands.

FIGURE

2.8

A BASIC CLASSICAL CONDITIONING PROCESS Dogs normally salivate when food is provided (left drawing). With his laboratory dogs, Ivan Pavlov paired the ringing of a bell with the presentation of food (middle drawing). Eventually, the dogs would salivate to the ringing of the bell alone, when no food was near (right drawing).

classical conditioning a process in which responses to new stimuli are learned through association unconditioned stimulus (UCS)

in classical conditioning, the stimulus that elicits an unconditioned response unconditioned response (UCR)

in classical conditioning, the unlearned response made to an unconditioned stimulus conditioned stimulus (CS)

in classical conditioning, a previously neutral stimulus that has acquired some of the properties of another stimulus with which it has been paired conditioned response (CR)

in classical conditioning, a learned response to a previously neutral stimulus that has acquired some of the properties of another stimulus with which it has been paired

Stimulus:

UCS (food)

UCS & CS (food & bell)

CS (bell alone)

Response:

UCR (salivation)

UCR (salivation)

CR (conditioned salivation)

The Classical Conditioning Paradigm Early in the twentieth century, Ivan Pavlov (1849–1936), a Russian physiologist, discovered a process known as classical conditioning, in which responses to new stimuli are learned through association. This process involves involuntary responses (such as reflexes, emotional reactions, and sexual arousal), which are controlled by the autonomic nervous system. Pavlov was measuring dogs’ salivation as part of a study of their digestive processes when he noticed that the dogs began to salivate at the sight of an assistant carrying their food. This response puzzled Pavlov and led to his formulation of classical conditioning. He reasoned that food is an unconditioned stimulus (UCS), which, in the mouth, automatically elicits salivation; this salivation is an unlearned or unconditioned response (UCR) to the food. Pavlov then presented a previously neutral stimulus (one, such as the sound of a bell, that does not initially elicit salivation) to the dogs just before presenting the food. He found that, after a number of repetitions, the sound of the bell alone elicited salivation. This learning process is based on association: the neutral stimulus (the bell) acquires some of the properties of the unconditioned stimulus (the food) when they are repeatedly paired. When the bell alone can provoke the salivation, it becomes a conditioned stimulus (CS). The salivation elicited by the bell is a conditioned response (CR)—a learned response to a previously neutral stimulus. Each time the conditioned stimulus is paired with the unconditioned stimulus, the conditioned response is said to be reinforced, or strengthened. Pavlov’s conditioning process is illustrated in Figure 2.8. Classical Conditioning in Psychopathology John B. Watson (1878–1958) is credited with recognizing the importance of associative learning in the explanation of abnormal behavior. In a classic and oft-cited experiment, Watson (Watson & Rayner, 1920), using classical conditioning principles, was able to demonstrate that

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OPERANT CONDITIONING IN THE CLASSROOM In operant conditioning, positive consequences increases the likelihood and frequency of a desired response. This is particularly important in teaching young children that appropriate behavior will be rewarded and inappropriate behavior will be punished. These first graders are being treated to a petting zoo for good behavior maintained in the classroom. The reward is changed on a monthly basis.

the acquisition of a phobia (an exaggerated, seemingly illogical fear of a particular object or class of objects) could be explained by classical conditioning. In fact, classical conditioning has provided explanations not only for the acquisition of phobias but also for certain unusual sexual attractions and other extreme emotional reactions. Yet the passive nature of associative learning limited its usefulness as an explanatory and treatment tool. Most human behavior, both normal and abnormal, tends to be much more active and voluntary. To explain how these behaviors are acquired or eliminated necessitates an understanding of operant conditioning. The Operant Conditioning Paradigm An operant behavior is a voluntary and controllable behavior, such as walking or thinking, that “operates” on an individual’s environment. In an extremely warm room, for example, you would have difficulty consciously controlling your sweating—“willing” your body not to perspire. You could, however, simply walk out of the uncomfortably warm room—an operant behavior. Most human behavior is operant in nature. Edward Thorndike (1874–1949) first formulated the concept of operant conditioning, which he called instrumental conditioning. This theory of learning holds that behaviors are controlled by the consequences that follow them. Some fifty years later, B. F. Skinner (1904–1990) developed Thorndike’s work and made the concept of reinforcement central. Operant conditioning differs from classical conditioning in two primary ways. First, classical conditioning is linked to the development of involuntary behaviors, such as fear responses, whereas operant conditioning is related to voluntary behaviors. Second, behaviors based on classical conditioning are controlled by stimuli, or events preceding the response: salivation occurs only when it is preceded by a UCS (food in the mouth) or a CS (the thought of a sizzling, juicy steak covered with mushrooms, for example). In operant conditioning, however, behaviors are controlled by reinforcers—consequences that influence the frequency or magnitude of the event they follow. Positive consequences increase the likelihood and frequency of a response. But when the consequences are negative, the behavior is less likely to be repeated. Operant Conditioning in Psychopathology Studies have demonstrated a relationship between environmental reinforcers and certain abnormal behaviors. For example, self-injurious behavior, such as head banging, is a dramatic form of psychopathology that is often reported in psychotic, autistic, and mentally retarded children. It has been hypothesized that some forms of head banging may be linked to

B. F. SKINNER (1904–1990) Skinner was a leader in the field of behaviorism. His research and work in operant conditioning started a revolution in applying the principles of learning to the psychology of human behavior. He was also a social philosopher, and many of his ideas fueled debate about the nature of the human condition. These ideas were expressed in his books Walden II and Beyond Freedom and Dignity.

operant behavior a voluntary and controllable behavior, such as walking or thinking, that “operates” on an individual’s environment operant conditioning a theory of learning that holds that behaviors are controlled by the consequences that follow them

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reinforcing features in the environment, as when parents distract the child by giving him or her candy (Corey, 2005; Sommers-Flanagan & Sommers-Flanagan, 2004). It has also been found that self-injurious behaviors, hallucinations, and delusional statements can be developed and maintained through reinforcement. Likewise, some forms of alcohol or substance abuse may be due to the initial pleasurable feelings and lowered anxieties people experience (Carey & Carey, 1995). Although positive reinforcement can account for some forms of self-injurious or other undesirable behaviors, in some instances other variables seem more important. Negative reinforcement (the removal of an aversive stimulus), for example, can also strengthen and maintain unhealthy behaviors. Consider a student who has enrolled in a class in which the instructor requires oral reports. The thought of doing an oral presentation in front of a class produces anxiety, sweating, an upset stomach, and trembling in the student. Having these feelings is aversive. To stop the unpleasant reaction, the student switches to another section in which the instructor does not require oral presentations. The student’s behavior is reinforced by escape from aversive feelings, and such avoidant responses to situations involving “stage fright” will increase in frequency.

Myth vs Reality Myth: Behavioral approaches assume that people are completely the products of their conditioning histories, that they are passive participants in the developmental process, and that they have little free will. These approaches deny the importance of “mental life” in people. They seem more focused on behaviors and seem to believe people are mechanistic and robotic in their actions. Reality: Whereas early behaviorism, under the influence of John B. Watson (and to some extent B. F. Skinner), saw people as primarily the products of their conditioning histories and felt that speculating about the “inner life” of a person was unscientific, such rigid concepts have given way to a more holistic and integrated interpretation of the learning process. Behaviorally oriented mental health professionals are now very much involved in understanding how the internal mental life of the person affects the acquisition and treatment of certain disorders. They now acknowledge that people are not passive beings and have increasingly moved toward using social modeling and cognitive processes to supplement the principles of both classical and operant learning models.

The Observational Learning Paradigm The traditional behavioral theories of learning—classical conditioning and operant conditioning—require that the individual actually perform behaviors to learn them. Observational learning theory suggests that an individual can acquire new behaviors simply by watching other people perform them (Bandura, 1997; Cormier & Cormier, 1998). The process of learning by observing models (and later imitating them) is called vicarious conditioning or modeling. Direct and tangible reinforcement (such as giving praise or other rewards) for imitation of the model is not necessary, although reinforcers are necessary to maintain behaviors learned in this manner. Observational learning can involve both respondent and operant behaviors, and its discovery has had such an impact in psychology that it has been proposed as a third form of learning. observational learning theory

theory that suggests that an individual can acquire new behaviors by watching other people perform them modeling process of learning by observing models (and later imitating them)

Observational Learning in Psychopathology Models that attribute psychopathology to observational learning assume—as do those that emphasize classical and operant conditioning—that abnormal behaviors are learned in the same manner as normal behaviors. More specifically, the assumption is that exposure to disturbed models is likely to produce disturbed behaviors (James & Gilliland, 2003). For example, when monkeys watched other monkeys respond with fear to an unfamiliar object, they learned to respond in a similar manner (Cook, Hodes, & Lang, 1986).

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Criticisms of the Behavioral Models Behavioral approaches to psychopathology have had a tremendous impact in the areas of etiology and treatment, and they are a strong force in psychology today. Opponents of the behavioral orientation, however, point out that it often neglects or places a low importance on the inner determinants of behavior. They criticize the behaviorists’ extension to human beings of results obtained from animal studies. Some also charge that because of its lack of attention to human values in relation to behavior, the behaviorist perspective is mechanistic, viewing people as “empty organisms.” This specific criticism is less applicable to proponents of modeling.

Cognitive Models Cognitive models are based on the assumption that conscious thought mediates, or modifies, an individual’s emotional state and/or behavior in response to a stimulus. According to these models, people actually create their own problems (and symptoms) by the ways they interpret events and situations. For example, one person who fails to be hired for a job may become depressed, blaming himself or herself for the failure. Another might become only mildly irritated, believing that failure to get the job had nothing to do with personal inadequacy. How does it happen that events (not being hired for a job) are identical for both people but the responses are very different? Cognitive theories argue that modifying thoughts and feelings is essential to changing behavior. How people label a situation and how they interpret events profoundly affect their emotional reactions and behaviors. How a person interprets events is a function of his or her schema—a set of underlying assumptions heavily influenced by a person’s experiences, values, and perceived capabilities. Cognitive psychologists usually search for the causes of psychopathology in one of two processes: in actual irrational and maladaptive assumptions and thoughts or in distortions of the actual thought process. Irrational and Maladaptive Assumptions and Thoughts Almost all cognitive theorists stress that disturbed individuals have both irrational and maladaptive thoughts (Beck, 1997; Ellis, 1997). Aaron Beck (1921– ) and Albert Ellis (1913–2007) are cognitive psychologists who explain psychological problems as produced by

models based on the assumption that conscious thought mediates an individual’s emotional state and/or behavior in response to a stimulus

cognitive models

LEARNING BY OBSERVING Observational learning is based on the theory that behavior can be learned by observing it. Although much has been made of the relationship between violence and aggression viewed on television and in movies and violent behavior in real life, observational learning can have positive benefits as well.

schema a set of underlying assumptions heavily influenced by a person’s experiences, values, and perceived capabilities

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irrational thought patterns that stem from the individual’s belief system. Unpleasant emotional responses that lead to anger, unhappiness, depression, fear, and anxiety result from one’s thoughts about an event rather than from the event itself. These irrational thoughts have been conditioned through early childhood, but we also add to the difficulty by reinstilling these false beliefs in ourselves by autosuggestion and self-repetition. Although being accepted and loved by everyone is desirable, it is an unrealistic and irrational idea, and as such it creates dysfunctional feelings and behaviors. Consider a student who becomes depressed after an unsuccessful date. An appropriate emotional response in such an unsuccessful dating situation might be frustration and temporary disappointment. A more severe depression will develop only if the student adds irrational thoughts, such as “Because this person turned me down, I am worthless.. . . I will never succeed with anyone of the opposite sex.. . . I am a total failure.” Distortions of Thought Processes The study of cognitions as a cause of psychopathology has led many therapists to concentrate on the process (as opposed to the content) of thinking that characterizes both normal and abnormal individuals. Ellis (1997) described the process by which an individual acquires irrational thoughts through interactions with significant others, and he called it the A-B-C theory of personality. A is an event, a fact, or the individual’s behavior or attitude. C is the person’s emotional or behavioral reaction. The activating event A never causes the emotional or behavioral consequence C. Instead, B, the person’s beliefs about A, causes C. Think back to the two job hunters. Job hunter 1, whose activating event A was being turned down for the position, may think to himself (irrational beliefs B), “How awful to be rejected! I must be worthless. I’m no good.” Thus he may become depressed and withdraw (emotional and behavioral consequence C). Job hunter 2, on the other hand, reacts to the activating event A by saying (rational beliefs B), “How unfortunate to get rejected. It’s frustrating and irritating. I’ll have to try harder” (healthy consequence C). The two sets of assumptions and expectations are very different. Job hunter 1 blamed himself and was overcome with feelings of worthlessness; job hunter 2 recognized that not every person is right for every job (or vice versa) and left the situation with self-esteem intact. Job hunter 1 interprets the rejection as “awful and catastrophic” and, as a result, reacts with depression and may cease looking for a job. Job hunter 2 does not interpret the rejection personally, reacts with annoyance, and redoubles her efforts to seek employment. Figure 2.9 illustrates the A-B-C relationship and suggests a possible path for a cognitive approach to treatment. FIGURE

2.9 ELLIS’S A-B-C

THEORY OF PERSONALITY The development of emotional and behavioral problems is often linked to a dysfunctional thinking process. The cognitive psychologist is likely to attack these problematic beliefs using a rational intervention process, resulting in a change in beliefs and feelings.

Irrational Cognitive Process A Activating event (e.g., loss of job)

Rational Intervention B Belief (e.g., “How awful to lose my job. I must be worthless.”)

C Emotional and behavioral consequence (e.g., depression and withdrawal)

D Disputing intervention (e.g., challenge belief: “Losing a job has nothing to do with my self-worth.”)

E New effective philosophy (e.g., “I'm okay. I won't give up.”)

F New feelings (e.g., “It's okay to feel frustrated. I won't give up.”)

Dimension Two: Psychological Factors

Cognitive Approaches to Therapy Certain commonalities characterize almost all cognitive approaches to psychotherapy. These have been summarized by Beck and Weishaar (1989): Cognitive therapy consists of highly specific learning experiences designed to teach patients (1) to monitor their negative, automatic thoughts (cognitions); (2) to recognize the connections between cognition, affect, and behavior; (3) to examine the evidence for and against distorted automatic thoughts; (4) to substitute more reality-oriented interpretations for these biased cognitions; and (5) to learn to identify and alter the beliefs that predispose them to distort their experiences. (p. 308)

Criticisms of the Cognitive Models Some behaviorists remain quite skeptical of the cognitive schools. Just before his death, B. F. Skinner (1990) warned that cognitions are not observable phenomena and cannot form the foundations of empiricism. In this context, he echoed the historical beliefs of John B. Watson, who stated that the science of psychology was observable behaviors, not “mentalistic concepts.” Although Watson’s reference was to the intrapsychic dynamics of the mind postulated by Freud, Watson might have viewed cognitions in the same manner. Cognitive theories have also been attacked by more humanistically oriented psychologists who believe that human behavior is more than thoughts and beliefs (Corey, 2005). They object to the mechanistic manner by which human beings are reduced to the sum of their cognitive parts. Do thoughts and beliefs really cause disturbances, or do the disturbances themselves distort thinking? Criticisms have also been leveled at the therapeutic approach taken by cognitive therapists. The nature of the approach makes the therapist a teacher, expert, and authority figure. The therapist is quite direct and confrontive in identifying and attacking irrational beliefs and processes. In such interactions, clients can readily be intimidated into acquiescing to the therapist’s power and authority. Thus the therapist may misidentify the client’s disorder, and the client may be hesitant to challenge the therapist’s beliefs.

Humanistic and Existential Models Attempting to describe humanistic-existential approaches to the development of mental disorders is a major challenge. In many respects, humanistic approaches are philosophical in nature, deal with values, speak to the nature of the human condition, decry the use of diagnostic labels, and prefer a holistic view of the person. For example, humanists would describe Steve (in the chapter-opening case) as a flesh-and-blood person, alive, organic, and moving, with thoughts, feelings, and emotions. Diagnostic labels would be objectionable and serve only to pigeonhole people and act as barriers to the development of a therapeutic relationship. Understanding the subjective world of Steve’s experience, a humanist might say that it appears that he is feeling trapped, immobilized, and lonely and that he is externalizing his problems. In this way Steve may be evading responsibility for making his own choices and may be protecting himself by staying in the safe, known environment of his “illness.” According to the humanist perspective, Steve needs to realize that he is responsible for his own actions, that he cannot find his identity in others, and that his life is not predetermined. The humanistic and existential approaches evolved as a reaction to the determinism of early models of psychopathology. For example, many psychologists were disturbed that Freudian theory did not focus on the inner world of the client but rather categorized the client according to a set of preconceived diagnoses (May, 1967). They described clients in terms of blocked instinctual forces and psychic complexes that made them victims of some mechanistic and deterministic personality structure. Similarly, cognitive-behavioral schools of thought seemed to describe human beings as “learned responses,” “automatic beings,” and “deterministic creatures” who were victims of their conditioning histories. Although the humanistic and existential perspectives represent many schools of thought, they nevertheless share a set of assumptions that distinguishes them from other approaches. The first of these assumptions is that people’s realities are products of unique experiences and perceptions of the world. Moreover, a person’s

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subjective universe—how he or she construes events—is more important than the events themselves. Hence, to understand why people behave as they do, psychologists must reconstruct the world from an individual’s vantage point. Second, humanistic-existential theorists assume that individuals have the ability to make free choices and are responsible for their own decisions. Third, they believe in the “wholeness” or integrity of the person and view as pointless all attempts to reduce human beings to a set of formulas, to explain them simply by measuring responses to certain stimuli. And fourth, they assume that people have the ability to become what they want, to fulfill their capacities, and to lead the lives best suited to them.

humanistic perspective

the optimistic viewpoint that people are born with the ability to fulfill their potential and that abnormal behavior results from disharmony between the person’s potential and his or her self-concept an inherent tendency to strive toward the realization of one’s full potential

self-actualization

an individual’s assessment of his or her own value and worth

self-concept

The Humanistic Perspective One of the major contributions of the humanistic perspective is its positive view of the individual. Carl Rogers (1902–1987) is perhaps the best known of the humanistic psychologists. Rogers’s theory of personality (1959; 1961) reflects his concern with human welfare and his deep conviction that humanity is basically “good,” forward moving, and trustworthy. The Actualizing Tendency Instead of concentrating exclusively on behavior disorders, the humanistic approach is concerned with helping people actualize their potential and with bettering the state of humanity. Humanistic psychological theory is based on the idea that people are motivated not only to satisfy their biological needs (for food, warmth, and sex) but also to cultivate, maintain, and enhance the self. The self is one’s image of oneself, the part one refers to as “I” or “me.” The quintessence of this view is the concept of self-actualization—a term popularized by Abraham Maslow (1954)—which is an inherent tendency to strive toward the realization of one’s full potential. The actualizing tendency can be viewed as fulfilling a grand design or a genetic blueprint. This thrust of life that pushes people forward is manifested in such qualities as curiosity, creativity, and joy of discovery. How one views the self, how others relate to the self, and what values are attached to the self all contribute to one’s self-concept—the individual’s assessment of his or her own value and worth. Development of Abnormal Behavior Rogers believed that if people were left unencumbered by societal restrictions and were allowed to grow and develop freely, the result would be fully functioning people. In such a case, the self-concept and the actualizing tendency would be considered congruent. However, society frequently imposes conditions of worth on its members, standards by which people determine whether they have worth. These standards are transmitted via conditional positive regard. That is, significant others (such as parents, peers, friends, and spouse) in a person’s life accept some but not all of that person’s actions, feelings, and attitudes. The person’s self-concept becomes defined as having worth only when others approve. But this reliance on others forces the individual to develop a distorted self-concept that is inconsistent with his or her self-actualizing potential, inhibiting that person from being self-actualized. A state of disharmony or incongruence is said to exist between the person’s inherent potential and his or her self-concept (as determined by significant others). This state of incongruence forms the basis of abnormal behavior. Rogers believed that fully functioning people have been allowed to grow toward their potential. The environmental condition most suitable for this growth is called unconditional positive regard (Rogers, 1951). In essence, people who are significant figures in someone’s life value and respect that person as a person. Giving unconditional positive regard is valuing and loving regardless of behavior. People may disapprove of someone’s actions, but they still respect, love, and care for that someone. Person-Centered Therapy The assumption that humans need unconditional positive regard has many implications for child rearing and psychotherapy. For parents, it means creating an open and accepting environment for the child. For the therapist, it means fostering conditions that allow clients to grow and fulfill their potential; this approach has become known as nondirective or person-centered therapy. Rogers emphasized that therapists’ attitudes are more important than specific counseling techniques. The therapist needs to have a strong positive regard for the client’s ability to deal constructively with all aspects of life. The more willing the therapist is to rely

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on the client’s strengths and potential, the more likely it is that the client will discover such strengths and potential. The therapist cannot help the client by explaining the client’s behavior or by prescribing actions to follow. Therapeutic techniques involve expressing and communicating respect, understanding, and acceptance. The Existential Perspective The existential approach is really not a systematized school of thought but a set of attitudes. It shares with humanistic psychology an emphasis on individual uniqueness, a quest for meaning in life and for freedom and responsibility, a phenomenological approach (understanding the person’s subjective world of experience) to understanding the person, and a belief that the individual has positive attributes that will eventually be expressed unless they are distorted by the environment. The existential and humanistic approaches differ in several dimensions: 1. Existentialism is less optimistic than humanism; it focuses on the irrationality, difficulties, and suffering all humans encounter in life. Although humanism allows the clear possibility of self-fulfillment and freedom, existentialism deals with human alienation from the social and spiritual structures that no longer provide meaning in an increasingly technological and impersonal world. 2. Both approaches stress phenomenology—the attempt to understand people’s subjective world of experience. Humanistic therapists attempt to reconstruct the subjective world of their clients through empathy. Existentialists believe that the individual must be viewed within the context of the human condition and that moral, philosophical, and ethical considerations are part of that context. 3. They differ in their views on responsibility. Humanism stresses individual responsibility: the individual is ultimately responsible for what he or she becomes in this life. Existentialism stresses not only individual responsibility but also responsibility to others. Self-fulfillment is not enough. Criticisms of the Humanistic and Existential Approaches Criticisms of the humanistic and existential approaches point to their “fuzzy,” ambiguous, and nebulous nature and to the restricted population in which these approaches can be applied. Although these phenomenological approaches have been extremely creative in describing the human condition, they have been less successful in constructing theory. Moreover, they are not suited to scientific or experimental investigation. The emphasis on subjective understanding rather than prediction and control, on intuition and empathy rather than objective investigation, and on the individual rather than the more general category all tend to hinder empirical study. Carl Rogers has certainly expressed many of his ideas as researchable propositions, but it is difficult to verify scientifically the humanistic concept of people as rational, inherently good, and moving toward self-fulfillment. The existential perspective can be similarly criticized for its lack of scientific grounding because of its reliance on the unique subjective experiences of individuals to describe the inner world. Such data are difficult to quantify and test. Nevertheless, the existential concepts of freedom, choice, responsibility, being, and nonbeing have had a profound influence on contemporary thought beyond the field of psychology. Another major criticism leveled at the humanistic and existential approaches is that they do not work well with severely disturbed clients. They seem to be most effective with intelligent, well-educated, and relatively “normal” individuals who may be suffering adjustment difficulties. This limitation, along with the occasional vagueness of humanistic and existential thought, has hindered broad application of these ideas to abnormal psychology.

Multipath Implications of Psychological Explanations All the psychological theories discussed have both strengths and weaknesses; no one of them can claim to tell “the whole truth.” Each model—whether psychodynamic, behavioral, cognitive, or existential-humanistic—represents different views of pathology. Each details a different perspective from which to interpret reality, the nature of people, the origin of disorders, standards used for judging normality and abnormality, and the therapeutic cure. Each model has devout supporters.

CARL ROGERS (1902–1987) Rogers believed that people need both positive regard from others and positive selfregard. According to Rogers, when positive regard is given unconditionally, a person can develop freely and become self-actualized.

a set of attitudes that has many commonalities with humanism but is less optimistic, focusing (1) on human alienation in an increasingly technological and impersonal world, (2) on the individual in the context of the human condition, and (3) on responsibility to others, as well as to oneself

existential approach

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The multipath model would suggest that we can best understand abnormal behavior only by evidence-based integration of the various approaches. It is possible that the models of psychopathology are describing the same phenomena but from different vantage points. Many models of psychopathology focus on one aspect of the human condition to the exclusion of others, overlooking the person as a “total package” and resulting in a distorted view. Some models emphasize the importance of history (psychodynamic), some of feeling (humanistic-existential), some of thinking (cognitive), and still others of behaving (behavioral). A truly comprehensive model of human behavior, normal and abnormal, must address the possibility that people are all of these—biological, historical, feeling, thinking, and behaving beings—and probably much more: social, cultural, spiritual, and political ones as well.

Dimension Three: Social Factors Almost all theories of psychopathology discussed so far focus on the individual and less so on the social environment. They have been negligent in addressing such important aspects of our lives as relationships with people and how such factors as family, social support, love, community, and belonging affect the manifestation and expression of behavior disorders. It is clear that we are social beings and that our relationships can influence the development, manifestation, and/or amelioration of mental disorders.

Social Relational Models Studies support the conclusion that social isolation and lack of emotional support and intimacy are correlated with depression, lower stress tolerance, and low selfesteem (McIntosh, 1991; Paykel et al., 2003). On the other hand, people with rich relationships and social networks have been found to live longer, are less prone to commit suicide, are less likely to develop psychiatric disorders such as depression and alcoholism, enjoy better physical health, recover quicker after an illness, and are generally happier and more optimistic (Berkman & Syme, 1979; House, Landis, & Umberson, 1988; Leserman et al., 2000; Segrin et al., 2003). Social relationships are important in places of employment, churches, neighborhoods, schools, and communities, and especially as they relate to family relationships. For example, Steve V. can be seen as a product of a dysfunctional family, a person who was never nurtured nor loved by his parents. Social-relational explanations of abnormal behavior make several important assumptions (Johnson & Johnson, 2003): (1) healthy relationships are important for human development and functioning; (2) these relationships provide many intangible healthy benefits (social support, love, compassion, trust, faith, sense of belonging, resistance to stress, etc.); and (3) when relationships prove dysfunctional or are absent, the individual may be subject to mental disturbances. Treatment of socially produced disorders is most effective by improving interpersonal relationships of clients through a systemic approach.

Family, Couples, and Group Perspectives

model that assumes that the behavior of one family member directly affects the entire family system

family systems model

In contrast to traditional psychological models, social-relational models emphasize how other people, especially significant others, influence our behavior. This viewpoint holds that all people are enmeshed in a network of interdependent roles, statuses, values, and norms. One of these, the family systems model, assumes that the behavior of one family member directly affects the entire family system. Correspondingly, people typically behave in ways that reflect family influences (both healthy and unhealthy responding). We can identify three distinct characteristics of the family systems approach (Corey, 2005). First, personality development is ruled largely by the attributes of the family, especially by the way parents behave toward and around their children. Second, abnormal behavior in the individual is usually a reflection or “symptom” of unhealthy family dynamics and, more specifically, of poor communication among family members. Third, the therapist must focus on the family system, not

Dimension Three: Social Factors

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solely on the individual, and must strive to involve the entire family in therapy. As a result, the locus of disorder is seen to reside not within the individual but within the family system.

Social-Relational Treatment Approaches The family systems model has spawned a number of treatment approaches. One group emphasizes the importance of clear and direct communications for healthy family system development (Satir, 1967, 1983; Satir & Bitter, 1991). Virginia Satir’s conjoint family therapeutic approach stresses the importance of teaching message-sending and message-receiving skills to family members. Like other family therapists, Satir believes that the identified patient is really a reflection of the family system gone awry. Strategic family approaches (Haley, 1963, 1987) deal with power struggles that occur among family members by attempting to shift the balance to a more healthy distribution. Structural family approaches (Minuchin, 1974) attempt to reorganize family members because they are either too involved or too little involved with one another. All of these approaches focus on communication, balancing power relationships among family members, and the need to restructure the troubled family system. Couples therapy includes both marital relationships and intimate relationships between unmarried partners. It is a treatment aimed at helping couples understand and clarify their communications, role relationships, unfulfilled needs, and unrealistic or unmet expectations. Couples therapy has become an increasingly popular treatment for those who find that the quality of their relationship needs improvement (Nichols & Schwartz, 2005). Another form of social-relational treatment is group therapy. Unlike couples and family therapy, members of the group are initially strangers. Group members may, however, share various characteristics. Groups may be formed to treat older clients, unemployed workers, or pregnant women; to treat clients with similar psychological disturbances; or to treat people with similar therapeutic goals. Most group therapies focus on interrelationships and the dynamics of interaction among members. Despite their wide diversity, successful groups and group approaches share several features that promote change in clients (Corey, 2004; Kottler & Brown, 1992; Yalom, 1970): (1) The group experience allows each client to become involved in a social situation and to see how his or her behavior affects others. (2) The therapist can see how clients actually respond in a real-life social and interpersonal context. (3) Group members can develop new communication skills, social skills, and insights. (4) Groups often help members feel less isolated and less fearful about their problems. (5) Groups can provide members with strong social and emotional support. The feelings of intimacy, belonging, protection, and trust (which members may not be able to experience outside the group) can be a powerful motivation to confront one’s problems and seek to overcome them.

Criticisms of Social-Relational Models There is no denying that we are social creatures, and by concentrating on this aspect of human behavior, the social-relational models have added an important social dimension to our understanding of abnormal behavior. Research on the effects of family and couples therapy has been consistent in pointing to the value of therapy compared with no-treatment and alternative-treatment control groups. However, research studies have generally not been rigorous in design; they often lacked appropriate control groups, follow-up periods of outcome, or good measures of outcome (Alexander, Holtzworth-Munroe, & Jameson, 1994). Further, considerable evidence exists that couples, marital, and family therapy operate under culture-bound definitions (Sue & Sue, 2008a). Other critics have voiced concern that family systems models may have unpleasant consequences. Too often, psychologists have pointed an accusing finger at the parents of children who suffer from certain disorders, despite an abundance of evidence that parental influence may not be a factor in those disorders. The parents are then burdened with unnecessary guilt over a situation they could not have otherwise controlled.

couples therapy a treatment aimed at helping couples understand and clarify their communications, role relationships, unfulfilled needs, and unrealistic or unmet expectations group therapy a form of therapy that involves the simultaneous treatment of two or more clients and may involve more than one therapist

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FAMILY DYNAMICS AND POSITIVE SELFIMAGE Family interaction patterns can exert tremendous influence on a child’s personality development, determining the child’s sense of self-worth and the acquisition of appropriate social skills. This picture shows a Hispanic family preparing dinner together. Notice the attentiveness and obvious expressions of joy by the parents toward their children (communicating a sense of importance to them) and how every family member is actively involved in their respective roles (emphasizing family cohesion and belonging).

Dimension Four: Sociocultural Factors Sociocultural perspectives emphasize the importance of considering race, ethnicity, gender, sexual orientation, religious preference, socioeconomic status, physical disabilities, and other such factors in explaining mental disorders. Research consistently reveals that belonging to specific sociodemographic groups influences the manifestation of behavior disorders and may subject members to unique stressors not experienced by other groups (Ponterotto, Utsey, & Pedersen, 2006; Sue & Sue, 2008a). The importance of the sociocultural dimension is clearly evident in DSM-IV-TR, in which Appendix I lists twenty-five culture-bound syndromes. These are disorders generally limited to a specific society or cultural group. For example, taijin kyofusho is a culture-specific disorder (not seen in the United States but in Japan) in which the individual fears that his or her body parts or function are offensive to other people because of appearance, odor, or movements. Ataque de nervios is reported among Latinos from the Caribbean and includes symptoms of uncontrollable shouting, seizure-like episodes, trembling, and crying. It is clear that people’s cultural experiences are important factors in the manifestation of mental disorders (Sue & Sue, 2008a). We briefly discuss three major sociocultural factors to illustrate their importance in understanding psychopathology: gender, socioeconomic class, and race/ethnicity.

Gender Factors Women are consistently subjected to greater stressors than their male counterparts (Spradlin & Parsons, 2008). They carry more of the domestic burden, more responsibility for child care, and more responsibility for social and interpersonal relationships. This is true even if they are employed full time outside of the home (Morales & Sheafor, 2004). The National Academies (National Academy of Sciences, National Academy of Engineering, & Institute of Medicine, 2006) describe the plight of women in the United States to be: (1) predominantly employed in low-wage, traditional female occupations; (2) subjected to sexual harassment (81 percent of eighth through eleventh graders, 30 percent of undergraduates, and 40 percent of graduate students); (3) paid less than their male counterparts in similar jobs; (4) given less recognition, encouragement, and approval in classrooms than their male counterparts; (5) more likely to live in poverty; (6) faced with more barriers to their career choices; and (7) faced with greater discrimination and victimization.

Dimension Four: Sociocultural Factors

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MULTICULTURAL PERSPECTIVES Multicultural models of human behavior regard race, culture, and ethnicity as central to the understanding of normality and abnormality. In China, children are taught to value group harmony over individual competitiveness. In contrast, in the United States, individual efforts and privacy such as working alone are valued. Note the common use of cubicles in work settings to separate people from one another.

The importance of gender in understanding psychopathology is clearly seen in rates of depression among women. Up to 7 million women currently suffer from depression, which is twice the number for men (Schwartzman & Glaus, 2000). Rather than a narrow explanation (biological or psychological alone), it is highly probable that many factors contribute. Further, women are placed in an unenviable position of fulfilling stereotyped feminine social roles defined by our society. In our chapter on eating disorders, we discuss more fully how stereotyped standards of beauty in advertisements and the mass media can affect the health and self-esteem of girls and women. Body dissatisfaction, eating disorders, and depression are all significantly related to sociocultural standards.

Socioeconomic Class Social class and “classicism” are two frequently overlooked sociodemographic factors in psychology and mental health (Smith, 2006). Lower socioeconomic class is related to lower sense of self-control, poorer physical health, and higher incidence of depression (Chen, Mathews, & Boyce, 2002; Liu et al., 2004). Increasingly, psychologists are beginning to appreciate how poverty subjects the poor to increased stressors. The person’s life is characterized by low wages, unemployment, underemployment, lack of savings, little property ownership, and lack of food reserves (Sue & Sue, 2008a). Meeting even the most basic needs of food and shelter becomes a major challenge. In such circumstances, the poor are likely to experience feelings of hopelessness, helplessness, dependence, and inferiority. Considerable bias against the poor is well documented in the literature (American Psychological Association Task Force on Socioeconomic Status, 2006). As a group, they are more likely to be oppressed and harmed. For example, they are more likely to be perceived unfavorably than middle- or upper-class persons, to be considered less worthy, to be stereotyped as less capable for jobs, and to be socially isolated. Low socioeconomic class is also associated with (1) exposure to stressors that undermine mental and physical health, (2) receiving less desirable forms of therapeutic treatment, and (3) clinician biases in assessment, diagnosis, and treatment that work to the detriment of those in poverty.

Race/Ethnicity: Multicultural Models of Psychopathology Early attempts to explain differences between various minority groups and their white counterparts tended to adopt one of two models. The first, the inferiority model, contends that racial and ethnic minorities are inferior in some respect to the majority population. For example, this model attributes low academic achievement and higher unemployment rates among African Americans and

inferiority model early attempt to explain differences in minority groups that contends that racial and ethnic minorities are inferior in some respect to the majority population

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controversy

Problems in Using Racial and Ethnic Group References

A

frican American, American Indian, Asian American, and Hispanic American have emerged as commonly used terms to refer to four recognized racial and ethnic minority groups in the United States. These terms, however, are not without controversy, nor are they universally accepted by those who are classified as belonging to the group. This task has been made even more difficult with changes in the 2000 U.S. Census that allow sixty-three possible racial categories. Because we refer to racial and ethnic groups throughout our text, we want to avoid potential confusion by clarifying some problematic issues. 1. Terms may be accepted in some regions but not in others, and some generations will prefer one term over another. For example, we use the term Hispanic to refer to individuals with ancestry from Mexico, Puerto Rico, Cuba, El Salvador, the Dominican Republic, and other Latin American countries (Sue & Sue, 2008a). Some individuals, however, prefer to be called Latinos or La Raza (the race). Some younger ethnically conscious Hispanics with roots in Mexico may refer to themselves as Chicanos, a statement

early attempt to explain differences in minority groups that contends that differences are the result of “cultural deprivation”

deficit model

multicultural model

contemporary attempt to explain differences in minority groups that suggests that behaviors be evaluated from the perspective of a group’s value system, as well as by other standards used in determining normality and abnormality

indicating racial pride and consciousness. Many older Mexican Americans, however, consider Chicanos to be an insulting reference associated with the uneducated and exploited farmhands of the Southwest. Those individuals who trace their ancestry to Africa may prefer the term black to African American. The latter term links identification to country of origin, whereas black is a much more political statement of identity arising from the late 1960s. Likewise, many older individuals of Asian ancestry prefer the term Oriental, whereas younger members prefer Asian American, which for them reflects a self-identification process rather than an identity imposed by the larger society. 2. Racial/ethnic references can create problems by failing to acknowledge ethnic and cultural differences within a group, thereby submerging many groups under one label. The term Asian American, for example, technically encompasses between twenty-nine and thirty-two distinct identifiable Asian subgroups (Chinese, Japanese, Korean, Filipino, Vietnamese, Asian Indian, Laotian, Cambodian,

Latinos to low intelligence (heredity). The second model—the deprivations or deficit model—explained differences as the result of “cultural deprivation.” It implied that minority groups lacked the “right” culture. Both models have been severely criticized as inaccurate, biased, and unsupported in the scientific literature (Ridley, 2005). During the late 1980s and early 1990s, a new and conceptually different model emerged in the literature. Often referred to as the multicultural model (or the culturally diverse model; Sue & Sue, 2008a), the new approach emphasized that being culturally different does not equal deviancy, pathology, or inferiority. The model recognizes that each culture has strengths and limitations and that differences are inevitable. Behaviors are to be evaluated from the perspective of a group’s value system, as well as by other standards used in determining normality and abnormality (Ivey, D’Andrea, Ivey, & Simek-Morgan, 2007). The multicultural model makes an explicit assumption that all theories of human development arise from a particular cultural context (Ivey et al., 2007). Thus many traditional European American models of psychopathology are culture bound, evaluating and viewing events and processes from a worldview not experienced or shared by other cultural groups. For example, individualism and autonomy are highly valued in the United States and are equated with healthy functioning. Most European American children are raised to become increasingly independent, to be able to make decisions on their own, and to “stand on their own two feet.” In contrast, many traditional Asians and Asian Americans place an equally high value on “collectivity,” in which the psychosocial unit of identity is the family, not the individual. Similarly, whereas European Americans fear the loss of “individuality,” members of traditional Asian groups fear the loss of “belonging.” Given such different experiences and values, unenlightened mental health professionals may make biased assumptions about human behavior—assumptions that may influence their judgments of normality and abnormality among various racial and ethnic minorities. For example, a mental health professional who does not

Dimension Four: Sociocultural Factors

etc.)—each with its own culture, language, customs, and traditions. The same can be said of the label “Hispanic American” (Mexican American, Puerto Rican American, Cuban American, etc.). 3. An increasing number of people have mixed ancestry, and many of them prefer not to be identified with one specific racial or ethnic group (Root, 1996). For the first time in history, the number of biracial babies is increasing at a faster rate than the number of monoracial babies. People of mixed ancestry may prefer to be known as biracial, biethnic, bicultural, multiethnic, or some other term. A whole new vocabulary associated with this phenomenon is increasingly finding its way into the social science literature, including, for example, Afroasian, meaning people of African and Asian heritage; Eurasian, people of mixed white European and Asian ancestry; and Mestiza, people of Indian and Spanish ancestry. 4. Reference to European American, white, Caucasian American, and Anglo is also filled with controversy.

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Anglo is perhaps least appropriate because it technically refers to people of English descent (or, more distantly, of Germanic descent). People who trace their ancestry to Italy, France, and the Iberian peninsula may object to being called Anglo American. Our experience has been that many whites in our society also react quite negatively to that term; they prefer to refer to themselves as Irish American, Jewish American, Italian American, and so on. The terms white and European American are, however, gaining wider usage, the latter in part because of the emerging trend of identifying the region or country of ancestry for Americans. For Further Consideration 1. Given the preceding discussion, when you think about a particular racial category, what images come to mind? Are they accurate or stereotypes? 2. What label do you prefer to describe your own race?

understand that Asian Americans value a collectivistic identity might see them as overly dependent, immature, and unable to make decisions on their own. Likewise, such a person might perceive “restraint of strong feelings”—a valued characteristic among some Asian groups—as evidence of being “inhibited,” “unable to express emotions,” or “repressed.” The multicultural model also suggests that sociocultural stressors reside in the social system rather than within the person. Racism, bias, discrimination, economic hardships, and cultural conflicts are just a few of the sociopolitical realities with which racial and ethnic minorities must contend. As a result, the role of therapist may be better served by ameliorating oppressive or detrimental social conditions than by attempting therapy aimed at changing the individual. Appropriate individual therapy may, however, be directed at teaching clients self-help skills and strategies focused on influencing their immediate social situation.

Criticisms of the Multicultural Model In many respects, the multicultural model operates from a relativistic framework; that is, normal and abnormal behavior must be evaluated from a cultural perspective. The reasoning is that behavior considered disordered in one context—seeing a vision of a dead relative, for example—might not be considered disordered in another time or place. As indicated in DSM-IV-TR, some religious practices and beliefs consider it normal to hear or see a deceased relative during bereavement. In addition, certain groups, including some American Indian and Hispanic/Latino groups, may perceive “hallucinations” not just as not disordered but actually as positive events. Critics of the multicultural model argue that “a disorder is a disorder,” regardless of the cultural context in which it is considered. For example, a person suffering from schizophrenia and actively hallucinating is evidencing a malfunctioning of the senses (seeing, hearing, or feeling things that are not there) and a lack of contact with reality. Regardless of whether the person judges the occurrence to be desirable or undesirable, it nevertheless represents a disorder (biological dysfunction), according to this viewpoint.

Did You Know?

D

ifferent racial groups have different rates of specific mental disorders and manifest their psychological problems differently. Asian Americans, for example, are more likely to somaticize (to have stomach cramps, sleeplessness, headaches, etc.) than are their European American counterparts when under stress.

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critical thinking

Applying the Models of Psychopathology

A

useful learning exercise to evaluate your mastery of the various models is to apply them to a case study. We invite you to try your hand at explaining the behavior of Bill, a hypothetical client. Afterward, we invite you to attempt a more integrated multipath approach to explaining Bill’s problem.

Bill was born in Indiana to extremely religious parents who raised him in a strict moralistic manner. His father, a Baptist minister, often told Bill and his two sisters to “keep your mind clean, heart pure, and body in control.” He forbade Bill’s sisters to date while they lived at home. Bill’s own social life and contacts were extremely limited, and he recalled how anxious he was around girls. Bill’s memories of his father included feelings of fear and intimidation. No one in the family dared disagree with the father openly, lest they be punished and ridiculed. The father appeared to be hardest on Bill’s two sisters, especially when they expressed any interest in boys. The arguments and conflicts between father and daughters were often loud and extreme, disrupting the typical quietness of the home. Although it was never spoken of, Bill was aware that one of his sisters suffered from depression, as did his mother; his sister had twice attempted suicide.

TA B L E

Bill’s recollections of his mother were unclear, except that she was always sick with what his father referred to as “the dark cloud,” which seemed to visit her periodically. His relationships with his sisters, who were several years older, were uncomfortable. When Bill was young, they teased him mercilessly, and when he reached adolescence, they seemed to take sadistic delight in arousing his hormones by flaunting their partially exposed bodies. The result was that Bill became obsessed with having sex with one of his sisters, and he tended to masturbate compulsively. Throughout his adolescence and early adulthood he was tortured by feelings of guilt and believed himself to be, as his father put it, “an unclean and damned sinner.” By all external standards, Bill was a quiet and well-behaved child. He did well in school, attended Sunday school without fail, never argued or spoke against his parents, and seldom ventured outside of the home. Although Bill did exceptionally well in high school, some of his teachers were concerned about his introverted behavior and occasional bouts of depression. When they brought Bill’s depression to the attention of his father, however, Mr. M. dismissed it as no reason to worry. Indeed, Mr. M. complimented Bill on his good grades and unobtrusive behavior, rewarding him occasionally with small privileges, such as a larger portion of dessert or the choice of a TV program. To some degree of

2.3

A COMPARISON OF THE MOST INFLUENTIAL MODELS OF PSYCHOPATHOLOGY BIOLOGICAL

PSYCHODYNAMIC

BEHAVIORAL

COGNITIVE

Motivation for Behavior

State of biological integrity and health

Unconscious influences

External influences

Interaction of external and cognitive influences

Basis for Assessment

Medical tests, self-reports, and observable behaviors

Personal history, oral selfreports

Observable, objective data, overt behaviors

Self-statements, alterations in overt behaviors

Theoretical Foundation

Animal and human research, case studies, and other research methods

Case studies, correlational methods

Animal research, case studies, experimental methods

Human research, case studies, experimental methods

Source of Abnormal Behavior

Biological trauma, heredity, biochemical imbalances

Internal: early childhood experiences

External: learning maladaptive responses or not acquiring appropriate responses

Internal: learned pattern of irrational or negative self-statements

Treatment

Biological interventions (drugs, ECT, surgery, diet)

Dream analysis, free association, transference; locating unconscious conflict from childhood; resolving problem and reintegrating personality

Direct modification of problem behavior; analysis of environmental factors controlling behavior and alteration of contingencies

Understanding relationship between self-statements and problem behavior; modification of internal dialogue

awareness, Bill felt that his worth as a person was dependent only on “getting good grades” and “staying out of trouble.” As a young child, Bill had exhibited excellent artistic potential, and his teachers tried to encourage him in that direction. In elementary school he had won several awards for his drawings, and teachers frequently asked him to paint murals in their classrooms or to design posters for school events. His artistic interests continued into high school, where his art instructor entered one of Bill’s drawings in a state contest. His entry won first prize. Unfortunately, Mr. M. discouraged Bill from his talents and told him that “God calls you in another direction.” Attempting to please his father, Bill became less involved in art and concentrated more on math and science. He did very well in these subjects, obtaining nearly straight A’s in high school. When Bill entered college, his prime objective was to remain a straight-A student. Although he had originally loved the excitement of learning and mastering new knowledge, he became cautious and obsessed with “safety”; he was fearful of upsetting his father. As his string of perfect grades became longer, safety (not risking a B grade) became more important. He began to choose safe and easy topics for essays, to enroll in easy courses, and to take incompletes or withdrawals when courses appeared tough. Toward the end of his sophomore year, Bill suffered a mental breakdown characterized by pessimism and hopelessness. He

became depressed and was subsequently hospitalized after he tried to take his own life.

Table 2.3 summarizes the various models, and the following hints will help you to begin this exercise: • Consider what each theory proposes as the basis for the development of a mental disorder. • Consider the type of data that each perspective considers most important. • Compare and contrast the models. • Because there are eight models represented, you might wish to do a comparison only between selected models (psychoanalytic, humanistic, and behavioral, for example). As you attempt to explain Bill’s behavior, notice how your adoption of a particular framework influences the type of data you consider important. Is it possible that all the models hold some semblance of truth? Are their positions necessarily contradictory? Is it possible to integrate them into a unified explanation of Bill? (Again, you may wish to consult Table 2.3.)

HUMANISTIC

EXISTENTIAL

FAMILY SYSTEMS

MULTICULTURAL

Self-actualization

Capacity for self-awareness; freedom to decide one’s fate; search for meaning

Interaction with significant others

Cultural values and norms

Subjective data, oral selfreports

Subjective data, oral selfreports, experiential encounter

Observation of family dynamics

Study of group norms/ behaviors; understanding of societal values and minority/ dominant group relations

Case studies, correlational and experimental methods

An approach to understanding the human condition rather than a firm theoretical model

Case studies, social psychological studies, experimental methods

Study of cultural groups; data from anthropology, sociology, and political science

Internal: incongruence between self and experiences

Failure to actualize human potential; avoidance of choice and responsibility

External: faulty family interactions (family pathology and inconsistent communication patterns)

Culture conflicts and oppression

Nondirective reflection; no interpretation; providing unconditional positive regard; increasing congruence between self and experience

Providing conditions for maximizing self-awareness and growth, to enable clients to be free and responsible

Therapy aimed at treating the entire family, not just the identified patient

Understanding of minority group experiences; social system intervention

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Another criticism leveled at the multicultural model is its lack of empirical validation concerning many of its concepts and assumptions. The field of multicultural counseling and therapy, for example, has been accused of not being solidly grounded in research (Ponterotto & Casas, 1991). Most of the underlying concepts of the multicultural model are based on conceptual critiques or formulations that have not been subjected to formal scientific testing. There is generally heavy reliance on case studies, ethnographic analyses, and investigations of a more qualitative type. Multicultural psychologists respond to such criticisms by noting that they are based on a Western worldview that emphasizes precision and empirical definitions. They point out that there is more than one way to ask and answer questions about the human condition.

I M P L I C AT I O N S

Each model discussed in this chapter—whether biological, psychodynamic, behavioral, cognitive, existential-humanistic, family systems, or multicultural—represents different views of pathology. In practice, most clinicians recognize that models of psychopathology do not completely contradict one another on every point (BrooksHarris, 2008). As the multipath model suggests, elements of various perspectives can complement one another to produce a broad and detailed explanation of a person’s condition (Corey, 2005). In line with a more integrative approach, the multipath model is holistic, addresses the four major dimensions of human development, involves dynamic and interactive factors rather than static ones, and is guided by research findings in explaining psychopathology (Corey, 2005; Norcross & Newman, 1992; Sommers-Flanagan & Sommers-Flanagan, 2004). Research now strongly supports the conclusion that many factors, interacting in all sorts of ways, contribute to disorders. Proponents of various theories have acknowledged that factors outside of their theoretical orientation are important. For example, psychodynamic theorists recognize the importance of neurotransmitters even as they talk about repression and rage turned inward in explaining depression. Current research on psychopathology has found it necessary to use concepts such as mediators, moderators, mutual and reciprocal influences, critical developmental time periods, multiple and different factors leading to single disorders, single factors leading to multiple and different disorders, heterogeneity of specific disorders, proximal and distal causes, dimensional rather than categorical concepts of disorders, and so forth in adequately accounting for mental disorders. Although we know on a general level the importance of complex interactions of factors that lead to mental disorders, our knowledge about the dynamics and precise relationship of these dimensions to one another is far from complete. Research linking micro (biological) and macro (cultural) variables, for example, is particularly difficult to find. What, if any, is the effect of a linkage between heredity and culture on anxiety disorders? This same question can be asked about the relationship of all four dimensions and factors within our model. Despite these limitations, however, we believe that the most influential theories of psychopathology will be those that adopt a multipath approach in which factors from different approaches are coherently linked.

Summary 1. What models of psychopathology have been used to explain abnormal behavior? ■ One-dimensional models have been traditionally used to explain disorders. They have become increasingly inadequate because mental disorders are multidimensional. 2. What is the multipath model of mental disorders? ■ The multipath model is proposed to explain the interaction of biological, psychological, social, and sociocultural contributors to mental disturbances. The model is not a theory but a way of looking at the variety and complexity of contributors to mental disorders. In some respects it is a metamodel, a model of models that provides an organizational framework for understanding the numerous causes of mental disorders, the complexity of their interacting components, and the need to view disorders from a holistic framework. 3. How much of mental disorder can be explained through our biological makeup? ■ Biological models cite various organic causes of psychopathology, including genetics, brain anatomy, biochemical imbalances, central nervous system functioning, and autonomic nervous system reactivity. A good deal of biochemical research has focused on identifying the role of neurotransmitters in abnormal behavior. Researchers have also found correlations between genetic inheritance and certain psychopathologies. Mental health research reveals that a predisposition to a disorder, not the disorder itself, may be inherited. Gene-environment interactions are a two-way process that is reciprocal in nature. 4. What psychological models are used to explain the etiology of mental disorders? ■

■

Psychodynamic models emphasize childhood experiences and the role of the unconscious in determining adult behavior. The early development of psychodynamic theory is credited to Freud. Psychoanalytic therapy attempts to help the patient achieve insight into his or her unconscious. Behavioral models focus on the role of learning in abnormal behavior. The traditional behavioral models of psychopathology hold that abnormal behaviors are acquired through association (classical conditioning), reinforcement (operant conditioning), or modeling. Negative emotional responses, such as anxiety, can be learned through classical conditioning: a formerly neutral stimulus evokes a negative response after it has been presented along with a stimulus that already evokes that response. Negative voluntary behaviors may be learned through operant conditioning if those behaviors are

reinforced (rewarded) when they occur. In observational learning, a person learns behaviors, which can be quite complex, by observing them in other people and then imitating, or modeling, those behaviors. ■

Cognitive models are based on the assumption that conscious thought mediates, or modifies, an individual’s emotional state and/or behavior in response to a stimulus. Cognitive therapeutic approaches are generally aimed at normalizing the client’s perception of events.

■

The humanistic perspective actually represents many perspectives and shares many basic assumptions with the existential perspective. Both view an individual’s reality as a product of personal perception and experience. Both see people as capable of making free choices and fulfilling their potential. Both emphasize the whole person and the individual’s ability to fulfill his or her capacities.

5. What role do social factors play in psychopathology? ■ Impairment or absence of social relationships have been found to be correlated with increased susceptibility to mental disorders. Good relationships seem to immunize people against stressors. ■ From the perspective of family systems, abnormal behavior is viewed as the result of distorted or faulty communication or unbalanced structural relationships within the family. Children who receive faulty messages from parents or who are subjected to structurally abnormal family constellations may develop behavioral and emotional problems. ■ Three social treatments described are family therapy, couples therapy, and group therapy. 6. What sociocultural factors may play a role in the etiology of mental disorders? ■ Proponents of the sociocultural approach believe that race, culture, ethnicity, gender, sexual orientation, religious preference, socioeconomic status, physical disabilities, and other variables are powerful influences in determining how specific cultural groups manifest disorders, how mental health professionals perceive disorders, and how disorders are treated. ■ Cultural differences have been perceived in three ways: (1) the inferiority model, in which differences are attributed to the interplay of undesirable elements in a person’s biological makeup; (2) the deprivation or deficit model, in which differences in traits or behaviors are blamed on not having the “right culture”; and (3) the multicultural model, in which differences do not necessarily equate with deviance.

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Assessment and Classification of Abnormal Behavior

E

chapter outline Reliability and Validity

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The Assessment of Abnormal Behavior

68

The Classification of Abnormal Behavior

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IMP LIC ATIONS

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CONTROVERSY Should

the Rorschach Be Used in Making Assessments? CRITICAL THINKING Can We Accurately Assess the Status of Members of Different Cultural Groups?

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mily was an attractive college student. Because she was having trouble meeting interesting men, she decided to try speed dating. In speed dating, men and women have brief conversations to see whether they can find someone they might like to date. Men and women are paired and converse for a few minutes. At the end of each pairing, participants move on to the next “date.” After making a number of pairings, participants indicate who, among those they met, they would like to meet again. If there is a match, contact information is sent to both parties. Emily met six men. Because she wanted to date men who were sharp-witted, humorous, generous, and good-looking, she had to quickly assess them. But how should she go about assessing the men? If you were in that situation, would you base your evaluation on appearance, verbal or non-verbal behaviors, spontaneity? How would you know whether someone was being honest or giving you a line?

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All of us have to evaluate or assess others in everyday life without thinking much about it. When we are introduced to a new person, buy a car from a salesperson, visit a professor’s office, interview someone for a position, or work collaboratively on a project with another person, we have to evaluate. We have to judge whether a person is trustworthy, honest, sincere, smart, capable, knowledgeable, likeable, friendly, and so on. We may use different methods to assess a person, and we may differ in our accuracy. In the mental health field, assessment is critical. Therapists must collect information on the well-being of individuals and organize information about a person’s condition. Among the assessment tools available to clinicians are observations, conversations, interviews, a variety of psychological and neurological tests, and the reports of the patient and his or her relatives and friends. When the data gathered from all sources are combined and analyzed, a therapist can gain a good picture of the patient’s behavior and mental state.

FOCUSQUESTIONS

1 In attempting to make an accurate evaluation or assessment of a person’s mental health, what kinds of standards must tests or evaluation procedures meet?

2 What kinds of tools do clinicians employ in evaluating the mental health of people?

3 How are mental health problems categorized or classified?

As we noted in Chapter 1, the evaluation of the information leads to a psychodiagnosis, which involves describing and drawing inferences about an individual’s psychological state. Psychodiagnosis is often an early step in the treatment process. For many psychotherapists, it is the basis on which a program of therapy is first formulated. To arrive at a psychodiagnosis, the therapist attempts to obtain a clear description of the client’s behavioral patterns and to classify or group them based on the symptom picture that emerges. In this chapter, we examine assessment methods and clinicians’ use of assessment tools. We also discuss the most widely employed diagnostic classification system, DSM-IV-TR, as well as objections some have made to the use of classification systems and labeling. Because questions of reliability and validity are essential to address in assessment tools and in any diagnostic system, we start the chapter with a discussion of reliability and validity.

Reliability and Validity To be useful, assessment tools and classification systems must demonstrate reliability and validity. Reliability is the degree to which a procedure or test—such as an evaluation tool or classification scheme—will yield the same results repeatedly under the same circumstances. There are many types of reliability (Robinson, Shaver, & Wrightsman, 1991). Test-retest reliability determines whether a measure yields the same results when given to an individual at two different points in time. For example, if we administer a measure of anxiety to an individual in the morning and then readminister the measure later in the day, the measure is reliable if the results show consistency or stability (that is, if the results are the same) from one point in time to another. Inconsistent results may reflect real changes in the behavior of the individual and not just a poor measure. Nevertheless, in such circumstances, there is poor test-retest reliability. In reliability that involves internal consistency, a measure is considered reliable if various parts of the measure yield similar or consistent results (Kline, 2005). For example, if responses to different items on a measure of anxiety are not related to one another, the items are unreliable because they may be measuring different things, not just anxiety. Finally, interrater reliability determines consistency of responses when different judges or raters administer the measure. For instance, imagine that two clinicians are trained to diagnose individuals according to a certain classification scheme. Yet one clinician diagnoses the patient’s disorder as schizophrenia and the other diagnoses mental retardation. There is a reliability problem between the two raters. Validity is the extent to which a test or procedure actually performs the function it was designed to perform. If a measure that is intended to assess depression instead assesses anxiety, the measure demonstrates poor validity for depression. As in the case of reliability, there are several ways to determine validity. The most important are predictive, criterion-related, construct, and content validity. Predictive validity refers to the ability of a test or measure to predict or foretell how a person will behave, respond, or perform. Colleges and universities often use applicants’ high school achievement test scores to predict their future college grades. If the test scores have good predictive validity, they should be able to differentiate students who will perform well from those who will perform poorly in college.

reliability the degree to which a procedure or test—such as an evaluation tool or classification scheme—will yield the same results repeatedly under the same circumstances

the extent to which a test or procedure actually performs the function it was designed to perform

validity

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Criterion-related validity determines whether a measure is related to the phenomenon in question. Assume, for example, that we devise a measure that is intended to tell us whether persons recovering from alcoholism are likely to return to drinking. If we find that those who score high on the measure start drinking again and that those who score low do not, then the measure is valid. Determining construct validity is actually a series of tasks with one common theme: all are designed to test whether a measure is related to certain phenomena that are empirically or theoretically thought to be related to that measure. Let’s say that a researcher has developed a questionnaire to measure anxiety. To determine construct validity, the researcher should show that the questionnaire is correlated with other measures, such as existing tests of anxiety. Furthermore, we would have increased confidence that the questionnaire is measuring anxiety if it is related to other phenomena that appear in anxious people, such as muscle tension, sweating, tremors, and startle responses. Finally, content validity refers to the degree to which a measure is representative of the phenomenon being measured. For example, we know that depression involves cognitive, emotional, behavioral, and physiological features. If a self-report measure of depression contains items that assess only cognitive features, such as items indicating pessimism, then the measure has poor content validity because it fails to assess three of the four known components of the disorder. Reliability and validity are also influenced by the conditions in which a test or measure is administered. Standardization or standard administration requires that those who administer a test strictly follow common rules or procedures. If an instructor creates a tense and hostile environment for some students who are taking final exams for a course but not for others, for example, the students’ test scores may vary simply because the instructor is not treating all students in a similar or standard fashion. An additional concern is the standardization sample—a group of people who have taken the measure and whose performance can be used as a standard or norm. The performance of another person can therefore be interpreted against this norm. However, the standardization sample must be appropriate to the person being evaluated. Our interpretations may not be valid if we compare the test score of a twentyyear-old African American woman with the scores of forty-year-old white American men in a standardization sample.

The Assessment of Abnormal Behavior

standardization in test administration, the use of identical procedures in the administration of tests; (in samples) the establishment of a norm or comparison group to which an individual’s test performance can be compared

with regard to psychopathology, the process of gathering information and drawing conclusions about the traits, skills, abilities, emotional functioning, and psychological problems of an individual

assessment

Assessment is the process of gathering information and drawing conclusions about the traits, skills, abilities, emotional functioning, and psychological problems of the individual, generally for use in developing a diagnosis. Assessment tools are necessary to the study and practice of mental health. Without them, data could not be collected, and psychologists could not conduct meaningful research, develop theories, or engage in psychotherapy. Data collection necessarily involves the use of tools to systematically record the observations, behaviors, or self-reports of individuals. Four principal means of assessment are available to clinicians: observations, interviews, psychological tests and inventories, and neurological tests. In general, assessment should be conducted using multiple methods and tests in order to get a more accurate view of clients (Kendall, Holmbeck, & Verduin, 2004). Assessment techniques and some specific tools for conducting them are discussed in the following pages and are summarized in Table 3.1.

Observations Observations of overt behavior provide the most basic method of assessing abnormal behavior. Clinical observations can be either controlled or naturalistic. Controlled (or analogue) observations occur in a laboratory, clinic, or other contrived (artificial) setting (Haynes, 2001). Naturalistic observations are made in a natural setting— a schoolroom, an office, a hospital ward, or a home—rather than in a laboratory.

The Assessment of Abnormal Behavior

Observations can be highly structured and specific, as when an observer notes the frequency of stuttering and the circumstances under which stuttering occurs in a client. Sometimes clients are asked to role-play social interactions, and these interactions are evaluated (Norton & Hope, 2001). On other occasions, observations may be less formal and specific, as when a clinician simply looks for any unusual behaviors on the part of a client. In such a situation, the observations and interpretations of the behaviors may be quite subjective in nature. Observations of behavior are usually made in conjunction with an interview. A trained clinical psychologist watches for external signs or cues and expressive behaviors that may have diagnostic significance. The client’s general mode of dress (neat, conventional, sloppy, flashy), significant scars or tattoos, and even choice of jewelry may be correlated with personality traits or, perhaps, with disorder. Likewise, other expressive behaviors, such as posture, facial expression, language and verbal patterns, handwriting, and selfexpression through graphic art may all reveal certain characteristics of the client’s life. Here is an example of some typical observations.

TA B L E

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3.1

ASSESSMENT TECHNIQUES OBSERVATIONS Controlled observations; naturalistic observations INTERVIEWS Clinical interview; mental status examination. PSYCHOLOGICAL TESTS AND INVENTORIES

Projective personality tests Rorschach technique; Thematic Apperception Test; sentence-completion tests; draw-a-person tests Self-report inventories Minnesota Multiphasic Personality Inventory; Beck Depression Inventory Intelligence tests Wechsler Adult Intelligence Scale; StanfordBinet Intelligence Scale; Wechsler Intelligence Scale for Children; Wechsler Preschool and Primary Scale of Intelligence; Kaufman Assessment Battery for Children Tests for cognitive impairment Bender-Gestalt Visual Motor Test; Halstead-Reitan Neuropsychological Test Battery; Luria-Nebraska Neuropsychological Battery NEUROLOGICAL TESTS Computerized axial tomography; positron

emission tomography; electroencephalograph; magnetic resonance imaging

Case Study Margaret was a thirty-seven-year-old depressive patient who was seen by one of the authors in a hospital psychiatric ward. She had recently been admitted for treatment. It was obvious from a casual glance that Margaret had not taken care of herself for weeks. Her face and hands were dirty. Her long hair, which had originally been done up in a bun, had shaken partially loose on one side and now hung down her left shoulder. Her beat-up tennis shoes were only halfway on her stockingless feet. Her disheveled appearance and her stooped body posture would lead one to believe she was much older than she was. When first interviewed, Margaret sat as though she did not have the strength to straighten her body. She avoided eye contact with the interviewer and stared at the floor. When asked questions, she usually responded in short phrases: “Yes,” “No,” “I don’t know,” “I don’t care.” There were long pauses between the questions and her answers. Each response seemingly took great effort on her part.

Some psychologists rely on trained raters or on parents, teachers, or other third parties to make the observations and gather information for assessment and evaluation. Others prefer their own observations to those of a third party. Regardless of who conducts the observation, two problems may occur (Sundberg, Taplin, & Tyler, 1983). First, observers must check the validity of their own interpretations of the patient’s behaviors. This is particularly important when the patient is from a culture different from that of the observer. Second, observers must try to minimize the impact of their observations on the patient’s behaviors. This effort is necessary because a person who is aware of being observed or assessed may change the way he or she usually responds, a phenomenon known as reactivity (Kline, 2005). For example, drivers who know that they are being observed by a police car may be extra careful in following traffic laws.

Interviews The clinical interview is a time-honored tradition as a means of psychological assessment. It lets the therapist observe the client and collect data about the person’s life

a change in the way a person usually responds, triggered by the person’s knowledge that he or she is being observed or assessed

reactivity

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NATURALISTIC VERSUS CONTROLLED OBSERVATIONS Naturalistic observations are made in settings that occur naturally in one’s environment. Here, on the left, a female researcher is taking notes while observing children at play in a playground in Los Angeles, California. The playground is a natural setting for the children to play in. In this photo on the right, a female researcher with a laptop computer is rating the behaviors in a mother-child interaction session conducted in a clinic laboratory. What are the advantages and disadvantages of naturalistic versus controlled observations?

situation and personality. Verbal and nonverbal behaviors, as well as the content (what the client is saying) and process (how the client is communicating—such as with anxiety, hesitation, or anger), of communications are important to analyze (Reiser, 1988). Depending on the particular disciplinary training of the interviewer, the interview’s frame of reference and its emphasis may vary considerably. Psychiatrists, being trained in medicine, are more likely to emphasize biological or physical variables. Social workers may be more concerned with life history data and the socioeconomic environment of the client. Clinical psychologists may be most interested in the client’s behaviors and psychological mood. Likewise, variations in therapeutic orientation within the discipline of psychology can affect the interview. Because of their strong belief in the unconscious origin of behavior, psychoanalysts may be more interested in psychodynamic processes than in the surface content of the client’s words. They are also more likely to pay particular attention to life history variables and dreams. Behaviorists are more likely to concentrate on current environmental conditions related to the client’s behavior. In practice, however, mental health practitioners with different therapeutic orientations can also exhibit a great deal of similarity in psychotherapeutic style. Standardization and Structure As mentioned in the earlier discussion of reliability and validity, standard administration means that common rules or procedures must be strictly followed. Interviews can vary in the degree to which they are structured, the manner in which they are conducted, and the degree of freedom of response on the part of the client. In some interviews, the client is given considerable freedom about what to say and when to say it. The clinician does little to interfere with conversation or to direct its flow. Psychoanalysts, who use free association, and Rogerians, who carry on nondirective therapy, tend to conduct highly unstructured interviews. Behaviorists tend to use more structured interviews. The most highly structured interview is the formal standardized interview, in which questions are usually arranged as a checklist, complete with scales for rating answers. The interviewer uses the checklist to ask each interviewee the same set of questions, so that errors are minimized. Although structured interviews often do not

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permit interviewers to probe interviewees’ responses in depth, they have the advantage of allowing consistent data to be collected across interviewees, and they are less subject to interviewers’ biases (Hill & Lambert, 2004). A less structured but also widely used interview procedure is the mental status examination. The intent of this examination is to determine in a general way a client’s cognitive, psychological, and behavioral functioning by means of questions, observations, and tasks posed to the client (Othmer & Othmer, 1994). The clinician considers the appropriateness and quality of the client’s responses (behaviors, speech, emotions, intellectual functioning) and then attempts to render provisional evaluations of the diagnosis, prognosis, client dynamics, and treatment issues. Errors In the field of mental health, straightforward questions do not always yield usable or accurate information. Believing personal information to be private, patients may refuse to reveal it, may distort it, or may lie about themselves. Furthermore, many patients may be unable to articulate their inner thoughts and feelings. Clinicians themselves may interpret interviews in a biased or invalid manner. An interview should therefore be considered a measurement device that is fallible and subject to error (Wiens, 1983).

Psychological Tests and Inventories Psychological tests and inventories are a variety of standardized instruments that have been used to assess personality, maladaptive behavior, development of social skills, intellectual abilities, vocational interests, and cognitive impairment. Tests have also been developed for the purpose of understanding personality dynamics and conflicts. They differ in form (that is, they may be oral or written and may be administered to groups or to individuals), structure, degree of objectivity, and content. To varying degrees (less so in the case of projective personality tests), they share two characteristics that involve standard administration and use of a standardization sample. First, they provide a standard situation in which certain kinds of responses are elicited. The same instructions are given to all persons who take the same test, the same scoring is applied, and similar environmental conditions are maintained to ensure that the responses are due to each test taker’s unique attributes rather than to differences in situations. Second, by comparing an individual test taker’s responses with norms, established by the standardization sample, the therapist can make inferences about the underlying traits of the person. For instance, the test taker may answer “yes” to questions such as “Is someone trying to control your mind?” more frequently than is the norm. The therapist might infer that this pattern of response is similar to that of individuals diagnosed with paranoia. In the remainder of this section, we examine two general types of personality tests and measures (projective and self-report inventories) and tests of intelligence and cognitive impairment. It should be noted that two-thirds of the assessments used by clinical psychologists are evaluations of personality psychopathology and intellectual achievement. The second most popular use of psychological testing is for neuropsychological assessment and adaptive-functional behavior assessment, according to half of the clinical psychologists surveyed for their assessment practices (Camara, Nathan, & Puente, 2000). Projective Personality Tests In a projective personality test, the test taker is presented with ambiguous stimuli, such as inkblots, pictures, or incomplete sentences, and asked to respond to them in some way. The stimuli are generally novel, and the test is relatively unstructured. Conventional or stereotyped patterns of response usually do not fit the stimuli. The person must “project” his or her attitudes, motives, and other personality characteristics onto the situation. The nature of the appraisal is generally well disguised: participants are often unaware of the true nature or purpose of the test and usually do not recognize the significance of their responses. Based largely on a psychoanalytic perspective, projective tests presumably tap into the individual’s unconscious needs and motivations or dynamics of perception and motivation (Meyer et al., 2003). No matter which form of test is used, the goal of

Did You Know?

I

n order to assess whether a client is functioning and thinking appropriately, clinicians often ask a client what time it is (or what the date is), who the client is, and where the client currently is. In one case, a client who was hospitalized in a psychiatric ward responded by saying, “It’s 1960, I’m Elvis Presley, and I’m staying in this hotel until I have to enter the army.”

psychological tests and inventories instruments used

to assess personality, maladaptive behavior, development of social skills, intellectual abilities, vocational interests, and cognitive impairment projective personality test test in which the test taker is presented with ambiguous stimuli, such as inkblots, pictures, or incomplete sentences, and asked to respond to them in some way

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projective testing is to get a multifaceted view of the total functioning person, rather than a view of a single facet or dimension of personality. Swiss psychiatrist Hermann Rorschach devised the Rorschach technique for personality appraisal in 1921. A Rorschach test consists of ten cards that display symmetrical inkblot designs. The cards are presented one at a time to participants, who are asked (1) what they see in the blots and (2) what characteristics of the blots make them see that. Inkblots are considered appropriate stimuli because they are ambiguous, are nonthreatening, and do not elicit learned responses. What people see in the blots, whether they attend to large areas or to details, whether they respond to color, and whether their perceptions suggest movement are assumed to be symbolic of inner promptings, motivations, and conflicts. Test takers react in a personal and “unlearned” fashion because there are no right or wrong answers. The psycholoTHE RORSCHACH TECHNIQUE Devised by Swiss psychiatrist gist then interprets the individual’s reactions. Both the basic Hermann Rorschach in 1921, the Rorschach technique uses a premise of the Rorschach test and the psychologist’s internumber of cards, each showing a symmetrical inkblot design pretation of the symbolism within the patient’s responses are similar to the one shown here. The earlier cards in the set strongly psychoanalytic. For example, seeing eyes or buttocks are in black and white; the later cards are more colorful. A may imply paranoid tendencies; fierce animals may imply client’s responses to the inkblots are interpreted according to aggressive tendencies; blood may imply strong uncontrolled assessment guidelines and can be compared by the therapist with the responses that other clients have made. emotions; food may imply dependency needs; and masks may imply avoidance of personal exposure (Klopfer & Davidson, 1962). The single most important rationale for using the Rorschach and other projective tests is that they presumably provide information about personality dynamics that are outside the conscious awareness of the test takers (Clarkin, Hurt, & Mattis, 1999). There are actually a variety of approaches to interpreting and scoring Rorschach responses. The most extensive and recent is the comprehensive system of Exner (1983, 1990), whose scoring system is based on reviews of research findings and studies of the Rorschach technique. Exner thinks of the Rorschach technique as a problemsolving task; test takers are presented with ambiguous stimuli that they interpret according to their preferred mode of perceptual-cognitive processing. Exner’s system has also yielded indexes of specific disorders such as depression, although the adequacy of the Rorschach technique in assessing specific disorders is a matter of Did You Know? continuing research (Ball et al., 1991). Because it relies on research findings and he Rorschach is employed by normative data, Exner’s system has become the standard for scoring the Rorschach a number of psychologists. In test (Weiss, 1988). one survey (Exner, 1995) of The Thematic Apperception Test (TAT) was first developed by Henry Murray psychologists, 75 percent reported in 1935 (Murray & Morgan, 1938). It consists of thirty picture cards, each typically that they used psychological tests depicting two human figures. Their poses and actions are vague and ambiguous in their practice; of those who used enough to be open to different interpretations. Some cards are designated for specific such tests, 43 percent used the age levels or for a single gender, and some are appropriate for all groups. Like the Rorschach at various times. Rorschach technique, the TAT relies on projection to tap underlying motives, drives, and personality processes. Most clinicians agree, however, that the TAT is best when it is used to uncover aspects of interpersonal relationships. Generally, twenty TAT cards are shown to the participant, one at a time, with instructions to tell a story about each picture. Typically, the tester says, “I am going to show you some pictures. Tell me a story about what is going on in each one, what led up to it, and what its outcome will be.” The entire story is recorded verbatim. There is usually no limit on time or the length of the stories. A trained clinician interprets the participant’s responses, either subjectively or by using a formal scoring system. Both interpretations usually take into account the style of the story (length, organization, and so on); recurring themes, such as retribution, failure, parental domination, aggression, and sexual concerns; the outcome of the

T

The Assessment of Abnormal Behavior

story in relationship to the plot; primary and secondary identification (the choice of hero or secondary person of importance); and the handling of authority figures and sexual relationships. The purpose is to gain insight into the individual’s conflicts and worries, as well as clues about his or her core personality structure. Woike and McAdams (2001) found that the TAT is particularly valuable in ascertaining an individual’s personality and motivation. Other types of projective tests include sentence-completion and draw-a-person tests. In the sentence-completion test, the participant is given a list of partial sentences and is asked to complete each of them. Typical partial sentences are “My ambition . . . ,” “My mother was always . . . ,” and “I can remember . . . .” Clinicians try to interpret the meaning of the individual’s responses. In draw-a-person tests, such as the Machover D-A-P (Machover, 1949), the participant is actually asked to draw a person. Then he or she may be asked to draw a person of the opposite sex. Finally, the participant may be instructed to make up a story about the characters that were drawn or to describe the first character’s background. Many clinicians analyze these drawings for size, position, detail, and so on, assuming that the drawings provide diagnostic clues. For example, persons suffering from brain impairments may draw disproportionately large heads. The validity of such assumptions is open to question, and well-controlled studies cast doubt on diagnostic interpretations (Anastasi, 1982). The analysis and interpretation of responses to projective tests are subject to wide variation. Clinicians given the same data frequently disagree with one another about scoring. Much of this disparity is caused by differences in clinicians’ orientations, skills, and personal styles. But, as noted earlier, the demonstrably low reliability and validity of these instruments means that they should be used with caution and in conjunction with other assessment measures. And even when projective tests exhibit reliability, they may still have low validity. For example, many clinicians agree that certain specific responses to the Rorschach inkblots indicate repressed anger. The fact that many clinicians agree makes the test reliable, but those specific responses could indicate something other than repressed anger. Illusory correlations may exist, and clinicians may erroneously link a patient’s response to the existence of a syndrome (Chapman & Chapman, 1967). Self-Report Inventories Unlike projective tests, self-report inventories require test takers to answer specific written questions or to select specific responses from a list of alternatives—usually self-descriptive statements. Participants are asked to either agree or disagree with the statement or to indicate the extent of their agreement or disagreement. Because a predetermined score is assigned to each possible answer, human judgmental factors in scoring and interpretation are minimized. In addition, participants’ responses and scores can be compared readily with a standardization sample. Perhaps the most widely used self-report personality inventory is the Minnesota Multiphasic Personality Inventory, or MMPI (Hathaway & McKinley, 1943). The MMPI-2, a revision by Butcher and colleagues (see Butcher, 1990; Graham, 1990; Greene, 1991), restandardized the inventory, refined the wording of certain items, eliminated items considered outdated, and attempted to include appropriate representations of ethnic minority groups. The MMPI-2 consists of 567 statements; participants are asked to indicate whether each statement is true or false as it applies to them. There is also a “cannot say” alternative, but clients are strongly discouraged from using this category because too many such responses can invalidate the test. The test taker’s MMPI-2 results are rated on ten clinical scales and a number of validity scales. The ten clinical scales were originally constructed by analyzing the responses of diagnosed psychiatric patients (and the responses of normal participants) to the 567 test items. These analyses allowed researchers to determine what kinds of responses each of the various types of psychiatric patients usually made, in contrast to those of normal individuals. The validity scales, which assess degrees of candor, confusion, falsification, and so forth on the part of the respondent, help the

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self-report inventories

an assessment tool that requires test takers to answer specific written questions or to select specific responses from a list of alternatives

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controversy

Should the Rorschach Be Used in Making Assessments?

A

lthough the Rorschach has been widely used in clinical assessment, it has generated considerable controversy. The controversy is over the reliability, validity, and usefulness of the Rorschach in clinical practice. Critics claim that the Rorschach has been overvalued because of biased beliefs that it can be a useful tool in assessment and treatment. Defenders of the Rorschach argue that its use for many decades has demonstrated its usefulness and that cumulative research clearly shows the validity of the Rorschach in making diagnoses and in giving treatment insights. In particular, critics and supporters make the following arguments. Critics Argue That: • A moratorium should be placed on many applications of the Rorschach until further research demonstrates its validity (Garb et al., 2005). • The use of the Rorschach can make normal individuals appear psychologically disturbed (Lilienfeld, Fowler, & Lohr, 2003). • The use of the Rorschach for formal assessment and treatment planning can cause harm to clients (Garb, 2003). • Training in the comprehensive system for the Rorschach should be eliminated (Garb et al., 2005).

as that found on the Minnesota Multiphasic Personality Inventory (Society for Personality Assessment, 2005). • With respect to the Rorschach, a small group of psychologists is deciding what is scientific and what is not and, on this basis, is urging, in effect, an end to the teaching and use of methods that do not pass their muster (Weiner, Spielberger, & Abeles, 2002; 2003). • The unjustified criticisms of the Rorschach resembles the “burning of books” (Weiner et al., 2002). It is unlikely that the debate will be settled. What would be helpful is for critics and supporters to jointly examine studies of the Rorschach, evaluate the adequacy of research designs and methodologies, analyze criteria for outcomes, and try to come to some joint conclusions. In this way, we can gain some insight into precisely in what areas consensus and disagreement exist. The controversy, however, has been valuable in that the two sides agree that scientific findings are critical in the debate, that Rorschach administration needs to be standardized, and that an assessment tool such as the Rorschach should be only one of many that are used to render clinical diagnosis. For Further Consideration 1. Which side of the Rorschach argument makes most sense to you?

Supporters Argue That: • The Rorschach has recently received a more intensive level of scrutiny than that given any other personality test. Yet research indicates that Rorschach validity is as good

2. If Rorschach administration were to be standardized, what standards might researchers and clinicians put into practice?

clinician detect potential faking or special circumstances that may affect the outcome of other scales (Bagby et al., 1997). Figure 3.1 shows possible responses to ten sample MMPI-2 items and the kinds of responses that contribute to a high rating on the ten MMPI clinical scales. A basic assumption of the original version of the MMPI was that a person whose MMPI answers are similar to those of diagnosed patients is likely to behave similarly to those patients. However, single-scale interpretations are fraught with hazards. Although a person with a high rating on Scale 6 may be labeled paranoid, this scale does not detect many persons with paranoia. Interpretation of the MMPI-2 scales can be quite complicated and requires special training. Generally, multiple-scale interpretations (pattern analysis) and characteristics associated with the patterns are examined. Although the MMPIs of clients are subjected to pattern and statistical analyses, client responses can also be viewed as direct communications of important content: information about the client’s symptoms, attitudes, and behaviors (Butcher, 1995). The MMPI-2 should be used by clinicians who have mastered its intricacies, who understand relevant statistical concepts, and who can interpret the client’s responses (Butcher, 1995; Graham, 1990; Newmark, 1985). Although labeled as a personality test, the MMPI was constructed to assess mental disorders (Clarkin et al., 1999). Whereas the MMPI-2 assesses a number of different personality characteristics of a person, some self-report inventories or questionnaires focus on only certain kinds of personality traits or emotional problems, such as depression or anxiety.

The Assessment of Abnormal Behavior

1.

2.

3.

4.

5.

Hypochondriasis (Hs)—Individuals showing excessive worry about health with reports of obscure pains.

NO

Depression (D)—People suffering from chronic depression, feelings of uselessness, and inability to face the future.

NO

Hysteria (Hy)—Individuals who react to stress by developing physical symptoms (paralysis, cramps, headaches, etc.).

NO

Masculinity-Femininity (Mf)—People tending to identify with the opposite sex rather than their own. Paranoia (Pa)—People who are suspicious, sensitive, and feel persecuted.

7.

Psychasthenia (Pt)—People troubled with fears (phobias) and compulsive tendencies.

Hypomania (Ma)—People who are physically and mentally overactive and who shift rapidly in ideas and actions.

10.

Social Introversion (Si)—People who tend to withdraw from social contacts and responsibilities.

FIGURE

YES

NO

NO

NO

There seems to be a lump in my throat much of the time.

I am about as able to work as I ever was. NO

NO

NO

NO

NO

NO

YES

NO

NO

YES

NO

Schizophrenia (Sc)—People with bizarre and unusual thoughts or behavior.

9.

My daily life is full of things that keep me interested.

My hands and feet are usually warm enough.

I like to read newspaper articles on crime.

I am easily awakened by noise.

I think I would like the work of a librarian.

I wake up fresh and rested most mornings. NO

Psychopathic Deviate (Pd)—People who show irresponsibility, disregard social conventions, and lack deep emotional responses.

6.

8.

I have a good appetite.

TEN MMPI CLINICAL SCALES WITH SIMPLIFIED DESCRIPTIONS

I like mechanics magazines.

SAMPLE ITEMS

3.1

NO

YES

NO

THE TEN MMPI-2 CLINICAL SCALES AND SAMPLE MMPI-2 TEST ITEMS Shown here are the MMPI-2 clinical scales and a few of the items that appear on them. As an example, answering “no” or “false” (rather than “yes” or “true”) to the item “I have a good appetite” would result in a higher scale score for hypochondriasis, depression, and hysteria.

Source: Adapted from Dahlstrom & Welsh (1965). These items from the original MMPI remain unchanged in the MMPI-2.

For example, the Beck Depression Inventory (BDI) is composed of twenty-one items that measure various aspects of depression, such as mood, appetite, functioning at work, suicidal thinking, and sleeping patterns (Beck et al., 1961). Though widely used, personality inventories have limitations. First, the fixed number of alternatives can hinder individuals from presenting an accurate picture of themselves. Being asked to answer “true” or “false” to the statement “I am suspicious

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of people” does not permit an individual to qualify the item in any way. Second, a person may have a unique response style or response set (a tendency to respond to test items in a certain way regardless of content) that may distort the results. For example, many people have a need to present themselves in a favorable light, and this can cause them to give answers that are socially acceptable but inaccurate. Some individuals may fake having a disorder or try to avoid appearing deviant. Third, interpretations of responses of people from different cultural groups may be inaccurate if norms for these groups have not been developed. Despite these potential problems, personality inventories are widely used. Some, such as the MMPI-2, have been extensively researched throughout the world, and in many cases their validity has been established. Sophisticated means have also been found to control for response sets and for faking. For example, although individuals can lower their psychopathology scores by trying to hide their symptoms on the MMPI (as in trying to fake being healthy when they are not), the MMPI has scales that can help alert clinicians to possible faking (Bagby et al., 1997). In general, inventories are inexpensive and more easily administered and scored than are projective tests. (In fact, many inventories are scored and interpreted by computer.) These features make the use of self-report inventories desirable, especially in a busy clinic or hospital environment. Moreover, although progress has been slow, the predictive ability and validity of personality assessment tests have been improved. Psychometrics—psychological measurement, which includes the measurement of knowledge, abilities, attitudes, and personality traits—is becoming increasingly sophisticated. Further refinement will be achieved when situational variables that help determine behaviors can be taken into account and when fluctuations in mood and other, more stable personality processes can be measured.

psychometrics mental measurement, including its study and techniques

Intelligence Tests Intelligence testing is intended to obtain an estimate of a person’s current level of cognitive functioning, called the intelligence quotient (IQ). An IQ score indicates an individual’s level of performance relative to that of other people of the same age. As such, an IQ score is an important aid in predicting school performance and detecting mental retardation. (Through statistical procedures, IQ test results are converted into numbers, with 100 representing the mean, or average, score. An IQ score of about 130 indicates performance exceeding that of 95 percent of all same-age peers.) Other functions of intelligence testing are determining intellectual deterioration in psychotic disorders and discovering how a person approaches a task, handles failure, and persists in or gives up the task. The two most widely used intelligence tests are the Wechsler scales (Wechsler, 1981) and the Stanford-Binet scales (Terman & Merrill, 1960; Thorndike, Hagen, & Sattler, 1986). The Wechsler Adult Intelligence Scale (the WAIS and its revised version, WAIS-III) is administered to persons age sixteen and older. Two other forms are appropriate for children ages six to sixteen (the Wechsler Intelligence Scale for Children, or WISC-III) and ages four to six (the Wechsler Preschool and Primary Scale of Intelligence, or WPPSI-III). The WAIS-III consists of six verbal and five performance scales, which yield verbal and performance IQ scores. These scores are combined to present a total IQ score. The WAIS consists of four factors: Verbal Comprehension, Perceptual Organization, Working Memory, and Processing Speed (Saklofske, Hildebrand, & Gorsuch, 2000). Table 3.2 shows subtest items similar to those used in the WAIS-III. The Stanford-Binet Intelligence Scale is used for individuals age two and older. Much more complicated in administration and scoring, and not standardized on an adult population, the Stanford-Binet requires considerable skill in its use. The test procedure is designed to establish a basal age (the participant passes all subtests for that age) and a ceiling age (the participant fails all subtests for that age), from which an IQ score is calculated. In general, the WISC is preferred over the Stanford-Binet for school-age children (La Greca & Stringer, 1985). It is easier to administer and yields scores on different cognitive skills (such as verbal and performance subtests). Yet the Stanford-Binet is the standard to which other tests are compared because of its long history, careful revision, and updating (Kline, 2005).

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ITEMS SIMILAR TO THOSE FOR THE WECHSLER ADULT INTELLIGENCE SCALE-III Information

1. How many pennies make a nickel? 2. What is ice made of? 3. What is salt?

Comprehension

1. Why do some people save rubber bands? 2. Why is copper often used in water pipes?

Arithmetic (all calculated “in the head”)

1. Susan had three pieces of candy, and John gave her two more. How many pieces of candy did Susan have altogether? 2. Four women divided twenty pieces of candy equally among themselves. How many pieces of candy did each person receive?

Similarities

In what way are the following alike? 1. horse/zebra 2. rake/lawn mower 3. triangle/rectangle

Vocabulary

This test consists simply of asking, “What is a _____?” or “What does _____ mean?” The words cover a wide range of difficulty.

There are four major critiques of the use of IQ tests. First, some investigators believe that IQ tests have been popularized as a means of measuring innate intelligence, when in truth the tests largely reflect cultural and social factors (Sternberg, 2005). The issue of racial differences in innate intelligence has a long history of debate. The publication of The Bell Curve (Herrnstein & Murray, 1994) refocused attention on this issue. The authors of that book propose that racial differences in IQ scores are determined by heredity and that social and status differences between intellectually different classes are therefore difficult to overcome (see Figure 3.2). More recently, Rushton and Jensen (2005) also argued that racial differences in IQ scores are determined by heredity. Critics (e.g., Nisbett, 2005; Suzuki & Aronson, 2005) have charged that the basic premises of Herrnstein and Murray’s book are faulty and that the frequent assumption that IQ tests measure innate intelligence is false. Second, the predictive validity of IQ tests has been criticized. That is, do IQ test scores accurately predict the future behaviors or achievements of different cultural groups? Proponents and critics disagree on this point (Anastasi, 1982). Third, investigators often disagree over criterion variables (in essence, what is actually being predicted by IQ tests). For example, two investigators may be interested in the ability of IQ –3 –2 –1 0 1 2 3 tests to predict future success. One may try to find a correlation Standard deviations from the mean between test scores and grades subsequently received in school. The other investigator may argue that grades are a poor indicaFIGURE A BELL CURVE SHOWING STANDARD DEVIATIONS The bell curve refers to the fact that the tor of success—that leadership skills and the ability to work with distribution of IQ scores in a population resembles the shape people are better indicators of success. Fourth, some researchers have questioned whether our current of a bell, with most scores hovering over the mean and conceptions of IQ tests and intelligence are adequate. A number fewer scores falling in the outlying areas of the distribution. of researchers have proposed that intelligence is a multidimen- IQ scores are transformed so that the mean equals 100, and deviations from the mean are expressed in terms of sional attribute. E. H. Taylor (1990) stated that an important standard deviations. One standard deviation from the mean aspect of intelligence, and one that cannot be adequately assessed (about 15 IQ points above or below the mean, or IQ scores using IQ tests, is social intelligence or competency. Social skills between 85 and 115) represent about 68 percent of the may be important in such areas as problem solving, adaptation to scores. Two standard deviations (about 30 IQ points above life, social knowledge, and the ability to use resources effectively. or below the mean, or IQs between 70 and 130) account Sternberg (2004) finds that intelligence can be viewed as analytical for over 95 percent of the scores.

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TESTING FOR INTELLECTUAL FUNCTIONING Intelligence tests can provide valuable information about intellectual functioning and can help psychologists assess mental retardation and intellectual deterioration. Although many of these tests have been severely criticized as being culturally biased, if used with care, they can be beneficial tools. Here, a three-year old child is shown taking the Stanford-Binet test. The Stanford-Binet Intelligence Scale is a standardized test that assesses intelligence and cognitive abilities in children and adults ages two to twenty-three.

Did You Know?

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Spanish-language version of the K-ABC is available, and norms for African American and Hispanic children have been developed. Interestingly, differences in performance between white and ethnic minority children are much lower on the K-ABC than on traditional IQ tests.

(ability to analyze and evaluate ideas, solve problems, and make decisions), creative (going beyond what is given to generate novel and interesting ideas), and practical (ability that individuals use to find the best fit between themselves and the demands of the environment). The controversies over the validity and usefulness of IQ testing may never fully subside. Some continue to claim that IQ tests demonstrate predictive validity for many important attributes, including future success (Barrett & Depinet, 1991). Others maintain that such tests are biased and limited (Helms, 1992). Reliance on IQ scores has resulted in discriminatory actions. In California, for example, African American children were, in the past, disproportionately assigned to classes for the educable mentally retarded on the basis of IQ results. The criticisms regarding cultural biases have resulted in attempts to find more culturally appropriate tests.

The Kaufman Assessment Battery for Children (K-ABC-II) An increasingly popular means of evaluating the intelligence and achievement of children ages two and a half to twelve and a half years is the Kaufman Assessment Battery for Children (K-ABC-II). Based on theories of mental processing developed by neuropsychologists and cognitive psychologists, the K-ABC-II is intended for use with both general and special populations. For example, the assessment battery has been used with children who have hearing or speech impairments and with those who have learning disabilities (Kaufman & Kaufman, 2004). The K-ABC can be used with exceptional children and members of ethnic minority groups. Its applicability to diverse groups has been attributed to measures that (1) are less culturally dependent than those found on traditional tests and (2) focus on the process used to solve problems rather than on the specific content of test items. Children are administered a wide variety of tasks, such as copying a sequence of hand movements performed by the examiner, recalling numbers, assembling triangles to match a model, and demonstrating reading comprehension. Their verbal performance and nonverbal performance are then assessed. For certain language-disordered children or those who do not speak English, nonverbal performance can be used to estimate intellectual functioning. The K-ABC tends to have high reliability and validity (Kaufman, Kamphaus, & Kaufman, 1985; Kaufman & Kaufman, 2004), and it provides a comprehensive, unique, and useful assessment tool for children (Reynolds, Kamphaus, & Rosenthal, 1989; Vazquez-Nuttall et al., 2007). Because many of the K-ABC subscales measure performance using social information, it may be more likely than traditional IQ tests to assess social intelligence (Taylor, 1990). Tests for Cognitive Impairment Clinical psychologists, especially those who work in a hospital setting, are concerned with detecting and assessing cognitive impairments due to brain damage. Such damage can have profound effects both physically (e.g., motor behavior) and psychologically (memory, attention, thinking, emotions, etc.; Gass, 2002). The use of individual intelligence tests such as the WAIS-III can sometimes identify such impairments. For example, a difference of twenty points between verbal and performance scores on the WAIS-III may indicate the possibility of brain damage. Overall, IQ scores have been found to be significantly correlated with neuropsychological test performance (Diaz-Asper, Schretlen, & Pearlson, 2004). Certain patterns of scores on the individual subtests, such as those that measure verbal concept formation or abstracting ability (comparison and comprehension), can also reveal brain damage. Because impaired abstract thinking may be characteristic of brain damage, a lower score on this scale (when accompanied by other signs) must be investigated. One of the routine means of assessing cognitive impairment is the BenderGestalt Visual-Motor Test (Bender, 1938; Brannigan, Decker, & Madsen, 2004), shown in Figure 3.3. Nine geometric designs, each drawn in black on a piece of

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white cardboard, are presented one at a time to the test taker, who is asked to copy them on a piece of paper. Certain errors in the copies are characteristic of neurological impairment. Among these are rotation of figures, perseveration (continuation of a pattern to an exceptional degree), fragmentation, oversimplification, inability to copy angles, and reversals. In addition to assessing brain damage and neurological impairment, the Bender-Gestalt is often used for the evaluation of visual-motor maturity and for screening children for developmental delays. The Halstead-Reitan Neuropsychological Test Battery, developed by Reitan from the earlier work of Halstead, has been used successfully to differentiate patients with brain damage from those without brain damage and to provide valuable information about the type and location of the damage (Boll, 1983). The full battery consists of eleven tests, although several are often omitted. Clients are presented with a series of tasks that assess sensorimotor, cognitive, and perceptual functioning, including abstract concept formation, memory and attention, and auditory perception. The full battery takes more than six hours to administer, so it is a relatively expensive and time-consuming assessment tool. Versions of the Halstead-Reitan Battery are available for children age five and older (Nussbaum & Bigler, 1989), and normative data for children have been collected. Reliability and validity of the tests are well established (Clarkin et al., 1999). A less costly test for cognitive impairment is the Luria-Nebraska Neuropsychological Battery, which requires about two hours to administer and is more standardized in content, administration, and scoring than is the Halstead-Reitan Battery. Developed by C. J. Golden and colleagues (Golden et al., 1981), this battery includes twelve scales that assess motor functions, rhythm, tactile functions, visual functions, receptive and expressive speech, memory, writing, intellectual processes, and other functions. Validation data indicate that the battery is highly successful in screening for brain damage and quite accurate in pinpointing damaged areas (Anastasi, 1982). A children’s version has been developed (Golden, 1989). Neuropsychological tests are widely used (Camara et al., 2000) and are effective and valid in evaluating cognitive impairment due to brain damage. In fact, they are far more accurate than evaluations made simply through interviews or informal observations (Kubiszyn et al., 2000).

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CT SCANS Neurological tests, such as CT scans, PET scans, and MRIs, have dramatically improved our ability to study the brain and to assess brain damage. Shown here on the left is a normal CT scan; on the right, a CT scan showing the enlarged ventricles (butterfly shape in the center) of an individual suffering from senile dementia.

Neurological Tests In addition to psychological tests, a variety of neurological medical procedures are available for diagnosing cognitive impairments due to brain damage or abnormal brain functioning. For example, x-ray studies can often detect brain tumors. A more sophisticated procedure, computerized axial tomography (CT) scan, repeatedly scans different areas of the brain with beams of x-rays and, with the assistance of a computer, produces a three-dimensional, cross-sectional image of the structure of the brain. That image can provide a detailed view of brain deterioration or abnormality. In addition to the study of brain damage, CT scans have been used to study brain tissue abnormalities among patients diagnosed with schizophrenia, affective disorders, Alzheimer’s disease, and alcoholism (Coffman, 1989). The positron emission tomography (PET) scan enables noninvasive study of the physiological and biochemical processes of the brain, rather than the anatomical structures seen in the CT scan. In PET scans, a radioactive substance is injected into the patient’s bloodstream. The scanner detects the substance as it is metabolized in the brain, yielding information about brain functioning. PET scans, like CT scans, have been used to study a variety of mental disorders and brain diseases. Characteristic metabolic patterns have been observed in many of these disorders (Holcomb et al., 1989). PET scans can be combined with information from other scans (such as CT scans) to provide comprehensive information about the brain. An older and more widely used means of examining the brain is the electroencephalograph (EEG). Electrodes attached to the skull record electrical activity (brain waves), and abnormalities in the activity can provide information about the presence of tumors or other brain conditions. A final technique, magnetic resonance imaging (MRI), creates a magnetic field around the patient and uses radio waves to detect abnormalities. MRIs can produce an amazingly clear crosssectional “picture” of the brain and its tissues. Because of these PET SCANS This PET scan reveals increased brain activity superior pictures, which are reminiscent of postmortem brain as a function of visual stimulation. The areas in red show slices, MRIs can often provide better images of lesions than CT the most intense stimulation, and as you can see, the more scans can (Andreasen, 1989; Morihisa et al., 1999). In functional complex the information being processed, the more active magnetic resonance imaging, both the structures and also those the brain is.

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changes that occur in specific brain functions can be observed. It provides high resolution, noninvasive views of neural activity detected by a blood-oxygen-leveldependent signal. These neurological techniques, coupled with psychological tests, are increasing diagnostic accuracy and understanding of brain functioning and disorders. Some researchers predict that in the future such techniques will allow therapists to make more precise diagnoses and to pinpoint precise areas of the brain affected by disorders such as Alzheimer’s and Huntington’s diseases.

Myth vs Reality Myth: Psychological tests are less accurate than medical tests because a person’s psychological status is more difficult to assess. Reality: The widely held belief that medical tests are more reliable and valid than psychological tests appears to be false. Meyer and colleagues (2001) conducted an evaluation of the validity of psychological and medical tests. Both kinds of tests were found to vary in reliability and validity. However, many psychological tests were found to be as good as or better than medical tests in detecting conditions. For example, neuropsychological tests were as accurate as the MRI in detecting dementia. Psychological tests are valuable tools.

The Ethics of Assessment Some people have objected to the widespread use of tests. Issues such as the confidentiality of client records, invasion of privacy, client welfare, cultural bias, and unethical practices have increasingly been raised (Bersoff, 1981; Weiner, 1995). In assessing and treating emotionally disturbed people, clinical psychologists must often ask embarrassing questions or use tests that may be construed as invasions of privacy. Test findings may be inaccurate, causing serious misdiagnosis and its consequences. Note the fears and concerns over the possible widespread use of tests to detect antibodies to the HIV virus (AIDS) and drug abuse, as well as the use of the polygraph in job settings. The increased role of computers in assessment has also raised a number of issues. For decades, computers have been used to score the test results and to provide psychological profiles of clients. More recently, computer programs have become available to administer clinical interviews, IQ tests, personality inventories, and projective tests. They may also interpret responses of clients or other persons, such as applicants for jobs, and many large testing corporations are using them (Kline, 2005). The computers are programmed, for example, to simulate a structured clinical interview. Individuals who are being assessed sit before a keyboard and answer questions shown on the computer screen. Computer assessment has some advantages over face-to-face assessment. First, with the rising costs of mental health care, this technique can free up the time of clinicians and other personnel who have traditionally administered the interviews or tests. The computer can easily perform scoring and interpretation. Second, the motivation and attention of clients may be increased because clients often enjoy using a computer. Third, because clinicians often differ in interviewing styles and backgrounds, computer assessment may provide superior standardization of procedures. But although the use of computers in assessment is increasing, the application of computer technology remains MAGNETIC RESONANCE IMAGING (MRI) In magnetic largely in the scoring rather than in the administration of tests resonance imaging, a magnetic field is created around the (Camara et al., 2000). Two important questions remain: How patient, and radio waves are then used to produce amazingly reliable and valid are computer assessments, and can they be a detailed pictures of the brain.

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critical thinking

Can We Accurately Assess the Status of Members of Different Cultural Groups?

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e often have a difficult time evaluating the behaviors of people from other cultures. Cultural groups differ in many aspects, including dietary practices, type of clothing, religious rituals, and social interactions. How do we decide whether an individual from a different culture is behaving in a certain way because of a mental disorder or because of cultural practices? What signs or clues indicate that someone is truly mentally and emotionally disturbed? Can we use assessment measures standardized in the United States with people from other countries? Can assessment measures administered in English be applied to those with limited English proficiency (Kohn & Scorcia, 2007)? These questions are only a sampling of the kinds of issues clinicians must consider when trying to assess members of ethnic minority groups or individuals from different cultures. Brislin (1993) has identified several major problems, including the equivalence of concepts and scales. First, certain concepts may not be equivalent across cultures. For instance, Americans living in the United States and the Baganda living in East Africa have different concepts of intelligent behavior. In the United States, one indicator of intelligence is quickness in mental reasoning; among the Baganda, slow, deliberate thought is considered a mark of intelligence. Obviously, tests of intelligence devised in the two cultures would differ. Individuals taking the tests could be considered intelligent on one culture’s measure but not on the other.

Second, scores on assessment instruments may not really be equivalent in cross-cultural research. For example, many universities use the Scholastic Assessment Test (SAT), which has a verbal and a quantitative component, as a criterion for admissions. Do the test scores mean the same thing for different groups in terms of assessing academic potential, achievements, and ability to succeed? SAT scores do tend to be moderately successful predictors of subsequent university grades. Sue and Abe (1988), however, found that the SAT score’s ability to predict success varies according to ethnicity and the components of the SAT. Whereas the SAT verbal component was a good predictor of university grades for white American students, the SAT quantitative portion was a good predictor of grades for Asian American students. Thus Asian American and white American students with the same overall SAT scores may receive very different grades in individual courses. Third, the manner in which symptoms are expressed may vary from culture to culture, and certain cultural groups may have disturbances that are specific to those groups (Griffith, Gonzalez, & Blue, 1999). For example, culturebound syndromes, such as those shown in Table 3.3, refer to syndromes that are often found in one cultural group but not others. What are the implications of these findings? Should we abolish measures of performance for members of groups that have not been part of the standardization process? If so, how can we evaluate them? These are only a few of the dilemmas involved in assessment.

substitute for face-to-face assessment between client and clinician? How can standardization occur when respondents may be giving their responses under very different settings (e.g., while simultaneously watching television, having others “help” complete the tests, eating while responding, and so forth)? Can security and privacy of responses be assured when tests are completed online? Thus, although there are advantages to computerized testing and Internet testing, a number of problems need to be addressed (Naglieri et al., 2004). Some studies of computer assessment have yielded encouraging results. Some findings indicate that the assessment has good reliability and validity and that patients have favorable views of rated computerized interviews (Strong & Farrell, 2003). One investigation (Farrell, Stiles-Camplair, & McCullough, 1987) evaluated the ability of a computer interview to assess the target complaints of clients. The clients completed a computer interview in which they were told to answer a series of questions by pressing the appropriate keyboard selections that corresponded to their feelings. Depending on their answers, further programmed questions were asked to refine their responses. The researchers also used traditional forms of assessment—clinical interviews and psychological tests—with these clients and compared those results with the computer interview results. The computer interview findings generally agreed with those of the traditional clinical interview and test results. However, most of the clients preferred being interviewed by the clinician.

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CULTURE-BOUND SYNDROMES Culture-bound syndromes are recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be classified in a particular DSM-IV-TR diagnostic category. Many of these patterns are indigenously considered to be illnesses or afflictions. The particular symptoms, course, and social response are often influenced by local cultural factors. Among the culture-bound syndromes that DSM-IV-TR recognizes are the following: Ataque de nervios An idiom of distress principally reported among Latinos from the Caribbean but recognized among many Latin American and Latin Mediterranean groups. Commonly reported symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, and verbal or physical aggression. Dissociative experiences, seizure-like or fainting episodes, and suicidal gestures are prominent in some attacks. A general feature is a sense of being out of control. Ataques de nervios frequently occur as a direct result of a stressful event relating to the family (such as news of the death of a close relative). People may experience amnesia for what occurred during the ataque de nervios, but they otherwise return rapidly to their usual level of functioning. Koro A term that refers to an episode of sudden and intense anxiety during which the penis (or, in females, the vulva and nipples) recedes into the body and possibly causes death. The syndrome is reported in South and East Asia, where it is known by a variety of local terms. It is occasionally found in the West. Koro at times occurs in localized epidemic form in East Asian areas. Rootwork A set of cultural interpretations that ascribe illness to hexing, witchcraft, sorcery, or the evil influence of another person. Symptoms may include generalized anxiety and gastrointestinal complaints (such as nausea, vomiting, and diarrhea), weakness, dizziness, the fear of being poisoned, and sometimes fear of being killed (“voodoo death”). “Roots,” “spells,” or “hexes” can be “put” or placed on other persons, causing a variety of emotional and psychological problems. The hexed person may even fear death until the root has been eliminated, usually through the work of a root doctor (a healer in this tradition), who can also be called on to bewitch an enemy. Rootwork is found in the southern United States among African American and European American populations and in Caribbean societies. Shenjing shuairuo (“neurasthenia”) In China, a condition characterized by physical and mental fatigue, dizziness, headaches, concentration difficulties, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and various signs suggesting disturbance of the autonomic nervous system. In many cases, the symptoms would meet the criteria for a DSM-IV-TR mood or anxiety disorder. Source: Adapted from American Psychiatric Association (2000a).

The Classification of Abnormal Behavior The goal of having a classification system for abnormal behaviors is to provide distinct categories, indicators, and nomenclature for different patterns of behavior, thought processes, and emotional disturbances. Thus the pattern of behavior classified as paranoid schizophrenia should be clearly different from the pattern named borderline personality. At the same time, the categories should be constructed in such a way as to accommodate wide variation in these patterns. That is, the clinician should be able to categorize paranoid schizophrenic behavior as such, even when the patient does not show the “perfect” or “textbook” paranoid schizophrenic pattern.

Diagnostic and Statistical Manual of Mental Disorders (DSM) As discussed in Chapter 1, toward the end of the nineteenth century, Emil Kraepelin devised the first effective classification scheme for mental disorders. Kraepelin held the organic view of psychopathology, and his system had a distinctly biogenic slant. Classification was based on the patient’s symptoms, as in medicine. It was hoped that disorders (similar groups of symptoms) would have a common etiology (cause or origin), would require similar treatments, would respond to those treatments similarly, and would progress similarly if left untreated.

classification system with regard to psychopathology, a system of distinct categories, indicators, and nomenclature for different patterns of behavior, thought processes, and emotional disturbances

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Many of these same expectations were held for the Diagnostic and Statistical Manual of Mental Disorders, based on the Kraepelinian system and published by the American Psychiatric Association in 1952. However, the reliability and validity of DSM were problematic. Early studies of the DSM that compared the diagnoses of pairs of clinicians found poor agreement (interrater reliability) between the members of each pair and weak test-retest reliability. The greatest disagreement was found in specific categories. As a rule, reliability was higher for broad distinctions than for fine distinctions. A fine distinction, for example, would focus on the precise type of personality disturbance or disorder. Many critics of DSM questioned the validity and usefulness of psychiatric classification (Ferster, 1965; Kanfer & Phillips, 1969; Ullmann & Krasner, 1965). They claimed that DSM did not adequately convey information about underlying causes, processes, treatment, and prognosis. (A prognosis is a prediction of the future course of a particular disorder.) The problem arose because early versions of DSM were strongly influenced by the biological model of mental illness, in which cause is supposed to be a basis of classification. With the exception of the categories involving brain damage, which may parallel diseases, most DSM categories were purely descriptive. In addition, a prerequisite for high validity is high reliability. Because the reliability of early versions of DSM was questionable, the validity of the DSM was also limited (McWilliams, 2006). In view of these problems, each subsequent version of DSM was developed to have greater reliability and validity. In addition, DSM tried to incorporate new research findings. Although Kraepelin’s concepts still formed the basis for some of its categories, successive versions of DSM contained substantial revisions. For example, to improve reliability, DSM specified the exact criteria that clinicians should use in making a diagnosis. What has also helped to increase reliability and validity has been the development of structured interviews (e.g., the Structured Clinical Interview for DSM-IV) that gather information pertinent to making a DSM diagnosis (Williams, 1999). Results of field trials indicated that good to excellent interrater reliability could be obtained for many, but not all, of the major classes of disorders (Williams, 1999). The American Psychiatric Association published the latest version, DSM-IV-TR, in 2000. DSM-IV-TR provides diagnostic categories and lists criteria to judge whether a person’s symptoms and behaviors fall into the category. It allows clinicians to examine and evaluate the individual’s mental state with regard to five factors or dimensions (called axes in the manual). Axes I, II, and III address the individual’s present mental and medical condition. Axes IV and V provide additional information about the person’s life situation and functioning. Together, the five axes are intended to provide comprehensive and useful information. Axis I—Clinical Syndromes and Other Conditions That May Be a Focus of Clinical Attention Any mental disorder listed in the manual (except those included on Axis II) is indicated on Axis I. If an individual has more than one mental disorder, they are all listed. The principal disorder is listed first. Axis II—Personality Disorders and Mental Retardation Personality disorders, as well as prominent maladaptive personality features, are listed on Axis II. Personality disorders may be present either alone or in combination with a mental disorder from Axis I. If more than one personality disorder is present, they are all listed. Also included on Axis II is mental retardation. Axis III—General Medical Conditions Listed on Axis III are any medical conditions that are potentially relevant to understanding and treating the person.

a prediction of the future course of a particular disorder

prognosis

Axis IV—Psychosocial and Environmental Problems These problems may affect the diagnosis, treatment, and prognosis of mental disorders. For example, a client may be experiencing the death of a family member, social isolation, homelessness, extreme poverty, and inadequate health services. The clinician lists these problems if they have been present during the year preceding the current evaluation or if they occurred before the previous year and are clearly contributory to the disorder

The Classification of Abnormal Behavior

or have become a focus of treatment. The clinician has various categories in which to classify the type of problems. Axis V—Global Assessment of Functioning The clinician provides a rating of the psychological, social, and occupational functioning of the person. Normally, the rating is made for the level of functioning at the time of the evaluation. The clinician uses a 100-point scale, on which 1 indicates severe impairment in functioning (for example, the individual is in persistent danger of severely hurting him- or herself or others or is unable to maintain minimal personal hygiene) and 100 refers to superior functioning with no symptoms. The disorders (categories) for Axes I and II that are included in DSM-IV-TR are shown on the inside covers of this book. Let’s look at an example of a client, as well as a possible clinician evaluation based on the DSM-IV-TR.

Case Study Mark was a fifty-six-year-old machine operator who was referred for treatment by his supervisor. The supervisor noted that Mark’s performance at work had deteriorated in the past four months. Mark was frequently absent from work, had difficulty getting along with others, and often had a strong odor of liquor on his breath after his lunch break. The supervisor knew that Mark was a heavy drinker and suspected that Mark’s performance was affected by alcohol consumption. In truth, Mark could not stay away from drinking. He consumed alcohol every day; during weekends, he averaged about sixteen ounces of Scotch per day. Although he had been a heavy drinker for thirty years, his consumption had increased after his wife divorced him six months previously. She claimed she could no longer tolerate his drinking, extreme jealousy, and unwarranted suspicions concerning her marital fidelity. Coworkers avoided Mark because he was a cold, unemotional person who distrusted others. During interviews with the therapist, Mark revealed very little about himself. He blamed others for his drinking problems: if his wife had been faithful or if others were not out to get him, he would drink less. Mark appeared to overreact to any perceived criticisms of himself. A medical examination revealed that Mark was developing cirrhosis of the liver as a result of his chronic and heavy drinking.

Mark’s heavy use of alcohol, which interfered with his functioning, resulted in an alcohol abuse diagnosis on Axis I. Mark also exhibited a personality disorder, which was diagnosed as paranoid personality on Axis II because of his suspiciousness, hypervigilance, and other behaviors. Cirrhosis of the liver was noted on Axis III. The clinician noted Mark’s divorce and difficulties in his job on Axis IV. Finally, Mark was given a 54 on the Global Assessment of Functioning (GAF) scale, used in Axis V to rate his current level of functioning, mainly because he was exhibiting moderate difficulty at work and in his social relationships. Mark’s diagnosis, then, was as follows: • Axis I—Clinical syndrome: alcohol abuse • Axis II—Personality disorder: paranoid personality • Axis III—Physical disorder: cirrhosis • Axis IV—Psychosocial and environmental problems: (1) Problems with primary support group (divorce), (2) occupational problems • Axis V—Current GAF, 54

DSM-IV-TR Mental Disorders The task of making a diagnosis of mental disorder involves classifying individuals on Axes I and II. Most disorders found in clients are listed under either Axis I or Axis II, but some clients may have disorders on both axes or more than one on each axis. Table 3.4 lists the broad categories of mental disorders, most of which are discussed in this book. It should be noted that many individuals who have one mental disorder also suffer from another. For example, an individual who is diagnosed with depression

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3.4

DSM-IV-TR DISORDERS CATEGORIES OF DISORDERS

FEATURES

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Impairment in cognitive and intellectual functioning, language or motor deficiencies, disruptive behaviors, poor social skills, anxiety, eating disorders, and so on

Delirium, Dementia, Amnestic, and Other Cognitive Disorders

Psychological or behavioral abnormality associated with a dysfunction of the brain, including problems that arise from head injuries, ingestion of toxic/intoxicating substances, brain degeneration or disease, and so on

Mental Disorders Due to a General Medical Condition

When medical conditions are causally related to a disorder, the client is considered to have a mental disorder due to a general medical condition. Example: hypothyroidism can be a cause of major depressive disorder; diagnosis would be “major depressive disorder due to a general medical condition (hypothyroidism)”

Substance-Related Disorders

Use of psychoactive substances (alcohol, cocaine, and so forth) that continues despite problems; some disorders (anxiety or mood) occur because of the ingestion of substances and are considered substance-induced disorders and are listed in the section for those disorders that share the symptoms

Schizophrenia and Other Psychotic Disorders

Marked by severe impairment in thinking and perception; speech may be incoherent, and person often has delusions, hallucinations, and inappropriate affect

Mood Disorders

Mood may be one of serious depression or mania; sometimes, in bipolar conditions, both depression and mania are exhibited

Anxiety Disorders

Anxiety is predominant symptom; avoidance behaviors are usually present (such as phobias). Individuals may exhibit obsessions (recurrent thoughts) or compulsions (repetitive behaviors), which cause distress when they are not performed

Somatoform Disorders

Symptoms of a physical disorder that cannot be explained by a medical condition are usually classified as somatoform disorders. Individuals complain of bodily dysfunctions, are preoccupied with beliefs of having a health problem, or experience pain

may also have a second disorder such as substance abuse. Comorbidity refers to this co-occurrence of different disorders. One large-scale survey (Kessler, Chiu, et al., 2005) found that the rate of comorbidity is high—60 percent of those with one disorder also had another disorder. One possible explanation is that factors involved in one disorder, such as stress, may influence the development of other disorders (Krueger et al., 1998). Furthermore, after each diagnosed disorder, clinicians can use specifiers that indicate severity and remission status. Severity is rated as mild, moderate, or severe, depending on the symptoms and degree of impairment. Remission refers to a disorder in which the full criteria for making the diagnosis were met at one time but in which the current symptoms or signs of the disorder are only partially apparent (partial remission) or no longer remain (full remission). Figure 3.4 shows the prevalence rate (the percentage of the population with the disorder) of certain disorders, as determined by a large national survey.

Evaluation of the DSM Classification System

comorbidity co-occurrence of different disorders

Field trials or studies on the adequacy of DSM-IV-TR have been conducted on certain diagnostic categories. One study found that symptom measures could differentiate between clients with DSM-IV-TR anxiety and mood disorders (Brown, Chorpita, & Barlow, 1998). Brown and colleagues (2001) also found good to excellent reliability

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3.4 (continued)

DSM-IV-TR DISORDERS CATEGORIES OF DISORDERS

FEATURES

Factitious Disorders

Intentional feigning of physical or psychological symptoms; individuals with this disorder are motivated by psychological need to assume sick role

Dissociative Disorders

Disturbance or alteration in memory, identity, or consciousness; individuals may not remember who they are, assume new identities, have two or more distinct personalities, or experience feelings of depersonalization

Sexual and Gender Identity Disorders

Two main groups of disturbances are included: paraphilias and sexual dysfunctions. In gender identity disorders, there is a cross-gender identification and a desire to be the other sex, coupled with a persistent discomfort with one’s own sex

Eating Disorders

Included are refusal to maintain body weight above a minimally normal weight and binge eating and purging

Sleep Disorders

Symptoms involve problems in initiating/maintaining sleep, excessive sleepiness, sleep disruptions, repeated awakening associated with frightening nightmares, sleepwalking, and so on

Impulse Control Disorders Not Elsewhere Classified

A separate class of disorders involves failure to resist an impulse or temptation to perform an act that is harmful to oneself or others; included are disorders involving loss of impulse control over aggression, stealing, gambling, setting fires, and pulling hair

Adjustment Disorders

Characterized by marked/excessive distress or significant impairment in social, occupational, or academic functioning because of a recent stressor; symptoms do not meet criteria for Axis I/II disorders and do not include bereavement

Personality Disorders

Personality traits are inflexible and maladaptive and notably impair functioning or cause subjective distress; typically involve odd or eccentric behaviors, excessive dramatic and emotional behaviors, or anxious and fearful behaviors

Not Otherwise Specified

These categories are intended to include disorders that do not fully meet the criteria for a particular disorder

for the majority of DSM-IV-TR anxiety and mood disorder categories. Factors decreasing reliability included disagreements over whether symptoms were sufficient in number, severity, or duration to meet DSM-IV-TR criteria. Because research findings helped shape DSM-IV-TR, reliability and validity are stronger than in the previous versions (Brown et al., 2001). In general, with the greater precision in specifying the criteria for making a diagnosis and with the increased role of research findings in defining disorders, reliability of diagnosis of disorders is higher in DSM-IV-TR than in earlier versions of DSM. However, increased reliability may not mean increased validity. As one critic (Sarbin, 1997) observes, sixteenth-century witch hunters developed explicit and reliable criteria (such as bodily abnormalities) for determining whether a person is a witch. Nevertheless, the diagnosis (“witch”) had no validity. A positive feature of DSM-IV-TR is its emphasis on cross-cultural assessment issues compared to previous versions. It has an introductory section that places diagnosis within a cultural context. It provides a description of pertinent culture, age, and gender features for each disorder, and it supplies guidelines for addressing the cultural background of the client and the context for evaluating the client. DSMIV-TR also contains an outline of culture-bound syndromes, disorders unique to a particular cultural group. (Table 3.3 describes some of these syndromes.) Many culture-bound syndromes involve not only psychological symptoms but also bodily or somatic symptoms (Dana, 1998); this reflects the fact that the mind-body distinction prevalent in western societies is absent in many other societies (Dana, 1998).

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These improvements make DSM-IV-TR far more culturally sensitive than were the previous editions. This trend might be taken even further by incorporating into DSM another axis that specifies the extent to which cultural factors influence the client’s clinical condition (Draguns, 1996). With this addition, DSM and the assessment process could be a great deal more appropriate for clients from different cultural backgrounds. The next edition, DSM-V, is planned for 2010 (Shore, 2006). Among the many criticisms of DSM are these: 1. DSM has a strong medical orientation, even though more than one-half of the disorders are not attributable to known or presumed organic causes and should not be considered biological in nature (Nelson-Gray, 1991; Schacht, 1985; Schacht & Nathan, 1977). Some psychologists see DSM’s medical emphasis in part as a response to psychiatrists’ need to define abnormality more strongly within their profession. 2. The procedures leading up to the development of DSM-IV-TR primarily involved committees negotiating the nomenclature rather than the use of scientifically derived data. Some categories were created out of compromises between conflicting views or were rooted in practical considerations, such as ease of application and acceptability to practitioners. Thus DSM-IV-TR attempts to be atheoretical—it lacks a scientific theory for its classification of disorders (Follette & Houts, 1996; Sarbin, 1997). 3. Certain diagnostic categories in DSM have been characterized as being sexist or culturally biased. For example, specific behaviors sometimes seen among women may be inappropriately interpreted as signs of mental disorders (D. Franklin, 1987; Kaplan, 1983). One example is the continuing discussion of whether to establish premenstrual dysphoric disorder as a DSM diagnostic category. Premenstrual dysphoric disorder, many times associated with women experiencing premenstrual syndrome (PMS), has been a hotly debated category. According to DSM-IV-TR, the symptoms include marked changes in mood and persistent anger, depression, or anxiety, often accompanied by complaints of breast tenderness and bodily aches. There is often an increase in interpersonal conflicts and a marked interference with work or social activities and relationships. These symptoms occur in a cyclical pattern a week before menses and remit a few days afterward. Although critics of this category acknowledge that many women have some of these symptoms, they believe that the disorder should be treated as a strictly physical or gynecological disorder. Labeling it as a psychiatric disorder stigmatizes women as being emotional and controlled by “raging hormones.” In recognition of the controversy, DSM-IV-TR considers premenstrual dysphoric disorder to be a proposed condition requiring further study rather than a new disorder category. 4. According to Shore (2006), the most inadequate part of DSM has been the categories dealing with childhood disorders. DSM is basically an adult sysWHAT IS A MENTAL DISORDER? A mother tem that has been extended downward to children rather than derived from poses at her home alongside a computer an understanding of developmental principles. showing the Web site of the support 5. One of the major problems with DSM is the categorization of disorders. group On-Line Gamers Anonymous on the Research shows that in many disorders, such as depression, the distinction screen. She says video and Internet games transformed her son from a courteous, between major and less severe mood states is a matter of degree rather than kind (Ruscio & Ruscio, 2000). Furthermore, as mentioned earlier, many outgoing, academically gifted teen into disorders are comorbid (i.e., occurring together), and symptoms of one dis- an aggressive, reclusive manipulator who order may overlap with another (Clark, 2005; Widiger & Samuel, 2005). flunked two tenth-grade classes and spent several hours day and night playing a popular These findings have led to a questioning of whether a disorder is better online video game. A leading council of the conceptualized as being categorical or continuous. Through the use of tax- American Medical Association now wants ometric statistical procedures in examining data on disorders, it is possible to have this behavior officially classified as to analyze whether a disorder tends to be categorical or continuous (Cole, a mental disorder, to raise awareness and 2004). The fact that disorders have common symptoms has also stimulated enable sufferers to get insurance coverage hierarchical models that regroup disorders on the basis of shared features for treatment. Should this problem be considered as a mental disorder? (Watson, 2005).

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Did You Know?

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epression was recognized from the very beginning of human existence. In the fourth century B.C., Hippocrates used the terms melancholia (black bile) and mania (to be mad) to refer to mood disorders and mental illness. Beginning in 1952, DSM considered psychotic depressive reaction to be a severe disorder that lacked a precipitant. In subsequent editions of DSM, mood disorder diagnoses were based on symptom clusters rather than on the presence or absence of a precipitant.

An attempt to clarify the intent of DSM and respond to its critics noted that the classification system was not intended to imply that all mental disorders have an organic basis. Rather, the important question is whether the DSM revised editions are a substantial improvement over past systems. Proponents of this position believe they are, and they argue that constructing a diagnostic classification system is an ongoing process, requiring continual revision and improvement. The limitations in the usefulness of DSM may therefore partly reflect holes in our knowledge of psychopathology. Furthermore, it is highly likely that the next version, DSM-V, will contain important modifications that consider dimensional issues, as suggested by Shore (2006). Consistent with our multipath model, there is increasing recognition that disorders are multidetermined, with many factors contributing to their development (Fauman, 2006). DSM-V will have to incorporate a wide range of factors in the description of disorders. The debates over the usefulness of the DSM system have been valuable in suggesting new research directions, increasing the role of research in developing the system, and stimulating the examination of conceptual, methodological, philosophical, and clinical assumptions in the classification of mental disorders. Future research, particularly research that examines the construct validity of DSM, is essential to evaluating the usefulness of the system. Alternatives to DSM classification are available. Goldfried and Davison (1976) devised a behavioral classification scheme in which deviant behaviors are classified according to the variables that are maintaining the behaviors. For example, a child may learn to be physically aggressive while playing football and then bring such behavior into the classroom (inappropriate behavior). The inappropriate behavior is classified as a stimulus control problem. Stimulus control is defective because the behavior does not conform to the appropriate stimulus (the child should be physically nonaggressive in the classroom). The change of stimuli (playing field to classroom) fails to change the child’s behavior. Because this classification scheme emphasizes the variables that maintain behavioral patterns, it lets the therapist isolate those variables for treatment purposes (Goldfried & Davison, 1976). Others have proposed different classification schemes that can supplement DSMIV-TR. For example, Berenbaum and colleagues (2003) have constructed a taxonomy of emotional disturbances. The taxonomy divides emotional disturbances (which cut across the spectrum of psychiatric disorders) into emotional valence disturbances, emotional intensity/regulation disturbances, and emotional disconnections. Finally, the Psychodynamic Diagnostic Manual has been proposed by a group of psychoanalytic organizations (McWilliams, 2006). It is intended to supplement DSM-IV-TR and to take into consideration dimensional rather than categorical functioning and developmental processes. It is unlikely that other diagnostic systems will gain popularity over DSM, especially if the planned DSM-V version takes into consideration new research findings.

Objections to Classification and Labeling Classification schemes can be of immense aid in categorizing disorders and in communicating information about them and conducting research on them. They have nevertheless been criticized because of negative consequences. 1. Labeling a person as having a mental disorder can result in overgeneralizations, stigmas, and stereotypes. For example, former mental patients may have a difficult time finding employment because of employers’ fears and stereotypes about mental disorders. The American Psychological Association (1990) has noted that stereotypes can lead to inaccurate generalizations about individuals that are often transformed into discriminatory behavior. It then becomes more difficult for others to respond to the person’s own particular characteristics, making accurate, differentiated, and unique impressions less likely.

The Classification of Abnormal Behavior

2. A label may lead others to treat a person differently. A classic study by Rosenthal and Jacobson (1968) showed that responses to a label can cause differential treatment. They tested schoolchildren and then randomly assigned them to either of two groups. Teachers were told that tests of one group indicated that they were potential intellectual “bloomers” (gaining in competence and maturity); the other group was not given this label. After a one-year interval, children from both groups were retested. Children who had been identified as bloomers showed dramatic gains in IQ scores. How did this occur? Many have speculated that the label led teachers to have higher intellectual expectations for the bloomers and thus to treat them differently. Even though there was no significant difference in IQ levels between the two groups to begin with, differences were present by the end of the year. Other studies have yielded similar results (Rappaport & Cleary, 1980). 3. A label may lead those who are labeled to believe that they do indeed possess such characteristics or may cause them to act out the label. Labels can become self-fulfilling prophecies. In the Rosenthal and Jacobson (1968) study just cited, the label not only caused teachers to behave differently but also may have affected the children. When people are constantly told that they are stupid or smart, they may come to believe such labels. It is reasonable to believe that people who ascribe certain stereotypical traits to a racial minority or an ethnic group will behave differently toward the group and will cause cognitive and behavioral changes among members of that group. Steele and his colleagues have also shown that labels and stereotypes can influence individuals not only to act out the stereotypes but also to devalue their personal status (Davies, Spencer, & Steele, 2005). For example, labeling a child as mentally retarded is not only demeaning but also detrimental to the child’s self-esteem. Many people believe that mental retardation is a biological anomaly, a permanent disability, and a gross intellectual handicap. Such beliefs and the accompanying reactions can have a profound effect on a child’s self-image. 4. A label may not provide the precise, functional information that is needed. Today, many forms of managed care organizations (MCOs)—such as health maintenance organizations, preferred provider organizations, and others—are gaining popularity in the provision of health and mental health care (Pallack, 1995). MCOs are less concerned about classifying or labeling clients’ mental disorders than about finding a more precise means of measuring client functioning. Given this trend, the assessment of functioning at work, home, school, and elsewhere may be of greater interest than the validity of the clinician’s diagnosis of schizophrenia or another disorder.

We know that assessment has improved over time. Focus on reliability and validity, increased psychometric and statistical procedures, new technologies, and large numbers of research studies on assessment have all served to increase our ability to evaluate human beings. In some cases, psychological testing is as strong as medical testing in terms of validity. However, although human beings share many psychological characteristics, they also have unique features that pose problems in making predictions about behaviors and means for successful treatment and prevention. Finding shared and unique characteristics among individuals is the critical task. Most psychologists agree that classification of disorders in some form is important. DSM has been the most widely used classification scheme. Although DSM has been criticized, the fact that changes are made in response to research findings is a positive aspect. To be more adequate, DSM needs to incorporate multipath, dimensional, and developmental features of disorders. It has to also consider the regrouping or separation of disorders, depending on common or distinct characteristics.

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.L. Rosenhan (1973) sent eight experimenters (pseudopatients) who were “normal” to different psychiatric hospitals. Their assignment was first to fake psychiatric symptoms to gain admission into psychiatric wards and, once there, to behave in a normal manner. Findings were interesting. First, no one on the hospital ward staff detected that the pseudopatients were normal. Second, nearly all pseudopatients were initially diagnosed as schizophrenic, and many of their normal behaviors were subsequently interpreted as manifestations of schizophrenia.

I M P L I C AT I O N S

Summary how a person takes the test are additional sources of information about personality attributes. The WAIS, Stanford-Binet, and Bender-Gestalt tests can be used to assess brain damage. The Halstead-Reitan and Luria-Nebraska test batteries specifically assess brain dysfunction.

1. In attempting to make an accurate evaluation or assessment of a person’s mental health, what kinds of standards must tests or evaluation procedures meet? ■

Assessment and classification of disorders are essential in the mental health field.

■

In developing assessment tools and useful classification schemes, researchers and clinicians have been concerned with issues regarding reliability (stability or the degree to which a procedure or test yields the same results repeatedly, under the same circumstances) and validity (the extent to which a test or procedure actually performs the function it was designed to perform).

2. What kinds of tools do clinicians employ in evaluating the mental health of people? ■ Clinicians primarily use four methods of assessment: observations, interviews, psychological tests and inventories, and neurological tests. ■ Observations of external signs and expressive behaviors are often made during an interview and can have diagnostic significance. ■ Interviews, the oldest form of psychological assessment, involve a face-to-face conversation, after which the interviewer differentially weighs and interprets verbal information obtained from the interviewee. ■ Psychological tests and inventories provide a more formalized means of obtaining information. In personality testing, projective techniques, in which the stimuli are ambiguous, or self-report inventories, in which the stimuli are much more structured, may be used. Two of the most widely used projective techniques are the Rorschach inkblot technique and the Thematic Apperception Test (TAT). Unlike projective tests, self-report personality inventories, such as the MMPI-2, supply the test taker with a list of alternatives from which to select an answer. Intelligence tests can be used to obtain an estimate of a person’s current level of cognitive functioning and to assess intellectual deterioration. Behavioral observations of

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■

Neurological medical procedures, including x-rays, CT and PET scans, EEG, and MRI, have added highly important and sophisticated means to detect brain damage.

3. How are mental health problems categorized or classified? ■ The first edition of DSM was based to a large extent on the biological model of mental illness and assumed that people who were classified in a psychodiagnostic category would show similar symptoms that stem from a common cause, that should be treated in a certain manner, that would respond similarly, and that would have similar prognoses. Critics questioned the reliability and validity of earlier versions of DSM. ■ The current DSM-IV-TR contains detailed diagnostic criteria; research findings and expert judgments were used to help construct this latest version. As a result, its reliability appears to be higher than that of the previous manuals. Furthermore, data are collected on five axes so that much more information about the patient is systematically examined. DSM is now undergoing revisions for a forthcoming DSM-V edition. ■ General objections to classification are based primarily on the problems involved in labeling and the loss of information about a person when that person is labeled or categorized. ■ A number of ethical questions have been raised about classifying and assessing people through tests. These include questions about confidentiality, privacy, and cultural bias. Concerned with these issues, psychologists have sought to improve classification and assessment procedures and to define the appropriate conditions for testing and diagnosis.

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twenty-four-year-old married Puerto Rican woman, Nayda, reported during an initial interview that she was in “utter anguish” and incapacitated by “epileptic fits.” These seizures were preceded by a strong headache and involved a loss of consciousness and convulsions. She had been diagnosed by a neurologist as suffering from intractable (difficult-to-treat) epilepsy. However, some symptoms appeared to be atypical compared with those seen in epilepsy. First, when regaining consciousness, she would sometimes not recognize her husband or children and claim not to be Nayda. Second, during some episodes she appeared fearful and would plead to an invisible presence to have mercy and not to kill her. Third, Nayda would often hit herself during seizures and burn items in the house. Her most recent seizures included hallucinations involving blood, during which she attempted to strangle herself with a rope. These behaviors were perplexing because she said she loved her husband and children and did not know why she would try to harm herself. Because of these unusual symptoms, Martinez-Taboas (2005) entertained the possibility that the seizures were psychogenic (psychological rather than physiological) in nature and that cultural beliefs may have been involved.

chapter outline The Scientific Method in Clinical Research

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Experiments

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Correlations

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Analogue Studies

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Field Studies

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Single-Participant Studies 108 Biological Research Strategies

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Epidemiological and Other Forms of Research

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Ethical Issues in Research 113

Psychogenic Contributors

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The therapist attempted to determine whether the seizures were the result of some type of earlier trauma such as sexual or physical abuse. Although Nayda reported none, she told of an event that had occurred when she was seventeen—two years before the seizures began. She tearfully related that one night at about 2 A.M., she was awakened by the smell of something burning. She was shocked when she saw her grandmother’s house in flames (her grandmother lived in a small house in the backyard). Strangely, she decided to go back to sleep and repeatedly told herself, “Tomorrow I will tell my parents of the fire” (Martinez-Taboas, 2005, p. 8). A few minutes later, the rest of the family was awakened by the smoke. Their

CRITICAL THINKING Attacks on Scientific Integrity 97 CONTROVERSY Repressed

Memories: Issues and Questions

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CRITICAL THINKING

Researcher Allegiance: A “Wild Card” in Comparative Research?

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FOCUSQUESTIONS

1 In what ways is the scientific method used to evaluate psychotherapy?

6 What are the various types of single-participant studies, and how are they used?

2 How does the use of an experimental design differ from other ways of investigating phenomena?

3 What are correlations, and how are they used to indicate the degree to which two variables are related?

4 What are analogue studies, and when is this type of investigation used?

5 What are field studies, and how are they used?

7 What are some of the advantages and shortcomings of the biological approach to understanding abnormal behavior?

8 What is epidemiological research, and how is it used to determine the extent of mental disturbance in a targeted population?

9 What are some ethical concerns about how research is conducted, and how can researchers best address these concerns?

attempts to rescue the grandmother failed. It was later determined that the grandmother had set the fire to take her own life. When Nayda was asked about her feelings regarding the incident, she cried profusely and said that it was her fault her grandmother had died. During the next session, while talking about the incident, Nayda had a seizure and began to beg an invisible presence not to kill her. With the client’s permission, hypnosis was used to further explore her reactions. When Nayda was asked about the seizures, she responded with terror and said “there is blood” and began to convulse on the floor. The therapist placed his hand on Nayda’s head and commanded that the seizure stop. It ended. The influence of psychogenic factors on Nayda’s seizures was clear. Cultural Formulation From a western perspective, Nayda’s symptoms of reporting a loss of personal identity, amnesia, seizures, and hallucinations involving blood could be indicative of dissociative, conversion, or even delusional disorders. The therapist wanted to investigate cultural influences as possible contributors to these symptoms. In many Latin American countries, there is a belief in espiritismo, in which the soul is immortal and, under certain circumstances, can communicate with the living. In some cases, a spirit can inhabit or possess a living person, who may display auditory and visual hallucinations during these episodes. When Nayda was asked about the seizures, she said that the spirit of her grandmother was not at peace and was causing her seizures and other problems. She believed that her not helping her grandmother during the fire resulted in a disturbed and revenge-seeking spirit. The therapist wanted to determine whether Nayda would be open to an alternative explanation and mentioned the possibility that her symptoms were due to the reexperiencing of traumatic memories and guilt rather than possession. This perspective was not accepted by Nayda, who remained convinced of her espiritismo beliefs. Therapy Approach Although one possible therapeutic approach might be to challenge Nayda’s belief that she was responsible for her grandmother’s death and question the utility of the belief in spiritual possession (Castro-Blanco, 2005), the therapist decided to work within Nayda’s belief system and combine it with western strategies. In the twentytwo therapy sessions that followed, the therapist had Nayda confront the spirit of her grandmother through the empty-chair technique, a process by which a client has

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an actual dialogue with an aspect of the self or with a significant other, imagined to be in the chair. Using this technique, Nayda explained to her grandmother that she loved her children and husband and that they needed her. Initially, the attempts were failures, and, in one episode, the grandmother spoke through Nayda and said that Nayda would never be free from her. In subsequent sessions, Nayda continued to confront her guilt and fear regarding her grandmother. Cognitive therapy was used to help Nayda develop alternative ways of thinking about her grandmother’s suicide. The family also participated in the empty-chair technique, telling the grandmother that Nayda was not responsible for her death. After several months of therapy, the grandmother’s presence became negligible and eventually disappeared completely. At a twelve-month follow-up, Nayda was no longer taking medication and had had only one brief seizure. Her depression score was within the normal range, and her dissociative symptoms had been dramatically reduced.

This case illustrates several points that are important in research, case formulation, and therapy. First, there is a tendency for individuals within their own fields of study to interpret events within a given paradigm. For example, the biological model assumes that every disease has a specific physical cause, and little attention is placed on psychological or environmental factors. In the case of Nayda, her neurologist believed the seizures were due to epilepsy and had prescribed Tegretol (an antiseizure medication) to treat the condition. Conversely, psychological theories tend to view disorders only from a psychological framework, placing less emphasis on biological or sociocultural and social explanations. A cognitive-behavioral analysis of Nayda’s behaviors might focus primarily on irrational thoughts. Therapy would involve challenging these thoughts or beliefs and substituting more realistic ones. Etiological explanations from a sociocultural perspective may focus only on cultural practices or beliefs. Second, research is often conducted from a specific model with little attention paid to other contributing factors. Recently, headlines appeared about the discovery of an obesity gene. A few weeks later, we were informed by another group of researchers that perceived social ties are predictive of obesity. The reader is left with a puzzle. Is obesity caused by a gene or by specific social patterns? We now know that the vast majority of mental health disorders are the result of a convergence of biological, psychological, sociocultural, and social risk factors. Therefore, when you are exposed to mental health research, remember that issues are best understood when a multipath model is utilized. With Nayda, it was important to consider all possible contributors to her problem. Seizures and symptoms reported in the case study could be the result of biological, psychological, sociocultural, or social factors or a combination of these influences. From a scientific perspective, we must investigate all possible causes and consider alternative explanations for behavior. Scientists are often described as skeptics. Rather than accept the conclusions from a single study, scientists demand that the results be replicated, or repeated by other researchers. Replication reduces the chance that findings are due to experimenter bias, methodological flaws, or sampling errors. The following findings were initially reported as “conclusive” in the mass media. Note their current status after further investigation: • A specific gene, the A1 allele of DRD2, plays a key role in alcoholism. Status: Subsequent research (Comings et al., 1991; Gelernter & Kranzler, 1999) found that the gene is present in fewer than 50 percent of people with alcoholism and that the gene is found in individuals with other disorders and in individuals who do not have drinking problems. The gene is neither sufficient nor necessary for the development of alcoholism.

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• In 2004, suicide rates for young people rose 14 percent. Some believe the increase may be tied to a reduction in prescriptions for antidepressants due to warnings placed on. Status: Needs further research. Some research has found that the incidence of suicide attempts in young children and adolescents was higher after antidepressant treatment compared with no antidepressant treatment (Leckman & King, 2007). • Early trials reported computer-based scans of blood flow in the brain to be 100 percent accurate in identifying patients with schizophrenia. Status: Needs replication. As one researcher, Robin Murray, points out, “Nobody has ever found a specific brain abnormality that all schizophrenics have that nobody else has” (BBC News, 2001). • Hyperactivity in children results from reactions to specific food groups or food additives. Status: Probably not supported (Eigenmann & Haenggeli, 2004). In general, experimental studies using biological-challenge or double-blind methods (described later in this chapter) have not documented change in behavior related to the consumption of certain foods or additives. • The majority of sexually abused children exhibit signs or symptoms of trauma that can be reliably detected by experts in the field of child sexual abuse. Status: There are no signs or symptoms that characterize the majority of abused children; a significant number appear to be asymptomatic (Hagen, 2003). • Traumatic memories are fixed and indelible. Status: Fifty-nine veterans of Operation Desert Storm were interviewed about highly traumatic combat events twenty-six months after their return from the Gulf War. Nearly 90 percent exhibited inconsistent recall. The greater the symptoms of posttraumatic stress disorder, the greater the inaccuracies (Southwick et al., 1997). As you can see, the search for “truth” is often a long journey. Answers regarding the causes of abnormal behavior come and go. In evaluating studies, we must consider the adequacy of the research. As Hunsley (2007) observed, “not all evidence is created equal” (p. 114). Some types of studies are more likely to be accurate, reliable, and generalizable because of their methodological or conceptual soundness. If we were to construct an evidence hierarchy based on internal validity considerations (i.e., confidence that one thing causes another), expert opinion would be placed on the lowest level of the hierarchy, followed by case studies. Group research designs that have high internal validity and single-participant designs would be rated higher. Systematic reviews of well-designed studies (including meta-analyses) would occupy the highest level of the evidence hierarchy. In this chapter, we discuss the components of the scientific method. Understanding different research designs and their shortcomings is necessary when evaluating reported findings in abnormal psychology.

The Scientific Method in Clinical Research Case Study A video segment showed a seventy-minute session in which a ten-year-old girl was begging for her life. Candace had been wrapped in a blanket and surrounded by four adults pressing pillows against her. She was undergoing “rebirthing therapy.” Candace was purportedly diagnosed with a reactive attachment disorder, a condition that prevents the formation of loving relationships. The purpose of the therapy was to enable Candace to be “reborn” and to be able to bond with her adoptive mother. The session involved the simulation of birth, in which the blanket represented the womb. On the tape, Candace complains about not being able to breathe. After being unwrapped, Candace wasn’t breathing and had no pulse. The cause of death was suffocation (Kohler, 2001). The two therapists, Julie Ponder and Connell Watkins, were convicted of reckless child abuse. The governor of Colorado signed a law outlawing rebirthing therapy. (Associated Press, 2001)

Hundreds of different forms of psychotherapies exist. How can so many different ways of conceptualizing the cause and treatment of the same disorder be accurate? This question must be addressed if psychotherapy is to have a scientific foundation

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Attacks on Scientific Integrity • Dr. Andrew Mosholder, a medical reviewer for the U.S. Food and Drug Administration (FDA), stated that he had been pressured to alter and hide information on a document submitted to congressional investigators concerning the possible link between antidepressant use and suicide in children (Richwine, 2004b). • An internal GlaxoSmithKline (a pharmaceutical company) memo concerning a study of paroxetine (an antidepressant) use in children stated, it would be “commercially unacceptable” to admit that paroxetine did not work in children and that the company would have to “effectively manage the dissemination of these data in order to minimize any potential negative impact” (Dyer, 2004, p. 1395). • The drug makers of antidepressants such as Prozac and Paxil did not publish nearly one-third of the studies evaluating their effectiveness. Nearly all of these had unfavorable results. In addition, some studies with negative or questionable results were published as if the drugs were effective (Turner et al., 2008). The scientific method requires that researchers be committed to the search for truth and to remain objective in the study of phenomena. When personal beliefs, values, political position, or conflicts of interest are allowed to influence our interpretation

of data, scientific integrity is threatened. The dependence on research in making informed decisions necessitates that scientists hold and maintain high ethical standards. Unfortunately, when financial considerations intersect with science, research can become the tool of the interested party rather than a mechanism to promote the welfare of society. Part of the problem is the vested interest that researchers often have in the drug companies themselves. Research funding by pharmaceutical companies rose from $1.5 billion to $22 billion between 1980 and 2001 (Warner & Roberts, 2004) and accounted for about 60 percent of funded studies in 2002 (Kelly et al., 2006). Equally problematic is the increasing percentage of researchers in academic medical centers who have financial interests in or who receive funding from for-profit companies (Warner & Roberts, 2004). These ties with pharmaceutical companies can produce a conflict of interest that threatens scientific integrity. There is suspicion that research findings unfavorable to “interested parties” are not being published. Researchers may be less likely to report findings that are considered unfavorable to their source of funding. In some cases, the publication of data is subject to the approval of the funding source. With researchers receiving funding from or sitting on the board of directors of pharmaceutical companies, how can the interests of consumers be promoted and scientific integrity be maintained?

(Melchert, 2007). Do therapists use the scientific method to determine the validity or effectiveness of approaches they are using to treat mental disorders? As Perez (1999, p. 206) argues, “We must decide if we want to foster an environment in which clinicians can practice whatever they want, even in the absence of scientific evidence that what they practice actually works. Conversely, we may choose to protect the rights of clients to receive the most effective treatments available.” Before employing a therapy such as rebirthing, should we know whether it has received any validation? What do you see as the advantages and disadvantages of requiring some type of experimental support for different therapies? The scientific method is a method of inquiry that provides for the systematic collection of data, controlled observation, and the testing of hypotheses. A hypothesis is a conjectural statement that usually describes a relationship between two variables. Different theories may result in different hypotheses for the same phenomenon. A theory is a group of principles and hypotheses that together explain some aspect of a particular area of inquiry. For example, hypothesized reasons for eating disorders have included biological or neurochemical causes, fear of sexual maturity, societal demands for thinness in women, and pathological family relationships. Each of these hypotheses reflects a different theory.

Characteristics of Clinical Research Clinical research can proceed only when the relationship expressed in a hypothesis is clearly and systematically stated and when the variables of concern are measurable and defined. We need to define clearly what we are studying and make sure that the variables are measured with reliable and valid instruments. Clinical research relies on characteristics of the scientific method, including the potential for self-correction, the development of hypotheses about relationships, the use of operational definitions, consideration

scientific method a method of inquiry that provides for the systematic collection of data, controlled observation, and the testing of hypotheses hypothesis a conjectural statement that usually describes a relationship between two variables

a group of principles and hypotheses that together explain some aspect of a particular area of inquiry

theory

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of reliability and validity, the acknowledgment of base rates, and the requirement that research findings be evaluated in terms of their statistical significance. Potential for Self-Correction Perhaps the unique and most general characteristic of the scientific method is its potential for self-correction. Under ideal conditions, data and conclusions are freely exchanged and experiments are replicable (reproducible). Discussion, testing, and verification are encouraged, resulting in data that are as free as possible from the scientists’ personal beliefs, perceptions, biases, values, attitudes, and emotions. When researchers do not follow these guidelines, ethical concerns arise. Hypothesizing Relationships Another characteristic of the scientific method is that it attempts to identify and explain (hypothesize) the relationship between variables. Examples of hypotheses include: “Some seasonal forms of depression may be due to decreases in light,” “Autism (a severe disorder beginning in childhood) is the result of poor parenting,” and “Eating disorders are the result of specific family interaction patterns.”

CONTROLLED OBSERVATIONS Research on animals can provide clues to the development of emotions in humans. Baby orangutans show empathy, laughter, and the ability to copy facial expressions.

Operational Definitions Concrete definitions of the variables that are being studied are called operational definitions. For example, an operational definition of depression might involve (1) a specific pattern of responses to a self-report depression inventory, (2) a rating assigned by an observer using a depression checklist, or (3) laboratory identification of specific neurochemical changes. Operational definitions are important because they force an experimenter to clearly define what he or she means by the variable. This allows others to agree or disagree with the way the variable was defined. When operational definitions of a phenomenon differ, comparing research is problematic, and conclusions can be faulty. Let’s consider the recent studies or reports linking child sexual abuse with panic disorder, phobias, depression, alcohol and substance abuse, multiple personality and dissociative disorders, and bulimia and anorexia nervosa (Briere, 1992; Pribor & Dinwiddie, 1992; Terr, 1991). Unfortunately, these studies employ different operational definitions (Haugaard, 2000). Consider the differences in the following definitions of child sexual abuse used in the research literature: • Any sexual activity, overt or covert, between a child and an adult (or older child), where the younger child’s participation is obtained through seduction or coercion. (Ratican, 1992, p. 33) • Any self-reported contact—ranging from fondling to sexual intercourse— experienced by a patient on or before age eighteen and initiated by someone five or more years senior or by a family member at least two years senior. (Brown & Anderson, 1991, p. 56) Other definitions of child sexual abuse include “any unwanted sexual experience before fourteen,” “any attempted or completed rape before eighteen years,” and “contact between someone under fifteen and another person five years older” (Briere, 1992, p. 198). The use of so many different definitions of child sexual abuse makes any general conclusions difficult when conducting research (Mallinckrodt, McCreary, & Robertson, 1995; Pope et al., 1994; Rind, Tromovitch, & Bauserman, 1998). Operational definitions need to be clear and precise. Research would certainly be enhanced if there were also consistency in definitions.

operational definitions concrete definitions of the variables that are being studied

Reliability and Validity of Measures and Observations The scientific method requires that the measures we use be reliable (consistent). Reliability refers to the degree to which a measure or procedure will yield the same results repeatedly (see Chapter 3, this volume). Consider, for example, an individual who has been diagnosed, by means of a questionnaire, as having an antisocial personality. If the questionnaire is reliable, the individual should receive the same diagnosis after filling out the questionnaire again. Results must be consistent if we are to have any faith in them. Even if consistent results are obtained, questions can arise over the validity of a measure. Does the testing instrument really measure what it was developed to

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Repressed Memories: Issues and Questions

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atricia Burgus claimed that during treatment, which included hypnosis and hypnotic drugs, therapists had induced recovered memories of her participation in a cannibalistic satanic cult and of her having sexually abused her two sons (Ewing, 1998). Burgus’s memories were later determined to be false and were attributed to suggestions and techniques used by the therapists. She was awarded $10.6 million in damages. Pope and Hudson (2007) do not believe that repressed memory is a scientifically valid phenomenon but one that was “manufactured” after the 1800s. In fact, they have posted a $1,000 reward on the Internet to anyone who can produce a published case of the phenomenon in fiction or nonfiction prior to 1800. They argue that if “repressed memory” were genuine, it would have been a subject of writings in the past. The first successful respondent will receive a check from the Biological Psychiatry Laboratory at the McLean Hospital in Massachusetts, and the case will be posted on the Web site. Conversely, the Recovered Memory Project (2007) is assembling information and cases of recovered memory. As they state on their Web site, “The purpose of this project is to collect and disseminate information relevant to the debate over whether traumatic events can be forgotten and then remembered later in life.” They want to assemble “evidence of [repressed memory] cases ignored or overlooked by self-described skeptics of various sorts.” The controversy over the existence of “repressed memory” is especially pronounced between experimental psychologists and clinicians (clinical psychologists and social

workers). In one study, only 34 percent of the experimental psychologists reported that they believed in the validity of the phenomenon, compared with over 60 percent of the clinicians (Dammeyer, Nightingale, & McCoy, 1997). The study also revealed some differences among the clinicians themselves. Those with psychoanalytic, psychodynamic, or eclectic orientations believed more strongly in repressed memories than did those with cognitive orientations. Many clinicians also believed that some therapeutic techniques could lead to false memories. Cases of repressed memory have been brought up in court. To address “junk science,” the Supreme Court in 1993 set forth the Daubert Standard, under which evidence offered by expert witnesses must meet certain standards: (1) The theory or technique must be falsifiable and testable; (2) it must have been subjected to peer review and publication; (3) the reliability of procedures or potential error rate should be specified; and (4) the theory or technique must be generally accepted by the relevant scientific community (Sanders, Diamond, & Vidmar, 2002). For Further Consideration 1. Do you believe repressed memories are real? How would you decide whether to maintain or abandon repressed memory as a genuine phenomenon? What would be the implications of your decision? 2. Why are experimental psychologists more likely than clinicians to have doubts regarding the existence of repressed memories?

measure? If we claim to have developed a test that identifies dissociative identity disorder, we must demonstrate that it can accomplish this task. The validity of many of the clinical tests used in studies has not been determined. We return to this topic later in the chapter. Base Rates A base rate is the rate of natural occurrence of a phenomenon in the population studied. When the base rate is not known or not considered, research findings can be misinterpreted. For example, both unwanted sexual events and eating problems are reported by a high percentage of females (Conners & Morse, 1993; Pope & Hudson, 1992). As a result, clinicians may find that the majority of individuals treated for eating problems report a history of sexual abuse. An investigator, not recognizing that both of these conditions occur with high frequency (have high base rates), may mistakenly conclude that one is the cause of the other. Base rate data is helpful in interpreting phenomena such as sexual behaviors in children. Is the presence of “sexualized” behaviors a sign of sexual abuse or a normative type of behavior? A wide range of sexual behaviors in 1,114 nonsexually abused children between the ages of two and twelve were reported by primary caregivers. As the researchers state regarding sexual touching, “Simply because a five-year-old boy touches his genitals occasionally, even after a weekend visit with his noncustodial parent, it does not mean he has been sexually abused. Rather, it is a behavior that is seen in nearly two-thirds of boys at that age” (Friedrich et al., 1998, p. 8). Base rate data, however, provide only the context within which to

base rate the rate of natural occurrence of a phenomenon in the population studied

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evaluate behavior. Whether “normative” or low-percentage sexual behaviors are due to abuse must be determined on an individual basis. The importance of base rates in clinical research can be seen in the responses of a control group to a psychotic-traits questionnaire. Persons with severe mental disorders are believed to have “unusual” thoughts or reactions. On one specific psychotic-traits questionnaire, however, a large percentage of the control group gave positive answers to the questions in Figure 4.1. Although individuals with schizophrenia are twice as likely as normal persons to endorse such statements (Jackson & Claridge, 1991), “normal” individuals in control groups also report disturbing thoughts and You Know? urges, “paranoid ideation,” and “magical thinking.” The fact f 3,247 scientists who received funding for studies that an individual or client reports having odd or bizarre from the National Institute of Mental Health thoughts or being bothered by the feeling of being watched (NIMH), less than 2 percent reported having may, therefore, not be indicative of a disorder.

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committed serious violations such as falsifying data or plagiarism. However: • 15.5 percent changed the design, methodology, or results of a study because of pressure from a funding source • 15.3 percent dropped observations or data points in their studies from analysis because of a “gut feeling” • 12.5 percent overlooked others’ use of flawed data or questionable interpretation of data • 6 percent failed to present data that contradicted their own previous research Source: DeVries, Martinson, & Anderson (2006).

Statistical Versus Clinical Significance The scientific method also requires that research findings be evaluated in terms of their statistical significance—the likelihood that the relationship is not due to chance alone. Even a statistically significant finding may have little practical significance in a clinical setting, however. For example, based on a study by Phillips, Van Voorhees, and Ruth (1992), various news reports have stated that women are more likely to die the week after their birthdays than in any other week of the year. This finding seemed to show that psychological factors have a powerful effect on biological processes. The study involved 2,745,149 persons, and the findings were statistically significant (not due to chance). The number of deaths for the week after a birthday, however, was only 3.03 percent higher than would be expected in any other week. Thus psychological factors associated with deaths and birthdays, although statistically significant, appear to play only a small role in deaths among women. When evaluating research, you must determine whether the statistical significance reported is really “clinically” significant. This problem is most likely to occur in studies with large sample sizes.

Experiments

a technique of scientific inquiry in which a prediction—an experimental hypothesis—is made about two variables; the independent variable is then manipulated in a controlled situation, and changes in the dependent variable are measured

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experimental hypothesis

a prediction concerning how an independent variable will affect a dependent variable in an experiment a variable or condition that an experimenter manipulates to determine its effect on a dependent variable

independent variable

The experiment is perhaps the best tool for testing cause-and-effect relationships. In its simplest form, the experiment involves the following: 1. An experimental hypothesis, which is the prediction concerning how an independent variable will affect a dependent variable in an experiment 2. An independent variable (the possible cause), which the experimenter manipulates to determine its effect on a dependent variable 3. A dependent variable, which is expected to change as a result of changes in the independent variable. The experimenter is also concerned about controlling extraneous or confounding variables (factors other than the independent variable that may affect the dependent variable). For example, expectancies of both the research participants and the researchers may influence the outcome of a study. Participants in a study may try to “help” the researcher succeed and, in so doing, may confound the results of the study (Anderson & Strupp, 1996). If the experimenter is effective in eliminating confounding variables in a study, the study has high internal validity. That is, we can be relatively certain that changes in the dependent variable are due only to the independent variable. The experimenter is also interested in external validity. This refers to whether the findings of a particular study can be generalized to other groups or conditions. Let’s clarify these concepts by examining an actual research study.

Experiments

Case Study

The Experimental Group An experimental group is the group that is subjected to the independent variable. In their study, Thom and her colleagues (2000) created two experimental groups: one treated with stress management training and exposure to images of dental scenes for a single session and the other provided with medication. The psychological treatment included cognitive, relaxation, and breathing training, which the patients practiced daily for one week. Because the investigators were interested in how treatment affects level of anxiety and reports of panic, the dependent variables were measured in several ways. Pre- and posttreatment measures were obtained for dental fear, as well as subjective ratings for pain during the procedure. The investigators also tabulated how many of the patients completed dental treatment with further appointments.

The Control Group If the participants in the two experimental groups in the study by Thom and her colleagues (2000) showed a reduction in anxiety based on pretesting to posttesting measures, could the researchers conclude that the treatments were effective forms of therapy? The answer would be no, because participants may have shown less anxiety about dental procedures merely as a result of the passage of time or as a function of completing the assessment measures. The use of a control group enables researchers to eliminate such possibilities. A control group is a group that is similar in every way to the experimental group except for the manipulation of the independent variable. In the study by Thom and her colleagues (2000), the control group also took the pretest measures, received dental work, and took the posttest measures. However, those in the control group did not receive any treatment. Because of this, we can be more certain that any differences found between the control and experimental groups were due to the independent variable (i.e., the treatment received). The findings revealed that the groups treated with either psychological intervention or antianxiety medication had significantly greater reductions on the Dental Fear Scale and Pain Scale than the control group. However, those treated with benzodiazepine showed a relapse following dental surgery, whereas those who received psychological intervention showed further improvement and continued dental treatment. Of those who completed additional dental procedures, 70 percent had been in the psychological intervention group, 20 percent in the antianxiety medication group, and 10 percent in the control group. Given these findings, the therapist might tell Melinda that both treatments can reduce her dental fear but that psychological interventions might

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Melinda N., a nineteen-year-old sophomore, sought help from a university psychology clinic for dental phobia. Her strong fear of dentists began when she was about twelve years old. It had been suggested to her that she might have a low pain threshold or have experienced some type of traumatic incident during dental work. Melinda had several cavities that were painful, so she decided to see if a therapist could offer some help. Because she had an appointment to see the dentist the following week, Melinda wanted something that could work quickly. The therapist had heard that an antianxiety medication, benzodiazepine, and psychological methods (relaxation training and changing thoughts about the procedure) were both successful in treating dental phobia. Before deciding which treatment to recommend, the therapist reviewed the research literature to determine whether studies had compared the effectiveness of these approaches. A study by Thom, Sartory, and Johren (2000) seemed to provide some direction. In that study, fifty patients with dental phobia were assigned to either a psychological treatment, a medication (benzodiazepine), or a no-treatment group. The psychological treatment took only one session and involved stress management training (relaxation exercises, visualization of dental work, and the identification and use of coping thoughts). The exercises learned in therapy were to be performed at home daily for one week. Those in the medication group received an antianxiety medication thirty minutes before the dental procedure. Those in the control condition were told that their surgeon specialized in patients with dental anxiety and would treat them carefully.

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RESPONSES TO PSYCHOTIC-TRAITS QUESTIONNAIRE This figure shows the percentage of “normal” individuals endorsing items on a questionnaire used to identify psychotic thinking and beliefs.

Source: Data from Jackson & Claridge (1991).

a variable that is expected to change when an independent variable is manipulated in a psychological experiment

dependent variable

internal validity the degree to which changes in the dependent variable are due solely to the effect of changes in the independent variable

the degree to which findings of a particular study can be generalized to other groups or conditions

external validity

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offer more long-term effects. However, because the intervention included relaxation, visualization, exposure, and cognitive strategies, it is uncertain which component or components were responsible for the outcome. If researchers wanted to further explore which of the psychological interventions (or combination of interventions) was most effective, how might they design a study to investigate this issue?

Myth vs Reality Myth: Increasing controls over an experiment always results in greater generalizability of the findings. Reality: Although a tightly controlled study increases internal validity, problems can occur with external validity—that is, the findings may not be generalizable to other populations because the conditions existing in an experimental setting may not resemble those found in real-life situations. Both internal and external validity have to be considered when designing a study.

The Placebo Group You should note that the results of an experiment may also be challenged for another reason. For example, what if the participants in the treated experimental groups improved not because of the treatment but because they had faith or an expectancy that they would improve? Some researchers have found that if participants expect to improve from treatment, this expectancy—rather than specific treatment—is responsible for the outcome. One method by which to induce an expectancy without using the specific treatment is to include a placebo control group. The Did You Know? study by Thom and her colleagues (2000) could have included a condition in which participants would have been given a medicaany findings are based on samples of college tion capsule containing an inert drug (a placebo). A plausible psystudents. The following conclusions were recently chological placebo condition (one that the experimenter believes reported by the Associated Press (2007c): would not reduce dental fear, such as a single-session group con• Muscular men are twice as likely as less muscular men to have had more than three sex partners (based on ninetyvened to discuss nutrition) could also be utilized. If the therapy nine UCLA undergraduates) groups improved more than the placebo control group, then one • Despite being stereotyped as “chatty,” women spoke could be more confident that therapy, rather than expectancy, was only 3 percent more per day than men (based on college responsible for the results.

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students) • Younger undergraduates are 6 percent more likely to complete verbal jokes than older participants (based on eighty-one college participants). Peterson (2001) raises questions about whether samples of college students are representative of “people in general,” “adults,” or even “college students in general.” How can we be certain that the results obtained are generalizable?

Additional Concerns in Clinical Research

Although researchers hope to control expectations of outcome through the use of a placebo control group, two types of problems can occur. First, the placebo control group may also report significant improvements. In a review of research, placebos duplicated up to 89 percent of the improvement seen with antidepressants (Antonuccio, Burns, & Danton, 2002). This finding would make it difficult to separate treatment from expectancy effects. Second, participants may “guess” correctly that they are receiving a placebo, thereby reducing any expectancy effects. Another problem associated with medication trials is that individuals who are strong responders to placebos are often eliminated from studies, ensuring a more favorable showing for medication (Sue & Sue, 2008b). Experimenter or participant expectations can also influence diagnosis and the outcome of a study. To control for experimenter expectations, the researcher may use a blind design, in which the clinicians doing the interviewing are not aware of the purpose of the study. A method to reduce the impact of both experimenter and participant expectations is the double-blind design. In this procedure, neither the individual working directly with the participant (such as the therapist or physician) nor the participant is aware of the experimental conditions. The effectiveness of this design is

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DOUBLE-BLIND DESIGN When researching the effects of a drug, experimenters will often use a doubleblind design to ensure that neither participants nor experimenter are aware of the experimental conditions. Shown here is a prepared card of drugs that could be used in a research study in such a way that neither patient nor doctor actually knows whether the patient is receiving a drug or a placebo. How would you determine whether this manipulation was successful?

dependent on whether participants are truly “blind” to the intervention, which may not always be the case. In a randomized, double-blind study (Margraf et al., 1991), patients with panic disorder were given one of two antidepressants (alprazolam or imipramine) or a placebo. All of the substances were dispensed in identical capsules. Were the patients and physicians “blind” to the conditions? Apparently not. The great majority of patients and physicians were able to correctly identify the antidepressant because of physiological reactions to the medication. Further, the physicians were able to distinguish whether the client was taking alprazolam or imipramine based on the reactions of the patients. These findings indicate the need to modify experimental designs so that the degree of “blindness” is increased. Otherwise, the results may be influenced by both client and experimenter expectations. As you can see, researchers have a difficult time controlling extraneous or confounding variables. External validity (the ability to generalize the results to other settings) is also very important to determine. In the study by Thom and her colleagues (2000), we would want to know whether psychotherapy and benzodiazepines are also effective in reducing anxiety in other populations and situations. Sometimes importing a therapy from a research setting to a real-life environment is difficult. Martin Seligman (1996) points out that research designs that produce high internal validity (such as those that use a manual to provide therapy, prescribe only a fixed number of sessions, and involve random assignment of clients with a single disorder) may have problems with external validity. “Real” therapy often does not follow treatment manuals precisely and may not be of a fixed duration. Patients frequently have multiple problems and are not randomly assigned to therapists in clinic settings. Thus, in some cases, designing research with very high internal validity may reduce the generalizability of the findings.

Correlations A correlation is the extent to which variations in one variable are accompanied by increases or decreases in a second variable. The variables in a correlation, unlike those in an experiment, are not manipulated. Instead, a statistical analysis is performed to determine whether increases in one variable are accompanied by increases or decreases in the other. The relationship is expressed as a statistically derived correlation coefficient, symbolized by the symbol r, which has a numerical value between ⫺1 and ⫹1. In a positive correlation, an increase in one variable is accompanied by an increase in

correlation the extent to which variations in one variable are accompanied by increases or decreases in a second variable

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r = 1.00

4.2 POSSIBLE

CORRELATION BETWEEN TWO VARIABLES The more closely the data points approximate a straight line, the greater the magnitude of the correlation coefficient r. The slope of the regression line rising from left to right in example (a) indicates a perfect positive correlation between two variables, whereas example (b) reveals a perfect negative correlation. Example (c) shows a lower positive correlation. Example (d) shows no correlation whatsoever.

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the other. When an increase in one variable is accompanied by a decrease in the other variable, there is a negative correlation. The greater the value of r, positive or negative, the stronger the relationship. See Figure 4.2 for examples of correlations. Correlations indicate the degree to which two variables are related but not the reason for the relationship. For example, the Parents Television Council (2007) reported that during the family hour time slots (8 p.m.–9 p.m. Monday though Saturday and 7 p.m.–9 p.m. on Sunday), nearly 50 percent of TV programs contained violent content, with approximately 4.19 violent acts or images per hour. Does watching aggressive fare lead to aggressive behavior? Johnson and colleagues (2002) assessed the relationship between the number of hours of television viewing and the number of aggressive behaviors over a seventeen-year period. A significant correlation was found. The greater the number of hours spent watching television per day, the greater the number of aggressive acts (assaults or physical fights resulting in injury; robbery, threats to injure someone, or using a weapon to commit a crime; and aggressive acts against another person). Of those who watched television less than one hour per day, 5.7 percent committed a violent act; 25.3 percent of those who watched more than three hours a day did so. The study controlled for possible confounding variables such as childhood neglect, low family income, unsafe neighborhoods, and psychiatric disorders. Because this was a correlation study, the authors cautioned, “It should be noted that a strong inference of causality cannot be made without conducting a controlled experiment, and we cannot rule out the possibility that some other covariates that were not controlled in the present study may have been responsible for these associations” (Johnson et al., 2002, p. 2470).

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Researcher Allegiance: A “Wild Card” in Comparative Research?

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he move to develop empirically supported treatments has resulted in research that compares two or more forms of therapy to determine which ones are the most effective for specific disorders. Although this appeared to be a clear-cut task, reviewers became puzzled as to why the results of comparative studies were so contradictory. In some studies, psychodynamic therapies would be superior to behavioral therapy in treatment outcome, and in other cases the reverse might be true. To determine what might be producing these discrepant findings, Luborsky and his colleagues (1999) reviewed twenty-nine studies that compared two therapies. Of these, nine involved cognitive versus behavioral therapy, seven involved behavioral versus psychodynamic therapy, four compared psychodynamic with cognitive therapy, and nine examined psychopharmacology versus psychotherapy. Because the reviewers were suspicious that the theoretical position or “alliance” to a specific approach by researchers in the studies might influence the outcome, ratings of the researcher’s alliance were obtained through self-ratings, ratings by colleagues, and reprints of research. These three measures of researcher alliance correlated .85 with the effect sizes of the difference in treatments compared. In other words, researcher allegiance was a very important influence. For example, behavioral researchers who conducted studies comparing behavioral versus psychodynamic therapies would find that their favored

approach would be “more effective.” The reverse was also true for psychodynamic researchers. Luborsky and his colleagues (1999) speculated about how the researcher’s allegiance to a treatment might be associated with the outcome in comparative research: 1. A less effective comparison treatment might have been selected to be compared with the favored treatment. 2. Research that reflected negatively on the researcher’s favored treatment might be shelved and not submitted for publication. 3. The therapist or therapy that is provided for the nonfavored treatment might differ in a way that favors the researcher’s allegiance; for example, the therapist may have less training with the treatment. 4. Subtle reinforcements or positive expectations by the researchers might be conveyed subtly to therapists providing the favored treatment. If the Luborsky study is correct in finding a very strong relationship between researcher allegiance and treatment outcome, what does this mean in terms of the validity of research that compares several types of treatment? Other than the preceding speculations by Luborsky and his colleagues (1999), what additional explanations can you give for the findings? What are different ways of identifying and minimizing research allegiance effects?

Correlational studies cannot be used to demonstrate cause and effect. To employ such a strategy in this case would involve randomly assigning children to different groups to view the same content for different hours over a period of time. This is not possible. The authors also tried to control for other variables that might be associated with television watching and aggression, but it is possible that other factors may be involved. Such third-variable possibilities in correlations are numerous. Consider the following actual observations. What third-variable explanations can you suggest for them? • The number of storks nesting on rooftops in certain New England communities is positively correlated with the human birthrate. • The number of violent crimes committed in a community is positively correlated with the number of churches in the community. In summary, a correlation indicates the degree to which two variables are related. It is a very important method of scientific inquiry because there are many variables we cannot control, such as genetic makeup, gender, and socioeconomic status. Manipulating other variables that we might be able to control, such as exposing a child to trauma or abuse, would be unethical. Correlations can tell us how likely it is that two variables occur together. Even when the variables are highly related, however, we must exercise caution in interpreting causality. The two variables may not be causally related, or both may be influenced by a third variable. Even if they are causally related, the direction of causality may be unclear.

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CORRELATIONAL STUDIES Identical twins* are often used in correlational studies to determine the influence of genetic factors. They tend to show greater behavioral similarities than do fraternal twins or siblings. This similarity is attributed to genetic factors. Could the way identical twins are treated also contribute to this finding? * These twins are the grandsons of author David Sue.

Analogue Studies As we have noted, ethical, moral, or legal standards may prevent researchers from devising certain studies on mental disorders or on the effect of treatment. In other cases, studying real-life situations is not feasible because researchers would have a difficult time controlling all the variables. In such cases, researchers may resort to an analogue study—an investigation that attempts to replicate or simulate, under controlled conditions, a situation that occurs in real life. The advantage of this type of investigation is that it allows us to study a phenomenon using experimental designs that are not possible with correlational studies. Here are some examples of analogue studies: 1. To study the possible effects of a new form of treatment on patients with anxiety disorders, the researcher may use students who have test anxiety rather than individuals diagnosed with anxiety disorders. 2. To test the hypothesis that human depression is caused by continual encounters with events that one cannot control, the researcher exposes rats to uncontrollable aversive stimuli and looks for an increase in depressive-like behaviors (such as lack of motivation, inability to learn, and general apathy) in the animals. 3. To test the hypothesis that sexual sadism is influenced by watching sexually violent films or television programs, an experimenter exposes “normal” male participants to either violent or nonviolent sexual programs. The participants then complete a questionnaire assessing their attitudes and values toward women and their likelihood of engaging in violent behaviors with women. an investigation that attempts to replicate or simulate, under controlled conditions, a situation that occurs in real life

analogue study

Obviously, each example is only an approximation of real life. Students with test anxiety may not be equivalent to individuals with anxiety disorders. Findings based on rats may not be applicable to human beings. And exposure to one violent sexual film and the use of a questionnaire may not be sufficient to allow a researcher

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CORRELATIONAL FINDINGS Social contact and support are associated with better mental health. How would you determine the direction of the relationship? Does friendship prevent mental disturbances or do individuals with psychological problems have fewer friends? What other factors might be involved to produce the relationship between mental health and social relationships?

to draw the conclusion that sexual sadism is caused by long-term exposure to such films. However, analogue studies can give researchers insight into the processes that might be involved in abnormal behaviors and treatment.

Field Studies In some cases, analogue studies would be too contrived to be accurate representations of a real-life situation. Investigators may then resort to a field study, in which behaviors and events are observed and recorded in their natural environment. The participants in a field study are most often members of a given social unit—a group, an institution, or a community. However, the investigation may also be limited to a single individual; single-participant studies are discussed in the next section. Field studies sometimes employ data collection techniques, such as questionnaires, interviews, and the analysis of existing records, but the primary technique is observation. The observers must be highly trained and have enough self-discipline to avoid disrupting or modifying the behavioral processes they are observing and recording. A field study may be used to examine mass behavior after events of major consequence, such as wars, floods, and earthquakes. It may also be applied to the study of personal crises, as in military combat, major surgery, terminal disease, or the loss of loved ones. An example of a field study is the in-person interviews conducted in New York City after the terrorist attacks on the World Trade Center. Nearly 11 percent of the interviewees had lost a family member or close friend. The most frequent symptoms reported were recurring painful memories of the event. Although 18.5 percent displayed posttraumatic stress disorder (PTSD) symptoms, only 11.3 percent had received any psychiatric help or were taking medications for the symptoms (DeLisi et al., 2003). Although field studies offer a more realistic investigative environment than other types of research, they suffer from certain limitations. First, as with other nonexperimental research, determining the direction of causality is difficult in field studies because the data are correlational. Second, so many variables are at work in real-life situations that it is impossible to control—and sometimes even distinguish—them all. As a result, the findings may be difficult to interpret. Third, observers can never be absolutely sure that their presence did not influence the interactions they observed.

an investigative technique in which behaviors and events are observed and recorded in their natural environment

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FIELD STUDIES The catastrophic damage wrought by the tsunami on December 26, 2004, caused nearly 100,000 fatalities in Meulaboh, Indonesia, alone. The majority of victims were women and children. Here, survivors survey the ruins. Many individuals involved in or witnessing the disaster suffered severe emotional and physical trauma. Disasters such as this provide a unique, though unwelcome, opportunity to observe events and reactions of individuals in the natural environment. Can social scientists remain detached and objective when recording a tragedy of such magnitude?

Single-Participant Studies Most scientists advocate the study of large numbers of people to uncover the basic principles governing behavior. This approach, called the nomothetic orientation, is concerned with formulating general laws or principles while deemphasizing individual variations or differences. Experiments and correlational studies are nomothetic. Other scientists advocate the in-depth study of one person. This approach, exemplified by the single-participant study, has been called the idiographic orientation. There has been much debate over which method is more fruitful in studying psychopathology. Although the idiographic method of studying a single participant has many limitations, especially lack of generalizability, it has proven very valuable in applied clinical work. Furthermore, arguing over which method is more helpful is not productive because both approaches are needed to study abnormal behavior. The nomothetic approach seems appropriate for laboratory scientists, whereas the idiographic approach seems appropriate for psychotherapists, who regularly face the pressures of treating disturbed individuals. There are two types of single-participant studies: the case study and the singleparticipant experiment. Both techniques may be used to examine a rare or an unusual phenomenon, to demonstrate a novel diagnostic or treatment procedure, to test an assumption, to generate future hypotheses on which to base controlled research, or to collect comprehensive information to better understand an individual. Only the singleparticipant experiment, however, can determine cause-and-effect relationships.

The Case Study Physicians have used the case study extensively in describing and treating medical disease. In psychology, a case study is an intensive study of one individual that relies on clinical data, such as observations, psychological tests, and historical and biographical information. A case study thus lacks the control and objectivity of many other methods and cannot be used to demonstrate cause-and-effect relationships. It can serve as the primary source of data in cases in which systematic experimental procedures are not feasible. Case studies can also be helpful in determining diagnosis, characteristics, course, and outcome of a disorder, as illustrated in the following example:

Case Study an intensive study of one individual that relies on clinical data, such as observations, psychological tests, and historical and biographical information case study

Stephen Shore, an individual diagnosed in childhood with atypical autism (a disorder characterized by impairments in social interaction and restricted interest in activities), now serves on the Board of Directors for the Autism Society of America. According to his mother, Stephen developed normally during his first year of life but stopped talking during his second year. At the time, little was known about autistic-like disorders. When his mother talked to Stephen, he did not respond.

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Using trial and error, she discovered that making nonsensical statements would attract his attention. She also found that he would not imitate her, but he acknowledged her with a glance when she made peculiar noises. At the age of four, Stephen became fascinated with watch motors and would take watches apart and put them back together again. He later attributed his obsession with watches to the fact that they provided structure. Based on his own experiences, Stephen believes that he can offer suggestions for working with individuals who have autistic disorders. For example, he suggests that topics such as airplanes, astronomy, bicycles, animals, chemistry, electricity, hardware, locks, and watches might be attractive to these children. Interactions can be structured around specific areas of interest, such as bicycling or computers. This allows conversation to revolve around an activity rather than “small talk,” which is difficult for people with autistic disorders. He also believes that individuals with autism can benefit by being provided with precise explanations of social interactions, as they are often unaware of the “rules” involved (Shore, 2003).

In this case, Stephen shared his life experience, explaining how he perceived the world and events. His account gives some clues as to the reasons for some of the unusual behaviors shown by individuals with autistic disorders, as well as suggested interventions. Case studies are also useful in helping clinicians formulate hypotheses that can be tested later in research.

The Single-Participant Experiment The single-participant experiment differs from the case study in that the former is actually an experiment in which some aspect of the person’s own behavior is used as a control or baseline for comparison with future behaviors. To determine the effectiveness of a treatment, for example, the experimenter begins by plotting a baseline to show the frequency of a behavior before intervention. Then the treatment is introduced, and the person’s behavior is observed. If the behavior changes, the treatment is withdrawn. If, after the withdrawal of treatment, the person’s behavior again resembles that observed during the baseline condition, we can be fairly certain that the treatment was responsible for the behavior changes observed earlier. In the final step, the treatment is reinstated. A multiple-baseline study is a second type of single-participant experimental design in which baselines on two or more behaviors or the same behavior in two or more settings are obtained prior to intervention. The same intervention is then introduced for one behavior or setting, its effects observed, and then applied to the next behavior or setting. If the behaviors change only with the intervention, confidence is increased that the intervention caused the changed behavior. Bock (2007) used a multiple-baseline approach to determine the effectiveness of a training program for four children with Asperger syndrome, a disorder characterized by the inability to develop peer relationships and to understand social customs and by the lack of social or emotional reciprocity. Baselines for the children’s behaviors were obtained during (1) cooperative learning activities, (2) organized sports, and (3) lunch with peers. Very few appropriate behaviors were found in each of these conditions. The intervention program, called “SODA,” provided rules and instructions to help the children attend to social cues and to develop appropriate responses. The program trained the children to reflect on their own behavior, the environment, and other individuals using the following strategies: Stop (What is the activity that people are engaged in?), Observe (What is he/she doing or saying?), Deliberate (What would I like to do or say? How will others feel or act if I do or say these things?), and Act (I plan to … ). The SODA strategies were applied sequentially—first to the cooperative learning situation for a number of sessions, then to recess, and finally to lunch. As shown in Figure 4.3, with one of the students, Bob, changes in appropriate behaviors for each of the three conditions occurred only after the intervention. (The same effect was observed for the other three students.) Single-participant designs tend to be relegated to the background because of the reliance and emphasis on research models that involve group comparisons or hypothesis testing. Because only one participant is used in this design, questions are raised about external validity or the generalizability of the findings. However, the focus on a single participant and on changes over time can be of great interest to parents, teachers, and therapists (Morgan & Morgan, 2001).

single-participant experiment

an experiment performed on a single individual in which some aspect of the person’s own behavior is used as a control or baseline for comparison with future behaviors multiple-baseline study a singleparticipant experimental design in which baselines on two or more behaviors or the same behavior in two or more settings are obtained prior to intervention

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Biological Research Strategies Baseline

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The Human Genome Project

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As noted in Chapter 2, in the year 2000, the entire 3.1-billion nucleotide basis of human DNA was identified. The focus of future research will turn away from identifying genes to understanding how they affect behavior. Efforts are being directed toward determining how genes work, with the hope that this will lead to gene-based diagnoses and treatment. For most forms of psychopathology, this approach will be most helpful in early identification. For example, phenylketonuria (PKU), a metabolic disorder that can produce mental retardation, is treated not by technological methods but by altering diet to prevent damage to the brain (Plomin & Crabbe, 2000).

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More and more biological research is being performed to determine the causes of and effective treatment for mental disorders. Some of these research strategies are applicable to psychological research.

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FIGURE

4.3

Genetic linkage studies attempt to determine whether a disorder follows a genetic pattern. If a disorder is genetically linked, individuals closely related to the person with the disorder (who is called the proband) should be more likely to display that disorder or a related one. Genetic studies of psychiatric disorders often employ the following procedure (Alexander, Lerer, & Baron, 1992): 1. The proband and his or her family members are identified. 2. The proband is asked for the psychiatric history of specific family members. 3. These members are contacted and given some type of assessment to determine whether they have the same or a related disorder. 4. Assessment of the proband and family members may include psychological tests, brain scans, and neuropsychological examinations.

A MULTIPLE-BASELINE STUDY The figures show the percentage of time Bob and a non-Asperger peer spent behaving appropriately during cooperative learning, recess, and lunch. During baseline, the percentage of time Bob displayed appropriate behaviors in cooperative learning, recess, and lunch was under 10 percent. With the SODA intervention, the percentage increased to about 70 percent during cooperative learning and recess and to more than 40 percent during lunch. At a five-month follow-up, it was found that the gains in appropriate behaviors were maintained.

Source: From Bock (2007, p. 92).

studies that attempt to determine whether a disorder follows a genetic pattern

genetic linkage studies

measurable characteristics (neurochemical, endocrinological, neuroanatomical, cognitive, or neuropsychological) that can give clues regarding the specific genes involved in disorders

endophenotypes

This research strategy depends on the accurate diagnosis of both the proband and the relatives. Kendler, Silberg, and colleagues (1991) have pointed out a possible source of error in the family history interview method, when the proband is asked whether relatives also have the same disorder. Kendler and colleagues used this method in a study of female twin pairs who were discordant for major depression, generalized anxiety disorder, and alcoholism—that is, in each pair, one twin had the disorder and the other did not. When asked whether her parents also had the disorder, the “sick” twin was more likely than the “well” twin to report that they did. As this study indicates, caution must be used in employing the family history method in genetic linkage studies. An individual’s psychiatric status (“sick” or “well”) may influence the accuracy of his or her assessment of the mental health of relatives. This bias in reporting may be reduced by using multiple informants or by assessing the family members directly.

The Endophenotype Concept Endophenotypes are measurable characteristics (neurochemical, endocrinological, neuroanatomical, cognitive, or neuropsychological) that can give clues regarding the specific genes involved in disorders. Some researchers believe that differences in eye tracking, attention and information processing deficits, and abnormalities in brain structure may be endophenotypes for schizophrenia. However, to qualify as an endophenotype, it must be (Gottesman & Gould, 2003):

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• associated with the disorder • heritable • manifested in an individual regardless of whether the disorder is present • found in a higher rate among nonaffected family members than in the general population Although the endophenotype concept has been around for decades, it has received increased emphasis with the advances in genetic research, brain scans, and biochemical findings.

Other Concepts in Biological Research Iatrogenic effects are unintended effects of therapy—such as an unintended change in behavior resulting from a medication prescribed or a psychological technique employed by a therapist. The therapist may not recognize the behavior change as a side effect of the medication or technique and may treat it as a separate disorder. For example, some have mistakenly diagnosed memory loss—which can be a side effect of antidepressant medication—as Alzheimer’s disease or other organic conditions. THE HUMAN GENOME PROJECT This massive undertaking Psychological interventions or techniques can also produce involved deciphering, mapping, and identifying DNA sequencing unexpected results. Researchers and therapists believe that some patterns and variations in approximately 30,000 genes in cases of dissociative identity disorder may be inadvertently human DNA. Scientists hope to determine the “message” contained in the DNA patterns that may contribute to human produced by hypnotism, the very method used to investigate it (Coons, 1988; Merskey, 1995; Ofshe, 1992). Hypnotism has been attributes and diseases. Such research raises ethical, legal, and used to retrieve memories reported by the different personalities, social concerns. and clinicians often believe that the information obtained in this manner is accurate. The Council on Scientific Affairs (1985), however, concluded the following in its investigation of hypnosis: 1. Traumatic memories retrieved may reflect an emotional reality rather than an accurate recollection. 2. Hypnosis produces a state in which an individual is more vulnerable to subtle cues and suggestions that often distort recollections. 3. Hypnosis increases both accurate and inaccurate information. 4. Without independent verification, neither the hypnotist nor the subject can distinguish between accurate and inaccurate information. 5. Hypnosis can “increase the subject’s confidence in his memories without affecting accuracy and . . . increase errors while also falsely increasing confidence” (p. 1921). 6. In general, recollections obtained during nonhypnotic recall are more accurate than those obtained during hypnosis. These conclusions indicate the need to question the accuracy of material obtained during a hypnotic state. Penetrance refers to the degree to which a genetic characteristic is manifested by individuals carrying a specific gene or genes associated with it. Complete penetrance occurs when a carrier always manifests the characteristic associated with the gene or genes. In mental disorders, incomplete penetrance is the rule. Even in cases of schizophrenia, only about half of the identical twins of the proband develop this disorder, even though their status as identical twins means that they carry the same genes. Pathognomonic refers to a biological or psychological symptom or characteristic on which a diagnosis can be made. A great deal of research has been directed to discovering a symptom that is specifically distinctive of a disorder. Biological challenge tests are often used to determine the effect of a substance on behavior. If we believe that a specific additive or food is responsible for hyperactivity

iatrogenic effects unintended effects of therapy—such as an unintended change in behavior resulting from a medication prescribed or a psychological technique employed by a therapist

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in a child, we might observe the child’s behavior after he or she eats food with the additive (the “challenge” phase) and after he or she eats food without the additive. If the additive and disruptive behaviors are linked, the behavior should be present during the challenge phase and absent during the other phase. We now examine the major techniques of clinical research. They vary in their adherence to the scientific method.

Epidemiological and Other Forms of Research In the field of abnormal and clinical psychology, investigators may employ experimental, correlational, case-study, or field-observation strategies in their research. The following strategies are important sources of information about disorders and their treatment. • Survey Research Collecting data from all or part of a population to assess the relative prevalence, distribution, and interrelationships of naturally occurring phenomena. • Longitudinal Research Observing and evaluating people’s behaviors over a long period of time so that the course of a disorder or the effects of some factor such as a prevention program can be assessed over time. • Historical Research Reconstructing the past by reviewing and evaluating evidence available from historical documents. • Twin Studies Focusing on twins as a population of interest because twins are genetically similar. Twin studies are often used to evaluate the influence of heredity and environment. • Treatment Outcome Studies Evaluating the effectiveness of treatment in alleviating mental disorders. Outcome is concerned with answering the question of whether treatment is effective. • Treatment Process Studies Analyzing how therapist, client, or situational factors influence one another during the course of treatment. Process research focuses on how or why treatment is effective. • Program Evaluation Analyzing the effectiveness of an intervention or prevention program.

epidemiological research

the study of the rate and distribution of mental disorders in a population

The reliance on experimental, correlational, and single-participant methods varies with the research strategy. For instance, survey researchers often collect data and then correlate certain variables, such as social class and adjustment, to discover whether they are related. Researchers may also combine elements of different methods in their research. For example, an investigator conducting treatment outcome studies may use both surveys and longitudinal studies. Surveys are frequently used in epidemiological research, which examines the rate and distribution of mental disorders in a population. This important type of research is used to determine the extent of mental disturbance found in a targeted population and the factors that influence the rate of mental disturbance. Two terms, prevalence and incidence, are used to describe the rates. As noted in Chapter 1, the prevalence rate tells us the percentage of individuals in a targeted population who have a particular disorder during a specific period of time. For example, we might be interested in how many older adults had a spider phobia during the previous six months (six-month prevalence rate), during the previous year (one-year prevalence rate), or at any time during their lives (lifetime prevalence rate). In general, shorter time periods have lower prevalence rates. When we compare the prevalence rate of disorders cited in studies, it is important to identify the specified time periods. Determining the prevalence rate is vital for planning treatment services because mental health workers need to know the percentage of people who are likely to be afflicted with disorders. The incidence rate tells us onset or occurrence—the number of new cases of a disorder that appear in an identified population within a specified time period.

Ethical Issues in Research

The incidence rate is likely to be lower than the prevalence rate because incidence involves only new cases, whereas prevalence includes new and existing cases during the specified time period. Incidence rates are important for examining hypotheses about the causes or origins of a disorder. For example, if we find that new cases of a disorder are more likely to appear in a population exposed to a particular stressor compared with another population not exposed to the stressor, we can hypothesize that the stress caused the disorder. Epidemiological research, then, is important not only in describing the distribution of disorders but also in analyzing the possible factors that contribute to disorders.

Ethical Issues in Research Although research is primarily a scientific endeavor, it also raises ethical issues. Consider the following examples: 1. To study the effects of a new drug in treating schizophrenia, a researcher needs an experimental group that receives the drug treatment and a control group that receives no treatment. Is it ethical to withhold treatment from a control group of individuals with schizophrenia in order to test the effectiveness of the drug? 2. To study the ways in which depressed individuals respond to negative feedback, an investigator deceives people suffering from depression into believing they performed poorly on a task. Is the deception ethical? 3. A researcher is interested in developing a new assessment tool to uncover personal conflicts. The assessment tool asks people to disclose information about their sexual conduct and private thoughts and feelings—information that may cause embarrassment and discomfort. Does the assessment measure invade the participants’ privacy? 4. A researcher hypothesizes that people with alcoholism cannot stop drinking after having one alcoholic drink. He arranges for patients with this disorder to have one drink and then examines how strongly they are motivated to have additional drinks. Is it unethical and detrimental for these patients to be given alcohol as a part of an experiment? 5. An investigator believes that people who are exposed to inescapable stress are likely to develop feelings of helplessness and depression. Because the investigator does not want to subject human beings to inescapable stress, the experiment is conducted with dogs, which are given painful and inescapable electric shocks. Is it ethical to cause pain to animals as part of a study? These examples raise a number of ethical concerns about how research is conducted and whether it has, or should have, limits. How can the rights of human beings (or animals) be protected without impeding valuable experimentation? There is no question that to understand psychopathology and to devise effective treatment and prevention, experimenters occasionally may have to devise investigations that cause pain and involve deception. To study human behavior, pain may be inflicted (for example, surgical implants may cause pain, or shocks may be used to induce stress), and deception is sometimes necessary to conceal the true nature of a study. The research must be consistent with certain principles of conduct, however, and must be designed to protect participants, as well as to enable researchers to contribute to the long-term welfare of human beings (and other animals). The American Psychological Association (APA, 2002) has adopted the principle that the prospective scientific, applied, or educational value of proposed research must outweigh the risk or discomfort to research participants. APA guidelines state that participants should be fully informed of the procedures and risks involved in the research and should give their consent to participate. Researchers may use deception only when alternative means are not possible, and they should provide participants with a sufficient explanation of the study as soon as possible. Participants should be free to withdraw from a study at any time. Furthermore, all participants must be treated with dignity, and research procedures must minimize pain, discomfort,

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TREATING ANIMALS ETHICALLY The center and right cats have been cloned to glow red when exposed to ultraviolet rays. Scientists believe that this achievement could help understand and lead to cures for human genetic diseases. Cloning raises additional ethical concerns. The APA’s ethical standards require that animals be treated “humanely” and that any procedure that subjects them to stress or pain be carefully evaluated. However, should we also determine whether the research can be “justified”? And how do these standards apply to technological advances such as cloning?

embarrassment, and so on. If undesirable consequences to participants are found, the researcher has the responsibility to detect the extent of these consequences and to remedy them. Finally, unless otherwise agreed on in advance, information obtained from participants is confidential. The American Psychological Association (1993) has also published guidelines for those working with culturally diverse populations. The guidelines indicate the need for researchers to (1) consider the impact of sociopolitical factors, (2) become aware of how their own cultural backgrounds might affect their perceptions, and (3) consider the validity of instruments used in research in a cross-cultural context.

I M P L I C AT I O N S

Research has contributed greatly to our knowledge of mental disorders. However, the quality of the research design influences the degree of faith that we can have regarding the finding. It is difficult to call clinical psychology a science when so many theoretical orientations (over four hundred) offer differing etiologies for disorders. How can all of these be accurate? Most theories have not been evaluated, and yet adherents attest to the validity of their views. The number of new, independent, and competing theories is representative of a young science. However, the field has evolved and appears ready to move to the next step—to strengthen the scientific foundations of clinical psychology (Melchert, 2007). In general, the scientific method, with its emphasis on observations, data collection, and evaluation, provides a means by which studies can be developed that will lead to reliable and valid conclusions. This framework is necessary if we are to move beyond speculating about phenomena. An important but not fully accepted means of evaluating therapies has been to identify empirically supported therapies, which use a randomized control design to demonstrate effectiveness. There is increasing evidence supporting the efficacy of certain forms of therapy for specific mental disorders. Difficulties exist in investigating disorders even when the scientific method is used. Part of the problem has been the attempt to consider only a specific etiological perspective when researching a disorder. In this book, we present evidence regarding the contributions of biological, psychological, social, and sociocultural factors in the development of specific mental disorders. Most of the research done within each of these perspectives disregard possible contributions from the other areas. As we noted in our beginning case study of Nayda, problems can occur when we adopt “theoretical blinders” and focus on a disorder from only one perspective, be it biological, psychological, social, or sociocultural. Recognizing that humans are

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biological, psychological, social, and cultural beings, we use the multipath model in discussing psychopathology and remind the reader of the importance of considering these aspects. There is a movement to combine some of these contributing factors, such as the research by Fox and colleagues (2005), who identified the contributions of gene-environment interactions to behavior inhibition. We discuss this study in greater detail in the next chapter. The scientific method, in which a dispassionate observer makes observations and collects and evaluates data regarding a phenomenon, may also have shortcomings. It is becoming clear that personal biases of a researcher, either conscious or unconscious, can influence the outcome, as illustrated by the research on researchers’ allegiances presented in the “Critical Thinking” box in this chapter and the pressure brought by funding sources. Silverstein, Auerbach, and Levant (2006) reject the notion that there is an “objective reality” that can be studied without bias. Because they believe that objectivity and neutrality are impossible, they stress the importance of identifying one’s social location, theoretical orientation, and values in conducting scientific inquiry. Participant or client characteristics can also affect the results of a study and have to be considered in research designs. We must not abandon the scientific framework but acknowledge and build into our investigation safeguards against possible biases to ensure the reliability and validity of the studies.

Summary 1. In what ways is the scientific method used to evaluate psychotherapy? ■

■

The scientific method is a method of inquiry that provides for the systematic collection of data, controlled observation, and the testing of hypotheses. Characteristics such as the potential for self-correction, the development of hypotheses, the use of operational definitions, a consideration of reliability and validity, an acknowledgment of base rates, and the requirement that research findings be evaluated in terms of their statistical significance enable us to have greater faith in our findings.

2. How does the use of an experimental design differ from other ways of investigating phenomena? ■ The experiment is the most powerful research tool we have for determining and testing cause-and-effect relationships. In its simplest form, an experiment involves an experimental hypothesis, an independent variable, and a dependent variable. ■ The investigator manipulates the independent variable and measures the effect on the dependent variable. The experimental group is the group subjected to the independent variable. A control group is employed that is similar in every way to the experimental group except for the manipulation of the independent variable. ■ Additional concerns include expectancy effects on the part of the participants and the investigator and the extent to which an experiment has internal and external validity. 3. What are correlations, and how are they used to indicate the degree to which two variables are related?

■

A correlation is a measure of the degree to which two variables are related, not what causes the relationship. It is expressed as a correlation coefficient, a numerical value between ⫺1 and ⫹1, symbolized by r. Correlational techniques provide less precision, control, and generality than experiments, and they cannot be taken to imply cause-and-effect relationships.

4. What are analogue studies, and when is this type of investigation used? ■ In the study of abnormal behavior, an analogue study is used to create a situation as close to real life as possible. It permits the study of phenomena under controlled conditions when such study might otherwise be ethically, morally, legally, or practically impossible. The generalizability of the findings to clinical populations has to be evaluated and cannot be automatically assumed. 5. What are field studies, and how are they used? ■ The field study relies primarily on naturalistic observations in real-life situations. As opposed to analogue studies, events are observed as they naturally occur. However, a field study cannot determine causality, and it may be difficult to sort out all the variables involved. 6. What are the various types of single-participant studies, and how are they used? ■

A case study is an intensive study of one individual that relies on clinical data, such as observations, psychological tests, and historical and biographical information. The case study is especially appropriate when a phenomenon is so rare that it is impractical to try to study more than a few instances.

116 ■

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C H A P T E R 4 • T H E S C I E N T I F I C M E T H O D I N A B N O R M A L P S Y C H O LO G Y

Single-participant experiments differ from case studies in that cause-and-effect relationships can be determined. They rely on experimental procedures; some aspect of the person’s own behavior is taken as a control or baseline for comparison with future behaviors. A multiple-baseline study is a second type of singleparticipant experimental design in which baselines on two or more behaviors or the same behavior in two or more settings are obtained prior to intervention.

7. What are some of the advantages and shortcomings of the biological approach to understanding abnormal behavior? ■ Biological research strategies allow us to search for genetic factors involved in psychological disorders or to identify biological markers or indicators of a disorder. As with any approach, consideration of other factors may be minimized because the stress is on the biological model. 8. What is epidemiological research, and how is it used to determine the extent of mental disturbance in a targeted population?

■

Epidemiological research examines the rate and distribution of mental disorders in a population. It can also provide insight into what groups are at risk for mental disturbance and what factors may influence disturbance.

■

There is often confusion between prevalence and incidence rates. Prevalence rates are comprised of new and existing cases during a specified time period. Incidence rates are comprised of new cases only.

9. What are some ethical concerns about how research is conducted, and how can researchers best address these concerns? ■ Like other tools, the scientific method is subject to misuse and misunderstanding, both of which can give rise to moral and ethical concerns. Such concerns have led the American Psychological Association (APA) to develop guidelines for ethical conduct and to establish ways for dealing with violations within the mental health professions. The APA has also published guidelines for those working with culturally diverse populations.

c h a p t e r

5

Anxiety Disorders

E

mily was hiking with her dog when another dog attacked her and bit her on the wrist. She was terrified. The wound became badly infected and very painful, requiring medical treatment. On another occasion, her sister, Marian, was walking in the fields when three large, growling dogs chased her. One began tearing at her pant legs. The owner heard the commotion and intervened before she was physically injured. Marian developed a fear of dogs, but Emily, who suffered painful injuries, did not. (Mineka & Zinbarg, 2006, p. 10)

Anxiety, a feeling of uneasiness or apprehension, is a fundamental human emotion that was recognized as long as five thousand years ago. It is common to experience anxiety. In fact, many observers regard anxiety as a basic condition of modern existence. “Reasonable doses” of anxiety act as a safeguard to keep us from ignoring danger, and anxiety appears to have an adaptive function, producing bodily reactions that prepare us for “fight or flight.” These physiological responses allow us to cope with potentially dangerous situations. In some cases, fear or anxiety can occur even when no danger is present, resulting in an anxiety disorder. Fear or anxiety symptoms are considered a disorder only when they interfere with an individual’s day-to-day functioning. The terms anxiety and fear are often used interchangeably, perhaps because they both produce the same physiological responses. However, anxiety is anticipatory; the dreaded event or situation has not yet occurred. Fear is the more intense emotion an individual feels when he or she is actually faced with a threatening situation. If either fear or anxiety becomes overwhelming, a panic attack can occur. Panic attacks are experienced as intense fear accompanied by symptoms such as a pounding heart, trembling, shortness of breath, or fear of losing control or dying. Three types of panic attacks are recognized (American Psychiatric Association, 2000a): (1) Situationally bound attacks occur before or during exposure to a feared stimulus. (2) Situationally predisposed attacks occur usually, but not always, when encountering the feared situation. For example, some people who have a fear of driving

chapter outline Understanding Anxiety Disorders from a Multipath Perspective

119

Phobias

124

Panic Disorder and Agoraphobia

133

Generalized Anxiety Disorder

138

Obsessive-Compulsive Disorder

141

IMP LIC ATIONS

147

CONTROVERSY Fear or

Disgust?

129

CRITICAL THINKING Panic

Disorder Treatment: Should We Focus on Internal Control?

138

a fundamental human emotion that produces bodily reactions that prepare us for “fight or flight”; anxiety is anticipatory; the dreaded event or situation has not yet occurred

anxiety

117

FOCUSQUESTIONS

1 How are biological, psychological, social, and

4 What is generalized anxiety disorder, what are its

sociocultural factors involved in the development of anxiety disorders?

2 What are phobias, what are their causes, and how

causes, and how is it treated?

5 What is obsessive-compulsive disorder, what are its causes, and how is it treated?

are they treated?

3 What are panic disorder and agoraphobia, what are their causes, and how are they treated?

may not always have a panic attack when performing this activity. (3) Unexpected or uncued attacks occur “spontaneously” and without warning. Panic attacks can occur in individuals with or without anxiety disorders. Anxiety disorders are the most common mental condition in the United States and affect about 40 million, or 18.2 percent of, adults in a given year (Kessler, Berglund, et al., 2005). It is estimated that nearly 29 percent of adults living in the United States will be affected by an anxiety disorder sometime during their lives (Kessler, Chiu, et al., 2005). The financial cost to the United States of anxiety disorders is estimated to be over $42 billion a year, with over half of these costs due to repeated use of health care facilities (Anxiety Disorders Association of America [ADAA], 2007). Gender and ethnic group differences have been found regarding anxiety disorders that have not been fully explained. For example, women have a significantly higher risk of developing an anxiety disorder, whereas blacks and Hispanics are at lower risk (Kessler, Berglund, et al., 2005). Anxiety disorders are responsible for a great deal of distress and dysfunction and are often accompanied by comorbid disorders such as depression, substance abuse, or other anxiety disorders. The strong association between depression and anxiety disorders suggests that they may involve different expressions of a common vulnerability (Brown, 2007). Substance abuse that co-occurs with anxiety disorders may be the result of individuals attempting to manage their anxiety symptoms by “self-medicating.” In this chapter, we discuss four major groups of anxiety disorders—phobias, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder (shown in Table 5.1). Acute stress disorder and posttraumatic stress disorder, which are also anxiety disorders, are covered in Chapter 7. In order to give you an understanding of the combination of predisposing factors that can result in an anxiety disorder, we begin our discussion with the multipath model we defined in Chapter 2.

Did You Know? Prevalence of Anxiety Disorders in the United States 15 12-month prevalence Lifetime prevalence

Percent

10

anxiety disorder

fear or anxiety symptoms that interfere with an individual’s day-to-day functioning

5

intense fear accompanied by symptoms such as a pounding heart, trembling, shortness of breath, or fear of losing control or dying

0

panic attack

118

Social phobia

Specific phobia

Panic disorder

Agoraphobia Generalized Obsessivewithout anxiety compulsive panic disorder disorder

Source: Kessler, Berglund, et al. (2005); Kessler, Chiu, et al. (2005)

Understanding Anxiety Disorders from a Multipath Perspective

TA B L E

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5.1

DISORDERS CHART ANXIETY DISORDER

Phobias —Social Phobias —Specific Phobias

ANXIETY DISORDERS SYMPTOMS

• Persistent, unrealistic fears of specific objects or situations • Exposure to feared stimulus produces intense fear or panic attacks • Avoidance responses are almost always present • Anxiety dissipates when phobic situation is not being confronted

Panic Disorder

• Recurrent and unexpected panic attacks

GENDER AND CULTURAL FACTORS

Social phobias more common in females. In Asian cultures may involve fear of offending others. Specific phobias approximately 2 times more common in females, though depends on type of phobia.

AGE OF ONSET

Social phobias: mid-teens Specific phobias: childhood or early adolescence (depends on type of phobia)

Late adolescence and mid-30s

• Can occur with or without agoraphobia

May involve intense fear of the supernatural in some cultures. 2–3 times more common in females.

Agoraphobia

• Anxiety or panic-like symptoms where escape might be difficult or embarrassing

Far more prevalent in females.

20s to 40s

Generalized Anxiety Disorder

• Excessive anxiety and apprehension over life circumstances for at least 6 months

Up to 2 times more prevalent in females. May be overdiagnosed in children.

Usually childhood or adolescence

Equally common in males and females. Less prevalent among African Americans, Asian Americans, and Hispanic Americans than white Americans.

Usually adolescence or early adulthood

• Concern about expected future panic attacks or about losing control

• Worry is difficult to control • General anxiety symptoms such as vigilance, muscle tension, restlessness, edginess, and difficulty concentrating ObsessiveCompulsive Disorder

• Recurrent and persistent intrusive thoughts and impulses • Attempts are made to suppress the thoughts or behaviors • Thoughts or behaviors are recognized as unreasonable (does not apply to children)

Understanding Anxiety Disorders from a Multipath Perspective In the case at the beginning of the chapter, Emily was exposed to greater trauma when she was attacked by a dog, but it was her sister Marian who developed an anxiety disorder. All of us have faced frightening situations. What makes some more vulnerable to anxiety disorders than others? In general, single etiological models, whether biological, psychological, or sociocultural, are insufficient to explain individual variations in response to fearful situations. A number of different factors may play a role in the acquisition of fears or phobias, including biological factors such as genetically based vulnerabilities and psychological factors such as personality variables, an individual’s sense of mastery or control, or direct or indirect conditioning experiences (Mineka & Zinbarg, 2006). In addition, cultural rules and norms can also influence the expression of anxiety disorders. The multipath model for anxiety disorders is shown in Figure 5.1. In the next section we consider the biological underpinnings of anxiety disorders, including some speculation regarding how genes exert their influence and how the environment influences the expression of genes.

Biological Dimension Two main biological factors affect anxiety disorders: brain structure and genetic influences.

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5.1

MULTIPATH MODEL OF ANXIETY DISORDERS The dimensions interact with one another and combine in different ways to result in a specific anxiety disorder. The importance and influence of each dimension varies from individual to individual.

Biological Dimension • Overactive fear circuitry in brain • Specific genetic contributors • Abnormalities in neurotransmitters

Psychological Dimension

Sociocultural Dimension • Gender differences • Cultural factors • Ethnicity

ANXIETY DISORDER

• Early childhood experience • Conditioning • Self-control or efficacy

Social Dimension • Daily environmental stress/community resources • Social support • Family relationships

Brain Structure The amygdala (a part of the brain involved in the formation and memory of emotional events) plays a central role in anxiety disorders. It alerts other brain structures, such as the hippocampus and prefrontal cortex, when a threat is present, triggering a fear or anxiety response. There are two pathways to the amygdala. One goes directly from the frightening sensory stimulus to the amygdala in just a few thousandths of a second. The second and slower path travels first to the prefrontal cortex, which evaluates the stimulus and can override the initial fear response. For example, when passengers in an airplane encounter turbulence, they may initially feel fear. However, when the pilot gives a reassuring explanation for the turbulence, parts of the prefrontal cortex reduce anxiety by acting to inhibit fear responses from the amygdala (Sotres-Bayon, Bush, & LeDoux, 2004). In some individuals, however, this fear network appears to be overactive, resulting in the symptoms displayed in anxiety disorders. The use of neuroimaging techniques such as positron emission tomography (PET) scans and magnetic resonance imaging (MRI) allows us to understand the brain circuitry involved in anxiety disorders and to measure structural characteristics of the involved brain systems. With neuroimaging, we can determine which parts of the brain are activated or not activated when an individual is exposed to a fearful stimulus and compare the brain activity of people with and without anxiety disorders. Increased reactivity in the amygdala has been observed in patients with anxiety disorders when they are exposed to specific emotional stimuli (Stein, Simmons, Feinstein, & Paulus, 2007). In addition, differences in the metabolism of certain areas of the brain can be seen in individuals with anxiety disorders even when fearful stimuli are not present. Neuroimaging techniques also allow us to observe the effects of both medication and psychotherapy. Medication appears to “normalize” anxiety circuits in the brain. Interestingly, psychotherapies also produce neurobiological changes similar to those seen with medications for anxiety disorders (Kumari, 2006). The connections between the amygdala and cortex allow us to speculate about why medications and psychotherapy may both be effective in treating anxiety disorders: each may operate on a different level of the brain. Therapy may reduce arousal by deconditioning fear at the level of the hippocampus while also strengthening the ability of the prefrontal cortex to inhibit fear responses from the amygdala. Medication may directly influence or decrease activity in the amygdala and other brain structures (Gorman et al., 2000; see Figure 5.2).

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Genetic Influences Genes appear to make a modest contribution to anxiety disorders. Past studies have attempted to estimate the heritability of characteristics of anxiety by examining families, siblings, and twins in an attempt to separate out environmental and genetic contributions. Currently, researchers are trying to identify specifically how genes might exert their influence. As you learned in Chapter 2, neurotransmitters are chemicals that help transmit messages in the brain. One specific neurotransmitter, serotonin, is implicated in mood and anxiety disorders. Consequently, a serotonin transporter gene (5-HTTLPR) has been the focus of attention. Alleles within a gene influence Prefrontal cortex the expression of a given genetic characteristic and can be either long or short. Researchers have found that short alleles in the serotonin transporter gene are Amygdala associated with (1) a reduction in serotonin activity and (2) increased fear and Hippocampus anxiety-related behaviors (Pezawas et al., 2005). This means that individuals with the short allele of this gene show more reactivity of the amygdala when FIGURE NEUROANATOMICAL exposed to threatening visual stimuli as compared with individuals with the BASIS FOR PANIC AND OTHER ANXIETY long allele. Those with the short allele also showed differences in brain strucDISORDERS The fear network in the brain ture in areas that affect mood and emotions such as anxiety and depression is centered in the amygdala and interacts (Hariri, Mattay, et al., 2002; Hariri, Drabant, et al., 2005). They show weaker with the hippocampus and areas of the connections between the amygdala and the cingulated cortex than those with prefrontal cortex. Antianxiety medications the long allele. This may result in a reduction of the cingulated cortex’s abilappear to desensitize the fear network. Some ity to regulate a “runaway” amygdala fear response (Pezawas et al., 2005). psychotherapies also affect brain functioning related to anxiety. Other investigators (Auerbach et al., 1999) have reported that the DRD4 gene that binds dopamine, another neurotransmitter, is also involved in anxiety. For example, two-month-old infants with short alleles of this gene show more distress during daily routines than do infants with long alleles. Although this research is promising, it is probable that many genes and interactions among genes contribute to anxiety. Even then, these genes would indicate only a predisposition to the development of anxiety. They do not guarantee that the characteristic will be expressed; this depends on interactions with other genes and with the environment (Leonardo & Hen, 2006). In addition, not all researchers have found the same association between these genes and anxiety (Van Gestel et al., 2002). Complicating the search for biological causes of anxiety disorders is the finding that other neurotransmitters, such as glutamate (GABA), are also involved in the modulation of learning and extinction of fear in the amygdala. In fact, benzodiazepines, a class of medications that are effective in treating anxiety disorders, exert their influence on GABA neurotransmitters present in the amygdala (Rauch, Shin, & Wright, 2003). Thus the search for biological factors includes identifying genes and gene interactions, understanding the relationship of the different brain systems, and determining which combinations of neurotransmitters are involved in anxiety disorders.

5.2

Biological, Psychological, and Social Interactions Although the genetic investigations cited previously have yielded important information, they do not consider the interplay between genetic and environmental influences. Researchers were initially puzzled by conflicting findings involved with the short allele of the serotonin transporter genes. For example, Auerbach et al. (2001) found that infants’ fear responses related to the short allele of the 5-HTTLPR gene were greatly reduced by the time the infants were twelve months old. Researchers began to wonder whether environmental factors such as parenting styles might influence the expression of genes. It is possible that some genetic predispositions may become “permanently” activated only when an environment “turns them on.” Characteristics such as anxiety and fear may result from genetic and environmental influences that are encoded by neural systems in the brain during a critical period of development (Leonardo & Hen, 2006). Fox and colleagues (2005) wanted to determine why only some children with the short allele 5-HTTLPR gene were shy. He hypothesized that parental behaviors may

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interact with a genetic predisposition and that behavioral inhibition (for example, shyness in speaking to or approaching an unfamiliar adult or playing with unfamiliar children) results when parents provide deficient social support for a child with the short 5-HTTLPR allele. For example, a mother who is “stressed” may transfer this feeling to a child or may not provide the support needed to overcome social anxiety. Using a longitudinal design, 153 children were observed and rated for characteristics of behavioral inhibition at age fourteen months and again at seven years. Mothers were assessed in terms of intimacy, social integration, self-esteem, nurturance, and social assistance provided to their children. DNA from each child was analyzed, and children were divided into two groups (those with the long allele and those with the short allele of the 5-HTTLPR gene). Fox et al. (2005) found that (1) there was greater evidence of behavioral inhibition for children with short alleles in families with low levels of social support and that (2) when there were high levels of social support, children with the short allele did not display behavioral inhibition. This means that a child who has a genetic predisposition to be fearful may be exposed to caregiver behaviors that provoke anxiety or fail to support the child when anxiety is experienced, thus reinforcing the underlying neural circuitry associated with anxiety. If, however, the child develops in a supportive environment that encourages interaction with others, anxious behaviors will not emerge. As Fox observed, “If you have two short alleles of this serotonin gene, but your mom is not stressed, you will be no more shy than your peers as a school age child. . . . But. . . . If you are raised in a stressful environment, and you inherit the short form of the gene, there is a higher likelihood that you will be fearful, anxious or depressed” (“Genes and Stressed-Out Parents Lead to Shy Kids, 2007,” p. 1). Gene-environment interaction has received a great deal of recent attention and shows greater promise than single-model approaches. However, other variables are also involved. Not all children with the short allele develop behavioral inhibition, even in stressful family environments, and some with long alleles are inhibited. There is support for the view that specific genes or combinations of genes predispose an individual to developing behavioral characteristics. Individuals without anxiety disorders with the short allele of the serotonin transporter 5-HTTLPR gene exhibit greater amygdala neuronal activity to fearful stimuli than do individuals who have the long allele (Pezawas et al., 2005).

Psychological Dimension Many etiological theories of mental disorders are psychological in nature and tend to deemphasize either biological or social influences. Psychoanalytic theorists focus primarily on the importance of the parent-child relationship in the development of anxiety disorders. In this respect, anxiety disorders are considered manifestations of problematic childhood experiences. For example, psychoanalytic theorists believe that panic symptoms represent problems with parents or caregivers over issues of separation, autonomy, and managing anger (Milrod et al., 2007). Cognitive-behavioral theories emphasize the importance of cognitive processes in the development and maintenance of anxiety disorders, both because the individual’s attention is overly focused on the threatening stimuli and because catastrophic or irrational thoughts reinforce the fear and anxiety (Rinck & Becker, 2006). For example, individuals with social anxiety may believe they are being scrutinized by others and think “Everyone in the room is watching me. I know I am going to do something stupid!” A personality variable, anxiety sensitivity (Reiss & McNally, 1985), may be a risk factor for the development of anxiety disorders. Individuals who score high in anxiety sensitivity are fearful of physiological changes in their bodies and interpret them as signs of danger. This characteristic may have been learned through watching parents or friends express fears about physical sensations or witnessing a traumatic event such as a heart attack (Schmidt, Lerew, & Jackson, 1997). Psychological variables such as one’s sense of control may also be involved in the development of anxiety disorders. Young monkeys reared in environments in which they could control access to water and food showed less fear when exposed

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123

to anxiety-provoking situations than did monkeys who did not have this control. Children raised in a manner such that they develop a sense of self-control and mastery also appear to be less vulnerable to developing anxiety disorders (Chorpita & Barlow, 1998). Thus early experiences can play a role in determining the vulnerability of children and need to be considered in the cognitive theories.

Social and Sociocultural Dimensions Any etiological theory of anxiety disorders should consider the impact of social and sociocultural factors and stresses. Daily environmental stress is a social factor that can produce anxiety, especially in individuals who have biological or psychological vulnerabilities. For example, those with lower incomes have higher rates of anxiety disorders (Kessler, Berglund, et al., 2005). Living in poverty and in areas of urban blight likely exacerbate both stress and CHILDREN AND SELF-CONTROL AND MASTERY Children who develop a sense of control and mastery are less susceptible to anxiety disorders. In this case, the anxiety. Disasters such as those associated with child is allowed to choose her dinner from an assortment of healthy foods and to terrorist attacks, school shootings, and natuserve herself. Within developmental and appropriate limits, how else can choices ral disasters such as Hurricane Katrina also and independence be encouraged in young children? increase the rate of anxiety disorders within the population (Palmieri, Weathers, Difede, & King, 2007; Weems et al., 2007). How these stressors are viewed by an individual’s social support network (family, friends, and peers) can either exacerbate or mitigate anxiety reactions (Brewin, Andrews, & Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003). The intactness of a community or the meaning that it ascribes to stressful events also influences reactions of the residents. With Hurricane Katrina, anxiety was heightened because people of color believed that failure of the federal government to respond adequately was due to race and class bias (Bourne, Watts, Gordon, & Figueroa-Garcia, 2006). Gender also plays a role in the development of anxiety disorders. With the exception of obsessive-compulsive disorder, females are more likely to suffer from anxiety disorders than males. Is the reason biological, social, or a combination of the two? Nolen-Hoeksema (2004) argues that women are more likely to be diagnosed with emotional disorders due to the lack of power and status that they contend with in society and to chronic stresses associated with poverty, lack of respect, and limited choices. Women are also more likely to be exposed to trauma than men; stress hormones produced by these events may make women more vulnerable to depression and anxiety. Thus psychological, social, and biological factors interact and result in an overrepresentation of women with respect to anxiety disorders. Cultural factors such as acculturation conflicts also contribute to anxiety disorders among ethnic minorities. Among Native Americans and Asian American undergraduate students, there is evidence of high levels of self-reported anxiety (De Coteau, Anderson, & Hope, 2006; Okazaki et al., 2002). Increased anxiety among some cultural groups may be due to differing cultural standards in terms of appropriate social interactions. In other cases, it may be the result of exposure to discrimination and prejudice. This is especially important to determine with marginalized groups such as those with disabilities, different sexual orientations, or of older ages. Culture may also influence how anxiety is expressed; for example, ataque de nervios—symptoms similar to a panic attack but also including crying or uncontrollable shouting—can be found among Latino groups. With the large increase in the immigrant population, an awareness of cultural manifestations of anxiety in the different groups is essential.

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Phobias The word phobia comes from the Greek word for fear. A phobia is a strong, persistent, and unwarranted fear of some specific object or situation. An individual with a phobia often experiences extreme anxiety or panic when he or she encounters the phobic stimulus. Attempts to avoid the object or situation notably interfere with the individual’s life. Adults with this disorder realize that their fear is excessive, although children may not. Most people with phobias also have anxiety, mood, or substance use disorders (Hofmann, Lehman, & Barlow, 1997). Phobias are the most common mental disorder in the United States. Indeed, nearly anything can become the focus of intense fear. There is even a fear of phobias called phobophobia (see Table 5.2). DSM-IV-TR includes three subcategories of

TA B L E

5.2

PHOBIAS AND THEIR OBJECTS

a strong, persistent, and unwarranted fear of some specific object or situation

phobia

PHOBIA

OBJECT OF PHOBIA

Acrophobia

fear of heights

Agoraphobia

fear of open spaces

Ailurophobia

fear of cats

Algophobia

fear of pain

Arachnophobia

fear of spiders

Astrapophobia

fear of storms, thunder, lightning

Aviophobia

fear of airplanes

Brontophobia

fear of thunder

Claustrophobia

fear of closed spaces

Dementophobia

fear of insanity

Genitophobia

fear of genitals

Hematophobia

fear of blood

Microphobia

fear of germs

Monophobia

fear of being alone

Mysophobia

fear of contamination/germs

Nyctophobia

fear of the dark

Ochlophobia

fear of crowds

Pathophobia

fear of disease

Phobophobia

fear of phobias

Pyrophobia

fear of fire

Syphilophobia

fear of syphilis

Topophobia

fear of performing

Xenophobia

fear of strangers

Zoophobia

fear of animals/particular animal

Phobias

TA B L E

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5.3

THOUGHTS REPORTED BY PATIENTS WITH SOCIAL PHOBIA DURING SOCIAL SITUATIONS PATIENT

AGE

DURATION (IN YEARS)

IDIOSYNCRATIC NEGATIVE BELIEF

1

27

5

I’ll shake constantly, and people will think that I’m an alcoholic.

2

29

7

I’ll look anxious, and people will think that I’m stupid.

3

34

11

I’ll babble a lot, and everyone will think that I’m nervous.

4

44

27

I’ll blush, and people will think that I’m anxious.

5

22

2

I’ll look very tense, and people around will stare at me.

6

18

4

I’ll sweat heavily, and everyone will think that I’m nervous.

7

25

8

I’ll go red, and people will think that I’m anxious.

8

43

24

I’ll tremble uncontrollably, and people will think that I have Parkinson’s disease.

Source: From Wells & Papageorgiou (1999).

phobias: agoraphobia, social phobias, and specific phobias. We discuss social phobias and specific phobias here and cover agoraphobia later in the chapter.

Social Phobias Case Study In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. When I would walk into a room full of people, I’d turn red, and it would feel like everybody’s eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say. . . . It was humiliating. . . . I couldn’t wait to get out. (National Institute of Mental Health [NIMH], 2007a, p. 9)

A social phobia is an intense, excessive fear of being scrutinized in one or more social or performance situations. Some people feel literally sick with fear when performing activities such as eating in public, standing in line at a ticket counter, or walking in a mall. Albert Ellis (1913–2007), the psychologist who developed rational emotive behavior therapy, reported that as a teenager he would wait until a movie started before going to a seat because he was fearful about being observed by other patrons. In social phobia, the person’s fear stems from anxiety that, when in the presence of others, he or she will perform one or more activities in a way that is embarrassing or humiliating (Bruch, Fallon, & Heimberg, 2003; Lipsitz, 2006). There is no such fear when the person engages in any of these activities in private. The most common fears seen in social phobia involve public speaking and meeting new people (American Psychiatric Association, 2000a). Table 5.3 shows some of the fearful thoughts reported by patients with social phobia during social situations. Individuals with high social anxiety tend to perceive other people’s emotions toward them as negative (Winton, Clark, & Edelmann, 1995), engage in negative self-observation and monitoring, and are alert to “threat” cues such as signs of disapproval or criticism (Harvey, Clark, Ehlers, & Rapee, 2000; Mogg, Philippot, & Bradley, 2004). People with social phobias, like those with other phobias, usually realize that their behavior and fears are irrational, but this understanding does not reduce the distress they feel. Social phobias can be divided into three types: 1. performance—excessive anxiety over activities such as playing a musical instrument, public speaking, eating in a restaurant, using public restrooms

social phobia an intense, excessive fear of being scrutinized in one or more social or performance situations

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2. limited interactional—excessive fear only in specific social situations, such as going out on a date or interacting with an authority figure 3. generalized—extreme anxiety displayed in most social situations About half of the individuals with social phobia have the generalized form (Schneier, 2006). In a sample of individuals with generalized social phobia, multiple social fears were present, including fear of public speaking, of using the toilet away from home, of eating or drinking in public, and of writing with someone watching (Kessler, Stein, & Berglund, 1998). Social phobias affect 8.7 percent of adults in a given year. Over 48 percent, however, rate the severity of their phobias as “mild” (Kessler, Chiu, et al., 2005). Women are twice as likely as men to have this disorder; however, more men seek treatment (NIMH, 1999; Kessler, Berglund, et al., 2005). Having generalized social phobia appears to affect the occupational status of women. They were more likely to be employed in noninterpersonally oriented jobs, to be underemployed, and to believe that their supervisors would rate them lower in dependability (Bruch et al., 2003). Social phobias tend to begin during adolescence, and they appear to be more common in families who use shame as a method of control and who stress the importance of the opinions of others (Bruch & Heimberg, 1994). These are common childrearing practices in Asian families, and fear of being evaluated by others tends to be more common in Chinese children and adolescents than in western comparison groups (Dong, Yang, & Ollendick, 1994). Asian American undergraduate students score higher on measures of social anxiety but do not differ significantly on behavioral indices of social anxiety compared with white undergraduate students (Okazaki et al., 2002). And in a study of eighty-six American Indian adolescents, self-reports of social anxiety were higher than those reported in other adolescent samples (West & Newman, 2007). It is also important to note that social fears and other anxiety disorders may be expressed differently in other cultures. Taijin Kyofusho, for instance, is a culturally distinctive phobia found in Japan that is somewhat similar to social phobia. However, instead of a fear involving social or performance situations, Taijin Kyofusho is a fear of offending or embarrassing others, a concept consistent with Japanese cultural

PHOBIAS Coulrophobia is an abnormal or exaggerated fear of clowns, perhaps due to their never-changing expressions from painted eyes and smiles. Celebrities reported to have a fear of clowns include Johnny Depp, P. Diddy, and Carol Burnett. Uma Thurman is reported to have claustrophobia (fear of enclosed places). What do you believe may cause these fears?

emphasis on maintaining interpersonal harmony (Okazaki, 1997; Suzuki et al., 2003). Individuals with this disorder are fearful that their appearance, facial expression, eye contact, body parts, or body odor are offensive to others.

Specific Phobias A specific phobia is an extreme fear of a specific object (such as snakes) or situation (such as being in an enclosed place). Exposure to the stimulus nearly always produces intense anxiety or a panic attack. DSM-IV-TR divides specific phobias into five types: 1. Animal (such as spiders or snakes) 2. Natural environmental (such as earthquakes, thunder, water) 3. Blood/injections or injury 4. Situational (includes fear of traveling in cars, planes, and elevators or fear of heights, tunnels, and bridges) 5. Other (phobic avoidance of situations that may lead to choking, vomiting, or contracting an illness)

Average age of onset

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28 26 24 22 20 18 16 14 12 10 8 6 4 2 0

Animal

FIGURE

Blood

Dental work

Social situations

Closed spaces

Crowds

5.3

PHOBIA ONSET This graph illustrates the average ages at which 370 patients said their phobias began. Animal phobias began during childhood, whereas the onset of agoraphobia did not occur until the individuals were in their late twenties. What do you feel accounts for the differences reported in the age of onset?

Source: Data from Öst (1987, 1992).

The following is a report of a common specific phobia in a twenty-six-year-old public relations executive:

Case Study If I see a spider in my house, I get out! I start shaking, and I feel like I’m going to throw up. I get so scared, I have to bolt across the street to drag my neighbor over to get rid of the spider. Even after I know it’s gone, I obsess for hours. I check between my sheets 10 times before getting in bed, and I’m so creeped out that I won’t get up and go to the bathroom at night, even if my bladder feels like it’s about to burst. (Kusek, 2001, p. 183)

Specific phobias affect 19.2 million adults, or 8.7 percent, in a Did You Know? given year in the United States alone and are twice as common in women as in men (Kessler, Berglund, et al., 2005; NIMH, 2007a). Fears or Phobias Reported by Actors The degree to which they interfere with daily life depends on how Jennifer Aniston—Flying (Aviophobia) easy it is to avoid the feared object or situation. These phobias Pamela Anderson—Mirrors (Eisoptrophobia) often begin during childhood. In a study of 370 patients with phoJohnny Depp—Clowns (Coulrophobia) bias (Öst, 1987, 1992), retrospective data revealed that animal Uma Thurman—Enclosed places (Claustrophia) phobias tended to have the earliest onset (age seven), followed by Sarah Michelle Geller—Graveyards (Coimetrophobia) blood phobia (age nine), dental phobia (age twelve), and claustroOrlando Bloom—Pigs phobia (age twenty). Figure 5.3 illustrates ages at which different Keanu Reeves—Darkness (Achluophobia) phobias typically begin. Tyra Banks—Dolphins and whales The most common childhood fears are of spiders, the dark, Justin Timberlake—Spiders (Arachnophobia) and snakes frightening movies, and being teased (Muris, Merckelbach, & (Ophidiophobia) Collaris, 1997). In a sample of 160 primary-school children, 17.6 percent met the criteria for a specific phobia (Muris & Merckelbach, 2000). Among adolescents, the most frequently reported fear was speaking in class, followed by speaking to strangers, heights, and animals. Most fears did not persist (Poulton et al., 1997). Blood phobias differ from other phobias because they are associated with a unique physiological response: fainting in the phobic situation. Fainting appears to result from an initial increase in autonomic arousal followed by a sudden drop in blood pressure and heart rate. Nearly 70 percent of those with blood phobias report a history of fainting in the feared situation (Antony, Brown, & Barlow, 1997). Many specific phobia an extreme fear are severely handicapped by the phobia. They may avoid medical examinations or of a specific object (such as snakes) or situation (such as being in an be unable to care for an injured child or shop at the meat counter in supermarkets enclosed place) (Hellstrom, Fellenius, & Öst, 1996).

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5.4

MULTIPATH MODEL OF PHOBIAS The dimensions interact with one another and combine in different ways to result in a phobia.

Biological Dimension • Genetic predisposition or vulnerability • Overactive amygdala or fear circuit preparedness

Sociocultural Dimension • Taijin Kyofusko: culturally distinct phobia • Cultural child-rearing patterns/culturally distinct fears • Gender differences (phobias twice as common in women)

Psychological Dimension

PHOBIAS

• • • •

Conditioning experiences Cognitive distortions Self-focus Observational learning

Social Dimension • Use of shame as method of control • Parental modeling • Negative information

Etiology of Phobias How do such strong and “irrational” fears develop? As we indicated at the beginning of the chapter, in most cases, predisposing conditions produced by genetics, psychological, social, and sociocultural factors play a role. In this section, we examine the factors related to the etiology of phobias, as shown in Figure 5.4.

Did You Know? • 3.5 percent of Americans have a severe injection phobia. • 50 percent who use medications that require self-injections are unable to perform the injections. • Those with an injection phobia fear pain or have unrealistic thoughts such as “the needle might break off.” Source: Mohr, Cox, & Merluzzi, 2005

Biological Dimension Some researchers (Muris et al., 2001) believe that biological factors play a major role in the etiology of phobias. Studies on male and female twin pairs have supported a moderate contribution from a common genetic factor for all phobia subtypes (Hettema et al., 2003; Kendler et al., 2001). Individuals with phobias may have more of an innate tendency to be anxious and respond more strongly to emotional stimuli; thus their chances of developing an anxiety disorder are increased. Neuroimaging studies have found amygdala activation and overactivity in social phobia and specific phobias. Overactivation of the amygdala has also been found in nonphobic individuals during classical conditioning experiments designed to produce fear (Rauch et al., 2003). These biological vulnerabilities may make an individual more susceptible to developing an anxiety disorder. A different biological view of the development of fear reactions is that of preparedness (Ohman & Mineka, 2001; Poulton et al., 2000; Seligman, 1971). Proponents of this position argue that fears do not develop randomly. In particular, they believe that it is easier for human beings to learn fears to which we are physiologically predisposed, such as fear of heights or fear of snakes. Such quickly aroused (or “prepared”) fears may have been necessary to the survival of pretechnological humanity. In fact, evolutionarily prepared fears (for example, fear of fire or deep water) may occur even without exposure to traumatic conditioning experiences (Forsyth, Eifert, & Thompson, 1996; Muhlberger et al., 2006). Although this is a promising area for further research, it is difficult to believe that most phobias stem from prepared fears. Many simply do not fit into the prepared-fear model. It would be difficult, for example, to explain the survival value of social phobias such as fear of using public restrooms or of eating in public, as well as many of the specific phobias. In addition, prepared fears appear to have a variable age of onset and are among the easiest fears to eliminate. Psychological Dimension Different psychological theories or perspectives have been developed to explain the development of phobias. Most acknowledge the influence of biological factors but place the greatest emphasis on childhood and learning experiences.

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controversy

Fear or Disgust?

A

re humans’ fears of animals such as spiders and rats due to the disgust evoked rather than to a threat of physical danger? Some researchers (Davey et al., 1998; de Jong, Vorage, & van den Hout, 2000) point out that spiders and rats are, in general, harmless. These researchers attribute the avoidance reaction to an inherent or “prepared” fear of disease or contamination, not to a threat of physical danger. In an experiment to determine whether disgust is involved in spider phobia, Mulkens, de Jong, and Merckelbach (1996) had women with and without spider phobias indicate their willingness to eat a cookie. An assistant of the researchers then guided a “medium sized” spider (Tegenaria Atrica) across the cookie. An associate then removed the spider from the room. The researchers reasoned that if disgust is a factor, those with a spider phobia should be more reluctant to eat the “contaminated” cookie. Results supported

this idea: only 25 percent of women with spider phobia eventually ate some of the cookie, compared with 70 percent of the control group participants. In another study, men and women with spider phobia were found to respond to spiders with a combination of fear and disgust, although fear appeared to predominate (Tolin et al., 1997). Thorpe and Salkovskis (1998) also report that individuals with spider phobia associate the words legs, hairy, creepy, black, and fast with spiders. Disgust received seventh or eighth place in a list of adjectives used to describe spiders. For Further Consideration 1. Other insects or animals, such as cockroaches, maggots, and slugs, also can elicit disgust. Does the avoidance of spiders and snakes stem from fear, disgust, or both? 2. How would you design an experiment to test this question?

Psychodynamic perspective According to the psychodynamic viewpoint, phobias are “expressions of wishes, fears and fantasies that are unacceptable to the patient” (Barber & Luborsky, 1991). These unconscious conflicts are displaced (or shifted) from their original internal source to an external object or situation. The phobia is less threatening to the person than recognition of the underlying unconscious impulse. A fear of knives, for example, may represent castration fears produced by an unresolved Oedipus complex or aggressive conflicts. People with agoraphobia— an intense fear of being in public places where escape or help may not be readily available—may develop their fear of leaving home because they unconsciously fear that they may act out unacceptable sexual desires. Therapists in the psychodynamic tradition believe that the level of phobic fear shows the strength of the underlying conflict. This formulation, presented by Freud in 1909, was based on his analysis of a fear of horses displayed by a five-year-old boy named Hans (Freud, 1909/1959). Freud believed that the phobia represented a symptomatic or displaced fear arising from the Oedipus complex. The hypothesized factors involved were the boy’s incestuous attraction to his mother, hostility toward his father because of the father’s sexual privileges, and castration fear (fear of retribution by his father). Freud became convinced that these elements were present in the phobic boy. At the age of three, Hans had displayed an interest in his penis (which he called his “widdler”); he would examine both animate and inanimate objects for the presence of a penis. One day as he was fondling himself, his mother threatened to have a physician cut off his penis (Freud, 1909/1959). Hans enjoyed having his mother bathe him and especially wanted her to touch his penis. Freud interpreted these events to suggest that Hans was aware of pleasurable sensations in his penis and that he knew it could be “cut off” if he did not behave. Wanting his mother to handle his genitals showed Hans’s increasing sexual interest in her. Hans’s fear that horses would bite him developed after he saw a horse-drawn van overturn. According to Freud, little Hans’s sexual jealousy of his father and the hostility it aroused produced anxiety. He believed that his father could retaliate by castrating him. This unconscious threat was so unbearable that the fear was displaced to the idea that horses “will bite me.” Freud concluded that phobias were adaptive because they prevented the surfacing of traumatic unconscious conflicts. The psychodynamic formulation has little research support. According to the psychodynamic perspective, if the phobia is only a symptom of an underlying unconscious

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conflict, treatment directed to that symptom—the feared object or situation—should be ineffective, leaving the patient defenseless and subject to overwhelming anxiety or leading to the development of a new symptom. Evidence does not support the view that eliminating the symptom is ineffective. The psychodynamic perspective does, however, point out the importance of early experiences to later behavior. Behavioral perspective Behaviorists have examined four possible processes— classical conditioning, modeling, negative information, and cognitions—in their attempt to explain the etiology of phobias. The specific process by which phobias develop may depend on the class of fear. Classical conditioning perspective The view that phobias are conditioned responses is based primarily on psychologist John Watson’s classic conditioning experiment with Little Albert. Watson caused the infant to develop a fear of white rats by pairing a white rat with a loud sound (Watson & Rayner, 1920/2000), demonstrating that fears can result through classical conditioning or association. There is some evidence that emotional reactions can be conditioned. Before undergoing chemotherapy for breast cancer, women were given lemon-lime Kool-Aid in a container with a bright orange lid. After repeated pairings of the drink and the chemotherapy, the women indicated emotional distress and nausea when presented with the container (Jacobsen et al., 1995). Many children with severe phobias report conditioning experiences as the cause (King, Clowes-Hollins, & Ollendick, 1997; King, Eleonora, & Ollendick, 1998). Similarly, more adult clients attribute their phobias to direct (classical) conditioning experiences than to any other factor (Öst, 1987; Öst & Hugdahl, 1981). Öst and Hugdahl (1981) found that the phobia most likely to be attributed to direct conditioning experiences is agoraphobia, followed by claustrophobia and dental phobia. However, a substantial percentage of surveyed patients report something other than a direct conditioning experience as the “key” to their phobias. Also, the classical conditioning perspective does not explain why only some people exposed to potential conditioning experiences actually develop phobias. Observational learning perspective Emotional conditioning can be developed through observational learning. Participants watched a video of a male involved in a fear conditioning experiment. The video displayed an uncomfortable shock being delivered to the man’s wrist in response to one stimulus. The observers were told that they would participate in a similar experiment after viewing the video. When they were shown the same stimulus that had been associated with the shock, the participants responded with fear. In the study, MRIs of the participants were also taken during the conditioning experiment. They showed activation of the amygdala, acquired through observational learning (Olsson, Nearing, & Phelps, 2007). Fear responses in children can result from the observation of fear displayed by a parent or friend or on television or in the movies. However, the observational learning perspective seems to share a problem with the classical conditioning approach: neither, by itself, can explain why only some people develop phobias after exposure to a vicarious experience. Negative information perspective To determine the influence of negative information—information that might cause someone to fear an object or situation— on the acquisition of nighttime fears in children, researchers asked questions such as, “Did you see frightening things on television about . . . ? ” (Muris et al., 2001). The most common fears included concern with intruders, imaginary creatures, frightening dreams, animals, and frightening thoughts. Many (73.3 percent) of the children attributed their fears to negative information acquired largely from television. However, it is still not clear whether negative information is sufficient to produce a phobia. Cognitive-behavioral perspective Why do individuals with spider phobia react with such terror at the sight of a spider? Some researchers believe cognitive distortions and catastrophic thoughts may cause such strong fears to develop. For example, people with spider phobia believe that spiders single them out for attack and that they will move rapidly and aggressively toward them (Riskind, Moore, & Bowley, 1995).

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Others report thoughts that the spider “will attack me” or “will take revenge” (Mulkens et al., 1996). Similar negative thoughts, such as “I will be trapped,” “I will suffocate,” or “I will lose control,” have been reported by individuals with claustrophobia. Removal of such thoughts results in a dramatic decrease in fear (Shafran, Booth, & Rachman, 1993). Studies also indicate that a person with a phobia is more likely to overestimate the odds of an unpleasant event occurring. Patients with acrophobia (fear of heights) overestimate not only the probability of falling but also the probability of being injured (Menzies & Clarke, 1995). Such studies seem to indicate that cognitions involving catastrophic or distorted thinking may be causal or contributing factors in phobias.

Treatment of Phobias

SPECIFIC PHOBIAS

The extreme fear of spiders is a specific

For all anxiety disorders, it is first important to rule out possible phobia. Is this fear due to a belief that the spider is malevolent and is planning to attack? medical or physical causes of anxiety symptoms such as hyper- or hypothyroidism, temporal-lobe epilepsy, asthma, cardiac arrhythmias, effects of stimulants (for example, excessive intake of caffeine), or withdrawal from alcohol (Katon, 2006). Specific and social phobias have been successfully treated by both behavioral methods and medication. In some studies the two types of treatments have been combined, although the results from combination have been mixed. For example, individuals with generalized social phobia were treated with either cognitive-behavioral therapy (CBT), fluoxetine, or both CBT and medication. The results indicated that both treatments were equally effective and that the combination produced no improvement in outcome (Davidson et al., 2004). Biochemical Treatments Biochemical treatments are predicated on the view that anxiety disorders involve neurobiological abnormalities that can be normalized with medication. The most commonly identified neurotransmitters thought to be involved in anxiety reactions are norepinephrine, serotonin, and dopamine. In general, antidepressants can help reduce not only the extreme fear but also the depression that often accompanies anxiety disorders. In treating phobias, a number of medications appear to be effective. For social phobia, both benzodiazepines (a class of antianxiety medication) and selective serotonin reuptake inhibitors (SSRIs) have shown “preliminary evidence of efficacy,” and benzodiazepines have been used with some success in treating specific phobias, as well (Lader & Bond, 1998). As with most medications, side effects or negative effects can occur. Benzodiazepines can produce dependence, withdrawal symptoms, and paradoxical reactions such as increased talkativeness, excessive movement, and even hostility and rage (Mancuso, Tanzi, & Gabay, 2004). In addition, symptoms often recur if the patient stops taking the medications (Sundel & Sundel, 1998).

Did You Know? Possible side effects of SSRIs include: • decrease in sexual arousal and functioning • weight gain • dry mouth • memory impairment Source: “Drugs and Talk Therapy” (2004).

Behavioral Treatments Phobias have also been successfully treated with a variety of behavioral approaches. These approaches include: • Exposure therapy: gradually introducing the individual to the feared situation or object until the fear dissipates. • Systematic desensitization: similar to exposure but with an additional response, such as relaxation, to help combat anxiety. • Cognitive restructuring: identifying irrational or anxiety-arousing thoughts associated with the phobia and changing them. • Modeling therapy: demonstration of another person’s successful interactions with the feared object or situation. Most behavioral treatments combine several techniques (Lipsitz, 2006). Exposure therapy In exposure therapy, the patient is gradually introduced to increasingly difficult encounters with a feared situation. For example, in agoraphobia,

exposure therapy therapy that involves gradually introducing the patient to increasingly difficult encounters with a feared situation

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which involves the fear of leaving the house, the therapist may first ask the patient only to visualize or imagine the anxiety-evoking situation. The person would eventually be asked to actually take walks outside the home with the therapist until the fear has been eliminated. Exposure therapy has also been used successfully to treat specific phobias, such as social phobia (Schneier, 2006), speech anxiety (Hofmann et al., 2004), fear of spiders (Muris, Merckelbach, & de Jong, 1995; Carlin, Hoffman, & Weghorst, 1997), claustrophobia (Booth & Rachman, 1992), fear of flying (Rothbaum et al., 1996), and fear of heights (Marshall, 1988). A variant of exposure therapy has been developed for the treatment of bloodinjection phobia, which is associated with fainting caused by a sudden drop in blood pressure and slowing of the heart rate. A procedure known as applied tension (described in the following case), combined with exposure, has proven effective (Hellstrom et al., 1996).

Case Study One patient, Mr. A., reported feeling faint when exposed to any stimuli involving blood, injections, injury, or surgery. Even hearing an instructor discuss the physiology of the heart caused Mr. A. to feel sweaty and faint. Mr. A. was taught to recognize the first signs of a drop in blood pressure and then to combat this autonomic response by tightening (tensing) the muscles of his arms, chest, and legs until his face felt warm. Mr. A. was then taught to stop the tension for about fifteen to twenty seconds and then to reapply the tension, repeating the procedure about five times. (The rise in blood pressure that follows this process prevents fainting, and the fear becomes extinguished.) After going through this process, Mr. A. was able to watch a video of thoracic surgery, watch blood being drawn, listen to a talk about cardiovascular disease, and read an anatomy book—stimuli that in the past would have produced fainting (Anderson, Taylor, & McLean, 1996). This procedure involving muscle tension is specific for phobias in which fainting may occur.

systematic desensitization

exposure strategy that uses muscle relaxation to reduce the anxiety associated with specific and social phobias cognitive strategy that attempts to alter unrealistic thoughts that are believed to be responsible for phobias

cognitive restructuring

modeling therapy procedures that include filmed modeling, live modeling, and participant modeling effective in treating certain phobias

Systematic desensitization Systematic desensitization uses muscle relaxation to reduce the anxiety associated with specific and social phobias. Wolpe (1958, 1973), who introduced the treatment, first taught clients a muscle relaxation response. Second, he had them visualize the feared stimuli (arranged from least to most anxiety provoking) while in the relaxed state. This was continued until the clients reported little or no anxiety with the stimuli. This procedure was adapted for Mr. B., who had a fear of urinating in restrooms when others were present. He was trained in muscle relaxation and, while relaxed, learned to urinate under the following conditions: no one in the bathroom, therapist in the stall, therapist washing hands, therapist at adjacent urinal, therapist waiting behind client. These conditions were arranged in ascending difficulty. The easier items were practiced first until Mr. B’s anxiety was sufficiently reduced. Over a period of seventeen weeks, the anxiety diminished completely, and the gains were maintained in a follow-up at seven and one-half months (McCracken & Larkin, 1991). Cognitive restructuring In cognitive restructuring, unrealistic thoughts are altered, as they are believed to be responsible for phobias. Individuals with social phobias, for example, tend to be intensely self-focused and fearful that others will see them as anxious, incompetent, or weak. Their own self-criticism is the basis for their phobia (Harvey et al., 2000; Hofmann, 2000). Cognitive strategies can help “normalize” social anxiety by encouraging patients to interpret emotional and physical tension as “normal anxiety” and by helping them redirect their attention from themselves to others in the social situations. This approach has been successful in treating individuals with public-speaking phobia, in which a strong relationship was found between a decrease in self-focus and a reduction in speech anxiety (Woody, Chambless, & Glass, 1997). Claustrophobic individuals have also been successfully treated by having them identify specific beliefs about danger and testing them when they are in an enclosed chamber (Kamphuis & Telch, 2000; Öst et al., 2001). Modeling therapy In modeling therapy, the individual with the phobia observes a model (either in a visual portrayal or in person) in the act of coping with, or responding appropriately in, the fear-producing situation. Participant modeling

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MODELING Watching a fear-producing act being performed successfully can help people overcome their fear. In this photo, the reluctant teen is exposed to a python by her friend. Modeling is effective in treating both specific and social phobias. Why do you think modeling works?

may also be involved, during which the individual with the phobia will perform the same responses demonstrated by a model with the phobic object (Ollendick & King, 1998). Some believe that modeling is a unique therapeutic approach in its own right, whereas others believe that it is a type of exposure treatment.

Panic Disorder and Agoraphobia Case Study At age thirty-eight, Eve Robinson of Oakland was sure she was losing her mind. While driving on the freeway one evening, she suddenly found she couldn’t swallow. In panic, she pulled over to calm herself and slowly made her way home, vowing never to use the freeway again. A few months later, Robinson’s heart started pounding as she boarded a plane to return home from her sister’s wedding in Los Angeles. Convinced she was going to die, she begged a flight attendant to let her off and wrapped her hands around his neck when he refused. . . . Eve soon hit rock bottom when she found herself so fearful of having more attacks that she was unable to leave the house for four months. (Cash, 1998, p. 34)

Panic Disorder Earlier, we defined panic attacks as intense fear accompanied by symptoms such as a pounding heart, trembling, shortness of breath, or fear of losing control or dying. According to DSM-IV-TR, a diagnosis of panic disorder includes recurrent unexpected panic attacks and at least one month of apprehension over having another attack or worrying about the consequences of an attack. Individuals with panic disorder report intense panic attacks, which usually peak in about ten minutes or less, alternating with periods of somewhat lower anxiety, during which they may be apprehensive about having another panic attack. The attacks are especially feared because they often occur unpredictably and without warning. Panic attacks often begin in late adolescence or early adulthood (NIMH, 2007a). The twelve-month prevalence rate for panic disorder is 2.7 percent (Kessler, Chiu, et al., 2005) and is twice as common in women as in men (NIMH, 2007a). During the attacks, people report a variety of physical symptoms, such as breathlessness, sweating, choking, nausea, and heart palpitations. Many go to emergency rooms with complaints of chest pain (Fleet et al., 2003). Individuals with panic disorder often have comorbid disorders involving other anxiety conditions or mood disturbances. One-third to

panic disorder recurrent unexpected panic attacks and at least one month of apprehension over having another attack or worrying about the consequences of an attack

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one-half of individuals diagnosed with a panic disorder also have agoraphobia, or anxiety about leaving the home, which is caused by fear of having a panic episode in a public place (American Psychiatric Association, 2000a). Such cases are diagnosed as panic disorder with agoraphobia. Because agoraphobia rarely exists without panic disorder (over 95 percent have a current diagnosis or history of panic disorder; American Psychiatric Association, 2000a), we discuss agoraphobia in this section. Although panic disorder is diagnosed in only a small percentage of individuals, panic attacks appear to be fairly common. Among U.S. college students, one-fourth to one-third reported having had a panic attack during a one-year period (Asmundson & Norton, 1993; Brown & Cash, 1990). Nearly 45 percent of U.S. college women reported having one or more panic attacks within the previous year (Whittal, Suchday, & Goetsch, 1994). Most panic attacks are associated with an identifiable stimulus. However, in one study, more than 12 percent reported experiencing unexpected panic attacks (Telch, Lucas, & Nelson, 1989). Panic attacks are relatively common, so it is reassuring to know that most people who have them do not develop a panic disorder. THE SCREAM, BY EDVARD MUNCH The Norwegian painter describes the scene this way: “I was walking along the road with two friends. The sun set. I felt a touch of melancholy. Suddenly the sky became a blood red. I stopped, leaned against a railing, dead tired (my friends looked at me and walked on), and I looked at the flaming clouds that hung like blood and a sword . . . over the blue-black fjord and the city. My friends walked on. I stood there trembling with fright. And I felt a loud unending scream piercing nature” (cited in Harris, 2004, p. 15).

Agoraphobia Agoraphobia is an intense fear of being in public places where escape or help may not be readily available. It arises from a fear that panic-like symptoms will occur and incapacitate the person or cause him or her to behave in an embarrassing manner, such as fainting, losing control over bodily functions, or displaying excessive fear in public. Anxiety over having a panic attack can prevent people from leaving their homes. Agoraphobia occurs much more frequently in females than in males. Although this phobia is relatively uncommon (less than 1 percent of U.S. adults in a given year), 41 percent of those affected rate the symptoms as serious (Kessler, Chiu, et al., 2005). Individuals who have agoraphobia may misinterpret and overreact to bodily sensations. In support of this view, Reiss and colleagues (1986) found that people with agoraphobia scored high on the Anxiety Sensitivity Inventory (ASI), which measures the degree to which individuals “fear” their physiological reactions. Similar results have been obtained for individuals with panic disorder.

Etiology of Panic Disorder and Agoraphobia

Did You Know?

T

he origin of the word panic is in Greek mythology. Pan was a Greek demigod who lived in isolated forests. He amused himself by rustling leaves and making other noises while following travelers who were traveling at night through the woods. He would continue to frighten them until they bolted in panic.

agoraphobia an intense fear of being in public places where escape or help may not be readily available

As with the other disorders we have discussed so far, biological, psychological, social, and sociocultural factors play a role in the etiology of panic disorder, as shown in Figure 5.5. Biological Dimension Higher concordance rates (percentages of relatives sharing the same disorder) for panic disorder have been found in monozygotic (identical) twins than in dizygotic (fraternal) twins; the degree of heritability for agoraphobia and panic disorder due to genetic factors was estimated to be about 35 percent, which is considered a modest contribution (Kendler et al., 1992). Research has also been directed at identifying specific genes, neural structures, and a neurochemical basis for panic disorder. This is a difficult process because so many possible patterns exist between these variables. In addition, the fact that panic symptoms often are accompanied by depression or other anxiety disorders complicates the search for specific mechanisms involved in panic disorder. As we mentioned earlier, brain structures such as the amygdala are involved in anxiety disorders, including panic disorder, and neurotransmitters, such as serotonin, play an important role in emotions. Implicated in shyness and anxiety is the serotonin transporter gene (5-HTTLPR). Similarly, disturbances or abnormalities in a serotonin receptor gene (5-HT1A) may contribute to panic disorder. Neuroimaging has revealed that individuals with panic disorder had nearly one-third fewer serotonin 5-HT1A receptors as compared with healthy controls (Neumeister et al., 2004). Fewer receptors would result in decreased levels of serotonin. It is interesting to note that SSRIs, medications designed to increase levels of serotonin in the brain, are effective in treating panic disorders, as well as other anxiety disorders.

Panic Disorder and Agoraphobia

FIGURE

MULTIPATH MODEL FOR PANIC DISORDER The dimensions interact with one another and combine in different ways to result in a panic disorder.

Biological Dimension • Modest heritability • Deficiency in serotonin and GABA receptors • Amygdala and fear circuitry

Sociocultural Dimension • Fewer panic attacks among Asian and Hispanic adolescents • Gender differences (more common in women) • Some cultures involve intense fear of witchcraft or magic

Psychological Dimension

PANIC DISORDER

5.5

135

• Anxiety sensitivity or physiological vigilance • Catastrophic thoughts • Conditioning

Social Dimension • Anxiety-filled social environment • Separation or loss

Genes may also increase risk for panic disorder by coding a decreased expression of the serotonin receptors. Although this line of research is promising, the findings should be considered tentative. Other studies have reported the reduction of GABA receptors in the hippocampus and amygdala areas (Roy-Byrne, Craske, & Stein, 2006) as being associated with anxiety and fear. As you see, determining the biology of panic disorder is a difficult quest. Psychological Dimension Different psychological theories regarding the etiology of panic disorder have been developed. The two major approaches are the psychodynamic and cognitive-behavioral perspectives, with the latter receiving the most research support. Psychodynamic perspective The psychodynamic view stresses the importance of internal conflicts (rather than external stimuli) in the origin of panic disorder. In this theory, the disorder is hypothesized to originate in sexual and aggressive impulses that are seeking expression. When a forbidden impulse threatens to disturb the ego’s integrity, an intense anxiety reaction occurs. Because this conflict is unconscious, the individual does not know the source of the anxiety. More recent psychodynamic formulations focus on uncovering the unconscious determinants of the panic symptoms on issues such as separation, autonomy, and anger because of problematic parent-child relationships. In one case, a client with panic disorder reported having high expectations of herself and was highly critical of her own work. During therapy, it was discovered that her self-criticism was linked to her mother’s high expectations and criticisms of her. The panic symptoms were related to unrealistic pressures on herself brought on by anger at her mother (Milrod et al., 2007). Cognitive behavioral perspective The cognitive-behavioral model attributes panic attacks to the individual’s interpretation of unpleasant bodily sensations as indicators of an impending disaster. Cognitions and somatic symptoms can best be viewed as a positive feedback loop that results in increasingly higher levels of anxiety. A model for the development of panic disorder and agoraphobia involved the following pattern (Roy-Byrne, Craske, & Stein, 2006): 1. A physiological change occurs, such as faster breathing or increased heart rate due to a precipitant (for example, exercise, excitement, hypervigilance, a stressor). 2. Catastrophic thoughts develop, such as “Something is wrong,” “I’m having a heart attack,” or “I’m going to die.”

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5.6

POSITIVE FEEDBACK LOOP BETWEEN COGNITIONS AND SOMATIC SYMPTOMS LEADING TO PANIC ATTACKS

Internal or External Stressor

Perception of unpleasant bodily sensations • Heart palpitations • Difficulty breathing • Dizziness, sweating, etc.

Catastrophizing thoughts • "I am dying." • "I am losing control." • "I am going crazy."

Source: Roy-Byrne, Craske, & Stein (2006, p. 1027).

More catastrophizing thoughts

Increased bodily sensations

3. These thoughts result in increased apprehension and fear and even more physiological changes in the body. 4. A circular pattern develops as the amplified bodily changes now result in even more fearful thoughts. 5. Through classical conditioning, the pairing of changes in internal bodily sensations (for example, increases in heart rate, respiration, muscle tension) with fear results in interoceptive conditioning—that is, the perception of bodily changes can now automatically produce fear and lead to panic attacks. 6. Agoraphobia may develop because the individual becomes fearful of leaving the house or entering places where a panic attack may occur. Figure 5.6 illustrates this pattern. Some research supports the cognitive hypothesis. Anxiety-producing cognitions such as thoughts of dying, passing out, or acting foolishly have been found to precede or accompany panic attacks (Bakker et al., 2002; Schmidt, Lerew, & Trakowski, 1997; Whittal & Goetsch, 1995). Preliminary evidence indicates that when there is a reduction in panic-related cognitions (as a result of cognitive-behavioral therapy), there is a subsequent reduction in panic symptoms (Hoffman et al., 2007). Social and Sociocultural Dimensions Many patients with panic disorder report a disturbed childhood environment that involved separation anxiety, family conflicts, school problems, leaving home, or the loss of a loved one (Laraia et al., 1994; Mahoney, 2000; Wittchen et al., 1994). Such an environment could create a predisposition to developing anxiety reactions Did You Know? and subsequently a panic disorder. Individuals who report having panic attacks indicate that they faced more major Examples of Catastrophic Thoughts in Panic Disorder life changes just before the attacks began (Pollard, Pollard, Physical Mental Social & Corn, 1989). Women have a higher prevalence rate of panic disorder and report a greater amount of respiration“I will die” “I will go crazy” “People will think related symptoms (difficulty breathing, feeling faint I’m crazy or weird” and smothered) than men do. It is possible that “I will have a “I will become “People will premenstrual hormonal fluctuations, which may influheart attack” hysterical” laugh at me” ence respiratory symptoms, contribute to panic disorder in “I will suffocate” “I will uncontrollably “People will stare women (Leskin & Sheikh, 2004). try to escape” at me” Culture can also play a role in panic disorder. Asian “I will pass out” and Hispanic adolescents reported higher anxiety sensitivity than white adolescents but were less likely to Source: Hicks et al. (2005). have panic attacks (Weems et al., 2002). In India, panic attacks are associated with physiological symptoms such as tachycardia and shortness of breath more than with thoughts of losing control or of going crazy (Neerakal & Srinivasan, 2003).

Treatment of Panic Disorder Both medication and cognitive-behavioral therapies have been effective in treating panic disorder (Hicks et al., 2005). With either therapy, it is important to

Panic Disorder and Agoraphobia

give clients information about panic disorders, as they believe they have a serious physical condition or might die. Biochemical Treatment A number of different classes of medications have been used successfully to treat panic disorder. Benzodiazepines have been used; however, they have proven less effective with panic episodes than with other anxiety disorders (Roy-Byrne et al., 2006). Panic disorder also has been successfully treated with tricyclic antidepressants (TCAs) and SSRIs; the older antidepressants, TCAs, are effective but have more side effects than the SSRIs (Marcus et al., 2007). It usually takes four to eight weeks for the medications to become fully effective, and some patients may initially have more panic attacks than usual during the first few weeks. Relapse rates after cessation of drug therapy appear to be quite high, especially among clients who believe that the remission of symptoms was due to the medication (Biondi et al., 2003). Behavioral Treatment Cognitive-behavioral treatments, including individual therapy (Barlow, Gorman, Shear, & Woods, 2000; Otto, Pollack, & Sabatino, 1996) and group therapy (Penava et al., 1998), have been successful in treating panic disorder. In fact, research reviews conclude that 80 percent or more of clients achieved and maintained panic-free status (Fava et al., 1995; Margraf et al., 1993). Cognitivebehavioral treatment involves extinction of fear associated with both internal bodily sensations (heart rate, sweating, dizziness, breathlessness, and so forth) and environmental situations associated with fear, such as being in crowds or in unfamiliar areas. Catastrophic thoughts are also identified and changed with corrective information (Hoffman et al., 2007). In general, cognitive-behavioral treatment for panic disorder involves the following steps (Hicks et al., 2005; Roy-Byrne et al., 2006; Taylor et al., 1996): 1. Educating the client about panic disorder and correcting misconceptions regarding the symptoms. 2. Identifying and correcting catastrophic thinking (for example, the therapist might comment, “Maybe you are attributing danger to what is going on in your body,” or “A panic attack will not stop your breathing”). 3. Teaching the client to self-induce physiological symptoms associated with panic (using hyperventilation, breathing through a straw, spinning, vigorous exercise, and so forth) to allow the extinction of panic reactions in response to bodily cues or sensations. 4. Encouraging the client to face the symptoms, both within the session and in the outside world, using such statements as, “Allow your body to have its reactions and let the reactions pass.” 5. Providing coping statements such as “This feeling is not pleasant, but I can handle it.” 6. Teaching the client to identify the antecedents of the panic: “What stresses are you under?” 7. Encouraging the use of cognitive strategies to combat the catastrophic thinking associated with panic attacks.

Myth vs Reality Myth: Because the metabolism rate in certain areas of the brain associated with anxiety disorders can be “normalized” with medication, biological explanations and treatments should predominate. Reality: Psychotherapy is highly effective with anxiety disorders and may also affect brain metabolism. Medications appear to affect the fear network at the level of the amygdala, whereas cognitive-behavioral therapy leads to changes in the prefrontal cortex and hippocampus.

137

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C H A P T E R 5 • ANXIETY DISORDERS

critical thinking

Panic Disorder Treatment: Should We Focus on Internal Control?

I

magine standing in the middle of a busy mall when suddenly your heart starts to pound, you begin to sweat, and you become nauseated and can barely breathe. You can’t move, and you are completely disoriented. You feel as though you will either pass out or die. What is happening to you? What brought on this terrifying experience? Will it happen again? When you regain composure, you think about what has just happened. If these panic attacks occur repeatedly, you will probably explore treatment options. Which techniques will you choose? Consider the following studies. Abraham Bakker and his colleagues (2002) compared outcomes of two groups of patients. In one group, the patients were treated with cognitive-behavioral therapy (CBT)—a therapy that encouraged patients to accept personal control over their panic reactions. In the other group, patients were given antidepressant medications without psychotherapy. Patients in the CBT group had lower relapse rates than those treated pharmacologically, and those in the CBT group learned to view their symptoms and their gains as the result of their own efforts, not as a matter of luck, therapy, or medication. Biondi and colleagues (2003) compared medication alone with a combination of medication and CBT. The CBT strategies used included sharing information about panic disorders; challenging catastrophic misinterpretations; considering alternative explanations for bodily sensations; practicing relaxation strategies; exposing clients to feared situations; and understanding the implications of having a

panic disorder. Before, during, and at the end of treatment, the researchers assessed participants’ beliefs concerning whether recovery was due to medication. After the treatment, relapse rate was 78.1 percent for the patients in the medication group compared with 14.3 percent for the CBT group. Long-term outcomes were found to be significantly better for patients who attributed their anxiety and recovery to internal factors compared with patients who credited their improvement to medication. Critical among the cognitive training strategies outlined here, and a common factor in both studies, is the enhancement of the patients’ self-efficacy—learning that both recovery and the ability to manage anxiety are under their own control. Patients who believed (or who came to believe) that success was in their own hands, thus demonstrating an internal locus of control over their bodies and their disorder, were significantly more likely to reduce their anxiety symptoms than patients who attributed their improvement to external factors, such as medication. Do you attribute anxiety in your life to internal factors (for example, “I must be making myself anxious”) or to external elements (for example, “things like this always happen to me”)? Do you believe medications are more likely to help you control your anxiety, or do you see yourself in control when it comes to understanding and dealing with anxietyprovoking events? Are there ways of altering medication practices or rationale that would also foster internal control over symptoms? Based on these studies, how would you structure an intervention for panic disorder?

Generalized Anxiety Disorder Case Study I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party or what would be a great present for somebody. I just couldn’t let go. (NIMH, 2007a, p.12)

generalized anxiety disorder (GAD) disorder characterized by

persistent, high levels of anxiety and excessive worry over many life circumstances that are present on more days than not for more than six months

All of us have had concerns or worries that are specific and time limited. Generalized anxiety disorder (GAD) is characterized by persistent, high levels of anxiety and excessive worry over many life circumstances that last for more days than not for more than six months. These concerns are great enough to cause problems in daily life and are accompanied by physiological responses such as heart palpitations, muscle tension, restlessness, trembling, sleep difficulties, poor concentration, and persistent apprehension and nervousness. It is a condition that develops gradually, beginning in childhood or adolescence (NIMH, 2007a). Individuals with GAD report higher anxiety levels, are more sensitive to bodily changes, and exhibit greater physiological responsiveness than do control participants (Hoehn-Saric et al., 2004). Over two-thirds of people with GAD have comorbid (co-occurring) disorders such as depression, substance abuse, or phobia (Stein, 2001). In any given year,

Generalized Anxiety Disorder

FIGURE

5.7

MULTIPATH MODEL FOR GAD The dimensions interact with one another and combine in different ways to result in generalized anxiety disorder (GAD).

Biological Dimension • Small genetic influence • Overactive fear network • Abnormalities with GABA receptors

Sociocultural Dimension • Stressful or poor living conditions • Prejudice and discrimination • Low socioeconomic status

139

Psychological Dimension

GENERALIZED ANXIETY DISORDER (GAD)

• • • •

Lower threshold for uncertainty Anxiety-evoking schemas Use of worry as coping Worry about worrying

Social Dimension • Lack of social network • Separation or loss

about 3.1 percent of the adult U.S. population has GAD (Kessler, Chiu, et al., 2005), and women are twice as likely to receive this diagnosis as men (Kessler, Berglund, et al., 2005). Among older adults, GAD is more common than major depression or severe cognitive impairment (Wetherell, Gatz, & Craske, 2003). In medical settings around the world, GAD is the most frequently diagnosed anxiety disorder (Goldberg, 1996; Stein, 2001). Because cultures differ in their expressions of worry and anxiety, the cultural context has to be considered when determining whether the worries are “excessive” (American Psychiatric Association, 2000a).

Etiology of Generalized Anxiety Disorder GAD is the result of biological factors combined with psychosocial stressors, as shown in Figure 5.7. Let’s take a look at each of the factors that may contribute to the etiology of GAD. Biological Dimension There appears to be less support for the role of genetic factors in GAD than in panic disorder. Still, there appears to be a small but significant heritability factor in GAD (Brawman-Mintzer et al., 1997; Gorman, 2001; Kendler et al., 1992). Twin studies indicate a moderate contribution of genetic influence (Ehringer et al., 2006). Genes may be expressed in terms of abnormalities with the GABA receptors, other neurotransmitters, and overactivity of the anxiety circuit in the brain. As mentioned earlier, the prefrontal cortex can modulate the response of the amygdala to threatening situations. GAD may involve a disruption in this system. In an MRI investigation, Monk and colleagues (2006) exposed eighteen adolescents with GAD and fifteen without GAD to angry faces. Those with GAD showed greater activation of the prefrontal cortex in response to angry faces. The researchers hypothesize that the prefrontal cortex may be attempting to regulate the anxiety aroused by the angry faces. Psychological Dimension Psychoanalytic and cognitive-behavioral theories have been developed regarding the etiology of GAD, and recent research has focused on the relationship between types of worry and GAD. Psychodynamic perspective The psychodynamic perspective views the worry and anxiety displayed in GAD as resulting from unacceptable impulses that lie close to consciousness. The defenses against these impulses are considered poorly organized and less effective than defenses mounted against other anxiety disorders. In a

Did You Know? Common Concerns of Children with GAD • • • • • •

Taking tests Doing schoolwork Being alone Hearing noises Being teased Experiencing personal harm

Source: Eisen & Silverman (1998).

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C H A P T E R 5 • ANXIETY DISORDERS

phobia, for example, the conflict between id impulses and the ego is displaced onto a specific external stimulus that can be controlled simply through avoidance. But the person with generalized anxiety disorder has only one defense—to try to repress the impulses. When that defense weakens, anxiety or panic attacks may occur. This psychodynamic formulation does not have research support. Cognitive-behavioral perspectives Cognitive-behavioral therapists believe that anxiety and worry are caused by dysfunctional thinking and beliefs. Individuals with GAD have a lower threshold for uncertainty, which leads to worrying. They have erroneous beliefs regarding worry and assume that “worry is an effective way to deal with problems” or that it prevents some type of negative outcome from occurring (Ladouceur et al., 2000). Beck (1985) believes that anxiety disorders result from a combination of temperament and negative early learning that have resulted in dysfunctional mental structures or schemas. Schemas may involve beliefs such as “I am incompetent” or “The world is dangerous.” The individual interprets events through the filter of the schemas so that ambiguous or even positive situations are viewed with concern and apprehension. Newer cognitive approaches built on the work of Beck are identifying the beliefs that individuals with GAD have about worry (Riskind, 2005). Wells (2005) developed a theoretical model of GAD. He believes that the roots of the disorder lie in beliefs regarding worry that are responsible for the persistent worrying. In the model, there are two types of worry. Type 1 worry involves positive beliefs regarding worry, such as its use as a coping strategy. Individuals believe that worry provides them a means of generating ways of coping with aversive situations. They do this by constantly generating solutions to “what if” scenarios. Once individuals believe “all the bases have been covered,” their worry and anxiety is reduced until another event triggers concern. Because of the continued stress involved with Type 1 worry, the individual begins to believe that worry is uncontrollable, harmful, and dangerous. The Type 2 worry involves worrying about worry, which contributes to the development of GAD. This worrying about worry leads to increased anxiety, thus reinforcing the view that worry has negative effects. The increased anxiety and worry result in the avoidance of situations and thoughts associated with the worries. This prevents the individual from determining whether the worry is accurate and maintains the GAD. This theoretical model has received research support (McLaughlin, Mennin, & Farach, 2007; Purdon, 1999; Wells & Carter, 2001). Social and Sociocultural Dimensions Stressful conditions such as poverty, poor housing, prejudice, and discrimination can also contribute to GAD. The disorder is twice as prevalent among those with low income (Kessler, Chiu, et al., 2005). It is also seen more frequently in individuals who are separated, divorced, or widowed and in the unemployed (Wittchen & Hoyer, 2001). GAD is more common among African Americans, especially females (Horwath & Weissman, 1997). Traumatic events can also be contributors to anxiety. According to Silverman and La Greca (2002), a substantial number of children exposed to trauma develop an anxiety disorder such as GAD.

Treatment of Generalized Anxiety Disorder Benzodiazepines have been successful in treating GAD, but because it is a chronic condition, medication dependence issues are a concern (Nutt, 2001), particularly if there is a history of substance abuse. Also, there is an increased risk of falls and hip fractures in the elderly (Gorman, 2001; Wagner et al., 2004). A newer antianxiety medication, buspirone, is also used to treat GAD. Unlike the benzodiazepines, it takes at least two weeks to achieve the antianxiety effect (NIMH, 2007a). Tricyclics and SSRI antidepressants have been successful in treating GAD and are the medications of choice, because they do not have the possible dependence issues involved with the benzodiazepines (Allgulander et al., 2007; Davidson, 2001; Seidel & Walkup, 2006).

Obsessive-Compulsive Disorder

Cognitive-behavioral therapy appears to have some success in treating GAD. It is the only consistently validated treatment for the disorder (Ballenger et al., 2000). In an evaluation of thirteen controlled clinical trials, cognitive-behavioral strategies were effective in treating GAD and were associated with low dropout rates and long-term improvement (Borkovec & Ruscio, 2001). CBT has also been found to be effective in treating GAD in older adults (Ayers et al., 2007). Symptom reduction may be slower with CBT than with medication, but it produces more enduring results (Zhang et al., 2002). The treatment strategies generally involve teaching clients to (Dugas & Ladouceur, 2000; Eisen & Silverman, 1998; Stanley et al., 2003): 1. Identify and modify the worrisome thoughts 2. Discriminate between worries that are amenable to problem solving and those that are not 3. Evaluate their beliefs concerning worry 4. Discuss evidence for and against the distorted beliefs 5. Decatastrophize worrisome thoughts

141

Did You Know?

I

n the seventeenth century, obsessions and compulsions were often described as symptoms of religious melancholy (depression). The unusual nature of the intrusive thoughts and compulsions associated with obsessive-compulsive disorder resulted in the disorder being considered a form of insanity until the 1850s (Berrios, 1989).

6. Develop self-control skills to monitor and challenge irrational thoughts and substitute more positive, coping thoughts 7. Use muscle relaxation to deal with somatic symptoms Another disorder characterized by persistent troublesome thoughts but that also has some unique features is obsessive-compulsive disorder.

Obsessive-Compulsive Disorder Case Study Washing my hair would take about an hour. I would wash the back of my hair, the sides of my hair, the front of my hair, the very top of my hair. Washing the front of my forehead, I would scrub it sixty times; it could never be sixty-one. The arms would start with the shoulders, and I would scrub them to the point where I was scrubbing so hard on my collarbone and shoulder blades that it almost felt like the bone was piercing through the skin and touching the soap. (Strobeck, 2002, p. 79)

Obsessive-compulsive disorder (OCD) is characterized by obsessions (intrusive, repetitive thoughts or images that produce anxiety) or compulsions (the need to perform acts or to dwell on thoughts to reduce anxiety). Although obsessions and compulsions can occur separately, they frequently occur together. Most individuals with OCD have both obsessions and behavioral or mental compulsions (Foa & Kozak, 1995; Freeston & Ladouceur, 1997). Individuals with obsessive-compulsive disorder often describe the thoughts and actions as not being the types of thoughts he or she would expect to have and not under voluntary control. The inability to resist or rid oneself of uncontrollable, alien, and often unacceptable thoughts or to keep from performing ritualistic acts over and over again arouses intense anxiety. In general, these thoughts and impulses are recognized as being unreasonable, although a minority of individuals with OCD do not recognize their symptoms as being senseless (Catapano et al., 2001). Failure to engage in ritual acts often results in mounting anxiety and tension. As one individual noted, “The reason I do these kinds of rituals and obsessing is that I have a fear that someone is going to die. This is not rational thinking to me. I know I can’t prevent somebody from dying by putting 5 ice cubes in a glass instead of 4” (Jenike, 2001, p. 2122). Individuals with obsessivecompulsive disorder report that their problem interferes with their work, school, or homemaking roles and with interpersonal relationships (Koran, Thienemann, & Davenport, 1996).

obsessive-compulsive disorder (OCD) a disorder characterized by

obsessions or compulsions obsession intrusive, repetitive thought or image that produces anxiety compulsion the need to perform acts or to dwell on thoughts to reduce anxiety

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C H A P T E R 5 • ANXIETY DISORDERS

40 35

Percent

30 25 20 15 10 5 0

Contamination

Harm

Exactness

OCD may be underdiagnosed. If it is suspected, screening questions such as these may be useful: “Do you have unpleasant thoughts you can’t get rid of? Do you worry that you might impulsively harm someone? Do you count things, or check things over and over? Do you worry a lot about whether you performed religious rituals correctly or have been immoral? Do you have troubling thoughts about sexual matters? Do you need to have things arranged symmetrically or in a very exact order? Do you have trouble discarding things, so that your house is quite cluttered?” (Work Group on Obsessive-Compulsive Disorder, 2007, p. 12) Although OCD is a single diagnostic category, it is composed of distinct subtypes, some of which show different patterns of genetic inheritance, neural activity, and response to treatment. The four types identified are (Saxena, 2007): 1. Harm-related, sexual, aggressive, and/or religious obsession with checking compulsions

Obsessions

2. Symmetry obsessions with arranging and repeating compulsions 40

3. Contamination obsessions with cleaning compulsions

35

4. Hoarding and saving compulsions

Percent

30 25 20 15 10 5 0

Checking

Cleaning/ washing

Repeating

Compulsions

FIGURE

5.8

COMMON OBSESSIONS AND COMPULSIONS About half of the patients reported both obsessions and compulsions. Twenty-five percent believed that their symptoms were reasonable. How would a therapist work with a patient who believed that his or her symptoms were sensible?

Source: Data from Foa & Kozak (1995).

Did You Know?

N

• • •

•

early 55 percent of U.S. undergraduates report compulsions such as: Checking (26.8 percent) Washing, cleaning, or ordering items (15.9 percent) Magical protective acts (saying a number or touching a lucky object) (10.5 percent) Avoiding particular objects (6.1 percent)

Source: Muris, Merckelbach, & Clavan (1997).

In a given year, about 1 percent of the U.S. adult population has obsessivecompulsive disorder. Over half report the severity of the disorder as “serious.” Only 15 percent consider it to be “mild” (Kessler, Chiu, et al., 2005). The disorder is about equally common in males and females but is less common in African Americans and Mexican Americans (Zhang & Snowden, 1999). Possibly because of the emotional distress associated with the symptoms of OCD, many with this disorder are depressed and may abuse substances. Tics are also common in OCD, and it is often diagnosed in individuals with Tourette’s disorder (Work Group on ObsessiveCompulsive Disorder, 2007). See Figure 5.8 for some of the more common obsessions and compulsions.

Obsessions As mentioned earlier, an obsession is an intrusive and repetitive anxiety-arousing thought or image. The person may realize that the thought is irrational, but he or she cannot keep it from arising over and over again. Among a sample of children and adolescents, the most common obsessions involved dirt or germs, disease and death, or danger to oneself or loved ones (Swedo et al., 1989). Obsessions common to adults involve bodily wastes or secretions, dirt or germs, and environmental contamination (George et al., 1993). To reduce the discomfort caused by obsessions, individuals use strategies such as changing their thoughts, focusing on something positive, listening to music, taking a walk, or reading (Freeston & Ladouceur, 1997). Although most of us have experienced persistent thoughts—for instance, a song or tune that keeps running through our minds—obsessions are stronger and more intrusive. They create great distress and can interfere with social or occupational activities. Do “normal” people have intrusive, unacceptable thoughts and impulses? Several studies (Edwards & Dickerson, 1987; Freeston & Ladouceur, 1993; Ladouceur, Freeston, et al., 2000) have found that more than 80 percent of normal samples report the existence of unpleasant intrusive thoughts and impulses. The content of obsessions reported by obsessive-compulsive patients and by normal populations overlap considerably. However, obsessive patients reported that their obsessions lasted longer, were more intense, produced more discomfort, were more difficult to dismiss, and were uncontrollable (Morillo, Belloch, & Garcia-Soriano, 2007).

Compulsions A compulsion is the need to perform acts or to dwell on mental acts repetitively. Distress or anxiety occurs if the behavior is not performed or if it is not done “correctly.” Compulsions are often, but not always, associated with obsessions. Mild

Obsessive-Compulsive Disorder

forms include behaviors such as refusing to walk under a ladder or step on cracks in sidewalks, throwing salt over one’s shoulder, and knocking on wood. The three most common compulsions among a sample of children and adolescents (Swedo et al., 1989) involved excessive or ritualized washing, repeating rituals (such as going in and out of a door and getting up and down from a chair), and checking behaviors (doors and appliances). Compulsive hoarding—acquiring or failing to discard useless items—is relatively common among individuals with OCD, and there is often a belief that the item hoarded may have value or some use in the future (Luchian, McNally, & Hooley, 2007). One client collected discarded objects such as soda cans, paper bags, and newspapers, saying she “may need them sometime.” Although movement around her house was impeded, she could not decide what to throw away (Samuels et al., 2007). Compulsions are also a common phenomenon in nonclinical populations (Muris, Merckelbach, & Clavan, 1997). A continuum appears to exist between “normal” rituals and “pathological” compulsions; in individuals with obsessive-compulsive disorder, the compulsions are more frequent and of greater intensity, and they produce more discomfort. In the severe compulsive state, the behaviors become stereotyped and rigid; if they are not performed in a certain manner or a specific number of times, the compulsive individual is flooded with anxiety. Table 5.4 contains additional examples of obsessions and compulsions.

Etiology of Obsessive-Compulsive Disorder The causes of obsessive-compulsive disorder remain speculative. It is further complicated by the many facets of OCD, suggesting that it may not be a single disorder with a single cause. In this section we examine the biological and psychological

TA B L E

143

CONTAMINATION OBSESSION The individual who wrapped this chair had an obsessive fear of dust that reached psychotic proportions. What kinds of thoughts about dust might produce such anxiety?

5.4

CLINICAL EXAMPLES OF OBSESSIONS AND COMPULSIONS PATIENT

DURATION OF OBSESSION IN YEARS

Age

Gender

21

M

6

Teeth are decaying, particles between teeth

42

M

16

Women’s buttocks, own eye movements

55

F

35

Fetuses lying in the street, killing babies, people buried alive

24

M

16

Contact with or thought of vomit

21

F

9

Strangling people

32

F

7

Contracting AIDS

Age

Gender

DURATION OF COMPULSION IN YEARS

42

F

17

Hand washing triggered by touching surfaces touched by other people

45

F

36

Touching doorknob and light switch in specific manner and number of times when leaving or entering a room

21

M

2

Intense fear of contamination after touching library books or money

7

M

4

Walking only on the edges of floor tiles

9

M

4

Going back and forth through doorways five hundred times

PATIENT

CONTENT OF OBSESSION

CONTENT OF COMPULSION

Source: Based on data from Jenike (2001); Kraus & Nicholson (1996); Rachman, Marks, & Hodgson (1973); Swedo et al. (1989); Williams, Chambless, & Steketee (1998).

144 FIGURE

C H A P T E R 5 • ANXIETY DISORDERS

5.9

MULTIPATH MODEL FOR OCD The dimensions interact with one another and combine in different ways to result in obsessivecompulsive disorder.

Biological Dimension • Dysregulation of orbital frontal caudate circuit • Lower activation of cingulated cortex • Subgroups differ on genetics and biological involvement

Sociocultural Dimension • Equally common in males and females • Onset in childhood more common in boys • Children usually do not request help

Psychological Dimension

OBSESSIVECOMPULSIVE DISORDER

• Lack of trust in own performance • Impulse control conflicts • Anxiety reduction • Immoral thoughts equivalent to behavior

Social Dimension • Social vulnerabilities: divorce, separation, unemployment

dimensions of the disorder, shown in Figure 5.9, and discuss whether it should be considered a single disorder. Biological Dimensions Biological explanations for obsessive-compulsive behaviors are based on data relating to brain structure, genetic studies, and biochemical abnormalities. Neuroimaging has revealed that some people with obsessive-compulsive disorder show increased metabolic activity in the frontal lobe of the left hemisphere. Perhaps this area of the brain, the orbital frontal cortex, is associated with obsessivecompulsive behaviors (Blier et al., 2000; see also Figure 5.10). Obsessive-compulsive disorder suggests dysregulation on the orbital frontal-caudate circuit. The orbital frontal cortex alerts the rest of the brain when something is wrong. When it is hyperactive, it triggers the feeling that something is not right. Connections to the caudate nucleus and gyrus (a ridge on the cerebral cortex) produce an even stronger feeling that something is “deadly wrong.” This message is relayed through the thalamus to the caudate nuclei, which normally lets only powerful impulses get through. In OCD, its ability is weakened, and disturbing thoughts leak through (Saxena et al., 1998). Of special interest is the fact that when these individuals were given fluoxetine (a medication that increases the activity level of serotonin), the cerebral blood flow to the frontal lobes was decreased to values found in individuals without the disorder, and patients reported a reduction in symptoms (Hoehn-Saric, Pearlson, Harris, Machlin, & Camargo, 1991). Similar results have also been reported with the use of cognitivebehavioral therapy (Rauch et al., 2003). Other researchers believe that OCD should be viewed as comprising a number of different subgroups rather than as a single disorder (Chamberlain et al., 2007; Mataix-Cols et al., 2004; Samuels et al., 2007). Use of MRIs has found that different brain areas are activated by different OCD symptoms, such as hoarding and washing (Saxena et al., 2004). Instead of the hypermetabolism in the orbitofrontal cortex, the caudate nuclei, and the thalamus found in other types of OCD, patients who hoard showed a pattern of significantly lower activation of the cingulate cortex (Saxena, 2007). Additional support for the view that OCD is an etiologically diverse condition is the finding that certain symptom types show different responses to treatment (Hurley, Saxena, Rauch, Hoehn-Saric, & Taber, 2002). Behavior therapy seems to be more effective for clients with aggressive-checking, contamination-cleaning, and symmetry-ordering symptoms than for those with sexual-religious obsessions (Mataix-Cols et al., 2002).

Obsessive-Compulsive Disorder

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Medications such as clomipramine, Paxil, Prozac, and Zoloft increase the amount of available serotonin in the brain, and these medications have been effective in treating many individuals with OCD. As a result, researchers have hypothesized that the disorder is the result of a serotonin deficiency (Greenberg, Altemus, & Murphy, 1997; Perse et al., 1987; Tollefson et al., 1994). Drugs such as benzodiazepines or antidepressants that are effective with other anxiety disorders but have less effect on raising serotonin availability have been less effective in treating this disorder (Zohar et al., 2007). However, individuals with the hoarding form of OCD show less response to SSRIs or cognitive-behavioral therapy than do other people with OCD (Samuels et al., 2007). Orbital frontal cortex

Psychological Dimensions Psychological theories have also been developed to explain the symptoms found in OCD. FIGURE ORBITAL FRONTAL Psychodynamic perspective In the psychodynamic perspective, obsessiveCORTEX Untreated patients with compulsive behaviors are attempts to fend off anal sadistic (antisocial), anal libid- obsessive-compulsive disorder show a high inous (pleasurable soiling), and genital (masturbatory) impulses (Burgy, 2001). metabolism rate in this area of the brain. For example, Freud (1949) believed that obsessions represent the substitution or Certain medications reduce metabolic replacement of an original conflict, usually sexual in nature, with an associated rates to “normal” levels and also reduce idea that is less threatening. He found support for his notion in the case histo- obsessive-compulsive symptoms. What ries of some of his patients. One patient, a girl, had disturbing obsessions about would it mean if similar results are found stealing or counterfeiting money; these thoughts were absurd and untrue. During with psychotherapy? analysis, Freud discovered that these obsessions reflected anxiety that stemmed from Did You Know? guilt about masturbation. When the patient was kept under constant observation, which prevented her from masturbating, the obsessional thoughts (or, perhaps, the group of researchers (Zohar reports of the thoughts) ceased. et al., 2007) are proposing Several other psychoanalytic defense mechanisms are considered prominent that OCD be removed from in obsessive-compulsive behaviors. For example, undoing is canceling or atonthe category of anxiety disorders ing for forbidden impulses by engaging in repetitive, ritualistic activities. Washing and be considered a separate one’s hands may symbolically represent cleansing oneself of unconscious wishes. diagnostic category. Reasons Because the original conflict remains, however, one is compelled to perform the act given are: (1) Unlike other anxiety disorders, OCD has similar of atonement over and over again. Reaction formation provides a degree of comfort prevalence among males and because it counterbalances forbidden desires with diametrically opposed behaviors. females; (2) neuroimaging studies To negate problems stemming from the anal psychosexual stage (characteristic of show that OCD involves brain those with obsessive-compulsive disorder), such as the impulse to be messy, patients circuitry different from that in other tend toward excessive cleanliness and orderliness. Those with obsessive-compulsive anxiety disorders; and (3) some disorder may also employ the defense of isolation, which allows the separation of medications that are effective with a thought or action from its effect. Aloofness, intellectualization, and detachment anxiety disorders have little effect reduce the anxiety produced by patently aggressive or sexual thoughts. on OCD. Although traditional psychoanalytic formulations have received little research support, some individuals with OCD do show an overly strong sense of guilt over moral issues. Any thought associated with “immorality” is believed to be the same as committing the act itself. This leads to compulsions such as washing in an attempt to cleanse themselves (Steketee & Barlow, 2002). Behavioral and cognitive perspectives Proponents of the behavioral perspective maintain that obsessive-compulsive behaviors develop because they reduce anxiety. A distracting thought or action recurs more often if it reduces anxiety. For example, many college students may develop mild forms of compulsive behavior during intense exam periods, such as final examinations. During this stressful and anxiety-filled time, students may find themselves engaging in escape activities such as daydreaming, straightening up their rooms, or eating five or more times a day, all of which serve to shield them from thoughts of the upcoming tests. If the stress lasts a long time, a compulsive behavior may develop. Researchers have also attempted to determine the cognitive factors that lead to severe doubts associated with compulsive behavior. It seems that patients with OCD do not trust their own memories and judgment and make futile attempts to determine whether they actually performed the behavior or performed it “correctly.” The uncertainty leads to the rituals, and doubts may occur even in the face of unambiguous evidence. An “OC checker may turn the key in the lock over and over again without

5.10

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being able to convince himself or herself that the door has in fact been locked, even though he or she can plainly see that the key is in the proper position, hear it engaging, and feel the lock snapping” (Dar et al., 2000, p. 673). Individuals with OCD may have a disconfirmatory bias—that is, they generate a search for evidence that undermines their confidence. The person checking the lock may develop thoughts of all the factors that may have prevented the door from staying locked. It is uncertain whether the lack of confidence leads to OCD or whether it is a result of having the disorder. Along with uncertainty, individuals with obsessive-compulsive disorders show two other cognitive characteristics: (1) probability bias, or the belief that having a thought, such as shouting obscenities in church, increases the chance that the action will occur; (2) morality bias, or the view that having an immoral thought, such as throwing a child in front of a car, is as bad as the actual behavior. Research has supported the view that these are important aspects in OCD and that therapy should address these cognitive biases (Rassin, Muris, Schmidt, & Merckelbach, 2000). Social and Sociocultural Dimensions OCD is more common among the young and among individuals who are divorced, separated, or unemployed (Karno & Golding, 1991). African Americans and Hispanic Americans are less likely to receive a diagnosis of OCD than European Americans are (Zhang & Snowden, 1999). In treating two African American women with OCD, Williams, Chambless, and Steketee (1998) found that each had believed that she was the only black person to have this problem (neither had contact with the other). Their sense of isolation was increased when they found that the local OCD support group had no black members. Both declined to join the group. Although both women improved with cognitive-behavioral therapy, the therapists, who were European Americans, were concerned about the possible impact of therapist-client racial match. They stress the need to be sensitive to special issues involved in therapy with ethnic minorities and point out that African Americans with OCD have been underrepresented in clinical outcome studies.

Treatment of Obsessive-Compulsive Disorder The primary modes of treatment for obsessive-compulsive disorder are either biological or behavioral in nature. Behavioral therapies have been used successfully for many years, but treatment with medication has recently received increased attention. Cultural aspects of treatment must also be considered. Biological Treatments Because obsessive-compulsive disorder is classified as an anxiety disorder, it might seem that benzodiazepines would be an effective treatment. However, these medications are less effective with OCD symptoms than with other anxiety disorders (Huppert et al., 2004). For severe cases of OCD, improvement has occurred with a combination of cognitive-behavioral therapy and medication (Bouvard, Milliery, & Cottraux, 2004). SSRIs are the antidepressants recommended for the treatment of OCD because they have fewer side effects than older antidepressants and are equally as effective (American Psychiatric Association, 2007). However, only 60 to 80 percent of persons with obsessive-compulsive disorder respond to these medications, and often the relief is only partial (Pigott & Murphy, 1991; Pigott & Seay, 1997). Children with OCD appear to be less responsive to treatment with antidepressants than adults are (Ulloa et al., 2007). In addition, there is a rapid return of symptoms, and relapse occurs within months of stopping the medication (Jenike, 2001; Stanley & Turner, 1995). A substantial minority of Asians and a small number of whites do best with only 60 percent of the average dose of clomipramine (a tricyclic antidepressant) because of metabolic differences (Work Group on Obsessive-Compulsive Disorder, 2007).

a technique that involves continued actual or imagined exposure to a fear-arousing situation at high anxiety level

flooding

Behavioral Treatments The treatment of choice for obsessive-compulsive disorder is the combination of exposure and response prevention (Abramowitz, Foa, & Franklin, 2003; Abramowitz & Larsen, 2007; Valderhaug, Larsson, & Gotestam, 2007). In treating OCD, exposure therapy involves continued actual or imagined exposure to a fear-arousing situation; it can involve immediate presentation of the most frightening stimuli (flooding) or more gradual exposure. Response prevention involves not allow-

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ing the individual with OCD to perform the compulsive behavior. The steps in exposure therapy with response prevention generally involve (Franklin et al., 2000): 1. Education about OCD and the rationale for exposure and response prevention 2. Development of an exposure hierarchy (from somewhat fearful to most-feared situations) 3. Exposure to feared situations until anxiety has diminished 4. Prevention of the performance of compulsive rituals such as hand washing Riemann (2006) also includes cognitive restructuring to help clients identify and correct errors in thinking, such as overestimating the probability of a negative event (for example, the chances of getting a disease from touching a doorknob) and catastrophic thinking (for example, thinking that someone will die if a ritual is not completed a certain number of times). It is becoming clear that single-model approaches are unable to explain why anxiety disorders develop in some individuals and not others. As Gabbard (2000) observed, “one of the greatest risks we face is reductionism . . . with psychosocial specialists in one camp and neuroscientists in another” (p. 118). Another approach that may not be useful is attempting to determine how much nature or nurture contributes to a characteristic. As Fox and his colleagues (2005) demonstrated in their study on behavior inhibition (shyness), it is quite possible that some genetic expressions may be “all or none.” That is, the genetic characteristic is activated only when certain environmental stimuli are present. Without the stimulus, the gene is not “turned on.” We don’t know, however, how many characteristics or traits are expressed in this manner. We must thus resist the temptation to believe in easy explanations. Every so often mass media will present research showing that they have found the “anxiety” gene. Anxiety disorders reflect the interactions of a number of different genes, brain structures, and neurotransmitters. It is unlikely that a simple explanation for anxiety disorders will be found. A multipath model that also considers psychological, social, and sociocultural dimensions is more likely to fully answer the question of why some individuals are more prone to developing an anxiety disorder.

I M P L I C AT I O N S

Summary 1. How are biological, psychological, social, and sociocultural factors involved in the development of anxiety disorders? ■ All of these factors are involved in anxiety disorders, but the contribution of each varies from individual to individual and circumstance to circumstance. ■ Biological contributors include an inherited overactive fear circuitry in the brain and neurotransmitter abnormalities. However, anxiety disorders may also not develop in vulnerable individuals in a supportive family or social environment. The impact of stressors can also be mitigated by personality variables, such as a sense of control and mastery. ■ Sociocultural factors such as power and status, discrimination, and poverty may be responsible for the greater number of women with anxiety disorders. 2. What are phobias, what are their causes, and how are they treated? ■ Phobias are strong fears that exceed the demands of the situation. Social phobias are irrational fears about

situations in which the person can be observed by others. Specific phobias include all the irrational fears that are not classed as social phobias or agoraphobia. Commonly feared objects include small animals, heights, and the dark. ■

■

Biological explanations are based on studies of the influence of genetic, biochemical, and neurological factors or on the idea that humans are prepared to develop certain fears. In the psychodynamic view, phobias represent unconscious conflicts that are displaced onto an external object. Behavioral explanations include the classical conditioning view, in which phobias are based on an association between an aversive event and a conditioned stimulus; conditioning through observational learning; the role of thoughts that are distorted and frightening; and reinforcement for fear behaviors. The most effective treatments for phobias seem to be biochemical (antidepressants) and behavioral (exposure and flooding, systematic desensitization, modeling, and graduated exposure).

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scious. Cognitive-behavioral theorists emphasize erroneous beliefs regarding the purpose of worry or the existence of dysfunctional schemas. Social and sociocultural factors such as poverty and discrimination can also contribute to GAD.

3. What are panic disorder and agoraphobia, what are their causes, and how are they treated? ■

■

■

Panic disorder is marked by episodes of extreme anxiety and feelings of impending doom. It is characterized by attacks that seem to occur “out of the blue.” Agoraphobia is an intense fear of being in public places where escape or help may not be possible; it can keep people from leaving home because attempts to do so may produce panic attacks. The causes of panic disorder and agoraphobia include biological factors (genetic contribution, neural structures, and neurotransmitters), psychological factors (the psychodynamic view stresses the importance of internal sexual and aggressive impulses, the cognitive-behavioral view emphasizes the importance of catastrophic thoughts regarding bodily sensations), and social and sociocultural factors (such as a disturbed childhood environment and genderrelated issues). Treatments for panic disorder and agoraphobia include biochemical treatments (benzodiazepines and antidepressants) and behavioral treatments (identification of catastrophic thoughts, correcting them, and substituting more realistic ones).

4. What is generalized anxiety disorder, what are its causes, and how is it treated? ■ Generalized anxiety disorder involves chronically high levels of anxiety and excessive worry that are present for six months or more. ■ There appears to be less support for the role of genetics in GAD than in other anxiety disorders, although there are some reports of abnormalities with the GABA receptors or overactivity of the anxiety circuitry in the brain. Psychoanalysts believe the disorder is inefficient because it stems from internal conflicts in the uncon-

■

Drug therapy (antidepressant medications), behavioral therapies, and psychodynamic therapies have been used to treat these disorders.

5. What is obsessive-compulsive disorder, what are its causes, and how is it treated? ■

Obsessive-compulsive disorder involves thoughts or actions that are involuntary, intrusive, repetitive, and uncontrollable. Most persons with obsessive-compulsive disorder are aware that their distressing behaviors are irrational.

■

Neuroimaging shows increased metabolic activity in the orbital frontal cortex in those with OCD. Freud believed the disorder represented the replacement of thoughts of a threatening conflict with a less threatening behavior or thought. According to the anxietyreduction hypothesis, obsessions and compulsions develop because they reduce anxiety. Cognitivebehavioral therapists have focused on factors such as confirmatory bias, probability bias, and morality bias. Social and sociocultural dimensions are also important in the etiology of OCD. It is more common among individuals who are divorced, separated, or unemployed and occurs less frequently among African Americans and Hispanic Americans. Some antidepressants have been effective in treating OCD. However, antianxiety medications are less effective with this disorder than with other anxiety disorders. The treatment of choice is a combination of flooding and response prevention, sometimes combined with cognitive therapy.

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Dissociative Disorders and Somatoform Disorders

J

oe Beiger, a beloved husband, father, grandfather, and assistant high-school athletic director, walked out of his front door one morning with his two dogs. Minutes later, his very identity was seemingly wiped from his brain’s hard drive. For twenty-five days, he wandered the streets of Dallas . . . unable to remember his name, what he did for a living or where he lived, until finally a contractor he had been working with happened to recognize him. (Associated Press, 2007b) A boy of twelve was referred for investigation of gait disorder. . . . He was noted to walk with a bizarre staggering gait, which on close inspection could be seen to be carefully coordinated. . . . Systematic detailed clinical examination showed no neurological abnormality. . . . Shortly before the onset of his illness he had moved with his peer group to a secondary school with high academic expectations of pupils. He had not been able to achieve these, and the teacher of his favorite subject had humiliated him by rejecting class work he had done and throwing his workbook on the floor. (Leary, 2003, p. 436)

These cases illustrate characteristics found in the dissociative disorders, mental disorders in which a person’s identity, memory, and consciousness are altered or disrupted, and the somatoform disorders, which involve physical symptoms or complaints that have no physiological basis. Both groups of disorders are believed to occur due to an underlying psychological conflict or need. The symptoms of the dissociative disorders and the somatoform disorders generally become known through self-report. Thus the possibility of faking must be considered. Wadlh El-Hage, charged as a conspirator with Osama bin Laden in the attacks on the U.S. embassies in Kenya and Tanzania, claimed that he suffered from a loss of memory. The court-appointed experts voiced the opinion that he was “faking the symptoms of amnesia” (Weiser, 2000). Lee Malvo, the Washington, D.C., sniper, claimed to have a dissociative disorder (Jackson, 2003). In addition to the possibility of faking, other questions have arisen about several of the dissociative disorders.

chapter outline Dissociative Disorders

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Somatoform Disorders

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IM PLICA TION S

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CRITICAL THINKING

Culture and Somatoform and Dissociative Disorders 156 CONTROVERSY “Suspect”

Techniques Used to Treat Dissociative Identity Disorder 160 CRITICAL THINKING

Factitious Disorder and Factitious Disorder by Proxy

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a group of disorders including dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder, all of which involve some sort of dissociation, or separation, of a part of the person’s consciousness, memory, or identity

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FOCUSQUESTIONS

1 What are dissociations? What forms can they take? How are they caused, and how are they treated?

2 When do physical complaints become a psychological disorder? What are the causes and treatments of these conditions?

For example, some researchers are concerned about the sudden increases in reports of dissociative identity disorder and dissociative amnesia. They believe that counselors and therapists (or their clients) may be inadvertently “creating” these disorders. Physical complaints from individuals with somatoform disorders are also difficult to evaluate when no biological basis seems to exist for the physical symptoms. Yet the fact remains that in genuine cases of dissociative and somatoform disorders, the symptoms are produced “involuntarily” or unconsciously. Affected individuals actually are puzzled by their memory losses and behavioral changes and suffer from their physical pain or disability. This situation leads to a paradox: a person does demonstrate memory disturbance in psychogenic amnesia (amnesia of psychological or emotional origin), yet that memory still exists somewhere in the brain. Similarly, a person may “lose” his or her sight in conversion disorder, yet physiologically the eyes are perfectly capable of seeing. What exactly happens in these cases?

Dissociative Disorders

HYPNOSIS AS THERAPY Some practitioners continue to use hypnosis to assess and treat dissociative disorders, based on the belief that these disorders may be induced by self-hypnosis. Is the trance induced by hypnosis similar to disturbances in consciousness found in the dissociative disorders? somatoform disorder a disorder involving physical symptoms or complaints that have no physiological basis, believed to occur due to an underlying psychological conflict or need

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The dissociative disorders—dissociative amnesia, dissociative fugue, depersonalization disorder, and dissociative identity disorder (multiple personality)—are shown in Table 6.1. Each disorder involves some sort of dissociation, or separation, of a part of the person’s consciousness, memory, or identity. The dissociative disorders are highly publicized and sensationalized, yet, except for depersonalization disorder, they have been considered relatively rare. However, as noted earlier, reports of one of these disorders—dissociative identity disorder—have increased dramatically. Corresponding to this increase is a complex legal debate about behaviors about which the individual is amnesic, as in the following: • A therapist claimed that it was one of her client’s twenty-four personalities who kidnapped and took sexual liberties with her and that the main personality was not responsible (Haley, 2003). • A man was charged with the rape of a woman with multiple personalities when one of the nonconsenting personalities brought up the charge. • A South Carolina woman with twenty-one personalities going through a divorce claimed that she had not committed adultery and that she had tried to stop the responsible personality, “Rosie,” from becoming involved in an extramarital affair. (In South Carolina, adultery is grounds for barring alimony payments.) Cases such as these raise questions regarding responsibility in these disorders. Does a diagnosis of dissociative identity disorder or dissociative amnesia constitute mitigating circumstances and “diminished capacity”?

Dissociative Amnesia Dissociative amnesia is the partial or total loss of important personal information, sometimes occurring suddenly after a stressful or traumatic event. Although amnesia can also be caused by strokes, substance abuse, or other medical conditions, dissociative amnesia is the result of psychological factors (Tikhonova et al., 2003). For example, several individuals listed as missing after the September 11, 2001, attacks on the World Trade Center had apparently developed amnesia (Tucker, 2002). An affected individual may be unable to recall information such as his or her name, address, or names of relatives yet remember the necessities of daily life—how to read, write, and drive. Individuals with this disorder often score high on tests measuring

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6.1

DISORDERS CHART DISSOCIATIVE DISORDER

DISSOCIATIVE DISORDERS

SYMPTOMS

PREVALENCE

AGE OF ONSET

COURSE

Dissociative Amnesia

• The sudden inability to recall information of a personal nature—not due to forgetfulness or other organic conditions

Recent increase involving forgotten early childhood trauma

Any age group

Acute forms may remit spontaneously, others are chronic; usually related to trauma or stress

Dissociative Fugue

• Inability to recall personal identity and past, with

0.2%; may increase during natural disasters or wartime

Usually adulthood

Related to stress or trauma; recovery is generally rapid

Unknown; 50% of adults may experience brief episodes of stress-related depersonalization

Adolescence or adulthood

May be short lived or chronic

Sharp rise in recently reported cases; up to nine times more frequent in women

Childhood to adolescence, but misdiagnosis may result in late reporting

Fluctuates; tends to be chronic and recurrent

—Sudden departure to new area —Confusion about personal identity or assumption of new identity Depersonalization Disorder

• Persistent symptoms involving changes in perception and being detached from one’s own thoughts and body • May feel that things are unreal or have a sense of being in a dreamlike state • Reality testing remains intact

Dissociative Identity Disorder (MultiplePersonality Disorder)

• Existence of two or more distinct personalities, each with its own memories, attitudes, and perceptions • Personalities alternate • Inability to recall important personal information

Source: Data from American Psychiatric Association (2000a).

hypnotizability and are likely to report depression, anxiety, or a history of trance states (American Psychiatric Association, 2000a). There are five types of dissociative amnesia—localized, selective, generalized, systematized, and continuous—varying in terms of the degree and type of memory that is lost. The most common, localized amnesia, is a failure to recall all the events that happened in a specific short period, often centered on some highly painful or disturbing event. The following case is typical of localized amnesia.

Case Study An eighteen-year-old woman who survived a dramatic fire claimed not to remember it or the death of her child and husband in the fire. She claimed her relatives were lying about the fire. She became extremely agitated and emotional several hours later, when her memory abruptly returned.

Selective amnesia is an inability to remember certain details of an incident. For example, a man remembered having an automobile accident but could not recall that his child had died in the crash. Selective amnesia is often claimed by people accused of violent criminal offenses (Mendlowicz et al., 2002). Many murderers report that they remember arguments but do not remember killing anyone. However, according

dissociative amnesia the partial or total loss of important personal information, sometimes occurring suddenly after a stressful or traumatic event, due to psychological, not physical, factors

a failure to recall all the events that happened in a specific short period, often centered on some highly painful or disturbing event

localized amnesia

selective amnesia an inability to remember certain details of an incident

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to one estimate, about 70 percent of criminals who say they have amnesia for the crime are feigning (Merryman, 1997). Generalized amnesia is an inability to remember anything about one’s past life. Because of the complete loss of memory of the individual’s entire life, law enforcement agencies or hospitals often become involved. The following case illustrates some of the psychological events associated with generalized amnesia.

Case Study Mr. A, a seventy-four-year-old white man, was brought to the hospital emergency room after awakening on a park bench not knowing who or where he was. He reported having no memory of how he got to the park, nor did he know his name or where he was from (Ballew, Morgan, & Lippmann, 2003, p. 347). Mr. A was treated with an antianxiety medication and recovered his memory. His family was contacted, and his sister reported that Mr. A had disappeared on two other occasions when under stress.

Systematized amnesia involves the loss of memory for certain categories of information. Patients may lose the ability to recall all memories of their families or of a particular person. In one case, shortly after the sudden death of her only daughter, an elderly woman had no recall of having had a daughter. Finally, continuous amnesia, the fourth and least common form of dissociative amnesia, is an inability to recall any events that have occurred between a specific time in the past and the present time. The individual remains alert and attentive but forgets each successive event after it occurs. This cognitive problem may be transient and is more common in people age fifty and over (Sadovsky, 1998). Cases of dissociative amnesia in which the amnesia comes to light only after an individual begins to recall a repressed memory have increased in recent years. These cases are generally believed to involve exposure to trauma that is so overwhelming or threatening that the individual represses the event (McNally, 2007). For example, one woman recovered memories of a teacher molesting her when she was in the sixth grade twenty years after the event. These memories were uncovered after years of psychiatric treatment (the teacher was convicted but the case was later overturned because of the weakness of the evidence; Loftus, 2003). In a sample of psychologists who had experienced childhood abuse, 40 percent reported a period of amnesia regarding some or all of the abuse. In 56 percent of the cases, the memory returned during therapy (Feldman-Summers & Pope, 1994). Laney and Loftus (2005) point out the complexities involved in interpreting reports of repressed memories: • Many abuse survivors claim that they forgot their abuse for a time, but this does not necessarily mean that they repressed their memories of it. • Many abuse survivors do not mention their abuse when initially asked, but this is not proof of repression. • Memory is malleable. Details can be distorted, and wholly false memories can be planted. generalized amnesia a complete loss of memory of the individual’s entire life systematized amnesia the loss of memory for certain categories of information

an inability to recall any events that have occurred between a specific time in the past and the present time

continuous amnesia

• Just because a memory report is detailed, confidently expressed, and emotional does not mean that it reflects a true experience. False memories can have these features (p. 823). Similarly, Pezdek, Blandon-Gitlin, and Gabbay (2006) point out that even implausible memories can be planted and may be further strengthened by information provided by parents or therapists. At this point, it is not clear how many cases of genuine “repressed memory” actually exist, or whether the phenomenon exists at all. Others argue that disorders such as dissociative amnesia are culture-bound syndromes—that is, they are not natural, neuropsychological phenomena but are, instead, socially constructed entities. Pope and his colleagues (Pope et al., 2006) could find no fictional or nonfictional portrayals of dissociative amnesia before 1800 and believe that they are products of modern western culture.

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Dissociative Fugue Dissociative fugue (also called fugue state) is confusion over personal identity (often involving the partial or complete assumption of a new identity), accompanied by unexpected travel away from home. Most cases involve only short periods away from home and an incomplete change of identity. However, there are exceptions, as shown in the following case.

Case Study Jane Dee Williams says she remembers nothing before the day in May 1985 when she was found wandering and disoriented in an Aurora, Colorado, shopping mall, wearing a green coat and carrying a Toyota key, a copy of Watership Down, two green pens, and a notebook—but having no clue as to who she was. She went to Aurora police for help and ended up at the Colorado Mental Health Institute at Fort Logan with a diagnosis of psychogenic fugue. She was treated and released without recovering her memory. During the next twelve years, she remained amnesic but started a new life, marrying and giving birth to two sets of twins. In 1997, a tip to the police from someone who recognized Williams from photographs led to her discovery. Jane Dee Williams was actually Jody Roberts, who had disappeared from her home and job as a reporter in Tacoma, Washington. She still has no memory of her biological family. (Merryman, 1997, A8)

As with dissociative amnesia, recovery from a fugue state is often abrupt and complete, although the gradual return of bits of information may also occur. Kopelman (2002) believes that genuine cases are short lived. “Fugue states usually last only a few hours or days, if prolonged, suspicion of simulation must always arise” (p. 2171). However, some fugue states may last for months (American Psychiatric Association, 2000a).

DISSOCIATIVE FUGUE Jeff Ingram was on his way to visit a terminally ill friend in Alberta and woke up four days later in Denver without any memory of his life. He was without his car or any personal identification. Although most people with dissociative fugue recover their memories within a short period of time, Jeff has not. He now wears a necklace jump drive and bracelet that contains his personal information. What psychological processes produce dissociative fugue?

Depersonalization Disorder Depersonalization disorder is perhaps the most common dissociative disorder. It is characterized by feelings of unreality concerning the self and the environment. Questions such as “Have you ever had the feeling recently that things around you were unreal?” or “Have you yourself felt unreal, that you were not a person, not living in the real world?” are used to screen for this disorder (Lambert et al., 2001). One woman described her symptoms this way: “It is as if the real me is taken out and put on a shelf and stored somewhere inside of me. Whatever makes me me is not there” (Simeon et al., 1997, p. 1110). Episodes of depersonalization can be fairly intense, and they can produce great anxiety because those who suffer from them consider them unnatural, as the following case illustrates.

Case Study A twenty-year-old college student became alarmed when she suddenly perceived subtle changes in her appearance. The reflection she saw in mirrors did not seem to be hers. She became even more disturbed when her room, her friends, and the campus also seemed to take on a slightly distorted appearance. The world around her felt unreal and was no longer predictable. During the day before the sudden appearance of the symptoms, she had been greatly distressed by the low grades she received on several important exams. When she finally sought help at the university clinic, she expressed concern that she was going insane.

A diagnosis of depersonalization disorder is given only when the feelings of unreality and detachment cause major impairment in social or occupational functioning. At one time or another, nearly half of adults have experienced brief symptoms typical of depersonalization disorder, usually following severe stress. The disorder may be either short lived or chronic in nature, depending on individual circumstances (American Psychiatric Association, 2000a). The condition is often accompanied by mood and anxiety disorders (Simeon et al., 2000).

dissociative fugue confusion over personal identity (often involving the partial or complete assumption of a new identity), accompanied by unexpected travel away from home depersonalization disorder

disorder characterized by feelings of unreality concerning the self and the environment

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DEPERSONALIZATION DISORDER An individual may feel like an automaton—mechanical and robotlike—when suffering from depersonalization disorder. This painting, “The Subway” (ca. 1950), by George Tooker, captures this feeling.

Dissociative Identity Disorder (Multiple-Personality Disorder) Dissociative identity disorder (DID), formerly known as multiple-personality disorder, is a dramatic condition in which two or more relatively independent personalities appear to exist in one person. The relationships among the personalities are often complex. Only one personality is evident at any one time, and the alternation of personalities usually produces periods of amnesia in the personality that has been displaced. However, one or several personalities may be aware of the existence of the others. The personalities usually differ from one another and sometimes are direct opposites, as the following case illustrates.

Case Study “Little Judy” is a young child who laughs and giggles. “Gravelly Voice” is a man who speaks with a raspy voice. The “one who walks in darkness” is blind and trips over furniture. “Big Judy” is articulate, competent, and funny. These are four of the forty-four personalities that exist within Judy Castelli. She was initially diagnosed with schizophrenia but later told that dissociative identity disorder was the appropriate diagnosis. She has become a lay expert on mental health issues, a singer, a musician, an inventor, and an artist whose work appeared on the February 2000 cover of the American Psychological Association Monitor. (Woliver, 2000)

dissociative identity disorder (DID) a condition in which two

or more relatively independent personalities appear to exist in one person; also known as multiplepersonality disorder

The characteristics of this disorder have changed over time. Goff and Simms (1993) compared case reports from between the years 1800 and 1965 with those from the 1980s. The earlier cases involved fewer personalities (three versus twelve), a later age of onset of first dissociation (age twenty as opposed to age eleven in the 1980s), a greater proportion of males, and a much lower prevalence of child abuse (see Figure 6.1). Similarly, Pope and colleagues (2006) tracked publications related to dissociative disorder and dissociative amnesia over a twenty-year period. The number of publications was low in the 1980s, rose to a sharp peak in the mid-1990s, then declined sharply by 2003. No other disorder showed this bubble phenomenon.

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Did You Know?

I

ndividuals with DID often claim that information about events happening to one personality is unavailable to other personalities. Research has found that learning does transfer between the different personalities (Huntjens et al., 2006). How is information unconsciously shared between personalities?

DISSOCIATIVE IDENTITY DISORDER Judy Castelli stands beside her stained glass artwork. The people in the art have no faces but are connected and touching each other. She considers her artistic endeavors a creative outlet for her continuing struggle with multiple personalities.

The researchers concluded that both DID and dissociative amnesia “enjoyed a brief period of fashion that has now waned . . . these diagnostic entities presently do not command widespread scientific acceptance” (p. 19). 90 80 70 60 Percent

Diagnostic Controversy Before the case of Sybil (a patient who appeared to have sixteen different personalities) became popularized in a movie and book in the 1970s, there had been fewer than two hundred reported cases of multiple-personality disorder worldwide. Now thousands of new cases are reported each year (Milstone, 1997). Foote and colleagues (2006) believe that the condition is relatively common but often not recognized and diagnosed. In their assessment of eighty-two admissions to an innercity outpatient psychiatric clinic, 29 percent met the criteria for a dissociative disorder, with five patients (6 percent) receiving a diagnosis of DID, eight patients (10 percent) diagnosed with dissociative amnesia, four patients (5 percent) having depersonalization disorder, and seven patients (9 percent) given a diagnosis of dissociative disorder NOS (not otherwise specified). This latter category includes disorders in which dissociative symptoms are prominent but do not meet the criteria for a specific dissociative disorder (for example, trance states, a belief that one is possessed, and atypical forms of amnesia). However, other practitioners believe that DID is rare and that the increase in numbers may be due to clinician bias, the use of faulty assessment, or the use of therapeutic techniques that increase the likelihood of a DID diagnosis (Cormier & Thelen, 1998). With the exception of the Netherlands and Turkey, DID is rarely diagnosed outside the United States and Canada (Merskey, 1995; Phelps, 2000; Tutkun et al., 1998). In a study of DID in Switzerland, Modestin (1992) concluded that it is relatively rare and estimated its prevalence rate to be 0.05 percent to 0.1 percent of patients. He also found that three psychiatrists accounted for more than 50 percent of the patients given this diagnosis. Why is it that some psychiatrists or therapists report treating many patients with dissociative identity disorder, whereas the majority do not? The psychiatrists who treated “Eve,” another well-known case on which a movie was based, received tens of thousands of referrals and found only one genuine case of dissociative identity disorder (Thigpen & Cleckley, 1984). After studying patients with reported dissociative identity disorder, Merskey (1992) contends that the “personalities” represent differences in mood, memory, or

50 40 30 20 10 0 Percentage of males with MPD

Percentage reporting child abuse histories (males and females)

Between 1800 and 1965 1980s

FIGURE

6.1

COMPARISON OF CHARACTERISTICS OF REPORTED CASES OF DISSOCIATIVE IDENTITY DISORDER (MULTIPLE-PERSONALITY DISORDER) This graph illustrates characteristics of multiple-personalitydisorder (MPD) cases reported in the 1980s versus those reported between 1800 and 1965. What could account for these differences?

Source: Data from Goff & Simms (1993).

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critical thinking

Culture and Somatoform and Dissociative Disorders

A

fifty-six-year-old South American man requested an evaluation and treatment. He had the firm belief that his penis was retracting and entering his abdomen, and he was reacting with a great deal of anxiety. He attempted to pull on his penis to prevent the retraction. This procedure had been effective with a previous episode that occurred when he was nineteen. An evaluation of his mental state ruled out other psychiatric diagnoses such as obsessive-compulsive disorder or schizophrenia (Hallak, Crippa, & Zuardi, 2000). Dibuk ak Suut, a Malaysian woman, goes into a trancelike state in which she will follow commands, blurt out offensive phrases, and mimic the actions of people around her. This happens when she has been suddenly frightened. She displays profuse sweating and increased heart rate but claims to have no memory of what she did or said (Osbourne, 2001). The symptoms of the first case fit the description of koro, a culture-bound syndrome listed in DSM-IV-TR (American Psychiatric Association, 2000a) that has been reported primarily in Southeast Asia, although cases have also been reported in West Africa (Dzokoto & Adams, 2005). The symptoms involve an intense fear that the penis or, in a woman, the labia, nipples, or breasts are receding into the body. Koro may be related to body dysmorphic disorder, but it differs in that koro is usually of brief duration and is responsive to positive reassurances. In the second case, the woman is displaying symptoms related to latah, a condition found in Malaysia and many other parts of the world that involves mimicking or following the instructions or behaviors of others and dissociation or trancelike states. Other culture-bound disorders may be related to either somatoform or dissociative disorders: Brain fag Found primarily in West Africa, this condition affects high school and college students who experience somatic

symptoms involving a “fatigued” brain, neck or head pain, or blurring of vision due to difficult course work or classes. Dhat A term used in India to describe hypochondriacal concerns and severe anxiety over the discharge of semen. The condition produces feelings of weakness or exhaustion. Ataque de nervios Commonly found in Hispanics residing in the United States and Latin America, the symptoms can include “brain aches,” stomach disturbances, anxiety symptoms, and dizziness. Patterns of symptoms can resemble somatoform, anxiety, dissociative, or depressive disorders. Pibloktoq Generally found in Inuit communities, these dissociative-like episodes accompanied by extreme excitement are sometimes followed by convulsions and coma. The individual may perform aggressive and dangerous acts and report amnesia after the episode. Zar A condition found in Middle Eastern or North African societies that involves the experience of being possessed by a spirit. Individuals in a dissociative state may engage in bizarre behaviors, including shouting or hitting their heads against a wall. Culture-bound syndromes are interesting because they point to the existence of a pattern of symptoms that are associated primarily with specific societies or groups. These “disorders” do not fit easily into the DSM-IV-TR classification or into many of the biological and psychological models for dissociative and somatoform disorders. What does it mean when disorders are discovered that do not fit into westerndeveloped classification systems? Would we assume that the etiology and treatment would be similar to those developed for somatoform and dissociative disorders?

attention and that they are developed by unwitting therapists through expectation, suggestion, and social reinforcement. Cases of dissociated states and multiple personalities produced through hypnosis or suggestion have been reported (Coons, 1988; Ofshe, 1992). Dissociation experiences such as alterations in memory, thoughts, and perceptions or a sense of depersonalization (feeling detached or numb) are not uncommon in the face of stress (Cardena & Weiner, 2004; Freinkel, Koopman, & Spiegel, 1994). Some clinicians may mistakenly interpret these symptoms of stress as indicators of dissociative disorders. Whether the increase in diagnosis of DID is the result of more accurate diagnosis, false positives, an artifact, or an actual increase in the incidence of the disorder is still being debated.

Myth vs Reality Myth: Dissociative identity disorder is relatively easy to diagnose; the category is accepted by most mental health professionals. Reality: There are no objective measures from which a diagnosis can be made, and cases involving feigning the disorder have been reported. Those who question the category raise the possibility that symptoms of the disorder are inadvertently produced through suggestion or hypnosis.

Dissociative Disorders

FIGURE

MULTIPATH MODEL FOR DISSOCIATIVE DISORDERS The dimensions interact with one another and combine in different ways to result in a specific dissociative disorder.

Biological Dimension • Brain activation pattern differences between different personalities • Hippocampus and amygdala volume reduction • Temporal lobe involvement

Sociocultural Dimension • Media portrayals of dissociative disorders • Role enactment • Gender factors (DID much more prevalent in women)

Psychological Dimension

DISSOCIATIVE DISORDER

6.2

157

• • • •

Hypnotizability or suggestibility Ability to dissociate Exposure to stress or trauma Inability to deal with stress

Social Dimension • Child abuse or trauma • Lack of social support • Mislabeling dissociative experiences • Iatrogenic or therapist involvement

Etiology of Dissociative Disorders The possible causes of dissociative disorders are subject to much conjecture. Because diagnosis depends heavily on patients’ self-reports, as noted, feigning or faking is always a possibility. Fabricated amnesia, fugue, or DID can be produced by individuals who “are attempting to flee a situation involving legal, financial, or personal difficulties, as well as in soldiers who are attempting to avoid combat or unpleasant military duties” (American Psychiatric Association, 2000a, p. 525). However, true cases of these disorders may also result from these types of stressors. Differentiating between genuine cases of dissociative disorders and faked ones is difficult. In this section, we consider the multipath dimensions that contribute to the dissociative disorders (see Figure 6.2). Although two models—the psychologically based posttraumatic model (PTM) and the sociocognitive model (SCM)—are currently the most influential etiological perspectives, neither is sufficient to explain why only some individuals develop these disorders. It is likely that vulnerabilities in the biological, psychological, social, and sociocultural dimensions play a role. Biological Dimension A number of studies using PET scans and MRIs on individuals diagnosed with DID have found variations in brain activity when comparing different personalities (Reinders et al., 2003; Sheehan, Sewall, & Thurber, 2005; Tsai et al., 1999). Switching between personalities is associated with activation or inhibition of certain brain regions, particularly the hippocampus (Tsai et al., 1999), an area involved in memories and hypothesized to be involved in the generation of dissociative states and amnesia (Teicher et al., 2002). Differences in temporal lobe activity have also been found among different personalities within an individual. This is interesting because temporal lobe seizures sometimes involve altered states of consciousness (Sheehan et al., 2005). However, these patterns of brain activity are difficult to interpret because it is unclear what causes them and what specific role they play, if any. Teicher and colleagues (2002) believe that permanent structural changes in the brain can occur as a result of childhood trauma through the chronic activation of a stress response. This may result in the reduction of the volume of the hippocampus and amygdala, which, in turn, may hamper the ability of the brain to encode, store, and retrieve memory, comprehend contradictory information, and integrate emotional memories (Spiegel, 2006). Vermetten and colleagues (2006) used an MRI to

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compare the hippocampal and amygdalar volumes in fifteen females with DID, all of whom reported histories of childhood sexual and/or physical abuse, and compared them with those of twenty-three females without DID. Hippocampal and amygdalar volumes were 19.2 percent and 31.6 percent smaller, respectively, in those with DID than in those in the comparison group. However, decreased brain volume in certain structures is also found with increasing age and among other psychiatric patients. In the Vermetten et al. study, the mean age of DID patients was 42.7 years versus 34.6 for the control group. After controlling for age, only the amygdalar volume was found to be significantly reduced among the DID patients (Smeets, Jelicic, & Merkelbach, 2006). Conclusions are difficult to reach because of the small number of participants involved in the study, the age differences among control and DID patients, and the presence of other comorbid psychiatric disorders in the patients studied. Psychological Dimension The primary psychological explanations for the dissociative disorders come from psychodynamic theory, although individual vulnerabilities such as hypnotizability or suggestibility are also thought to play an important role. Psychodynamic theory views the dissociative disorders as a result of an individual’s use of repression to block from consciousness unpleasant or traumatic events (Richardson, 1998). When complete repression of these impulses is not possible because of the intensity of the impulses or poor ego strength, dissociation or separation of certain mental processes may occur. In dissociative amnesia and fugue, for example, large parts of the individual’s personal identity are no longer available to conscious awareness. This process protects the individual from painful memories or conflicts. The dissociation process is carried to an extreme in dissociative identity disorder. Here, the splits in mental processes become so extreme that more or less independent identities are formed, each with its own unique set of memories (Gleaves, 1996). Following this line of thinking, the contemporary psychodynamic perspective conceptualizes dissociative identity disorder as resulting from severe childhood abuse as illustrated in their posttraumatic model (PTM). According to Kluft (1987), the four factors necessary for the development of DID are: 1. Exposure to overwhelming childhood stress, such as traumatic physical or sexual abuse 2. The capacity to dissociate 3. Encapsulating or walling off the experience 4. Developing different memory systems If a supportive environment is not available or if the personality is not resilient, DID results from these factors (Irwin, 1998; also see Figure 6.3). Thus, according to the posttraumatic model, the split in personality develops because of traumatic early experiences combined with an inability to escape them. In the case of Sybil, for example, Sybil was severely abused by her mother. Dr. Wilbur, Sybil’s psychiatrist, speculated that “by dividing into different selves [which were] defenses against an intolerable and dangerous reality, Sybil had found a [design] for survival” (Schreiber, 1973, p. 158). Consistent with this perspective, most individuals diagnosed with DID do report a history of physical or sexual abuse during childhood (Boon & Draijer, 1993; Coons, 1994; Foote et al., 2006; Sheehan et al., 2005; Vermetten et al., 2006). To develop DID, the individual must have the capacity to dissociate—or separate—certain memories or mental processes in response to traumatic events. A person’s susceptibility to hypnotism may be a characteristic of the dissociation process, and, in fact, people who have DID appear to be very susceptible to hypnotic suggestion. Some researchers believe that pathological dissociation is a result of the interaction between auto- or self-hypnosis and acute traumatic stress (Butler et al., 1996). People might escape unpleasant experiences through self-hypnosis—by entering a hypnotic state. In contrast to individuals with other psychiatric disorders, females with DID have a history of trance states and sleepwalking and report more alterations in consciousness (International Society for the Study of Dissociation, 2005; Scroppo et al., 1998).

Dissociative Disorders

As with most psychodynamic conceptualizations, it is difficult to formulate and test hypotheses. In addition, the posttraumatic model presupposes exposure to childhood trauma. In most studies, information on child abuse is based on patient self-reports, is not independently corroborated, and involves varying definitions of abuse (Lilienfeld et al., 1999). Questions have also been raised regarding reports of memories retrieved from very early ages. Clients with DID have reported the emergence of alternate personalities at the age of two or earlier (Dell & Eisenhower, 1990), and in one study, 11 percent reported being abused prior to age one (Ross et al., 1991). Reports regarding memories of events at these ages would be highly suspect. Social and Sociocultural Dimensions An approach that takes both social and sociocultural factors into consideration is the sociocognitive model (SCM) of DID, developed by Spanos (1994) and further elaborated by Scott Lilienfeld and his colleagues (1999). In this perspective, the disorder is conceptualized as a syndrome that consists of rule-governed and goal-directed experiences and displays of multiple role enactments that have been created, legitimized, and maintained by social reinforcement. Patients with DID synthesize these role enactments by drawing on a wide variety of sources of information, including the print and broadcast media, cues provided by therapists, personal experiences, and observations of individuals who have enacted multiple identities. (Lilienfeld et al., 1999, p. 507)

159

Exposure to Overwhelming Childhood Stressor

High capacity for self-hypnosis

Low capacity for self-hypnosis

Lack of environmental support

Encapsulating the traumatic experience

Possible development of other childhood disorders

Development of different memory systems

FIGURE

6.3

THE POSTTRAUMATIC MODEL FOR DISSOCIATIVE IDENTITY DISORDER Note the importance of each of the factors in the development of dissociative identity disorder.

Source: Adapted from Kluft (1987); Loewenstein (1994).

According to this model, patients learn about the phenomenon and its characteristics through the mass media. The behaviors of individuals with DID become well known and, under the right circumstances, people can enact these roles. Vulnerable individuals may demonstrate these behaviors when therapists provide the appropriate cues. The “personalities” developed through this process are displayed spontaneously and without conscious deception. Proponents of the SCM model cite the large increase shown in DID cases after mass media portrayals of this disorder as support for this perspective. For example, after the 1973 publication of Sybil (whose subject had sixteen personalities), the mean number of personalities for those diagnosed rose from three to twelve (Goff & Simms, 1993). CROSS-CULTURAL FACTORS AND DISSOCIATION Dissociative trance states can be entered voluntarily as part of certain cultural or religious practices, as demonstrated by this Haitian woman during a voodoo ceremony. Can the study of such phenomena in another culture shed light on the process of dissociation in western societies?

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controversy

“Suspect” Techniques Used to Treat Dissociative Identity Disorder

B

ennett Braun, who founded the International Society for the Study of Dissociation and who trained many therapists to work with dissociative identity disorder, was brought up on charges by the Illinois Department of Professional Regulation. A former patient, Patricia Burgess, claimed that Braun inappropriately used hypnotic drugs, hypnosis, and leather strap restraints to stimulate “abuse” memories. Under repressed-memory therapy, Burgess became convinced that she possessed three hundred personalities, was a high priestess in a satanic cult, ate meatloaf made of human flesh, and sexually abused her children. Burgess later began to question her “memories.” In November 1997, she won a $10.6 million lawsuit, alleging inappropriate treatment and emotional harm (Associated Press, 1998). Braun lost his license to practice for two years and was placed on probation for an additional five years (Bloomberg, 2000). Another former patient, Elizabeth Gale, also won a $7 million settlement against Braun and other staff at the hospital. She became convinced she was raised as a “breeder” to produce babies who would be subjected to sexual abuse. She has since sought to reestablish

relationships with family members whom she accused of being part of a cult (Dardick, 2004). Such lawsuits create a quandary for mental health practitioners. Many feel intimidated by the threat of legal action if they attempt to treat adult survivors of childhood sexual abuse, especially cases involving recovered memories. However, discounting the memories of patients may represent further victimization. Especially worrisome is the use of techniques such as hypnosis, trance work, body memories, or age regression, as they may produce inaccurate “memories” (Benedict & Donaldson, 1996). For Further Consideration 1. In the case of “repressed memories,” should clients be told that some techniques are experimental and may produce inaccurate information? 2. Under what conditions, if any, should a therapist express doubt about information “remembered” by a client? 3. Given the high prevalence of child sexual abuse and the indefinite nature of “repressed” memories, how should clinicians proceed if a client discusses early memories of abuse?

Therapists are also influenced by exposure to mass media regarding DID and may “unconsciously” encourage reports of DID from clients. This would be referred to as an iatrogenic disorder—a condition unintentionally produced by a therapist through mechanisms such as selective attention, suggestion, reinforcement, and expectations that are placed on the client. Could some or even most cases of dissociative identity disorder be iatrogenic? A number of researchers and clinicians say yes. They believe that many of the “cases” of DID and dissociative amnesia have unwittingly been produced by therapists, self-help books, and the mass media (Aldridge-Morris, 1989; Chodoff, 1987; Goff & Simms, 1993; Loftus, Garry, & Feldman, 1994; Merskey, 1995; Ofshe, 1992; Weissberg, 1993). Clients most sensitive to these influences may have predisposing characteristics. For example, research findings indicate that women who report dissociations are also prone to engage in fantasy (McNally et al., 2000). The authenticity of one well-known case of DID, Sybil, has been questioned (Borch-Jacobsen, 1997). Herbert Spiegel, a hypnotist, worked with Sybil and used her to demonstrate hypnotic phenomena in his classes. He described her as a “Grade 5” or “hypnotic virtuoso,” something found in only 5 percent of the population. Sybil told Spiegel that her psychiatrist, Cornelia Wilbur, had wanted her to be “Helen,” a name given to a feeling she expressed during therapy. Spiegel later came to believe that Wilbur was using a technique in which different memories or emotions were converted into “personalities.” Sybil also wrote a letter denying that she had multiple personalities and stating that the “extreme things” she told about her mother were not true. Tapes of sessions between Wilbur and Sybil indicate that Wilbur may have described personalities for Sybil (Rieber, 2006). Although iatrogenic influences can be found in any disorder, such effects may be more common with dissociative disorders, in part because of the high levels of hypnotizability and suggestibility found in individuals with these conditions (Simeon et al., 2001). As Goff (1993) states, it is “no coincidence that the field of [multiple-personality disorder] studies in the United States largely originated among

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161

practitioners of hypnosis” (p. 604). Hypnosis and other memory-retrieval methods may create rather than uncover personalities in suggestible clients. Although some cases of DID probably are therapist produced, we do not know to what extent iatrogenic influences can account for this disorder. However, the sociocognitive model of DID does offer some testable hypotheses.

Treatment of Dissociative Disorders A variety of treatments for the dissociative disorders have been developed, including supportive counseling and the use of hypnosis and personality reconstruction. Currently, there are no specific medications for the dissociative identity disorders. Instead, medications are prescribed to treat concurrent anxiety or depression. Dissociative Amnesia and Dissociative Fugue The symptoms of dissociative amnesia and fugue tend to remit, or abate, spontaneously. Moreover, patients typically complain of psychological symptoms other than the amnesia, perhaps because the amnesia interferes only minimally with their day-to-day functioning. It has been noted that depression is often associated with the fugue state and that severe stress is often associated with both fugue and dissociative amnesia (Kopelman, 2002). A reasonable therapeutic approach is then to treat these dissociative disorders indirectly by alleviating the depression (with antidepressants or cognitive-behavioral therapy) and the stress (through stress-management techniques). Depersonalization Disorder Depersonalization disorder is also subject to spontaneous remission, but at a much slower rate than seen with dissociative amnesia and fugue. Treatment generally concentrates on alleviating the feelings of anxiety or depression or the fear of going insane. Occasionally a behavioral approach has been tried. For example, behavior therapy was successfully used to treat depersonalization disorder in a fifteen-year-old girl who had blackouts that she described as “floating in and out.” These episodes were associated with headaches and feelings of detachment, but neurological and physical examinations revealed no biological cause. Treatment involved getting increased attention from her family and reinforcement from them when the frequency of blackouts was reduced, training in appropriate responses to stressful situations, and selfreinforcement (Dollinger, 1983). Dissociative Identity Disorder The mental health literature contains more information on the treatment of dissociative identity disorder than on all of the other dissociative disorders combined. Treatment for this disorder is not always A FAMOUS CASE OF DISSOCIATIVE IDENTITY DISORDER Chris Sizemore, whose experiences with dissociative identity disorder inspired the book and movie The Three Faces of Eve, is an artist today and no longer shows any signs of her former disorder. How do individuals with DID reconcile having different identities?

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successful. Chris Sizemore (who was the inspiration for the book and movie The Three Faces of Eve) developed additional personalities after therapy but has now recovered. She is a writer, lecturer, and artist. Sybil also recovered—she became a college art professor and died in Lexington, Kentucky, in 1998 at the age of seventy-five (Miller & Kantrowitz, 1999). Success, however, may be difficult to achieve. Coons (1986) conducted a follow-up study of twenty patients with dissociative identity disorder. Each patient was studied for about thirty-nine months after his or her initial assessment. Nine patients achieved partial or full recovery, but only five patients maintained it—the others dissociated again. More than one-third were unable to work because of their disorder. However, a more recent two-year follow-up study of fifty-four patients with dissociative identity disorder showed more optimistic results. Most showed improvement, especially those who had been able to integrate their separate personalities during therapy (Ellason & Ross, 1997). The major goal in the treatment of dissociative identity disorder is the fusion and complete integration of all the individual personalities. In many cases, this cannot be achieved. A hierarchical treatment approach involves (International Society for the Study of Dissociation, 2005): 1. Working on safety issues, stabilization, and the reduction of symptoms 2. Identifying and working through the traumatic memories underlying the disorder 3. Attempting to integrate the personalities Hypnosis is often used to attempt the fusion or integration. With the patient in a hypnotic state, the different personalities are asked to emerge and introduce themselves to the patient, to make the patient aware of their existence. Then the personalities are asked to help the patient recall the traumatic experiences or memories that originally triggered the development of new personalities. An important part of this recalling step is to enable the patient to experience the emotions associated with the traumatic memories. The therapist then explains to the patient that these additional personalities developed to serve a purpose but that alternative coping strategies are available now. The final steps involve piecing together the events and memories of the personalities, integrating them, and continuing therapy to help the patient adjust to the new self.

Somatoform Disorders The somatoform disorders, shown in Table 6.2, involve complaints of physical symptoms that closely mimic authentic medical conditions. Although no actual physiological basis exists for the complaints, the symptoms are not considered voluntary or under conscious control. The patient believes the symptoms are real and indications of a physical problem. The somatoform disorders include somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder. Individuals with somatoform disorders are also likely to have comorbid disorders such as mood disorder, personality disorder, and substance use disorder (Noyes et al., 2001; Smith et al., 2000). The somatoform disorders are a disparate group, and some researchers have suggested that disorders such as hypochondriasis and body dysmorphic disorder be moved from this category and placed under anxiety disorders (Fava, Fabbri, Sirri, & Wise, 2007; Starcevic, 2006). Kroenke, Sharpe, and Sykes (2007) recommended classifying hypochondriasis as a “health anxiety disorder” and body dysmorphic disorder as a variant of obsessive-compulsive disorder. In addition, patients are often unhappy with a somatoform diagnosis, feeling that the diagnosis implies that their physical complaints or suffering is not genuine (Starcevic, 2006). Depending on the particular primary care setting, 10 to 50 percent of all patients report physically unexplained symptoms (Arnold et al., 2006; DeWaal et al., 2004; McCarron, 2006; Rief & Hiller, 2003). However, determining whether the proper

Somatoform Disorders

TA B L E

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6.2

DISORDERS CHART

SOMATOFORM DISORDERS

SOMATOFORM DISORDER

SYMPTOMS

PREVALENCE

AGE OF ONSET

COURSE

Somatization Disorder

• History of vague multiple physical complaints before the age of 30

Up to 2%; mostly women with less education; high rates also found among African Americans

Often by adolescence; menstrual complaints are often first symptom in women

Chronic and fluctuating; rarely remits completely

Mostly women of low socioeconomic status

Adolescence or early adulthood

Unpredictable

Relatively rare; only 1 to 3% of referrals to mental health clinics; more women; lower socioeconomic status

Late childhood to early adulthood; onset usually acute

Mixed; if of sudden onset, with identifiable stressor, prognosis is better

Relatively common; gender ratio is unknown

Any age

Most resolve with treatment; poorer prognosis with more pain areas

Equally common in males and females; from 2 to 7% of all medical-practice patients

Any age but most often in early adulthood

Usually chronic; waxes and wanes

Equally common in males and females; from 5 to 15% depending on setting

Early adolescence to 20s; onset may be sudden or gradual

Fairly continuous

—Four pain symptoms involving at least four different sites or functions —Two gastrointestinal symptoms —One sexual symptom —One pseudoneurological symptom Undifferentiated Somatoform Disorder

• One or more physical complaints

Conversion Disorder

• Loss or disturbance of physical functioning resembling a physical disorder

• Duration of six months of more; residual category for somatization disorder

• Psychological factors involved in either —Initiating or exacerbating the symptoms —Allowing individual to avoid aversive activity —Receiving reinforcement for sick behavior Pain Disorder

• Preoccupation with pain • No organic basis found or complaint in excess of what would be expected from physical findings

Hypochondriasis

• Preoccupation with bodily function and disease • Belief in nonexistent physical problems despite medical reassurance to the contrary

Body Dysmorphic Disorder

• Preoccupation with imagined defect in appearance • Overconcern with slight defects if they exist

Source: Data from American Psychiatric Association (2000a); Phillips et al. (1993); Swartz et al. (1991).

diagnosis for these individuals is somatoform disorder can be difficult. As Peveler (1998) points out, “Somatoform disorder diagnoses are still mostly diagnoses of exclusion, rather than constructs with clinical utility” (p. 94). Sykes (2007) points out that the current classification encourages a mind-body distinction and that is difficult to determine whether physical complaints regarding symptoms are “disproportionate” or “not fully explained.” In some cases, physical or neurological factors that explain the symptoms have, in fact, later been discovered (Alao & Chung, 2007; Moser et al., 1998).

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Did You Know?

T

he expression of psychological and social distress through physical symptoms is the norm in many cultures of the world: • Worldwide, the most common somatoform symptoms are gastrointestinal complaints or abnormal skin sensations, whereas menstrual pain, abdominal pain, and chest pain are most common in the United States. • Distinctive cultural somatoform symptoms include concerns about body odor (Japan), body heat and coldness (Nigeria), loss of semen while urinating (India), and kidney weakness (China). Source: From Singh (2007).

Before we discuss the somatoform disorders individually, we should note that they are wholly different from either malingering—faking a disorder to achieve some goal, such as an insurance settlement—or the factitious disorders. Factitious disorders are mental disorders in which the symptoms of physical or mental illnesses are deliberately induced or simulated with no apparent incentive. In contrast to both of these conditions, individuals with somatoform disorders firmly believe that a physical condition exists.

Somatization Disorder An individual with somatization disorder chronically complains of bodily symptoms that have no physical basis. According to DSM-IV-TR (American Psychiatric Association, 2000a), the following are necessary for a diagnosis of somatization disorder: • A history of complaints that involve at least four pain symptoms in different sites, such as the back, head, and extremities • Two gastrointestinal symptoms, such as nausea, diarrhea, and bloating • One sexual symptom, such as sexual indifference, irregular menses, or erectile dysfunction • One pseudoneurological symptom, such as conversion symptoms, amnesia, or breathing difficulties If the individual does not fully meet these criteria but has at least one physical complaint of six months’ duration, he or she would be given a diagnosis of undifferentiated somatoform disorder. The following case illustrates several of the characteristics involved in these disorders.

Case Study

malingering faking a disorder to achieve a specific goal

a mental disorder in which the symptoms of physical or mental illnesses are deliberately induced or simulated with no apparent incentive factitious disorder

somatization disorder a disorder involving chronic complaints of specific bodily symptoms that have no physical basis undifferentiated somatoform disorder the diagnosis given an

individual who does not fully meet the criteria for somatization disorder but who has at least one physical complaint of six months’ duration physical problems or impairments in sensory or motor functioning controlled by the voluntary nervous system that suggest a neurological disorder but with no underlying organic cause conversion disorder

Cheryl was a thirty-eight-year-old separated Italian American woman who was raising her ten-yearold daughter Melanie without much support. . . . Cheryl suffered from vertigo and had a history of neck pain and other vague somatic complaints, as well as a history of several abusive relationships and unresolved grief about the loss of her mother. . . . Cheryl and Melanie described in rich detail an elaborate system of cues that Melanie had learned to respond to by comforting her mother, providing remedies such as back rubs and hot compresses or taking over activities such as grocery shopping if her mother felt dizzy in the store. (McDaniel & Speice, 2001)

In this case, the problem was treated by helping Cheryl and Melanie identify “nonhelpful behaviors” that may reinforce the symptoms and those that are useful in adapting to problem situations. Alternate ways of getting support were also discussed. However, in many cases the “cause” of the behavior is difficult to determine. Anxiety and depression and other psychiatric disorders are common complications of somatization disorder (Allen et al., 2001; Stern, Murphy, & Bass, 1993). Although somatization disorder is considered a chronic condition, in one large study, only about one-third of those diagnosed with the disorder met the criteria twelve months later (Simon & Gureje, 1999). Although physical complaints are common, the diagnosis of somatization disorder (or hysteria, as it was formerly called) is relatively rare, with an overall prevalence rate of up to 2 percent for women and less than 0.2 percent for men (American Psychiatric Association, 2000a). The diagnosis is more prevalent in African Americans and twice as likely among those with less than a high school education or those of lower socioeconomic status (Noyes et al., 2006; Swartz et al., 1991).

Conversion Disorder Conversion disorder is one of the more puzzling disorders. The original name for the disorder, conversion neurosis, comes from Freud, who believed that an unconscious sexual or aggressive conflict was “converted” into a physical problem. An individual with conversion disorder demonstrates physical problems or impairments in sensory or motor functions controlled by the voluntary nervous system—such as paralysis, loss of feeling, and deficits in sight or hearing—suggesting a neurological

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critical thinking

Factitious Disorder and Factitious Disorder by Proxy Two remarkable types of mental disorder are illustrated in the following cases: Factitious Disorder In a two-year period, four women presented for HIV-related care, claiming that they were HIV-seropositive. However, repeated serologic testing revealed no evidence of HIV infection. In all cases, the women were either quite angry or appeared surprised when told they did not have HIV infection. A common denominator in all four cases was a history of prolonged sexual, physical, or emotional abuse. Three of the four had been to multiple physicians, changing doctors as soon as the absence of HIV infection was established (Mileno et al., 2001, p. 263). Factitious Disorder by Proxy (proposed new diagnosis) A hidden camera at a children’s hospital captured the image of a mother suffocating the baby she had brought in for treatment of breathing problems. In another case, a child was brought in for treatment of ulcerations on his back; hospital staff discovered the mother had been rubbing oven cleaner on his skin. Another “sick” infant had been fed laxatives for nearly four months (Wartik, 1994). In each of these cases, no apparent motive was found other than the attention the parent received from the hospital staff that cared for the child’s “illness.”

These cases illustrate a group of mental disorders, termed factitious disorders in DSM-IV-TR, in which people intentionally simulate physical or mental conditions or voluntarily induce an actual physical condition. The criteria include (1) intentional production or feigning of physical or psychological symptoms; (2) that the only apparent motivation for the behavior is to assume the sick role or to be a patient; and (3) that the purpose of this behavior is not for external incentives such as economic gain, avoiding legal responsibilities, and so forth. Another term used for this disorder is Munchausen syndrome.

This practice differs from malingering, which involves simulating a disorder to achieve some goal—such as feigning sickness to collect insurance. The goals in malingering are usually apparent, and the individual can “turn off” the symptoms whenever they are no longer useful. In factitious disorders, the purpose of the simulated or induced illness is much less apparent, complex psychological variables are assumed to be involved, and the individual is usually unaware of the motivation for the behaviors. The individual displays a compulsive quality in the need to simulate illness. Signs of a factitious disorder may include long unexplained illnesses with multiple surgical or complex treatments, “remarkable willingness” to undergo painful or dangerous treatments, tendency to anger if the illness is questioned, and the involvement of multiple doctors (Flaherty et al., 2001; Gregory & Jindal, 2006). If an individual deliberately feigns or induces an illness in another person, the diagnosis is factitious disorder by proxy (or Munchausen by proxy). In the preceding cases, the mothers produced symptoms in their children to vicariously assume the sick role. Because this diagnostic category is somewhat new, little information is available on prevalence, age of onset, or familial pattern. However, diagnosis of this condition is difficult. In Seattle, one pediatrician has been involved in over one hundred purported cases during the past twenty-five years, some resulting in children being removed from their families. One appeals court judge wrote that the pediatrician “apparently has a penchant for diagnosing Munchausen syndrome by proxy, notwithstanding its rarity and his questioned qualification to make that diagnosis” (Smith, 2002, p. A10). If factitious disorder by proxy becomes an official diagnosis, what safeguards should be put in place to balance protection of the child with the possibility of a false accusation against the parent?

disorder but with no underlying organic cause (Listernick, 2007). Although rare, complaints may also include memory loss or “cognitive or intellectual impairment” that resembles dementia (Liberini et al., 1993). Individuals with conversion disorder are not consciously faking symptoms, as are those who have a factitious disorder or who are malingering. A person with conversion disorder actually believes that there is a genuine physical problem, and it produces notable distress or impairment in social or occupational functioning. As discussed in Chapter 1, it was known earlier as hysteria, and Mesmer was able to effect cures using hypnosis. Psychological factors are considered important contributors to conversion disorder, in either the initiation or exacerbation of the problem, as illustrated in the following cases:

Case Study A forty-four-year-old woman was admitted to a psychiatric hospital from a neurology ward with “pseudo-seizures” and “functional hemiplegia” (paralysis of one side of the body). She was wheelchair-bound. . . . She described a disrupted childhood with a physically abusive, alcoholic father. She had two stormy and violent marriages. . . . Although reluctant to accept a psychological

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CONVERSION DISORDER Although there is nothing physically wrong with the eyes of this Cambodian woman, she claims to be blind. It is thought that trauma suffered in Cambodian prison camps due to the brutality of the Khmer Rouge produced such horror that her eyesight “shut down” psychologically. Hysterical blindness is a very rare conversion disorder in the United States but is quite high among Cambodian refugees. Approximately 150 individuals (mostly women) from a Cambodian community of 85,000 people in Long Beach, California, suffer from this disorder.

origin of her symptoms, she agreed to undergo hypnosis. Under hypnosis, she walked and moved her paralyzed limbs normally. She received psychotherapy, exploring her childhood and relationship difficulties. Within six months she was using her right upper limb normally and walking with a frame. (Singh & Lee, 1997, pp. 426–427) The boy was referred at age ten as a case of juvenile myasthenia gravis (weakening of the voluntary muscles). For five weeks he had been unable to open his eyes, and the consequent “blindness” had stopped him from attending school. . . . On detailed physical examination, no other abnormalities were found. In the hospital ward it was noted that he did not walk into furniture. . . . He was the local village football star . . . and had been blamed for his team’s defeat . . . and from that day he had been unable to open his eyes. (Leary, 2003, p. 436)

The most common conversion symptoms seen in neurological clinics involve psychogenic pain, disturbances of stance and gait, sensory symptoms, dizziness, and psychogenic seizures (Rechlin, Loew, & Joraschky, 1997). The occurrence of symptoms is often related to stress. Nearly 75 percent of respondents in one sample reported that their conversion symptoms developed after they had experienced a stressor (Singh & Lee, 1997). In a ten-year follow-up study of individuals diagnosed with conversion disorder, symptoms persisted in about 40 percent of the cases (Mace & Trimble, 1996). Sudden onset, shorter duration of symptoms, and a good premorbid (pre-illness) personality are associated with a positive outcome (Crimlisk et al., 1998; Singh & Lee, 1997). It is often difficult to distinguish between actual physical disorders and conversion reactions. In one sample of sixty patients with sudden onset of neurological symptoms, 50 percent had physical disorders, and the remainder received a diagnosis of conversion disorder (Binzer, Eisenmann, & Kullgren, 1998). Conversion disorder usually involves either the senses or motor functions that are controlled by the voluntary (rather than the autonomic) nervous system, and there is seldom any actual physical damage. For example, a person with hysterical paralysis of the legs rarely shows the atrophy of the lower limbs that occurs when there is an underlying biological cause, although in some persistent cases, disuse can result in atrophy (Schonfeldt-Lecuona et al., 2003). Some symptoms, such as the inability to talk or whisper while still being able to cough or glove anesthesia (the loss of feeling in the hand, ending in a straight line at the wrist), are easily diagnosed as conversion disorders because coughing indicates an intact vocal cord function and, in glove anesthesia, the area of sensory loss does not correspond to the distribution of nerves in the body (Brown, 2004; see Figure 6.4).

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Other symptoms may require extensive neurological and physical examinations to rule out a true medical disorder before a diagnosis of conversion disorder can be made. Discriminating between people who are faking and those with conversion disorder is difficult. For example, participants asked to simulate a hearing loss can produce response patterns highly similar to those of individuals with hearing loss from conversion disorder (Aplin & Kane, 1985). Nerve pathways

Pain Disorder Pain disorder is characterized by reports of severe pain that may (1) have no physiological or neurological basis, (2) be greatly in excess of that expected with an existing physical condition, or (3) linger long after a physical injury has healed. As with the other somatoform disorders, psychological conflicts are involved. People who have pain disorder have numerous physical complaints, make frequent visits to physicians, and may become drug or medication abusers. Unexplained physical pain involving the abdomen, head, and limbs is present in a considerable number of young children (Hunfeld et al., 2002). Chronic pain is relatively common and affects 30 percent of the U.S. population (Hoffman, Papas, Chatkoff, & Kerns, 2007). Because psychological factors do play a role in exacerbating pain, it is difficult to determine when pain is to be considered “excessive” or is “lingering too long.” Understandably, questioning the veracity of reports of pain results in feelings of anger and frustration from patients (Merten & Brunnhuber, 2004). Some researchers (Fava & Wise, 2007) believe that pain disorder should be viewed as a psychophysiological disorder, indicating that both physical and psychological factors are involved. A multipath model of pain allows one to consider how biological, psychological, and socioenvironmental factors can moderate the pain experience.

Hypochondriasis Case Study

Area of anesthesia

FIGURE

6.4

GLOVE ANESTHESIA In glove anesthesia, the lack of feeling covers the hand in a glovelike shape. It does not correspond to the distribution of nerve pathways. This discrepancy leads to a diagnosis of conversion disorder.

A 41-year-old woman, Linda, reported having a history of concerns about cancer, especially stomach or bowel cancer. Her grandmother had bowel cancer when Linda was 22. Media stories of illness, medical documentaries, or reading about people who are ill trigger her worries: . . . “I notice a feeling of discomfort and bloating in my abdomen. . . . I wonder if this could be an early sign of cancer. Cancer is something that can happen at my age. People can have very few symptoms and then suddenly it is there and a few months later they are gone.” (Furer & Walker, 2005, p. 261)

The primary characteristic of hypochondriasis is a persistent preoccupation with one’s health and physical condition, even in the face of negative findings. Fear of death or aging is common, as are anxiety or depressive disorders (Bleichhardt, Timmer, & Reif, 2005). Characteristics of the disorder include (Furer & Walker, 2005; Kellner, Hernandez, & Pathak, 1992; Leibbrand, Hiller, & Fichter, 2000): 1. Bodily preoccupation: a tendency toward self-observation, oversensitivity to bodily sensations, and alarm when unpleasant or unusual symptoms are identified 2. Disease phobia: the fear of having a serious illness or dying from an undetected disease 3. Disease conviction: the belief remains even with frequent assurance from physicians, family, and friends that nothing is wrong (Starcevic, 2005). In a study of twenty individuals with hypochondriasis (ten females and ten males), the most common health concerns involved undetected cancer, heart attack, and brain tumors. As opposed to individuals in a control group, the participants showed a tendency to overestimate negative outcomes with ambiguous healthrelated information (Haenen et al., 2000). Hypochondriasis is often characterized by fearful thoughts of having a fatal disease (Avia & Ruiz, 2005; Barsky, 1991). Because this disorder does not involve a physical symptom or complaint, some researchers believe hypochondria should be placed under anxiety disorders and called “health anxiety disorder” (Abramowitz & Moore, 2007; Fava et al., 2007; Starcevic, 2006).

pain disorder a disorder characterized by reports of severe pain that appear to have no physiological or neurological basis, that are in excess of what would be expected from an existing physical condition, or that linger long after a physical injury has healed

a persistent preoccupation with one’s health and physical condition, even in the face of physical evaluations that reveal no organic problems

hypochondriasis

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Percentage of patients targeting area

60 55 50 45 40 35 30 25 20 15 10 5 0 Skin, Head hair, Nose, body hair, shape or acne, and beard size of blemishes growth

Eyes

Head/face Stomach/ shape waist and size

Teeth

Ugly face

Breasts

Buttocks

Penis

Area of imagined defects

FIGURE

6.5

IMAGINED DEFECTS IN PATIENTS WITH BODY DYSMORPHIC DISORDER This graph illustrates the percentage of thirty patients who targeted different areas of their body as having “defects.” Many of the patients selected more than one body region.

Source: From Phillips et al. (1993).

An estimated 2 to 7 percent of general medical patients have this disorder (American Psychiatric Association, 2000a).

Body Dysmorphic Disorder Case Study The patient was a twenty-four-year-old Caucasian male in his senior year of college. He presented at intake by stating, “I’ve got a physical deformity (small hands) and it makes me very uncomfortable, especially around women with hands bigger than mine. I see my deformity as a sign of weakness; it’s like I’m a cripple.”… He spent considerable time researching hand sizes for different populations and stated at intake that his middle finger is one and one-fourth inches smaller than the average size for a male in the United States. … He also reported being concerned that women might believe small hands are indicative of having a small penis. (Schmidt & Harrington, 1995, pp. 162–163)

body dysmorphic disorder (BDD) preoccupation with an

imagined defect in appearance in a normal-appearing person or an excessive concern over a slight physical defect

According to DSM-IV-TR, body dysmorphic disorder (BDD) involves a preoccupation with an imagined defect in appearance in a normal-appearing person or an excessive concern over a slight physical defect. The term comes from the Greek word dysmorphia, which means abnormal shape. This disorder is often referred to as the “fear of ugliness” (Rivera & Borda, 2001). The preoccupation produces marked clinical distress and may be underdiagnosed because individuals may be unwilling to bring attention to the “problem” (Grant, Kim, & Crow, 2001). Individuals with this disorder often engage in frequent mirror checking, regard their “defect” with embarrassment and loathing, and are concerned that others may be looking at or thinking about their defect. They make frequent requests for cosmetic surgeries despite the outcome of previous treatment (Fontenelle et al., 2006; Rivera & Borda, 2001). Concern commonly focuses on bodily features such as excessive hair or lack of hair and the size or shape of the nose, face, or eyes (see Figure 6.5). Among twenty patients with BDD in Brazil, many had other psychiatric disorders, and three-quarters had obsessive-compulsive disorder. Over one-third had active suicidal ideation, and 30 percent had no insight into their difficulties (Fontenelle et al., 2006). The degree

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of insight in BDD clients can range from good to absent (Lucchelli, Bondolfi, & Bertschy, 2006; Phillips et al., 2001). BDD tends to be chronic and difficult to treat. In a one-year follow-up of 183 individuals with BDD, 84 percent of whom received mental health treatment, only 9 percent had full remission and 21 percent had partial remission of symptoms (Phillips et al., 2006). Some bodybuilders who show a pathological preoccupation with their muscularity may also suffer from BDD. Researchers identified a subgroup of bodybuilders who scored high in body dissatisfaction, had low self-esteem, and mistakenly believed they were “small” even though they were large and very muscular (Choi et al., 2002; Olivardia, Pope, & Hudson, 2000). In DSM-IV-TR, body build or muscularity has been added as an area of body preoccupation in BDD. As with the other somatoform disorders, individuals with BDD seek medical attention—often from dermatologists or plastic surgeons. They are also likely to undergo multiple medical procedures (Phillips & Rasmussen, 2004). Persons with BDD often suffer from functional impairment. They may avoid social activities, work, and school and may become housebound and suicidal (Schmidt & Harrington, 1995). The more a person agrees with the following statements, the more likely he or she is to have BDD. 1. Do you believe that there is a “defect” in a part of your body or appearance? 2. Do you spend considerable time checking this “defect”? 3. Do you attempt to hide or cover up this “defect” or remedy it by exercising, dieting, or seeking surgery? 4. Does this belief cause you significant distress, embarrassment, or torment? 5. Does the “flaw” interfere with your ability to function at school, at social events, or at work? 6. Do friends or family members tell you that there is nothing wrong or that the “defect” is minor? Researchers (Fava et al., 2007; Kroenke, Sharp, & Sykes, 2007; Starcevic, 2006) have questioned the placement of BDD within the somatoform disorders category because it does not involve physical disease or dysfunction. They argue that BDD is a variant of obsessive-compulsive disorder and should be considered an anxiety disorder. Indeed, some people with BDD have been successfully treated with fluoxetine, a serotonin reuptake inhibitor, which is also used to treat obsessive-compulsive disorder (Lydiard, Brady, & Austin, 1994; Phillips & Rasmussen, 2004).

Etiology of Somatoform Disorders Most etiological theories tend to focus on what they consider to be the “primary” cause of somatoform disorders. However, they are unable to explain why only some individuals exposed to these “causes” develop somatoform disorders. In the vast majority of cases, multiple factors contribute, as evidenced by the multipath model that includes biological (sensitivity to bodily cues), psychological (negative thoughts related to pain or bodily functioning), social (modeling by parents, relatives, or friends), and sociocultural dimensions (gender and cultural influences), as shown in Figure 6.6. Biological Dimensions Research involving twin (Torgersen, 1986) or family studies (Noyes et al., 1997) provides little evidence for heredity in somatoform disorders. The exception is BDD, which may, in fact, be a variant of OCD (Rivera & Borda, 2001). Instead, biological vulnerabilities in terms of lower pain thresholds or greater sensitivity to somatic cues have been hypothesized (Kellner, 1985; Starcevic, 2005). Barsky and Wyshak (1990) believe that a predisposition may be “hard-wired” into the central nervous system that involves (1) hypervigilance or exaggerated focus on bodily sensation, (2) increased sensitivity to even mild bodily sensations, and (3) a disposition to react to somatic sensations with alarm. The predisposition becomes a fully developed disorder only when a trauma or stressor occurs that the individual cannot deal with. In a test involving a physical stressor (foot placed in cold water), individuals with hypochondriasis demonstrated greater increases in heart rate, displayed a greater drop

169

Did You Know? In a survey of college students: • 74.3 percent were “very concerned” about the appearance of parts of their body • 28.7 percent were preoccupied with a “defective” part • 6 percent reported spending from one to over three hours a day worrying about their perceived defect • 4 percent appeared to meet the criteria for BDD Source: Bohne et al. (2002).

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6.6 MULTIPATH

Biological Dimension

MODEL FOR SOMATOFORM DISORDERS The dimensions interact with one another and combine in different ways to result in a specific somatoform disorder.

• Innate sensitivity to body sensations • Lower threshold for pain • History of illness or injury

Sociocultural Dimension • Social class • Degree of knowledge about medical concepts • Cultural acceptance of physical symptoms

Psychological Dimension

SOMATOFORM DISORDER

• Bodily sensation preoccupation • Anxiety or stressful event producing physical reactions • Catastrophic thoughts regarding bodily sensations • Social isolation

Social Dimension • Parental models for injury or illness • Reinforcement from others for physical symptoms • Attention and escape from responsibilities

in temperature in the immersed limb, rated the experience as more unpleasant, and terminated the task more frequently relative to a control group (Gramling, Clawson, & McDonald, 1996). It has been hypothesized that “people who continually report being bothered by pain and bodily sensations may have a higher-than-normal arousal level, which results in increased perception of internal stimuli” (Hanback & Revelle, 1978, p. 523). Innate factors may account for greater sensitivity to pain and bodily functions (Kellner, 1985; Starcevic, 2005). Additionally, individuals with somatoform disorders often have had serious illness or physical injury (Smith et al., 2000; Starcevic, 2005). Psychological Dimension Theoretical explanations have included the psychodynamic and cognitive-behavioral perspectives. Certain psychological characteristics have also been associated with the somatoform disorders. Psychodynamic perspective In psychodynamic theory, somatic symptoms are seen as a defense against the awareness of unconscious emotional issues (Dworkin, VonKorff, & LeResche, 1990). Freud believed that hysterical reactions (biological complaints of pain, illness, or loss of physical function) were caused by the repression of some type of conflict, usually sexual in nature. To protect the individual from intense anxiety, this conflict is converted into a physical symptom (Breuer & Freud, 1895/1957). The psychodynamic view suggests that two mechanisms produce and then sustain somatoform symptoms. The first provides a primary gain for the person by protecting him or her from the anxiety associated with the unacceptable desire or conflict; the need for protection gives rise to the physical symptoms. This focus on the body keeps the patient from an awareness of the underlying conflict (Simon & VonKorff, 1991). Then a secondary gain accrues when the person’s dependency needs are fulfilled through attention and sympathy. In one study of twenty-five patients with a somatoform disorder, all relied on family members and friends to complete domestic tasks and were receiving disability allowances (Allanson, Bass, & Wade, 2002). Cognitive-behavioral perspective Cognitive-behavioral researchers point to the importance of reinforcement, modeling, cognitions, or a combination of these factors in the development of somatoform disorders. Some contend that people with somatoform disorders assume the “sick role” because it is reinforcing and because it allows them to escape unpleasant circumstances or to avoid responsibilities (Schwartz,

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Slater, & Birchler, 1994). The importance of reinforcement was shown in a study of male pain patients. Men with supportive wives (attentive to pain cues) reported significantly greater pain when their wives were present than when their wives were absent. The reverse was true of patients whose wives were nonsupportive: reports of pain were greater when their wives were absent (Williamson, Robinson, & Melamed, 1997). Some patients may seek out contact with medical staff as a source of reinforcement because of social isolation or an inability to connect with family or friends (Stuart & Noyes, 2005). Individuals with somatoform disorders have reported being rejected by family members at an early age and feeling unloved (Rivera & Borda, 2001). Parental modeling and reinforcement of illness behaviors may also be influential in determining people’s current reactions to illness. Over 50 percent of a sample of individuals with conversion disorder, somatization disorder, pain disorder, or hypochondriasis had had a serious physical illness in the preceding twelve months, and many reported serious physical illnesses among family members (Smith et al., 2000). Individuals with somatoform disorders showed a background of parental models or family members with chronic physical illnesses (Smith et al., 2000; Starcevic, 2005), and they were also more likely to report having missed school for health reasons and having had childhood illnesses (Barsky et al., 1995). The most recent views of somatoform disorders stress the importance of cognitive factors (Avia & Ruiz, 2005; Furer & Walker, 2005; Lipsitt & Starcevic, 2006; Severeijns et al., 2004). According to this perspective, a somatoform disorder may develop in predisposed individuals (that is, those who have somatic sensitivity, a low pain threshold, a history of illness, and parental attention to somatic attention or modeling) in the following manner (Barsky, 1991; Starcevic, 2005): (1) an anxiety- or stress-arousing event; (2) the perception of somatic changes such as pain, increased heart rate, and respiration; (3) the thought that these sensations reflect a disease process; (4) amplification of bodily sensations, causing even more pain or concern; (5) increased catastrophic thoughts regarding these sensations, creating a circular feedback pattern. Individuals with somatoform disorders have been shown to make unrealistic interpretations of bodily sensations and to overestimate the dangerousness of bodily symptoms (Haenen et al., 2000). Social and Sociocultural Dimensions Hysteria, now known as conversion disorder, was originally perceived as a problem that afflicted only women; in fact, it derived its name from hystera, the ancient Greek word for uterus. Hippocrates believed that a shift or movement of the uterus resulted in complaints of breathing difficulties, anesthesia, and seizures. He presumed that the movement was due to the uterus “wanting a child.” However, Satow (1979) argued that hysteria was more prevalent in women when social mores did not provide them with appropriate channels for the expression of aggression or sexuality. Anna O., a patient of physician Josef Breuer, was a twenty-one-year-old woman who developed a variety of symptoms, including dissociation, muscle rigidity, and insensitivity to feeling. Freud and Breuer both believed that these symptoms were the result of intrapsychic conflicts. They did not consider the impact of social role restrictions on abnormal behavior. According to Hollender (1980), Anna O. was highly intelligent, but her educational and intellectual opportunities were severely restricted because she was a woman. Breuer described her as “bubbling over with intellectual vitality.” As Hollender pointed out, “Not only was Anna O., as a female, relegated to an inferior position in her family with future prospects limited to that of becoming a wife and mother, but at the age of twenty-one she was suddenly called on to assume the onerous chore of nursing her father” (Hollender, 1980, p. 798). It is possible that many of her symptoms were produced to relieve the guilt she felt because of her resentment of this duty—as well as to maintain her intellectually stimulating contact with Breuer. After treatment, Anna O. was supposedly cured. However, she, in fact, remained severely disturbed and received additional treatment at an institution. Later, she headed a home for orphans, was involved in social work, and became recognized as a feminist leader.

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Did You Know?

I

n the second century, Galen believed that hysteria was a result of sexual deprivation in women. Treatment involved marriage or, for women who remained single, vaginal massage by a midwife. Later, physicians treated the condition by producing “hysterical paroxysm,” or orgasm, in women. An electric vibrator was advertised in a Sears catalog in 1918 to treat hysteria.

Source: Maines (1999).

CONVERSION DISORDER OR SOCIETY’S VICTIM? Anna O., whose real name was Bertha Pappenheim, was diagnosed as being severely disturbed, even though her later years were extremely productive. Was her condition a product of societal restrictions on the role of women or her inability to conform to that role? Or was it something totally different?

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Cultural factors can influence the frequency, expression, and interpretation of somatic complaints. Risk factors associated with somatoform disorders include lower educational levels, ethnicity, and immigrant status (Noyes et al., 2006). Physical complaints often occur in reaction to stress among Asian Americans (Sue & Sue, 2008a). In fact, Asian Indian children who were referred for psychiatric services had three times as many somatoform disorders as their white counterparts (Jawed, 1991). Among some African groups, somatic complaints (feelings of heat, peppery and crawling sensations, and numbness) differ from those expressed in western cultures (Ohaeri & Odejide, 1994). Reports of pain also differ between white and Hispanic patients with current health problems. Hispanics report more pain, which might be due to the cultural acceptance of physical problems as an expression of distress (Hernandez & Sachs-Ericsson, 2006). Differences such as those just described may reflect different cultural views of the relationship between mind and body. The dominant view in western culture is the psychosomatic perspective, in which psychological conflicts are expressed in physical complaints. But many other cultures have a somatopsychic perspective, in which physical problems produce psychological and emotional symptoms. Although we probably believe that our psychosomatic view is the “correct” one, the somatopsychic view is the dominant perspective in most cultures. As White (1982) claimed, “It is rather the more psychological and psychosomatic mode of reasoning found in Western cultures which appears unusual among the world’s popular and traditional system of belief” (p. 1520). Physical complaints expressed by persons of ethnic minorities may need to be interpreted differently from similar complaints made by members of the majority culture.

Treatment of Somatoform Disorders Although somatoform disorders are considered to be difficult to treat, newer biological and psychological treatments have met with greater success. There is also increasing recognition of the necessity of moving away from a mind-body distinction, understanding the client perspective regarding somatoform disorders, and acknowledging the relationship between stressors and their role in physical complaints.

Case Study Mr. X was a sixty-eight-year-old Chinese man who reported sleep disturbances, a loss of appetite, dizziness, and a sensation of tightness around his chest. Several episodes of chest pain led to admission and medical evaluation at the local hospital. All results, including tests for ischemic heart disease, were normal. He was referred for psychiatric consultation. Because traditional Chinese views of medicine recognize an interconnection between mind and body, the psychiatrist accepted and showed interest in the somatic symptoms, such as their onset, duration, and exacerbating and relieving factors. Medication was provided as a supportive treatment. A stressor was identified that involved arguments with his wife. Suggestions were made on how to improve communication, which led to a decrease in physical complaints. (Yeung & Deguang, 2002)

Biological Treatment Antidepressant medications such as the selective serotonin reuptake inhibitors (SSRIs) have shown promise with somatoform disorders, primarily somatization and somatoform pain disorders (Taylor, Asmundson, & Coons, 2005). In addition, interventions involving an increase in physical activity have been recommended for conversion disorders (Smith et al., 2000). SSRIs have been successful in improving nearly two-thirds of a sample of individuals with body dysmorphic disorder (Phillips et al., 2001; Phillips & Rasmussen, 2004). However, these biological treatments appear to be beneficial primarily with the depression, anxiety, and other comorbid conditions that accompany somatoform disorders. Psychological Treatments The most promising interventions for somatoform disorders involve the cognitive-behavioral approach. A fundamental focus is an understanding of the client’s view regarding his or her problem. Individuals with somatoform disorders are often frustrated, disappointed, and angry following years of encounters with the medical profession. They believe that the treatment strategies have

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been ineffective and resent the implication that they are “fakers” or problem patients (Lipsitt & Starcevic, 2006). Medical personnel do show negative reactions when interacting with individuals with somatoform disorders (Merten & Brunnhuber, 2004). Because of these reactions, patients and physicians have a difficult time establishing a positive relationship. A more recent approach has been to demonstrate empathy regarding the physical complaints and focus on helping the individual develop better coping skills, as indicated in the following statement to a patient: “I don’t know exactly the cause of your problem, and I’m not certain that I can provide immediate relief. Nevertheless, I will work with you as best I can to find solutions” (Monopoli, 2005, p. 293). In another approach, somatoform disorders are viewed within a social context— a belief that somatic complaints are a reflection of unsatisfying or inadequate social relationships. Individuals who assume a “sick role” often receive some reinforcement, such as escape from responsibility and control of others through bodily complaints. However, negative aspects include rejection from others, which may result in increased social isolation. Therapy is therefore directed toward developing and improving the individual’s social network. A therapist may say something such as: “There is treatment available that may be helpful to you, if you would like to participate. This involves learning new ways of understanding and coping with stresses, other than turning to substances or going to the nearest emergency room. Treatment will also involve learning more about yourself and finding out what gets in the way of developing more fulfilling relationships” (Gregory & Jindal, 2006, p. 34). A randomized controlled trial was conducted (Allen et al., 2006) to compare cognitive-behavioral therapy (CBT) with standard medical care augmented by psychiatric consultation for somatization disorder. CBT was based on the biopsychological model in which pain or bodily symptoms were seen to be related to the degree of stress or anxiety affecting the patient. The approach involved: (1) scheduling regular appointments rather than making appointments by patient request, (2) brief examinations by a physician regarding the physical complaints, (3) providing psychoeducation regarding the relationship between pain or bodily symptoms and stress and anxiety, (4) relaxation training to reduce physiological arousal, (5) encouraging more social contact and involvement in pleasurable and meaningful activities, and (6) identifying and modifying negative thoughts. The ten-session CBT program was significantly more effective in reducing somatization symptoms and complaints than standard medical care augmented with psychiatric consultation. Because many patients with somatoform disorders appear to have cognitive distortions, such as a conviction that they are especially vulnerable to disease, cognitivebehavioral approaches focused on correcting these misinterpretations have been successful (Barsky & Ahern, 2004). In one program, individuals with hypochondriasis who had fears of having cancer, heart disease, or other fatal diseases were educated about the relationship between misinterpretations of bodily sensations and selective attention to illness themes. Six two-hour group sessions were held that covered topics such as “What Is Hypochondriasis?” “The Role of Your Thoughts,” “Attention and Illness Anxiety,” “Stress and Bodily Symptoms,” and “Your Own Vicious Cycle.” As homework assignments, participants monitored and challenged hypochondriacal thoughts. After completing these sessions, most participants showed considerable improvement or no longer met the criteria for hypochondriasis, and the gains were maintained at a six-month follow-up (Hiller et al., 2002). Reattribution training has also led to improvement among individuals with somatic complaints. Case studies indicate that systematic desensitization, exposure, and cognitive therapy are promising approaches in the treatment of body dysmorphic disorder (Neziroglu & Yaryura-Tobias, 1997; Rosen, Reiter, & Orosan, 1995).

The two primary models for dissociative disorders include the psychoanalytically based posttraumatic model (PTM) and the sociocognitive model (SCM). Both models account for only certain etiological aspects of dissociative disorders. The PTM model is dependent on childhood trauma for the development of DID. However, there are

I M P L I C AT I O N S

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cases of DID in which childhood traumas were not reported, and certainly the majority of individuals who have been abused as children do not develop this disorder. The SCM model (which stresses the importance of exposure to mass media portrayals of DID and therapist suggestions) also has shortcomings. The model fails to explain why only a very small number of individuals who undergo therapy and are aware of the characteristics of DID develop this disorder. Because each perspective is limited in breadth, minimal attention is paid to other biological, psychological, social, or sociocultural dimensions, which limits the explanatory power of both models. Views regarding somatoform disorders are changing, from focusing on a mindbody distinction to interactions between psychological events and physical functioning. For example, a complaint of back pain can be a result of tension of the muscles of the back due to workplace stress. In this case both the pain and stress can be treated together through medication and relaxation training. Social factors, such as relationship problems or even the relationship between the therapist and client, can influence reports of pain. However, etiological theories regarding somatoform disorders (psychoanalytic, cognitive-behavioral, family, medical) remain distinct from one another and rarely consider the other dimensions.

Summary 1. What are dissociations? What forms can they take? How are they caused, and how are they treated? ■

Dissociation involves a disruption in consciousness, memory, identity, or perception and may be transient or chronic.

■

Dissociative amnesia and dissociative fugue involve a selective form of forgetting in which the person can not remember information that is of personal significance. Depersonalization disorder is characterized by feelings of unreality—distorted perceptions of oneself and one’s environment. Dissociative identity disorder involves the alternation of two or more relatively independent personalities in one individual.

■

Biological explanations for DID have focused on studies finding variations in brain activity when comparing different personalities. Some researchers believe that childhood trauma and chronic stress can result in permanent structural changes in the brain. Psychoanalytic perspectives attribute these disorders to the repression of impulses that are seeking expression and ways of coping with childhood abuse. Sociocultural explanations for dissociation include exposure to media portrayals of dissociation and role enactment. Social explanations include childhood abuse, subtle reinforcement, responding to the expectations of a therapist, or mislabeling dissociative experiences.

■

Dissociative amnesia and dissociative fugue tend to be short-lived and remit spontaneously; behavioral therapy has also been used successfully. Dissociative identity disorder has most often been treated with psychotherapy and hypnosis, as well as with behavioral and family therapies.

2. When do physical complaints become a psychological disorder? What are the causes and treatments of these conditions? ■ Somatoform disorders involve complaints about physical symptoms that mimic actual medical conditions but have no apparent organic basis. Instead, psychological factors are directly involved in the initiation and exacerbation of the problem. Somatization disorder is characterized by chronic multiple complaints and early onset. Conversion disorder involves a physical impairment that has no organic cause. Pain disorder is a condition in which reported severe pain has a psychological rather than a physical basis. Hypochondriasis involves a persistent preoccupation with bodily functioning and disease. Body dysmorphic disorder involves preoccupation with an imagined bodily defect. ■ Biological explanations have suggested that there is increased vulnerability to somatoform disorder when individuals have high sensitivity to body sensations, a lower pain threshold, and/or a history of illness or injury. The psychoanalytic view holds that somatoform disorders are caused by the repression of sexual conflicts and their conversion into physical symptoms. Other psychological factors include social isolation, high anxiety or stress, and catastrophic thoughts regarding bodily sensations. Social explanations suggest that the role of “being sick” is reinforcing. Parental models for injury or illness can also be influential. From a sociocultural perspective, somatoform disorders result from societal restrictions placed on women, who are affected to a much greater degree than men by these disorders. Additionally, social class, limited knowledge about medical concepts, and cultural acceptance of physical symptoms can play a role.

c h a p t e r

7

Stress Disorders

A

hmet and Hasan are male Turkish citizens in their 30s who were arrested, imprisoned, and tortured. Ahmet was imprisoned for several years and experienced a great deal of torture; Hasan was imprisoned for several weeks and experienced far less torture. . . . Why did Hasan, but not Ahmet, develop posttraumatic stress disorder? (Mineka & Zinbarg, 2006, p. 10) Nineteen adults who appeared to have had a massive heart attack after an emotional event (e.g., car accident, news of a death, surprise birthday party, armed robbery, court appearance) were found to have 30 times the normal level of adrenalin or epinephrine in their blood stream, an amount toxic to the heart and capable of producing heart failure. This reversible cardiac condition which is precipitated by emotional stress has been called the “broken heart” syndrome. (Wittstein et al., 2005) A 12-year longitudinal study focused on the impact of downsizing on employees. This study followed the remaining workforce of approximately 13,000 after a reduction of workers by nearly half over a period of one year. Of those studied, two-thirds showed health declines such as increases in heart attacks, strokes, obesity rates, depression, and substance abuse. However, one-third of the employees appeared to thrive. (Maddi, 2002)

Stressors are external events or situations that place a physical or psychological demand on a person. They range from chronic irritation and frustration to acute and traumatic events. Stress is an internal psychological or physiological response to a stressor. Something that disturbs one person doesn’t necessarily disturb someone else, and two people who react to the same stressor may do so in very different ways. Many people who are exposed to stressors, even traumatic ones, eventually move on with their lives. Other people show intense and somewhat long-lasting psychological or physical stress disorders. What leads some individuals to be more susceptible to stressors than others?

chapter outline Acute and Posttraumatic Stress Disorders

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Etiology of Acute and Posttraumatic Stress Disorders

177

Treatment of Acute and Posttraumatic Stress Disorders

181

Physical Stress Disorders: Psychophysiological Disorders 182 Etiology of Psychophysiological Disorders

192

Treatment of Psychophysiological Disorders

197

IM PLICA TION S

199

CRITICAL THINKING

The Hmong Sudden Death Syndrome

183

CONTROVERSY Can Laughter or Humor Influence the Course of a Disease? 191

175

FOCUSQUESTIONS

1 What are acute and posttraumatic stress disorders, and how are they diagnosed?

4 What role do stressors play in physical health, and what are the psychophysiological disorders?

2 What causes acute and posttraumatic stress disorders?

3 What are the different treatments for acute and

5 What causes psychophysiological disorders? 6 What methods have been developed to treat psychophysiological disorders?

posttraumatic stress disorders?

In the months following the earthquake that hit Los Angeles in 1994, there was an increase in cardiovascular deaths, from an average of 15.6 to 51 a day (Underwood, 2005). These deaths occurred primarily among vulnerable individuals with preexisting coronary heart disease or high blood pressure who succumbed due to emotional stress. Along with the involvement of stressors in physical problems such as headaches, high blood pressure, and asthma, stress-related psychological disorders such as acute and posttraumatic stress disorders can also develop. In this chapter we cover first the psychological disorders produced by traumatic stressors and then the physical illnesses, such as hypertension, that are stress related. As we will see, these disorders may be best explained by examining biological, psychological, social, and sociocultural dimensions using the multipath model.

Acute and Posttraumatic Stress Disorders

stressor an external event or situation that places a physical or psychological demand on a person

an internal psychological or physiological response to a stressor stress

acute stress disorder (ASD)

disorder characterized by anxiety and dissociative symptoms that occur within one month after exposure to a traumatic stressor posttraumatic stress disorder (PTSD) disorder characterized

by anxiety, dissociative, and other symptoms that last for more than one month and that occur as a result of exposure to extreme trauma

176

Acute stress disorder and posttraumatic stress disorder develop in response to an extreme psychological or physical trauma. Acute stress disorder (ASD) is characterized by anxiety and dissociative symptoms that occur within one month after exposure to a traumatic stressor. Posttraumatic stress disorder (PTSD) is characterized by anxiety, dissociative, and other symptoms that last for more than one month and that occur as a result of exposure to extreme trauma. For example, in a group of individuals directly affected by the terrorist attacks on September 11, 2001 (those who were in the World Trade Center complex during the attacks, who experienced injury in the attacks, or who had friend or relatives killed in the attacks), 12 percent developed PTSD (Marshall et al., 2007). The prevalence of PTSD is as high as 19 percent among veterans serving in Iraq or Afghanistan (Hoge et al., 2004; Seal et al., 2007). Other situations that may lead to PTSD include being sexually assaulted or a victim of a violent crime, domestic violence, school shooting (Curry, 2001), sexual harassment (O’Donohue et al., 2006), natural disaster, car accident, or other situation in which there is a fear of severe injury or death (National Institute of Mental Health [NIMH], 2007f).

Diagnosis of Acute and Posttraumatic Stress Disorders The diagnostic criteria for acute stress disorder and posttraumatic stress disorder are similar. They both necessitate an exposure to a traumatic stressor and differ primarily in onset (ASD within four weeks and PTSD at any time) and duration (ASD lasts two to twenty-eight days, and PTSD lasts longer than one month). An individual with an initial diagnosis of ASD is likely to receive a diagnosis of PTSD if the symptoms persist for more than four weeks. The following case illustrates the features and origins of PTSD:

Case Study I was raped when I was twenty-five years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling. Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn’t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out. (NIMH, 2007f, p. 7)

Etiology of Acute and Posttraumatic Stress Disorders

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In the National Comorbidity Survey, the lifetime prevalence of PTSD for American adults is 6.8 percent, with about twice as many women as men receiving the diagnosis (Kessler, Berglund, et al., 2005; NIMH, 2007f). Of the few studies available on ASD, lifetime prevalence rates from 14 to 33 percent of those exposed to traumatic stress have been reported (American Psychiatric Association, 2000a). However, the prevalence of ASD may be underestimated, as those with the symptoms may not seek treatment within the twenty-eight-day period that defines the disorder. The DSM-IV-TR diagnostic criteria for acute stress disorder and posttraumatic stress disorder are: 1. Exposure to a traumatic stressor that: (a) involved possible death or severe injury and (b) is experienced by the individual with intense fear or horror. IMPACT OF NATURAL CATASTROPHES Acute stress disorders as 2. The trauma is relived through intrusive and distress- a result of stress increased dramatically in the victims of Hurricane ing recollections of the event, flashbacks, nightmares, Katrina. Here Leona Watts sits in a chair in the wreckage of her intense physiological reactivity or distress when exposed home of sixty-one years. She had returned to look for some of her belongings. Not everyone develops a stress disorder after facing a to reminders of the event. One woman who had been catastrophe. Why? forced to play Russian roulette described flashbacks and nightmares of the event, “Different scenes came back, replays of exactly what happened, only the time is drawn out. . . . It seems to take forever for the gun to reach my head” (Hudson et al., 1991, p. 572). Did You Know? 3. Emotional numbing, or avoiding stimuli associated with the trauma. As a defense against intrusive thoughts, people may withdraw emotionally and may avoid • 37 percent of survivors who were anything that might remind them of the event. One Iraq veteran avoided social in the World Trade Center during events and cookouts: even grilling hamburgers reminded him of burning flesh the 9/11 attacks probably met that he was exposed to in Iraq (Keltner & Dowben, 2007). diagnostic symptoms for ASD. • 44 percent of those who were 4. Heightened autonomic arousal. This reaction can include symptoms such as not directly exposed to the 9/11 sleep disturbance, hypervigilance, irritability, and poor control over aggressive attacks but received information impulses. Veterans of the Iraq war can become “unglued” at the sound of a door about the event reported at slamming, a nail gun being used, or the click of a camera. An Iraq veteran who least one symptom of PTSD. The became so frustrated he almost attacked some strangers at a sports event explains number of hours spent watching his anger: “When friends say ‘I know where you’re coming from,’. . . How could news of the attacks was related they? They didn’t have to deal with insects, the heat, not knowing who is the to the severity of PTSD symptoms enemy, not knowing where the bullet is coming from” (Lyke, 2004, p. A8). In both ASD and PTSD, the acute reactions can be considered normative responses to an overwhelming and traumatic stimulus. Symptoms such as numbing, detachment, depersonalization, and dissociation can help the individual minimize awareness of traumatic memories and subsequently alleviate discomfort. Most victims show a marked decrease in symptoms with time (Delahanty, 2007; Shalev et al., 1998).

reported.

Source: Delahanty (2007).

Etiology of Acute and Posttraumatic Stress Disorders What are the factors associated with an increased risk of developing ASD or PTSD after exposure to trauma? Certainly the magnitude of the stressor may be very important in the development of PTSD. In a study of Cambodian refugee immigrants who had experienced multiple stressors, such as the deaths of family members, torture, extreme fear, and deprivation during their escapes, 86 percent met the criteria for PTSD (Carlson & Rosser-Hogan, 1991). Rape is also clearly a traumatic event. Immediately after a sexual assault, 74 percent of the victims met the criteria for ASD, and, after three months, 35 percent met the criteria for PTSD

178 TA B L E

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7.1

LIFETIME PREVALENCE EXPOSURE TO STRESSORS BY GENDER AND PTSD RISK LIFETIME PREVALENCE (%)

PTSD RISK

Male

Female

Male

Female

Life-threatening accident

25.0

13.8

6.3

8.8

Natural disaster

18.9

15.2

3.7

5.4

Threatened with weapon

19.0

6.8

1.9

32.6

Physical attack

11.1

6.9

1.8

21.3

0.7

9.2

65.0

45.9

Trauma

Rape

Note: Some traumas are more likely to result in PTSD than others. Significant gender differences were found in reactions to “being threatened with a weapon” and “physical attack.” What accounts for the differences in risk for developing PTSD among the specific traumas and for the gender differences? Source: From Ballenger et al. (2000).

Did You Know?

A

fter a traumatic event such as a terrorist attack or airplane crash, it is common to develop an exaggerated fear of vulnerability to the event. The real probability of death from each of these events is: • Auto accidents: 1 in 6,029 • Homicide: 1 in 25,123 • Hit by a car when walking: 1 in 46,960 • Terrorist attack: 1 in 97,927 • Pool drowning: 1 in 478,345 • Airplane crash: 1 in 619,734,440 person trips

Source: Marshall et al. (2007).

(Valentiner et al., 1996). These data support the contention that some extreme stressors may produce PTSD in almost everyone. Table 7.1 shows PTSD prevalence associated with specific stressors. There appears to be a strong correlation between the level of danger perceived from a trauma and the likelihood of developing PTSD. However, there is also evidence that PTSD symptoms can develop in individuals faced with repeated subtraumatic stressors, such as employment problems or marital distress (Astin et al., 1995; Scott & Stradling, 1994). Many social workers who worked with clients suffering from trauma also experienced intrusive memories, avoidance of stimuli associated with the traumatic stories, and anxiety when exposed to cues of the event. About 15 percent met the criteria for PTSD (Bride, 2007). If a situation meets all of the criteria for PTSD with the exception of exposure to a traumatic stressor, should there be a diagnosis of PTSD? More work needs to be done to clarify the nature of traumatic stressors in PTSD and to determine the necessity of direct experience with the trauma in the diagnosis of the disorder. Not everyone exposed to a traumatic event will develop one of the stress disorders. Other factors, such as the person’s individual characteristics, his or her perception of the event, and specific vulnerabilities, have an influence or moderate the impact of a traumatic event (La Greca & Silverman, 2006). In this section we use the multipath model to consider the biological, psychological, social, and sociocultural dimensions of the stress disorders, as shown in Figure 7.1.

Biological Dimension As compared with trauma-exposed individuals who do not have PTSD, those who develop the disorder show a sensitized autonomic system (Keltner & Dowben, 2007; Orr et al., 2000; Rauch, Shin, & Wright, 2003). There is some evidence that PTSD is not a biologically normative stress response but one in which a number of neural and biological systems are sensitized, resulting in hypersensitivity to stimuli that are similar to the traumatic event (Kennedy, 2002). The normal fear response involves the amygdala, the part of the brain that is the major interface between sensory experiences such as trauma and the neurochemical and neuroanatomical circuitry of fear. One’s response to a fear stimulus is rapid, occurring in milliseconds. The signal to the sympathetic nervous system produces increases in heart rate and blood pressure. Additional stress responses occur from the hypothalamic-pituitary-adrenal (HPA) axis, the neuroendocrine system involved in stress reactions and regulation of body processes such as the immune system, mood, digestion, and energy. When there is a fear response, cortisol is released. It is a major stress hormone that prepares the body for “fight or flight” by raising blood pressure, blood sugar level, and heart rate.

Etiology of Acute and Posttraumatic Stress Disorders

7.1

FIGURE MULTIPATH MODEL FOR PTSD The dimensions interact with one another and combine in different ways to result in PTSD.

Biological Dimension • • • •

Sensitized autonomic system HPA axis dysfunction Hippocampus atrophy Sensitized neural circuit

Psychological Dimension

Sociocultural Dimension • Low socioeconomic status • Gender differences • Immigration/refugee status

PTSD

179

• Preexisting anxiety or depression • Cognitive skill level • Meaningfulness of trauma

Social Dimension • History of childhood neglect or abuse • Lack of social support • Social isolation

Cortisol also helps restore homeostasis after the stressor is removed. Individuals with PTSD continue to demonstrate enhanced stress levels even when the stressor is no longer present. Why this is so is unclear. It is possible that chronic stress results in the inability to inhibit the sympathetic nervous system, resulting in a continued stress response (Koren, Hemel, & Klein, 2006). Some also hypothesize that long-term exposure to cortisol by brain structures such as the hippocampus can lead to cell damage, resulting in impaired memory and reexperiencing of the traumatic event (Townsend & Weisler, 2007). Smaller hippocampal volume has been found in individuals with PTSD, but it is unclear whether it is a result of exposure to stressors or represents a preexisting vulnerability (Koren et al., 2006). The nature of the alteration of the neurobiology of PTSD is still being investigated. The changes in sensitivity of the neural and biological systems may not be permanent, as over half of those with PTSD recover (Yehuda, 2000).

Psychological Dimension What are the preexisting or psychological contributions to developing a stress disorder? Specific psychological vulnerabilities have been identified, although the precise role they play varies from individual to individual. In a twin study, Gilbertson and colleagues (2006) studied forty-three Vietnam veterans and their twin brothers who had not been exposed to combat. Nineteen of the veterans developed PTSD, whereas none of the noncombatant twin brothers did. The researchers wanted to determine whether neuropsychological deficits in memory, attention, and intellectual functioning were the result of exposure to trauma or whether lower cognitive functioning is a preexisting risk. The researchers assessed the cognitive functioning of two sets of monozygotic (identical) twins. The researchers found the following results when comparing twin sets who did or did not develop PTSD: 1. The non-combat-exposed twin of the one who developed PTSD showed similar cognitive performance to that of his brother. This leads to the conclusion that lower cognitive functioning was not due to exposure to combat. 2. The cognitive performance of the twin pair who developed PTSD was significantly lower than that of the twin set without PTSD. Lower cognitive functioning may serve as a vulnerability to PTSD. However, Gilbertson and colleagues point out that most of the twins scored in the normal range on the cognitive tests. In other words, above-average cognitive

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Did You Know?

P

TSD was not officially recognized as a diagnosis until 1980, but its symptoms have been recorded throughout history and known by different names: • Soldier’s heart in the Civil War (most prevalent among soldiers ages 9–17) • Shell shock in World War I • Battle fatigue in World War II • Post-Vietnam syndrome after the Vietnam War Source: Pizarro, Silver, & Prause (2006).

skills seemed to act as a protective factor. Why this occurs and which cognitive skills are important in PTSD is not known. Preexisting conditions such as trait anxiety and depression were found to be risk factors for the development of PTSD among youths exposed to Hurricane Katrina (Weems et al., 2007). Also, individuals who are anxiety prone and who score high on the characteristic of neuroticism (Breslau, Davis, & Andreski, 1995) appear to be more vulnerable to PTSD. Individuals with higher anxiety may react much more strongly to a traumatic event. Other psychological factors may also play a role. Disaster survivors with psychiatric histories were more likely to develop PTSD than those without previous disorders (North, Smith, & Spitznagel, 1997). One study showed that war veterans who developed PTSD were more likely to have sustained injuries, engaged in firefights, come closer to their own deaths, and witnessed others die (Hoge et al., 2004). Because a traumatic event precipitates the disorder, several researchers (Orr et al., 1995; Yehuda & McFarlane, 1995) believe that classical conditioning is involved. People who have PTSD often show reactions to stimuli present at the time of the trauma (e.g., darkness, time of day, smell of diesel fuel, propeller noises). According to this perspective, the reason that extinction does not occur is that the individual avoids thinking about the situation.

Social Dimension Poor or inadequate support during childhood has also been identified as possibly contributing to the development of the stress disorders (Bremner et al., 1993). Individuals who are more socially isolated and without an adequate support system appear to be more vulnerable (Schnurr, Friedman, & Rosenberg, 1993). In one study, those who reported low social support in the six months prior to exposure to the 9/11 attacks were more than twice as likely as those with high levels of social support to report symptoms of PTSD (Galea et al., 2002). The lack of social support after experiencing a trauma may be more important than the influences of childhood abuse and family history (Brewin, Andrews, & Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003).

Sociocultural Dimension Recent immigrants and refugees from countries in which there have been civil disturbances or conflict may have elevated rates of the stress disorders (Sue & Sue, 2008a). PTSD AND ABUSE In this photo, Cheryl, center, consoles Catherine, twenty-four, during group therapy. Catherine is reliving the physical and emotional abuse she received during her childhood. Posttraumatic stress disorder is not isolated to combat situations. Women who have been battered or have suffered sexual assaults often report high rates of acute stress or posttraumatic stress disorder.

Treatment of Acute and Posttraumatic Stress Disorders

Ethnic differences in response patterns were seen in a survey of 1,008 New York adult residents following the terrorist attacks of 9/11; 3.2 percent of Asian Americans, 6.5 percent of white Americans, 9.3 percent of African Americans, and 13.4 percent of Hispanic Americans reported symptoms consistent with PTSD (Galea et al., 2002). Women are also twice as likely as men to suffer from a stress disorder (Galea et al., 2002; NIMH, 2007f). This may result from an inherent vulnerability or from greater exposure to stressors that are likely to result in PTSD. In analyzing the data from the National Violence Against Women Project, Cortina and Kubiak (2006) concluded that the greater prevalence of stress disorders in women was due to more exposure to violent interpersonal situations. In a similar fashion, Tolin and Foa (2006) performed a meta-analysis of studies to determine whether gender differences existed in terms of PTSD vulnerability. When they controlled for exposure to interpersonal violence, the difference in rates of PTSD between men and women was reduced, but not eliminated, suggesting that additional factors are involved in the gender differences in prevalence.

Treatment of Acute and Posttraumatic Stress Disorders SSRI antidepressant medication (Zoloft, Paxil, Prozac) has been successful in the treatment of ASD and PTSD (Nacasch et al., 2007). These medications alter serotonin levels, acting at the level of the amygdala and its connections and desensitizing the fear network. Depending on the specific medication, 50 to 85 percent report much or very much improvement in symptom relief, although from 17 to 62 percent of those on placebos also report the same degree of improvement (Davidson, 2000). However, discontinuation rates are twice as high with medication as compared with behavioral treatments (Davidson, 2000; Foa, 2000), perhaps due to side effects such as insomnia, diarrhea, nausea, fatigue, and depressed appetite. Exposure to cues associated with the trauma appears to be effective in treating PTSD (Basoglu, Livanou, & Salcioglu, 2003; Nacasch et al., 2007; Foa, 2000; Taylor et al., 2003). The process of exposure may involve asking the person to re-create the traumatic event in his or her imagination. In one study of victims of sexual assault (Foa et al., 1999), the women were asked to repeatedly imagine and describe the assault “as if it were happening now.” They verbalized the details of the assault, as well as their thoughts and emotions regarding the incident. Their descriptions were recorded, and this process was repeated for about an hour. The women were then instructed to listen to the recordings once a day and, when doing so, to “imagine that the assault is happening now.” This process allowed extinction to occur. It is believed that the more accurate the imagined details, the more effective the therapy will be. Exposure also appears to effectively correct erroneous cognitions associated with the traumatic event. Cognitive factors may also account for some of the symptoms of PTSD. Battered women with PTSD have thoughts associated with guilt or self-blame. Cognitions such as “I could have prevented it,” “I never should have . . . ,” and “I’m so stupid” maintain the symptoms of PTSD. In one study, the condition remitted in 87 percent of battered women who underwent the following procedure (Kubany et al., 2004): 1. Psychoeducation about PTSD, along with the rationale for exposure homework 2. Exposure homework assignments that involved watching movies on domestic violence and/or looking at pictures of the abusive partner 3. Psychoeducation about the importance of developing a solution-oriented attitude and the role of negative self-talk in perpetuating the symptoms of PTSD 4. Cognitively based homework assignments that identified guilt thoughts 5. Exercises employed to correct thinking errors 6. Psychoeducation about stress management and training in muscle relaxation

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PTSD AND THE MILITARY The 2nd Brigade combat team from Fort Carson, Colorado, suffered heavy casualties in Iraq. Many of the soldiers in the unit suffered from PTSD. However, the army was not always receptive to complaints related to PTSD. An investigation showed systematic abuse of soldiers with this disorder. Tyler Jennings, Corey Davis, and Alex Orum all received a diagnosis of PTSD and suffered mistreatment by the army.

Physical Stress Disorders: Psychophysiological Disorders Case Study The data from 200 patients who happened to have defibrillators implanted before the World Trade Center attack on September 11, 2001, provided interesting information regarding the impact of the stressful event. The defibrillators, which record serious arrhythmias, showed that the frequency of lifethreatening tachyarrhythmias increased twofold for thirty days after 9/11. (Steinberg et al., 2004)

“Broken heart” syndrome and the illnesses suffered by individuals as a result of the stress discussed at the beginning of the chapter illustrate the impact that stressors can have on physical conditions. Most researchers now acknowledge that attitudes and emotional states can have an impact on physical well-being. In the past, physical disorders such as asthma, hypertension, and headaches that stem from stressors were called psychosomatic disorders. The use of this term was meant to distinguish disorders from conditions considered strictly physical in nature. Mental health professionals now recognize, however, that almost any physical disorder can have a strong psychological component or basis. Although the psychosomatic disorders were previously considered a separate class of disorders, DSM-IV-TR (American Psychiatric Association, 2000a) does not categorize them as such. Instead, it contains the category “Psychological Factors Affecting Medical Conditions.” This classification acknowledges the belief that both physical and psychological factors are involved in all human processes. The term psychosomatic disorder has been replaced with psychophysiological disorder, meaning any physical disorder that has a strong psychological basis or component.

Myth vs Reality Myth: Psychophysiological disorders are merely psychological in nature and can be treated with only psychotherapy. Real physical problems are not present.

psychophysiological disorder

any physical disorder that has a strong psychological basis or component

Reality: Although psychophysiological disorders do have a psychological component, actual physical processes or conditions are involved. They differ from conversion reactions that are only psychological in nature. Any physical condition can be considered a psychophysiological disorder if psychological factors are implicated etiologically, if they make the condition worse, or if they delay improvement. In most cases, both medical and psychological treatments are needed.

Physical Stress Disorders: Psychophysiological Disorders

183

critical thinking

The Hmong Sudden Death Syndrome

V

ang Xiong is a former Hmong (Laotian) soldier who, with his wife and child, resettled in Chicago in 1980. The change from his familiar rural surroundings and farm life to an unfamiliar urban area must have produced a severe culture shock. In addition, Vang vividly remembered seeing people killed during his escape from Laos, and he expressed feelings of guilt about having to leave his brothers and sisters behind in that country. He reported having problems almost immediately. [He] could not sleep the first night in the apartment, nor the second, nor the third. After three nights of sleeping very little, Vang came to see his resettlement worker, a bilingual Hmong man named Moua Lee. Vang told Moua that the first night he woke suddenly, short of breath, from a dream in which a cat was sitting on his chest. The second night, the room suddenly grew darker, and a figure, like a large black dog, came to his bed and sat on his chest. He could not push the dog off, and he grew quickly and dangerously short of breath. The third night, a tall, white-skinned female spirit came into his bedroom from the kitchen and lay on top of him. Her weight made it increasingly difficult for him to breathe, and as he grew frantic and tried to call out he could manage but a whisper. He attempted to turn onto his side, but found he was pinned down. After fifteen minutes, the spirit left him, and he awoke, screaming. (Tobin & Friedman, 1983, p. 440)

As of 1993, 150 cases of sudden death among Southeast Asian refugees had been reported. Almost all were men,

with the possible exception of one or two women; most occurred within the first two years of residence in the United States. Autopsies produced no identifiable cause for the deaths. Some cases of sudden unexplained deaths have also been reported in Asian countries (Aoki et al., 2003). Although the number of cases is declining, these deaths remain a most puzzling phenomenon (Gib Parrish, Centers for Disease Control, personal communication, 1993). All of the reports were the same: a person in apparently good health went to sleep and died in his or her sleep. Often, the victim displayed labored breathing, screams, and frantic movements just before death. Some consider the deaths to represent an extreme and very specific example of the impact of psychological stress on physical health. Vang was one of the lucky victims of the syndrome—he survived it. He went for treatment to a Hmong woman, Mrs. Thor, who is a highly respected shaman in Chicago’s Hmong community. She interpreted his problem as being caused by unhappy spirits and performed the ceremonies required to release them. After that, Vang reported he had no more problems with nightmares or with his breathing during sleep. In many nonwestern cultures, physical or mental problems may be attributed to supernatural forces such as witchcraft or evil spirits (Sue & Sue, 2008a). When differences in perspectives regarding illnesses exist, how should they be dealt with? Should Vang have been given antianxiety medications? Why was the spiritual treatment successful?

Characteristics of Psychophysiological Disorders Psychophysiological disorders involve actual tissue damage (such as coronary heart disease), a disease process (immune impairment), or physiological dysfunction (as in asthma or migraine headaches). Both medical treatment and psychotherapy are usually required. The relative contributions of physical and psychological factors in a physical disorder may vary greatly. Although psychological events are often difficult to detect, repeated association between stressors and the disorder or its symptoms should increase the suspicion that a psychological component is involved. In this section we discuss several of the more prevalent psychophysiological disorders—coronary heart disease, hypertension (high blood pressure), headaches, and asthma—and then consider the evidence suggesting a connection between stress and disease as a result of decreased immunological functioning. Research identifying biological, psychological, social, and sociocultural dimensions of the specific psychophysiological disorders is also reviewed.

Coronary Heart Disease Coronary heart disease (CHD) involves the narrowing of cardiac arteries, resulting in the restriction or partial blockage of the flow of blood and oxygen to the heart. Symptoms of CHD may include chest pain (angina pectoris), heart attack, or, in severe cases, cardiac arrest. Approximately 452,300 Americans die of coronary heart disease each year, although the rate has been declining (American Heart Association, 2007).

coronary heart disease (CHD)

the narrowing of cardiac arteries, resulting in the restriction or partial blockage of the flow of blood and oxygen to the heart

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Stress plays a role in coronary heart disease from both a biological and psychological perspective. Stress, resulting in the A release of hormones that activate the sympathetic nervous system, can lead to changes in heart rhythm, such as ventricular fibrillation (rapid, ineffective contractions of the heart), bradycardia (slowing of the heartbeat), tachycardia (speeding up of the heartB beat), or arrhythmia (irregular heartbeat). Figure 7.2 shows an example of ventricular fibrillation. Psychological factors are also implicated in cardiovascular disease. In a sample of 335 older adults in Pittsburgh, diary ratings of stressful demands and levels of perceived control in daily life were obtained. Individuals who perceived greater daily stress and lower control were found to have thickening of the lining of the carotid artery, a marker of atherosclerosis (Kamarck et al., 2007). Chronic work stress has been found to be related to an increased risk of a second heart attack. Workers in their forties or fifties were interviewed regarding their lifestyle and work stress (heavy workload, time demands, and little control) six weeks after returning to work FIGURE VENTRICULAR DEFIBRILLATION IN following a heart attack, and then two and six years after their heart SUDDEN UNEXPLAINED DEATH A Thai man fitted with a defibrillator showed ventricular episodes (rapid spikes on attacks. During the six-year follow-up, of the 972 workers who had the graph) when asleep. A represents a transient episode had heart attacks, 111 had a second, nonfatal heart attack, 13 died that resolved itself. B depicts a sustained ventricular episode of heart disease, and 82 were hospitalized for chest pain. People accompanied by labored breathing that set off the defibrillator, who reported high levels of work stress during the first two interwhich normalized the heart rate. Is this the explanation for the views were twice as likely to be in the group with heart attacks or sudden unexplained death syndrome? cardiovascular complications (Aboa-Eboule et al., 2007). Source: Nademanee et al. (1997). In a longitudinal study, depression seems to be a risk factor for cardiac mortality, both in individuals who had and did not have cardiac disease at the beginning of the study. The risk was twice as high for those with major than with minor depression, although any depression was associated with increased mortality (Penninx et al., 2001). Studies suggest that both psychological and social variables, such as hostility, and childhood experiences, such as physical, sexual, or emotional abuse, may be contributory factors that produce certain pathogenic physiological changes (Richards, Alvarenga, & Hof, 2000; Underwood, 2005). Psychological and social factors have been shown to directly affect physiological processes that influence both blood coagulation and increases in blood pressure, thereby increasing the thickness of artery walls and contributing to CHD (Harenstam, Theorell, & Kaijser, 2000; Kamarck et al., 2004).

7.2

Hypertension Case Study On October 19, 1987, the stock market drastically dropped 508 points. By chance, a forty-eightyear-old stockbroker was wearing a device measuring stress in the work environment on that day. The instrument measured his pulse every fifteen minutes. At the beginning of the day, his pulse was sixty-four beats per minute and his blood pressure was 132 over 87 (both rates within the normal range). As stock prices fell dramatically, the man’s physiological system surged in the other direction. His heart rate increased to eighty-four beats per minute and his blood pressure hit a dangerous 181 over 105. His pulse was “pumping adrenaline, flooding his arteries, and maybe slowly killing him in the process.” (Tierney, 1988)

essential hypertension a chronic condition characterized by blood pressure of 140 (systolic) over 90 (diastolic) or higher

This reaction illustrates the impact of a stressor on blood pressure, the measurement of the force of blood against the walls of the arteries and veins. Many people who experienced the stock market plunge that occurred after the terrorist attacks on 9/11 or who survived the exploding and collapsing buildings at the World Trade Center may also have shown dangerously high levels of blood pressure. We all experience a transient physiological response to stressors, but in some people, it develops into a chronic condition called essential hypertension, a blood pressure of 140 (systolic) over 90 (diastolic) or higher. Essential hypertension is found in about 29 percent of

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185

50 45 40

Percent

35 30 25 20 15 10 5 0

Non-Hispanic African White American

Men

FIGURE

Mexican American

Asian American

American Indian

All individuals 50 or older

Women

7.3

GENDER AND ETHNIC DIFFERENCES IN HYPERTENSION AMONG U.S. ADULTS The highest prevalence of chronic high blood pressure occurs among African Americans and among all individuals over the age of fifty. Women tend to score somewhat lower than other groups. Biological, psychological, social, and sociocultural factors have been implicated in the gender and ethnic differences in hypertension.

Source: Data from Burt et al. (1995); American Heart Association (2007).

STRESS AND HYPERTENSION On September 11, 2001, many survivors of the World Trade Center recounted the terror they felt during the attack and their fight for survival. Onlookers were also horrified to see people jump to their deaths; many people barely escaped the collapsing building. The survivors and observers went through a traumatic event that produced severe physiological reactions. What was happening to them?

the U.S. adult population. Over 72 million have high blood pressure that needs treatment (American Heart Association, 2007). However, 30 percent are unaware of their hypertension, and more than 40 percent are not being treated (Chobanian et al., 2003). Three-quarters of women and two-thirds of men over the age of seventy-five have hypertension (Centers for Disease Control, 2005). It is most prevalent in the African American population and older adults (American Heart Association, 2007). Chronic hypertension may lead to arteriosclerosis (narrowing of arteries) and to increased risk of strokes and heart attacks. Figure 7.3 shows some gender and ethnic comparisons of hypertension among adults. Biological, psychological, social, and sociocultural factors appear to have interrelated roles in the development of hypertension. Individuals placed under stress experience significant increases in blood pressure (Bishop et al., 2003; Smith, Ruiz, & Uchino, 2000). Individuals with high blood pressure have exhibited exaggerated reactions to a stressor compared with their counterparts with normal or borderline high blood pressure (Tuomisto, 1997). A familial component may also be involved. In examining cardiovascular stress reactivity among monozygotic and dizygotic twins, genetic factors were found to contribute significantly to blood pressure (De Geus et al., 2007). Psychological and social aspects of gender may also be involved in the development of hypertension. In a study by Lai and Linden (1992), men and women were evaluated on emotional expressiveness and classified as either “anger in” (suppressing anger) or “anger out” (expressing anger). They were then exposed to verbal harassment and either allowed to release their anger or inhibited from doing so. Men displayed greater cardiovascular reactivity to the harassment than did women. The opportunity to release anger facilitated heart rate and blood pressure recovery in men but not in women. Holding in anger did not produce the strong negative physiological reactions in women that it did in men. The researchers hypothesized that these differences in recovery patterns may be due to the differential socialization of males and females. Sociocultural factors, such as living in crowded neighborhoods and working in stressful occupations, are also associated with high blood pressure (Ely & Mostardi, 1986; Fleming et al., 1987).

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ETHNICITY AND HYPERTENSION David Thomas was buying groceries and decided to get a blood pressure check at a clinic located in the store. He found that he was a prime candidate for a stroke and received blood pressure treatment along with his bread. African Americans have much higher rates of hypertension than their white counterparts, whereas Asian Americans and American Indians have much lower rates. What factors may account for the large between-group differences?

Migraine, Tension, and Cluster Headaches Case Study A forty-two-year-old woman described her headaches as a throbbing that pulsed with every heartbeat. The pain was accompanied by visual effects, such as sparklers flashing across her visual field. The symptoms would last for up to three days. (Adler & Rogers, 1999) Frank Weeden describes his headaches in the following manner: “It feels like someone walked up to me, took a screwdriver and jammed it up in my right eye and kept digging it around for 20 minutes.” (Linn, 2004, p. A1)

Headaches are among the most common psychophysiological complaints. About 90 percent of males and 95 percent of females have at least one headache during a given year. Over 45 million Americans suffer from chronic, recurring headaches (Meeks, 2004). The pain of a headache can vary in intensity from dull to excruciating. Although we discuss migraine, tension, and cluster headaches separately, the same person can be susceptible to more than one type of headache. (Figure 7.4 illustrates some differences among the three types.) A number of biological, psychological, social, and sociocultural factors have been associated with the onset of headaches, including stress, negative emotions, sexual harassment, poor body posture, eyestrain, exercise, too much or too little sleep, exposure to smoke or strong odors, the weather, temperature changes, and changes in altitude (Martin & Seneviratne, 1997; National Institute of Neurological Disorders and Stroke [NINDS], 2007a; Silberstein, 1998). In an experiment, Martin and Seneviratne (1997) attempted to verify that food deprivation and negative emotions can precipitate headaches. For nineteen hours, they either withheld food from thirty-eight women and eighteen men who suffered from migraine or tension headaches or exposed them to a stressor that produced negative emotions (difficult-to-solve anagrams). The findings supported the view that the two conditions can induce headaches. Individuals who had been deprived of food or subjected to the anagrams reported both more headaches and headaches of greater intensity than individuals who had been allowed to eat or were not exposed to stress. migraine headache moderate to severe pain resulting from constriction of the cranial arteries followed by dilation of the cerebral blood vessels

Migraine Headaches Moderate to severe pain resulting from constriction of the cranial arteries followed by dilation of the cerebral blood vessels are the distinguishing features of migraine headaches. Anything that affects the size of these blood vessels, which are connected to sensitive nerves, can produce a headache. Thus certain chemicals, such as sodium nitrate (found in hot dogs), monosodium glutamate, and

Physical Stress Disorders: Psychophysiological Disorders

Migraine

Tension

187

Cluster

Headache

Location

Often one side of head but location varies

Both sides of head, often concentrated

Centered on one eye on same side of head

Duration

Hours to 4 days

Hours to days

Usually less than an hour

Severity of Pain

Mild to severe

Mild to moderate

Excruciating

Nausea, sensitivity to light, sound, odors, and movement

Tightness or pressure around neck, head, or shoulders

Eye often teary, nose clogged on side of head with pain; pacing and rubbing head

Sex Ratio

More common in young adult women

More common in women

More common in men

Heredity

Often hereditary

Probably not hereditary

Not hereditary

Symptoms

FIGURE

7.4 THREE TYPES OF HEADACHES

Source: Data adapted from “Headaches” (2006); Silberstein (1998).

tyramine (found in red wines), can produce headaches by distending blood vessels in certain people. Pain from a migraine headache may be mild, moderate, or severe. It may last from a few hours to several days and is often accompanied by nausea and vomiting. Migraines affect nearly 12 percent of the U.S. adult population, most commonly young adult women (Hamelsky & Lipton, 2006; Marquardt, 2000). A nationwide survey (Stewart et al., 1992) revealed that migraine headaches were common not only among women but also among people with lower incomes. They are less common among African Americans than among white Americans. Among young children and adolescents, 8 million have migraines. During childhood, migraines appear to occur at about the same rates among boys and girls. After puberty, the headaches become more common in females (Silberstein, 1998). Migraine headaches appear to involve a biological predisposition, such as greater reactivity of the blood vessels in the brain that respond to physical and psychological stressors. The precise mechanism involved, however, is not known. Physical treatments such as drug therapy, eliminating certain foods associated with migraines, and exercise can reduce symptoms. Several psychological interventions, such as relaxation, cognitive therapy, and biofeedback, have also been used to treat headaches (NINDS, 2007). Tension Headaches Tension headaches are produced by prolonged contraction of the scalp and neck muscles, resulting in vascular constriction and steady pain. They are the most common form of headache and tend to disappear once the stress producing the muscle tension is over (NINDS, 2007). In one study, psychological factors were found to precipitate the headaches in up to 61 percent of the patients,

tension headache produced by prolonged contraction of the scalp and neck muscles, resulting in vascular constriction and steady pain

188 FIGURE

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7.5 AN ASTHMA

Bronchiole

Alveoli

ATTACK Asthma attacks and deaths have increased dramatically since the 1980s.

Mucous gland Air passage Cell lining Smooth muscle

Source: Cowley & Underwood (1997, p. 61).

Healthy bronchiole: When they're clear and relaxed, the small airways accommodate a constant flow of air. Mucous secretion Constricted air passage Contracted muscle

Bronchiole network: Air is distributed

Asthmatic bronchiole: During an attack,

throughout the lungs via small airways known as bronchioles.

mucus and tight muscles narrow the airways and interfere with breathing.

most of whom were women (Martin & Seneviratne, 1997). Tension headaches are generally not as severe as migraine headaches, and they can usually be relieved with aspirin or other analgesics. A population-based study (Schwartz et al., 1998) of 13,345 people revealed some prevalence rates for tension headaches. Episodic tension headaches are relatively common, with an overall yearly prevalence rate of 38.4 percent. The rate peaks between the ages of thirty and thirty-nine. More women than men get these headaches, and whites had a higher prevalence of tension headaches (40.1 percent for men, 46.8 percent for women) than did African Americans (22.8 percent for men, 30.9 percent for women). Interestingly, headaches were more frequently reported among the most educated individuals, with the highest rates occurring for those who have a graduate school education (at nearly 49 percent for both men and women). Cluster Headaches Cluster headaches are excruciating stabbing or burning sensations located in the eye or cheek. Episodic cluster headaches occur in cycles, and incapacitating attacks can occur a number of times a day (Meeks, 2004). Each attack may last from fifteen minutes to three hours before ending abruptly. Along with the headache, the individual may experience tears or a stuffy nose on the same side of the head on which the pain is felt (Silberstein, 1998). The cycles may last from several days to months, followed by pain-free periods. In those with chronic cluster headaches, no more than one week passes without a headache. Only about 10 to 20 percent of cluster headaches are of the chronic type. Cluster headaches do not appear to run in families and, in contrast to other headaches, are more common in men (Silberstein, 1998).

Asthma

cluster headache excruciating stabbing or burning sensations located in the eye or cheek asthma chronic inflammatory disease of the airways in the lungs

Asthma is a chronic inflammatory disease of the airways in the lungs. Bronchiospasms, excessive mucus secretion, and edema constrict the airways, making it difficult to completely empty the lungs and thereby reducing the amount of air that can be inhaled (see Figure 7.5). Symptoms range from mild and infrequent to severe daily wheezing with the need to seek emergency care. In severe asthma attacks, respiratory failure can occur. In the United States, asthma has increased dramatically since the 1980s. It afflicts up to 20 million individuals, with a disproportionate recent increase among women (Asthma and Allergy Foundation of America, 2007). Ethnic minority children living in inner cities are more vulnerable to asthma. In one study involving 654 Hispanic

Physical Stress Disorders: Psychophysiological Disorders

FIGURE Female1 6.4

Mexican1

5.0

Puerto Rican1

17.0

Total Hispanic1

6.2

1

Non-Hispanic black

Source: National Center for Health Statistics (2007).

9.4

Non-Hispanic white1

7.6

Asian1

4.9

American Indian/Alaska native1

9.2

1

Black

9.5

1

White

7.4

18 years and over

7.2

0–17 years

8.9

Total

7.7

0

5

10

15

20

Percent 1

7.6

PERCENT OF CURRENT ASTHMA PREVALENCE: UNITED STATES, 2005 This figure shows the prevalence of asthma among different groups. Puerto Rican, African Americans, American Indians, women, and those up to the age of seventeen appear to be especially vulnerable.

8.8

Male1

189

Age adjusted to 2000 U.S. standard population.

American children between the ages of nine and twelve, nearly 28 percent had symptoms of asthma (Christiansen et al., 1996). High rates of asthma have also been reported among Puerto Rican children (Ortega et al., 2004) and among multiracial, Native American, and African American children. The prevalence is lowest among Asian American and Native Hawaiian children (Rhodes, Bailey, & Moorman, 2004). Puerto Ricans and African Americans are over three times more likely to die from asthma than other Americans (National Center for Health Statistics, 2007). Figure 7.6 shows the current asthma prevalence among different groups. Many of the deaths that occur from asthma may happen because the individual or others underestimate the severity of the attack and delay seeking assistance; people with asthma seem to have a poor perception of air flow obstruction. Some fail to notice when their airflow is reduced even by 50 percent (Stout, Kotses, & Creer, 1997). Asthma appears to have a diurnal variation: symptoms often are worse during the night and early morning. Biological, psychological, social, and sociocultural factors appear to all play a role in the development of asthma. First, asthma can be triggered by allergies and may have a genetic component. For example, the chance that a child will have asthma if one parent has asthma is one in three. If both parents have asthma, the chances increase to seven in ten (Asthma and Allergy Foundation of America, 2007). The recent increase in the number of asthma cases in the United States is puzzling. Suspicion grows that a number of different pollutants (cigarette smoke, air pollution, pet hair and dander, indoor molds, and cockroaches) may be responsible. Rosenstreich, Eggleston, and Kattan (1997) examined 476 children with asthma who lived in inner cities. They found that 23 percent were allergic to pets, 35 percent to dust mites, and 37 percent to cockroaches. Allergy to cockroaches had the highest association with emergency room treatment, hospitalization, and school absences in these children. A program to reduce environmental allergens within the houses of children with asthma was associated with a reduction in symptoms (Morgan et al., 2004).

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Although pollutants may be responsible for the increase in asthma cases, psychological, social, and sociocultural factors seem to be important in producing attacks. Higher hostility levels among African American men and white women were associated with significant reductions in lung function. White men with high hostility scores did not show this reduction. It is possible that hostility has stronger consequences for women and minority men than for white men (Jackson, Kubzansky, Cohen, & Jacobs, 2007). Children who have parents with asthma are more likely to develop this condition if their family environment is characterized as being negative when compared to children with asthmatic parents who did not provide poor or conflictual parenting (McCarthy, 2002). Emotional arousal has been found to be associated with decreased size of the airways in the lungs (Isenberg, Lehrer, & Hochron, 1992) and feelings of breathlessness in individuals with asthma (Rietveld, Everaerd, & van Beest, 2000). In one study (Fritz, Rubenstein, & Lewiston, 1987), psychological factors such as depression and family conflicts were found to be the main causes in 18 percent of individuals with this disorder. However, asthma in a child might be the cause of family conflict rather than being the result of family problems (Chen, Bloomberg, et al., 2003).

Stress and the Immune System

UNDER ATTACK This highly magnified photo shows the surface of a T-cell that is infected with the HIV virus. T-cells function as a part of the immune response to viruses and infections. In this case it is being compromised. Some believe that one’s attitude can influence the susceptibility of components of the immune system such as T-cells, whereas others disagree.

We have already suggested a relationship between stress and illness. How do emotional and psychological states influence the disease process? We know that stress is related to illness, but what is the precise relationship between the two? How does stress affect health? Stress itself does not appear to cause infections, but it may decrease the immune system’s efficiency, thereby increasing a person’s susceptibility to disease. The white blood cells in the immune system help maintain health by recognizing and destroying pathogens such as bacteria, viruses, fungi, and tumors. In an intact system, over one thousand billion white blood cells circulate through the bloodstream. Two major classes of white blood cells are lymphocytes and phagocytes. Lymphocytes include B-cells (which produce antibodies against invaders), T-cells (which detect and destroy foreign cells), and natural-killer (NK) cells (which act as an early detection system to prevent the growth of tumors). Phagocytes similarly respond to infection (Cohen & Herbert, 1996; Kiecolt-Glaser & Glaser, 1993). As mentioned earlier, stress produces physiological changes in the body. Part of the stress response involves the release of several neurohormones that impair immune functioning. Corticosteroids, for example, have very strong immunosuppressive actions and are often used to suppress immunity caused by allergic reactions. Endorphins, although also associated with positive effects, such as the production of a sense of well-being, can inhibit or decrease natural-killer cells’ tumor-fighting ability. A deficient immune system may fail to detect invaders or produce antibodies. The ability to fight infection may be impaired, or its blood cells may be unable to multiply. Because of the weakening in defenses, infections and diseases are more likely to develop or worsen. Exposure to chronic stress does appear to increase vulnerability to upper respiratory infection and accelerates the progression of disease (Miller, Chen, & Zhou, 2007). Cohen and his associates (1998) had 276 volunteers complete a life stressor interview, after which they were evaluated to determine whether they were ill. Those who were healthy were then quarantined and given nasal drops containing cold viruses to determine whether they would develop a cold within five days. Of this group, 84 percent became infected with the virus, but only 40 percent developed cold symptoms. Types of life stressors varied for those who did and did not develop colds. Participants with acute stressful life events lasting less than one month tended not to develop colds. In contrast, those who suffered severe stress for one or more months were much more likely to develop colds. The types of chronic stressors most closely related to colds were long-term conflicts with family or friends and either unemployment or underemployment. Although deteriorations in immune system functioning may be related to vulnerability to certain diseases, can they influence processes such as cancer? Consider the following case:

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191

controversy

Can Laughter or Humor Influence the Course of a Disease?

C

lown noses, whoopee cushions, and the antics of the Three Stooges can produce laughter. Can humor reduce the severity of a physical illness or even be curative? Norman Cousins, who suffered from rheumatoid disease, described how he recovered his health through laughter. He claimed that ten minutes of laughter would provide two hours of pain relief (Cousins, 1979). In 1999, Patch Adams, a physician who used humor with his patients, received an award for “excellence in the field of therapeutic humor” at the American Association of Therapeutic Humor. Ohio psychologist Steve Wilson quit clinical practice in 1998 to found the World Laughter Tour and to teach classes in therapeutic laughter. He believes humor can reduce the need for pain medication, possibly boost immune functioning, and lower blood pressure (“Psychosomatic Medicine,” 2004). Some research shows that exposing participants to humorous videos reduces stress and improves immune system functioning (Bennett, Zeller, Rosenberg, & McCann, 2003). However, the evidence is mixed and relatively weak (Bennett & Lengacher, 2006). How might humor influence the disease process? Several routes are possible:

1. Humor may have a direct impact on physiological functioning. 2. Humor may influence people’s beliefs about their ability to carry out health-promoting behaviors and give them greater confidence that their actions can relieve the illness. 3. Humor may serve as a buffer between exposure to stressors and the development of negative states, such as depression, which have been found to be related to the development or severity of physical conditions. 4. Humor may make an individual more likely to receive social support from friends and family. For Further Consideration 1. How would you respond to researchers who might argue that laughter and humor are ineffective in slowing the progression of a disease such as cancer and that it is disrespectful to furnish patients with false hope? 2. Knowing that humor does produce physiological changes in the body, what are some criticisms of studies that indicate that it has little impact on the disease process?

Case Study Anne was an unhappy and passive individual who always acceded to the wishes and demands of her husband. She had difficulty expressing strong emotions, especially anger, and often repressed her feelings. She had few friends and, other than her husband, had no one to talk to. She was also depressed and felt a pervasive sense of hopelessness. During a routine physical exam, her doctor discovered a lump in her breast. The results of a biopsy revealed that the tumor was malignant.

Could Anne’s personality or emotional state have contributed to the formation or the growth of the malignant tumor? If so, how? Could she now alter the course of her disease by changing her emotional state and thereby improving her immune functioning? Several problems exist in research that investigates the relationship between moods and personality on cancer (Honda & Goodwin, 2004). First, cancer is a general name for a variety of disease processes, each of which may have a varying susceptibility to emotions. Second, cancer develops over a relatively long period of time. Determining a temporal relationship between its occurrence and a specific mood or personality is not possible. Third, most studies examining the relationship between psychological variables and cancer have been retrospective—that is, personality or mood states were assessed after the cancer was diagnosed. The discovery that one has a life-threatening disease can produce a variety of emotions. People who receive the life-threatening diagnosis of cancer may respond with depression, anxiety, and confusion. Thus, instead of being a cause, negative emotions may be a result of the knowledge of having a life-threatening disease. Do stress, emotional difficulties, or personality characteristics increase the chance that a person will develop cancer or increase the cancer’s severity if it does occur? Certain emotions and stressors have been associated with a less efficient immune system, and under these conditions cancer might be more likely to gain a foothold. Nevertheless, the connection between stress and naturally occurring cancers has yet to

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be demonstrated. In a critical review of the literature on the impact of psychological factors on the progression of cancer, Coyne, Stefanek, and Palmer (2007) concluded, “an adequately powered study examining effects of psychotherapy on survival after a diagnosis of cancer would require resources that are not justified by the strength of the available evidence” (p. 367).

Etiology of Psychophysiological Disorders Case Study Florida was hit by four hurricanes within a six-week period. One woman was able to deal with the first, even though Hurricane Francis smashed her windows, flooded her carpets, and caused her to throw food away. Then Hurricane Jeanne hit her again, causing similar damage. She had to wait in the hot sun to get ice and was without food or water for her children. As she related, “The first one, I stayed strong. But this second one, I started crying and couldn’t stop.” (Barton, 2004, p. A3)

As we have seen, not everyone who faces stressful events develops an illness or shows reduced immune functioning. Daily living involves constant exposure to stressors: work expectations at school or on the job, relationship problems, illness, marriage, divorce, and aging, to name a few. Why is it that only some individuals develop a physical disorder when exposed to stressors? In this section, we use the multipath model to explore some of the biological, psychological, social, and sociocultural dimensions of the disease process, as shown in Figure 7.7. Although we are discussing these dimensions separately, there are significant interactions among them.

Biological Dimension Stressors can directly produce physiological changes through the release of neurohormones (epinephrine, norepinephrine, catecholamines, and cortisol). These neurohormones, along with the activation of the sympathetic nervous system, prepare the body for emergency action by increasing heart rate, respiration, alertness, and decreased vulnerability to inflammation. This preparation helps humans respond

FIGURE

7.7

MULTIPATH MODEL FOR PSYCHOPHYSIOLOGICAL DISORDERS The dimensions interact with one another and combine in different ways to result in a specific psychophysiological disorder.

Biological Dimension • Chronic activation by neurohormones and sympathetic nervous system • Genetic contribution • Somatic weakness • Autonomic response specificity • General adaptation syndrome

• • • • •

Sociocultural Dimension Gender differences Racial or ethnic background Socioeconomic status Exposure to racism Culture conflicts

PSYCHOPHYSIOLOGICAL DISORDER

Social Dimension • Inadequate social network • Abrasive marital interactions • Marriage (for men)

Psychological Dimension • Helplessness or control • Optimism • Hostility • Self-efficacy

Etiology of Psychophysiological Disorders

TA B L E

7.2

ADAPTIVE (SHORT-TERM) AND MALADAPTIVE (CHRONIC) RESPONSES TO STRESS ADAPTIVE RESPONSES (SHORT-TERM STRESS)

MALADAPTIVE RESPONSES (CHRONIC STRESS)

increased glucose

hyperglycemia (diabetes)

increased blood pressure

hypertension, breakage of plaque in arteries

increased immunity

impaired immune response to illnesses

increased vigilance

hypervigilance

diminished interest in sex

global loss of interest in sex

improved cognition and memory

increased focus on traumatic events, lack of attention to current environment

faster blood clotting

increased thickness of coronary artery walls

Source: From Carels et al. (2003); Keltner & Dowben (2007).

quickly to a crisis situation. However, when such activation occurs over an extended period of time, a psychophysiological disorder can develop (Stone et al., 2000; White & Moorey, 1997). Table 7.2 compares short-term adaptive responses of the body to stressors with symptoms that sometimes develop when these physiological reactions continue and become chronic. As mentioned earlier, physical conditions such as headaches, asthma, hypertension, and immune functioning may have a genetic component. In addition, exposure to chronic stress results in the continued activation of the hypothalamic-pituitaryadrenal systems and the release of stress hormones that contribute to psychophysiological disorders and a weakened immune system. Early environmental influences such as traumatic childhood experiences may also produce changes in brain structure and in the stress-responsive neurobiological systems, resulting in increased vulnerability to the development of a psychophysiological disorder (Anda et al., 2006). Three other biological explanations for psychophysiological disorders have been suggested: somatic weakness, autonomic response specificity, and general adaptation syndrome. The somatic weakness hypothesis is a commonsense explanation for the development of particular psychophysiological disorders. This view suggests that congenital factors or vulnerability acquired through physical trauma or illness may predispose a particular organ to develop irregularities when exposed to stressors. The particular physiological disorder that develops is determined by whichever system is the “weakest link” in the body. Logical as it may seem, the somatic weakness hypothesis is difficult to validate because it is not yet possible to measure the relative strengths of the different physical systems in the human body before a bodily weakness appears. Closely related to the somatic weakness hypothesis is the concept of autonomic response specificity—the hypothesis that some individuals respond to different stressors with the same physiological response. For example, an individual who constantly shows exaggerated cardiovascular reactions to a number of different situations may be more likely to develop hypertension. In fact, twins have been found to respond similarly with increases in blood pressure under stress (De Geus et al., 2007). Tuomisto (1997) found that, when exposed to different stressors, individuals with hypertension displayed an exaggerated reactivity in blood pressure compared with individuals without hypertension. The suggestion that these physiological responses are innate is supported by researchers who have observed that distinctive autonomic behavior patterns in infants tended to persist throughout early childhood (Thomas, Chess, & Birch, 1968).

193

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Hans Selye (1956, 1982) proposed a helpful model for understanding the body’s physical reaction to biological stressors. He put forth a three-stage model, which he called the general adaptation syndrome (GAS), for understanding the body’s physical and psychological reaction to biological stressors. The stages are alarm, resistance, and exhaustion. Selye describes the alarm stage as a “call to arms” of the body’s defenses when it is invaded or assaulted biologically. During this first stage, the body reacts immediately to the assault, with rapid heartbeat, loss of muscle tone, and decreased temperature and blood pressure. A rebound reaction follows as the adrenal cortex enlarges and the adrenal glands secrete corticoid hormones. This initial response enhances the body’s recovery from injury (Underwood, 2005). If exposure to the stressor continues, the adaptation or resistance stage follows. The body mobilizes itself to defend, destroy, or coexist with the injury or disease. The symptoms of illness may disappear. With HIV, for example, the immune system reacts by producing nearly a billion lymphocytes a day to combat the virus. Over time, the immune system gradually weakens and is overcome (Ho et al., 1995). The decrease in the body’s resistance increases its susceptibility to other infections or illnesses. If the stressor continues to tax the body’s finite resistive resources, the symptoms may reappear as exhaustion of the defense system sets in (thus the name exhaustion stage). If stress continues unabated, death may result. Research does support the view that brief exposure to stressors enhances immune functioning, whereas long-lasting stress is associated with its deterioration (Segerstrom & Miller, 2004). Although genetics and physiological response to chronic stress play a role in physical illness, so do psychological, social, and sociocultural factors.

Psychological Dimension Psychological and personality characteristics can also mediate the effects of exposure to stressors. For example, a longitudinal study of remaining employees after nearly half of the workforce was removed during downsizing showed that although twothirds developed health problems, one-third appeared to thrive. The individuals who did well had three characteristics: (1) commitment—they were involved in ongoing changes rather than giving up and feeling isolated; (2) control—they made attempts to influence decisions and refused to feel powerless, and (3) challenge—changes were viewed as opportunities (Maddi, 2002). Depression Psychological conditions such as depression can influence both physiological functioning and behaviors that affect health. Depressed individuals show a dysregulation of the autonomic nervous system. They have elevated levels of catecholamines (epinephrine and norepinephrine), resulting in exaggerated cardiovascular responses to stressors (Carney, Freedland, & Veith, 2005). In addition, an individual who is depressed may sleep and exercise less, eat less healthy food, and consume more caffeine, alcohol, or cigarettes. A depressed individual may also be less likely to seek help or follow a treatment regimen (Weinman & Petrie, 1997). These behaviors may in turn increase the individual’s susceptibility to disease or may prolong an existing illness. Also, an individual’s beliefs about the causes, symptoms, duration, and curability of the disease may determine whether the person seeks help and follows the treatment program. Patients who strongly believe that an illness is controllable or treatable often recover more quickly than others who believe otherwise.

general adaptation syndrome (GAS) a three-stage model for

understanding the body’s physical and psychological reactions to biological stressors

Helplessness or Control Control and the perception of control over the environment and its stressors appear to mitigate the effects of stress. In a study of older adults with physical health problems, those who had high levels of control behaviors, such as engaging in health-improving strategies, seeking help, and remaining motivated to address their physical problems, did not show the pattern of biological dysregulation typical of those with health issues (Wrosch et al., 2007).

Etiology of Psychophysiological Disorders

One study of nursing home residents examined the impact of control on the residents’ health and emotional states (Langer & Rodin, 1976). In the “responsibility induced” group, residents were allowed to make certain decisions, such as how to arrange their rooms, when to see movies, whether to accept visitors, and whether to have plants in their rooms. The “traditional” group was not offered these choices and had decisions made for them. Within a short period, the nurses rated 71 percent of the traditional group as more debilitated and 93 percent of the responsibility-induced group as improved. Self-report questionnaires revealed that the responsibility-induced group rated themselves as happier and more active. Mortality rates also differed between the two groups. After eighteen months, 15 percent (7 of 47) of those in the responsibility-induced group had died versus 30 percent (13 of 44) in the traditional group. The reason for the differences in mortality rates is unclear. Some deaths, however, might be associated with a less efficient immune system.

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CONTROL AND STRESS The lack of a sense of control or unpredictability can dramatically increase stress. Alma Rollins, an interpreter, tells of the impact of the immigration raids at the Swift & Company meat packing plant in Nebraska on both the workers and their children. The effects of the raids produced emotional turmoil and stress reactions in those affected. Approximately five million U.S. children have at least one undocumented parent, and researchers are determining the effect of potential deportation on their mental health.

Self-Efficacy Another cognitive variable that appears to have an impact on illness is the belief in one’s ability to take action to attain goals or to effect change. An individual with high self-efficacy may engage in more health-related activities when an illness occurs, whereas low self-efficacy would result in feelings of hopelessness. Self-efficacy has been related to recovery from orthopedic surgery; the stronger the belief in the ability to recover by participating in rehabilitation, the more successful the outcome (Waldrop et al., 2001).

Hostility The emotion of hostility has been implicated in several physiological disorders, particularly coronary heart disease (Richards et al., 2000). Several possibilities exist that may explain the relationship between hostility and coronary heart disease. First, hostility may increase the hostile person’s cardiovascular responsivity and physiology, subsequently increasing the risk of developing coronary heart disease. At least one study (Miller et al., 1998) supports this view. In that study, individuals who scored high on hostility showed exaggerated cardiovascular reactivity to a stressor (verbal harassment) compared with participants who were low on hostility. Thus hostility may lead to damaging physiological responses. The experience of strong anger in young healthy males when they were frustrated or treated unfairly was related to elevations in serum cholesterol and low-density lipoproteins, both of which have been found to increase the risk of developing coronary heart disease (Richards et al., 2000). Hostility in children and adolescents has also been related to elevated lipids and blood pressure (Raikkonen, Matthews, & Salomon, 2003). Optimism Optimism, another cognitive state, also appears to mediate the impact of a disease. In a study on psychosocial predictors of the course of illness in men with AIDS, Taylor and colleagues (2000) found that those with a high realistic acceptance of death died an average of nine months earlier than those with a low realistic acceptance. What might cause such a difference? The researchers believe that “an optimistic, even unrealistically optimistic, view of the future, may reserve resources that not only help people manage the ebb and flow of everyday life but that assume special significance in helping people cope with intensely stressful and life-threatening events” (p. 106).

Did You Know?

S

ocial isolation has been associated with decreased immune functioning. Is this due to the physiological impact of isolation, or to the fact that socially connected individuals have friends who might bring them food or medicine when they are ill? Hermes and colleagues (2006) compared rats raised in isolation with those who lived in a small group. All were fed the same amount of food. When a substance was injected under their skin, the rats that were isolated took longer to heal. Isolation itself was responsible for the poorer immune response.

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Social Dimension Coronary heart disease, impaired immunological functioning, and other adverse health outcomes has been associated with a variety of social stressors (Dickerson & Kemeny, 2004; Pike et al., 1997). Having a strong social network is associated with positive health behaviors (Cohen & Lemay, 2007). Divorced or separated men tend to have more physical illness than their married counterparts (Eaker et al., 2007), and separated and divorced men who were preoccupied with thoughts of their former partners showed a lower level of immune functioning (Kiecolt-Glaser et al., 1987). Abrasive marital interactions between long-married men and women are also associated with negative health changes (Kiecolt-Glaser et al., 1997). Number and quality of social relationships may also affect our vulnerability to illnesses, and a person’s perception or interpretation of the event is important, as well. Although our discussion has focused on the direct physiological impact of stress on health, indirect pathways must also be considered. For example, an individual with a spouse or a large social network may receive encouragement for healthy eating habits, exercise, and other health-promoting activities, thus increasing resistance to disease.

Sociocultural Dimension

Did You Know?

S

pirituality and religion have been shown to be associated with physical health. In one study of 5,300 African Americans, a group at risk for high blood pressure, those involved in religious activities had significantly lower blood pressure than those who were not. This effect was found even though religious African Americans were heavier and had lower levels of medication adherence. Source: Wyatt (2006).

Conflicts with societal standards, discrimination, and cultural expectations can have a significant impact on health. Women are more likely to be affected by stress because of their role as caregivers for children, partners, and parents (Stambor, 2006). Women who reported high job stress or who perceived their relationships with their bosses to be poor had higher fibrinogen levels than those found among other female employees. Fibrinogen, a blood-clotting compound, may contribute to coronary heart disease by contributing to atherosclerosis and the formation of blood clots (Davis, Mathews, Meilahn, & Kiss, 1995). Although genetic and other biological explanations may explain the high rate of hypertension in African Americans, another line of research supports a sociocultural explanation. Exposure to racism is associated with elevations in cardiovascular responses in African American men and women (Clark, 2006; Merritt et al., 2006). African Americans who watched videos or imagined depictions of social situations involving racism showed increases in heart rate and blood pressure (Fang & Myers, 2001; Jones et al., 1996). Elevations in cardiovascular responses were also observed among a sample of African American men who were exposed to subtle racism (Merritt et al., 2006). Thus exposure to discrimination may function as a prevalent stressor and increase the chances of hypertension (Troxel et al., 2003). However, at least among African American women, the relationship may be more complicated. Increases in blood pressure when exposed to racism were only found among women who were low in seeking social support; those who were high in seeking social support did not show this tendency (Clark, 2006). Thus coping ability, resources, and social support may mitigate vascular reactivity. Cultural changes or conflict can also affect health. In a study of Japanese persons living in Japan, Hawaii, and California, the highest mortality rate from coronary heart disease was found among those living in California and the lowest among those living in Japan. This difference was not accounted for by the risk factors for coronary heart disease discussed earlier in this chapter. In trying to decide what was responsible for the variation in mortality rates, the researchers compared Japanese immigrants who had maintained a traditional lifestyle with those who had acculturated (adopted the habits and attitudes prevalent in their new country). The coronary heart disease rate for acculturated Japanese individuals was five times greater than that for those who had retained their traditional values (Marmot & Syme, 1976). Perhaps breaking close social and community ties, which is part of the acculturation process, promoted a greater vulnerability to the disease.

Treatment of Psychophysiological Disorders

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MAINTAINING TRADITION AND REDUCING RISK Japanese Americans who maintain traditional lifestyles have a lower rate of coronary heart disease than those who have acculturated. The difference does not appear to be due to diet or other investigated risk factors. What reasons can you come up with to explain the findings?

Cultural changes also have been found to affect health in Samoa. Samoans have a culture that stresses rigid control of behaviors, including strict discipline for children, control of anger for females, and suppression of emotions in adults. Steele and McGarvey (1997) hypothesized that the Samoan traditional pattern in which women were expected to suppress their emotions could conflict with the expanded roles expected by modern young women, resulting in increases in blood pressure. In support of their hypothesis, the investigators found an interesting contrast: higher blood pressure was related to an inhibition of anger in young women but to an outward expression of anger in older women. The roles or behavior patterns the women were socialized to (modern or traditional) appeared to influence whether the expression of anger increased blood pressure.

Treatment of Psychophysiological Disorders Psychotherapy has been found to be effective in treating the psychophysiological disorders. Individuals who showed “burnout” due to chronic job stress had significantly lower cortisol levels as compared with a control group. After fourteen sessions of psychotherapy, they showed an increase in morning cortisol levels (Mommersteeg et al., 2006). Although mind-body techniques may not cure illness, individuals who engage in stress-management techniques report less pain, less anxiety, improved sleep, a higher quality of life, and a sense of participation in their treatment. Stress hormones are also reduced (Tyre, 2004). Treatment programs for psychophysiological disorders generally consist of both medical treatment for the physical symptoms and psychological therapy to eliminate stress and anxiety. This combination provides a wide array of approaches to these disorders, with mainly positive results. Two of the dominant psychological approaches are stress management and anxiety management programs, which usually include either relaxation training or biofeedback.

Relaxation Training Relaxation training is a therapeutic technique in which a person acquires the ability to relax the muscles of the body in almost any circumstance. It is possible that this reduces the “fight or flight” reaction that may be triggered by muscle tension (Marr, 2006). Progressive muscle relaxation has been effective in reducing physiological arousal and the impact of stressors (Rausch, Gramling, & Auerbach, 2006).

relaxation training therapeutic technique in which a person acquires the ability to relax the muscles of the body in almost any circumstance

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Current programs are typically modeled after Jacobson’s (1938, 1967) progressive relaxation training. Imagine that you are a patient who is beginning the training. You are instructed to concentrate on one set of muscles at a time—first tensing them and then relaxing them. First you clench your fists as tightly as possible for approximately ten seconds, then you release them. As you release your tightened muscles, you are asked to focus on the sensation of warmth and looseness in your hands. You practice this tightening and relaxing cycle several times before proceeding to the next muscle group, in your lower arms. After each muscle group has received individual attention in tensing and relaxing, the trainer asks you to tighten and then relax your entire body. The emphasis throughout the procedure is on the contrast between the feelings produced during tensing and those produced during relaxing. For a novice, the entire exercise lasts about thirty minutes. A relaxation-based treatment was found to be effective in producing “clinically significant” reductions in headache activity among recurrent headache sufferers. The program was unique in that it was conducted over the Internet and through e-mail. Participants received instructions for applied relaxation and its application in stressful situations. Although dropout rates were high, a large number of participants appeared to benefit from a minimal-therapist-contact and self-help-focused intervention (Strom, Pettersson, & Andersson, 2000).

Biofeedback In biofeedback training, the client is taught to voluntarily control some physiological functions, such as heart rate or blood pressure. During training, the client receives second-by-second information (feedback) regarding the activity of the organ or function of interest. For someone attempting to lower high blood pressure, for example, the feedback might be actual blood pressure readings, which are presented visually on a screen or as some auditory signal transmitted through a set of headphones. The biofeedback device enables the patient to learn to control the targeted physiological function. Eventually the patient learns to use that method without benefit of the feedback device.

Case Study A twenty-three-year-old male patient reported having a resting heart rate that varied between 95 and 120 beats when he was in high school. This variation was associated with apprehension over exams. The patient came into treatment because his high rate had continued and he was concerned that it might lead to a serious cardiac condition. The treatment consisted of eight sessions of biofeedback training. The patient’s heart rate was monitored, and he was provided with both a visual and an auditory feedback signal. After the treatment period and one year later, his heart rate had stabilized and was within normal limits (73 beats per minute). The patient reported that he had learned to control his heart rate during stressful situations by both relaxing and concentrating on reducing the heart rate. (Janssen, 1983)

biofeedback training

a therapeutic approach that combines physiological and behavioral approaches, in which a patient receives information regarding particular autonomic functions and is rewarded for influencing those functions in a desired direction

Biofeedback is essentially an operant conditioning technique in which the feedback serves as reinforcement. It has been used to help people lower their heart rates and decrease their blood pressure during stressful situations (Nakao et al., 1997; Shahidi & Salmon, 1992), treat migraine and tension headaches (Holroyd et al., 1995; Hovanitz & Wander, 1990), decrease the need for medication in asthma (Lehrer et al., 2004), reduce muscle tension (Gamble & Elder, 1983), and redirect blood flow (Reading & Mohr, 1976). Biofeedback and verbal reinforcement were used to help children with asthma control their respiratory functioning (Kahn, Staerk, & Bonk, 1974).

Cognitive-Behavioral Interventions Because hostility is associated with hypertension, cognitive-behavioral programs have been developed to reduce the expression of this emotion. In one study, individuals with hypertension participated in a six-week anger management program (Larkin &

Treatment of Psychophysiological Disorders

Zayfert, 1996). When initially exposed to confrontational roleplaying situations, they experienced sharp rises in blood pressure. The participants learned to relax by using muscle relaxation techniques and to change their thoughts about confrontational situations. They also received assertiveness training to learn appropriate ways of expressing disagreements. After the various types of training, their blood pressure was significantly reduced when they again participated in confrontational role-playing scenes. The discovery or knowledge that one has a life-threatening disease can affect an individual’s belief system. The world may be seen as unfair, leading to feelings of depression or avoidance and an inability to process the disease experience. Social-cognitive processing approaches attempt to help the individual adjust and find validation and meaning in the experience. In a study of seventy women cancer survivors, the type of cognitive process was found to predict adjustment to cancer (Cordova et al., 2001). Those who were unable to cognitively process their diseases because of invalidation (“When I talk about cancer, my husband tells me I’m living in the past”) or because of discomfort (“It’s difficult to share with those you love, as they are scared, too”; p. 709) reported more depressive symptoms. In contrast, women who reported being able to talk about cancer were less depressed and better adjusted. Cognitive strategies to improve coping skills and to manage stress have also been effective in improving both physiological functioning and psychological distress in HIV-positive men (Cruess et al., 2000). Patients with asthma who engaged in three sessions of writing about a trauma (“write about the most stressful experience in your life”) significantly improved lung function as opposed to those who wrote only about time management (Stone et al., 2000). With many diseases, having the opportunity to express fears, to cognitively process beliefs, and to develop adaptive strategies appears to improve patients’ feelings of wellbeing and physical health.

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CONTROLLING PHYSIOLOGICAL RESPONSES Meditation is associated with a relaxed bodily state produced by minimizing distractions and focusing on a positive image, mantra, or word. This process has been associated with the reduction in the level of stress hormones and the development of a sense of control. It has been found to be helpful in the treatment of hypertension and headaches.

As we mentioned earlier, psychologists are becoming increasingly aware that single-cause models of psychophysiological illness are inadequate. Not everyone exposed to the same set of stressors develops a psychophysiological disorder. In addition, we must be able to explain why an individual develops coronary heart disease rather than asthma. It is clear that the search for an explanation must consider biological, psychological, social, and sociocultural dimensions. We are just beginning to understand the biology of stress disorders and the specific brain structures involved, but many questions remain. For example, what does it mean that parts of the brain become “sensitized”? Have structural changes occurred, and are they reversible? Psychological characteristics also mediate the relationship between a stressor and its impact on the body. Negative emotions may amplify the event, whereas cognitive characteristics such as control, optimism, and self-efficacy may defuse its impact. Do these qualities directly affect physical health through the immune system, or is it that individuals with these qualities behave in a manner that affects health (amount of exercise, sleep, type of food)? Social networks and sociocultural factors have also been found to be related to health. Why does marriage appear to have more health benefits for men than for women? Why are there gender and racial differences in the prevalence of both the psychological and physical stress disorders? As you can see, many questions remain that can be answered only by continuing to examine the multitude of possible contributors to the stress disorders.

I M P L I C AT I O N S

Summary tissue damage (such as coronary heart disease), a disease process (immune impairment), or physiological dysfunction (as in asthma or migraine headaches). Examples of psychophysiological disorders include coronary heart disease (CHD); essential hypertension; migraine, tension, and cluster headaches; and asthma.

1. What are acute and posttraumatic stress disorders, and how are they diagnosed? ■

■

Acute and posttraumatic stress disorders involve exposure to a traumatic event, resulting in intrusive memories of the occurrence, attempts to forget or repress the memories, emotional withdrawal, and increased arousal. Acute stress disorder (ASD) is characterized by anxiety and dissociative symptoms that occur within one month after exposure to a traumatic stressor. Posttraumatic stress disorder (PTSD) is characterized by anxiety, dissociative, and other symptoms that last for more than one month and that occur as a result of exposure to extreme trauma.

2. What causes acute and posttraumatic stress disorders? ■

Various biological, psychological, sociocultural, and social factors have been implicated in the stress disorders. Possible biological factors involve a sensitized autonomic system, involvement of stress hormones, and brain cell damage. Psychological factors include level of cognitive functioning, trait anxiety and depression, and classic conditioning. Poor or inadequate support during childhood has also been identified as possibly contributing to the development of the stress disorders, as have various sociocultural factors, such as immigration status and gender.

3. What are the different treatments for acute and posttraumatic stress disorders? ■

Antidepressant medication has been successful in the treatment of ASD and PTSD, as has exposure to cues associated with the trauma. Exposure and cognitivebased therapies such as psychoeducation have also proven effective in some cases.

4. What role do stressors play in physical health, and what are the psychophysiological disorders? ■

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Any external events or situations that place a physical or psychological demand on a person can serve as stressors and can affect physical health. Stressors can range from chronic irritation and frustration to acute and traumatic events. A psychophysiological disorder is any physical disorder that has a strong psychological basis or component. Psychophysiological disorders involve actual

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Not everyone develops an illness when exposed to the same stressor or traumatic event because stress is an internal psychological or physiological response to a stressor. Individuals reacting to the same stressor may do so in very different ways.

5. What causes psychophysiological disorders? ■ Various biological, psychological, sociocultural, and social factors have been implicated in the psychophysiological disorders. ■ Biological explanations include (1) chronic activation of the sympathetic nervous system and continual release of neurohormones, (2) genetic contributions, and (3) somatic weakness, autonomic response specificity, and general adaptation syndrome. ■ Psychological contributors include characteristics such as helplessness versus control, optimism, hostility, selfefficacy, and the role of classical and operant conditioning in acquiring or maintaining these disorders. ■ Social contributors include having an inadequate social network, abrasive interpersonal interactions, a stressful environment, and, for men, being unmarried. ■ Sociocultural factors such as gender, racial, or ethnic background are risk factors in certain physiological disorders. Stressful environments associated with poverty, prejudice and racism, and cultural conflicts have been related to illnesses. 6. What methods have been developed to treat psychophysiological disorders? ■

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These disorders are treated through stress management or anxiety management programs, combined with medical treatment for physical symptoms or conditions. Relaxation training and biofeedback training, which help the client learn to control muscular or organic functioning, are usually a part of such programs. Cognitive-behavioral interventions, which involve changing anxiety-arousing thoughts, have also been useful.

c h a p t e r

8

Personality Disorders

T

he epitome of a hard-driven, successful businessman, Robert T. seemed to have it all: enormous financial wealth, influence with politicians, a private jet, a young, beautiful wife, and, despite his reputation as a ruthless corporate raider, he enjoyed high regard from associates for his business acumen. Then, in less than a year, he lost everything, including his wife, who filed for divorce. Stockholders raised questions about nonstandard accounting practices, inappropriate personal use of funds for family vacations, and unauthorized purchase of properties in the name of his wife. When banks refused to loan him funds on a prospective takeover bid and creditors demanded repayment of loans, his financial world collapsed. Lawsuits from investors against Robert and his company followed, with the trustees finally demanding his resignation. Although Robert refused to resign and launched a campaign against his own board of directors, accusing them of a personal vendetta and of conspiring against him, he was eventually removed from his post. Only with his downfall did the facts about Robert’s tendency to exaggerate and distort the truth become known. He was not a graduate of the Wharton School of Business, as his resume had indicated; he had told people that he was divorced once, but in fact he had been married four times (two of the marriages ended in divorce before age twenty); and his fortune did not come from “old money” but from a series of questionable business schemes in real estate that often left investors holding bad debts: he referred to them as “collateral damage.” People who knew him in the past often described him as deceitful, cunning, and calculating. He showed a disregard for the rights of others, manipulated them, and then discarded them when they served no further use to him. This attribute was evident even in his early years. For example, he had married a sixteen-year-old girl from a wealthy family, but when her father refused to support them, Robert blamed his wife and constantly belittled her until their divorce three months later. He never expressed regret or remorse for any of his actions but operated from a belief that “this is a dog-eat-dog

chapter outline Diagnosing Personality Disorders

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Disorders Characterized by Odd or Eccentric Behaviors

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Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors

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Disorders Characterized by Anxious or Fearful Behaviors

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Multipath Analysis of One Personality Disorder: Antisocial Personality Disorder 221 Treatment of Antisocial Personality Disorder

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IMP LIC ATIONS

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CRITICAL THINKING Is There

Gender Bias in Diagnosing Mental Disorders? 207 CONTROVERSY Impulse Control Disorders

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FOCUSQUESTIONS

1 What are personality disorders, and how are they viewed?

and fearful?

2 What personality disorders are considered odd or eccentric?

5 How does the multipath model explain antisocial personality disorder?

3 What personality disorders are considered dramatic, emotional, or erratic?

4 What personality disorders are considered anxious

6 What types of therapy are used in treating antisocial personality disorder?

world” and “do unto others before they do unto you.” He had never been in therapy, but school records revealed a pattern of juvenile alcohol use, poor grades, frequent lying, and petty theft. At age fourteen, he was tentatively diagnosed with a conduct disorder when school officials became concerned with his fascination for setting fires in the restroom toilets. Nevertheless, it is interesting that the school psychologist described Robert as “charming, very bright, persuasive, and with high potential for future success.”

personality disorder a disorder characterized by inflexible, long-standing, and maladaptive personality traits that cause significant functional impairment, subjective distress, or a combination of both for the individual

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Robert T. typifies our definition of an individual with a personality disorder in that he possesses a constellation of inflexible, long-standing, and maladaptive personality traits that cause significant functional impairment, subjective distress, or a combination of both (American Psychiatric Association, 2000a). As we shall shortly see, Robert can best be described as having an antisocial personality disorder. He pushes the boundaries of social convention and often violates moral, legal, and ethical rules for his own personal gain, with little regard for the feelings of others. His characteristic way of handling things is long-standing and developmental in nature (evident in his early teens; Weston & Riolo, 2007). Although these traits can be quite functional in some settings, they inevitably bring about personal and social difficulties (Millon et al., 2004). People with personality disorders often display temperamental deficiencies or aberrations (Robert’s tendency to blame others), rigidity in dealing with life problems (deceiving others through lying, exaggeration, and manipulation), and defective perceptions of self and others (“do unto others before they do unto you”). In spite of all these difficulties, people with personality disorders often function well enough to get along without aid from others. They often fall under the radar and are simply described as odd, peculiar, dramatic, or unusual. They may not see themselves as having a problem. For example, a person with a pronounced tendency to avoid social interactions is described as “shy” (avoidant personality disorder), a person with a strong self-orientation is described as “selfish” (narcissistic personality disorder), and a person with a preference to be alone is described as a “hermit” (schizoid personality disorder). Indeed, some pronounced personality traits may actually serve as an asset in some situations (such as Robert T.’s behaviors in a highly competitive business environment). For these reasons, many people with personality disorders rarely come to the attention of mental health professionals, seldom seek help from them, and often terminate prematurely when in therapy (Millon et al., 2004). As a result, the incidence of personality disorders has been difficult to ascertain, but available statistics indicate that these disorders account for 5 to 15 percent of admissions to hospitals and outpatient clinics. The overall lifetime prevalence of personality disorders is 9 to 13 percent, which suggests that the disorders are relatively common in the general population (Lenzenweger et al., 2007; Phillips, Yen, & Gunderson, 2004; Weissman, 1993).

Diagnosing Personality Disorders

Diagnosing Personality Disorders All of us have characteristic ways of responding, thinking, and feeling when encountering situations or other people. Some of us are outgoing, sociable, and adventurous in new or unfamiliar situations. Others of us are more cautious, laid back, and hesitant to form new relationships until we have adequately familiarized ourselves with our surrounding environment. In other words, most of us have a degree of consistency and predictability in our outlook on life and in how we approach people and situations (Millon et al., 2004). Yet all of us possess a degree of flexibility in how we respond to similar or different situations. A shy coworker, for example, is not necessarily shy in all situations, nor when he or she gets to know other employees. People with personality disorders, however, possess extreme patterns of responding that are inflexible, long-standing, and enduring and that can extend into the elderly years (Abrams & Bromberg, 2007); they are shy and withdrawn in nearly all situations and continue to be uncomfortable even with people they know well. Personality disorders begin early in life and generally become evident in adolescence (Weston & Riolo, 2007), but there are frequently telltale signs in childhood, as well. Robert T. was diagnosed with a conduct disorder in middle school, which is often thought to be a forerunner of antisocial personality disorder (Millon et al., 2004). DSM-IV-TR uses the following criteria to diagnose a personality disorder. 1. Enduring pattern of inner experience and behavior that deviates from person’s culture in two or more of the following areas: cognition, affect, interpersonal functioning, or impulse control. 2. Relatively inflexible and pervasive across personal and social situations. 3. Significant distress or impairment in social, occupational, and other areas of functioning. 4. Pattern is stable and long-term and can be traced to adolescence or early childhood. 5. Not accounted for by another mental or general medical condition. In diagnosing a personality disorder, DSM-IV-TR recognizes the importance of culture and ethnicity. It acknowledges that culture shapes habits, customs, values, and personality characteristics, so that expressions of personality in one culture may differ from those in another culture. Asians, for example, are more likely to exhibit shyness and collectivism, whereas Americans are more likely to show assertiveness and individualism (Sue & Sue, 2008a). Japanese people and Asian Indians (South Asians) display the overt dependent behaviors characteristic of dependent personality disorders more than Americans or Europeans display them (Bornstein, 1997). Does this mean that people in Japan and India are more likely to have this personality disorder? More likely, the high incidence of these behaviors reflects the influence of other factors, one of which may be cultural bias in the classification system. In one study conducted in the United Kingdom, it was found that whites were 2.8 times more likely to be given a diagnosis of antisocial personality disorder than African Caribbeans (Mikton & Grounds, 2007). The diagnosis varied not only with the race of the client but also with that of the clinician. The three possible explanations of bias were (1) belief that antisocial and criminal behavior is more “normal” among African Caribbean men, (2) tendency to attribute antisocial behavior to environmental factors for blacks, and (3) reluctance to attribute pathology to blacks because of sensitivity to risks of prejudice and stigmatization. Anyone making judgments about personality functioning and disturbance must consider the individual’s cultural, ethnic, and social background (American Psychiatric Association, 2000a). Gender implications are also important in the diagnosis of personality disorders, although there are some inconsistencies due primarily to the year of the studies and the locations from which the populations are drawn (Millon et al., 2004). One major

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study found that men are more likely than women to be diagnosed as having antisocial personality disorder (Grant et al., 2004), whereas women more often receive diagnoses of borderline, dependent, or histrionic personality disorders (Millon et al., 2004; Torgersen, Kringlen, & Cramer, 2001). The existence of gender differences in the diagnosis of certain personality disorders is widely known in the profession. The question, however, is whether these differences are attributable to biases in making diagnoses or to actual gender variations in disorders (Widiger & Coker, 2002). It is important to note that personality disorders are diagnosed under Axis II in the DSM-IV-TR, whereas most of the other disorders are reported under Axis I. As you recall, the multiaxial classification of mental disorders lists all the clinical disorders on Axis I, whereas personality disorders, mental retardation, and long-standing defenses are noted on Axis II. This distinction is made for several reasons: (1) it is believed that personality disorders are distinct from Axis I disorders in that they are chronic, developmental, and relatively inflexible patterns of responding that are less likely to be successfully changed in treatment, and (2) given this reasoning, it is entirely possible for a personality disorder to coexist with one or more clinical disorders on Axis I. For example, a person with a personality disorder may also be diagnosed with schizophrenia or alcohol dependency (Axis I disorders). Usually, people with personality disorders are hospitalized only when a second, Axis I superimposed disorder so impairs social functioning that they require inpatient care. In fact, the treatment outcome for people with Axis I disorders who also have personality disorders is worse than for those who have only Axis I disorders (Benjamin & Karpiak, 2002; Clarkin & Levy, 2004). Diagnosing personality disorders is difficult for a number of reasons (see Table 8.1). First, to varying degrees and at various times, we all exhibit some of the traits that characterize personality disorders—for example, suspiciousness, dependency, sensitivity to rejection, or compulsiveness. For this reason, many investigators (Bienenfeld, 2007b; Widiger, 2007) prefer to view personality disorders as the extremes of underlying dimensions of normal personality traits. They argue that dimensions such as extraversion (sociability), agreeableness (nurturance), neuroticism, conscientiousness, and openness to experience may be used to describe personality disorders (Costa & McCrae, 2005). Because people differ in the extent to which they possess a trait, a clinician may have trouble deciding when a client exhibits a trait to a degree that could TA B L E

8.1

CATEGORICAL WEAKNESSES OF DSM AXIS II PERSONALITY DISORDERS A number of weaknesses or problems in using Axis II to categorize personality disorders have been identified (Widiger, 2007). WEAKNESS

DESCRIPTION

Pejorative connotations

Because personality disorders are thought to be relatively unchangeable even in therapy, insurance carriers are reluctant to provide coverage. To be diagnosed with such a condition gives the impression that there is little prospect of improvement, even though research provides compelling evidence that meaningful change can occur.

Excessive diagnostic co-occurrence

It is not unusual for a person to meet criteria for an excessive number of personality disorders. Which one does he or she have?

Differences among those sharing the same diagnosis

People possessing the same diagnosis of a personality disorder often appear very different from one another; they rarely share the same personality features.

Inconsistent and arbitrary diagnostic boundaries

The boundaries used to determine normal personality features and personality disorders are inconsistent, subjective, and arbitrary. No clear rationale is given for establishing these boundaries.

Inadequate scientific base

Except for the study of antisocial and borderline personality disorders, the eight other disorders are lacking in a research base and seem to be based more on subjective clinical formulations.

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be considered a symptom of a disorder (Millon et al., 2004). DSM-IV-TR criteria for diagnosing disorders are based on a categorical model in which a disorder is present if “enough of” certain symptoms or traits are exhibited and is not present if “not enough of” the symptoms are demonstrated (American Psychiatric Association, 2000a). Thus, according to DSM, people are classified as either having or not having a disorder. In reality, people may “have” a personality disorder to varying degrees. Researchers are now using taxometric methods (analyzing data to discover the underlying data structure) to see which personality disorders better fit a categorical or continuous model. So far, based on these methods, schizotypal personality disorder appears to be categorical in nature (Haslam, 2003), whereas others appear to fit a dimensional model. In addition, personality patterns may not be stable. Many personality characteristics exhibited in one situation may vary or be unstable across situations. Second, although diagnosticians show excellent reliability in diagnosing whether a particular client has a personality disorder, they show much lower reliability when they must classify clients as to the precise type of personality disorder (Bornstein, 1998; Costa & McCrae, 2005). Co-occurrence is common in that a person diagnosed with one personality disorder often meets criteria for others as well (Widiger, 2007). Because people can have more than one type of personality disorder, the problems in diagnosing these disorders are formidable. Moreover, although the distinction between personality disorders and other disorders is valid, many individuals have symptoms that do not neatly characterize a particular disorder and that overlap with different disorders (Widiger & Shea, 1991). The third reason that personality disorders are difficult to diagnose is that clinicians may not adhere to diagnostic criteria. In one study, clinicians were asked to indicate the symptoms exhibited by their clients who had been diagnosed with personality disorders. In many cases, the clinicians’ diagnoses were incongruent with the symptom patterns that DSM requires for diagnosing the personality disorders (Morey & Ochoa, 1989). DSM-IV-TR asserts that a number of traits, not just one, must be considered in determining whether a disorder exists. For example, to diagnose dependent personality disorder, the clinician must find a constellation of characteristics (such as the inability to make decisions independently and the subordination of one’s own needs). The clinician must also consider other criteria or factors. For example, the personality pattern (1) must characterize the person’s current, as well as long-term, functioning, (2) must not be limited to episodes of illness, and (3) must either notably impair social or occupational functioning or cause subjective distress. Thus a person who is temporarily dependent because of an illness would not be diagnosed as having a dependent personality. As Table 8.2 shows, DSM-IV-TR lists ten specific personality disorders and groups them into three clusters, depending on whether they are characterized by (1) odd or eccentric behaviors; (2) dramatic, emotional, or erratic behaviors; or (3) anxious or fearful behaviors. We begin by discussing each of the ten personality disorders rather briefly. Then we focus in greater detail on the multipath analysis of one of them—antisocial personality disorder—primarily because more empirical findings and information are available concerning this disorder.

Disorders Characterized by Odd or Eccentric Behaviors Three personality disorders are included in this cluster: paranoid personality, schizoid personality, and schizotypal personality.

Paranoid Personality Disorder

paranoid personality disorder

People with paranoid personality disorder show unwarranted suspiciousness, hypersensitivity, and reluctance to trust others. They interpret others’ motives as being malevolent, question their loyalty or trustworthiness, persistently bear grudges, or are suspicious of the fidelity of their partners, as seen in the following case.

a personality disorder characterized by unwarranted suspiciousness, hypersensitivity, and a reluctance to trust others

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8.2

DISORDERS CHART

PERSONALITY DISORDERS

PERSONALITY DISORDER

SYMPTOMS

GENDER DIFFERENCES

PREVALENCE

Disorders Characterized by Odd or Eccentric Behaviors Paranoid personality disorder

• Unwarranted suspiciousness, hypersensitivity, and reluctance to confide in others

Higher in males

0.5–4.4

Schizoid personality disorder

• Socially isolated, emotionally cold, indifferent to others

Higher in males

0.2–0.3

Schizotypal personality disorder

• Peculiar thoughts and behaviors, poor interpersonal relationships

Higher in males

2.5–3.0

Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors Antisocial personality disorder

• Failure to conform to social or legal codes, lack of anxiety and guilt, irresponsible behaviors

Higher in males

2.0–3.6

Borderline personality disorder

• Intense fluctuations in mood, self-image, and interpersonal relationships

Higher in females

1.4–2.0

Histrionic personality disorder

• Self-dramatization, exaggerated emotional expressions, and attention-seeking behaviors

Mixed findings

1.0–3.0

Narcissistic personality disorder

• Exaggerated sense of self-importance, exploitativeness, and lack of empathy

Higher in males

1.0–2.0

Disorders Characterized by Anxious or Fearful Behaviors Avoidant personality disorder

• Fear of rejection and humiliation, reluctance to enter into social relationships

None

0.3–1.0

Dependent personality disorder

• Reliance on others and inability to assume responsibilities

Unclear

1.9–2.5

Obsessive-compulsive personality disorder

• Perfectionism, interpersonally controlling, devotion to details, and rigidity

Higher in males

1% (DSM-IV-TR); 7.9% (Grant et al. 2004)

Note: In all of the personality disorders, early symptoms appear in childhood or adolescence. Personality disorders tend to be stable and to endure over time, although symptoms of antisocial and borderline personality disorders tend to remit with age. Source: Based on American Psychiatric Association (2000a); Corbitt & Widiger (1995); Grant et al. (2004); Marmar (1988); Weissman (1993). Prevalence figures and gender differences have varied from study to study, and investigators may disagree on these rates.

Case Study Ralph and Ann married after a brief, intense courtship. The first year of their marriage was relatively happy, although Ralph tended to be domineering, opinionated, and very protective of his wife. Ann had always known that Ralph was a jealous person who demanded a great deal of attention. She was initially flattered that Ralph would become upset when other men flirted with her because it indicated he cared. It soon became clear, however, that his jealousy was excessive, as he seemed to impute nefarious intentions not only to men but also to Ann herself. For example, when Ann came home from shopping later than usual, Ralph would become very hostile and agitated and would demand an explanation. He often doubted her explanations, and would embarrass Ann by calling her coworkers or neighbors to confirm her stories. As the situation progressively worsened, Ralph began to suspect that Ann was having affairs with other men, and he would leave work early to be with his wife. He said that business was slow and that they could spend more time together. Whenever the phone rang, Ralph insisted on answering it himself. Wrong numbers and male callers took on special significance for him; he felt that they must be trying to contact Ann. Ann found it difficult to discuss the matter with Ralph. He

Disorders Characterized by Odd or Eccentric Behaviors

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critical thinking

Is There Gender Bias in Diagnosing Mental Disorders?

W

e know that gender differences exist in the diagnosed prevalence of mental disorders such as depression and anorexia nervosa, which have been found to be higher among women than among men. Men have been found to have a higher rate of the following personality disorders: 1. Paranoid personality disorder 2. Schizoid personality disorder 3. Schizotypal personality disorder 4. Narcissistic personality disorder 5. Obsessive-compulsive personality disorder 6. Antisocial personality disorder Women have been found to have a higher rate of the following: 1. Borderline personality disorder 2. Histrionic personality disorder Two disorders appear to have similar rates regardless of gender: 1. Avoidant personality disorder 2. Dependent personality disorder (findings unclear and mixed with occasional higher rates for females) Do these differences reflect real genetic and sociocultural influences, or are they simply the result of gender biases? Gender bias occurs when diagnostic categories are not valid and when they have a different impact on men and women. The mere fact that men and women have different prevalence rates for a particular disorder is not sufficient to prove gender bias. Rates may differ because of actual biological conditions (for example, a genetic

predisposition) or social conditions (stressors) that affect one gender more than another. For the diagnostic system to be biased, the differences must be attributable to errors or problems in the categories or diagnostic criteria. Widiger and Spitzer (1991) attempted to enumerate the sources of biases, in addition to failings in the diagnostic system. Try your hand at this task by examining the following sources of potential bias and indicating areas in which you believe bias can occur. 1. In what ways can clinicians themselves be biased when evaluating others or when making a diagnosis? For example, might a clinician evaluate the same behavior (such as aggressiveness) differently, depending on whether a man or a woman displays it? 2. How might a clinical assessment instrument be biased? Can you think of characteristics that western culture considers desirable and healthy that are associated more with one gender than the other and that could be used in a questionnaire? Some would argue that characteristics associated with women are more likely to be considered deviant or undesirable than are those associated with men. Masculine norms tend to define characteristics found primarily in women as negative. 3. Can you think of a situation in which sampling bias could distort the findings in a study of the prevalence of depression in women? Sampling bias occurs in cases in which one gender with a particular disorder is more likely than the other gender to be present in a particular setting in which the research is conducted. 4. Given that gender bias can occur, what can a clinician do to guard against such bias in his or her work? This final question is, perhaps, the most important to address.

was always quick to take the offensive, and he expressed very little sympathy or understanding toward her. He thought she and her male friends were playing him for a fool. Ralph’s suspicions regarding his wife’s fidelity were obviously unjustified. Nothing that Ann did implicated her with other men. Yet Ralph persisted in his pathological jealousy and suspiciousness and became angry when she suggested that he was wrong in distrusting her. This behavior pattern, along with Ralph’s absence of warmth and tenderness, suggested a paranoid personality disorder. Follow-up: After several weeks of treatment, Ann began to feel stronger in her relationship with Ralph. During one confrontation in which Ralph objected to her seeing the therapist, Ann asserted that she would continue the treatment. She said that she had always been faithful to him and that his jealousy was driving them apart. In a rare moment, Ralph broke down and started crying. He said that he needed her and begged her not to leave him. At this time, both are seeing a counselor for marital therapy.

People with paranoid personality disorder may demonstrate restricted affect (that is, aloofness and lack of emotion), and they tend to be rigid and preoccupied with unfounded beliefs that stem from their suspicions and sensitivity. These beliefs are extremely resistant to change. Many persons with this disorder fail to go for treatment because of their guardedness and mistrust (Meissner, 2001).

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Certain groups, such as refugees and members of minority groups, may display guarded or defensive behaviors not because of a disorder but because of their minority group status or their unfamiliarity with the majority society. To avoid misinterpreting the clinical significance of such behaviors, clinicians assessing members of these groups must do so cautiously. The prevalence of paranoid personality disorder ranges from 0.5 to 4.4 percent of the population (American Psychiatric Association 2000a; Grant et al., 2004). Some psychodynamic explanations propose that persons with paranoid personality disorder engage in the defense mechanism of projection, denying their unacceptable impulses and attributing them to others (“I am not hostile; they are”). Vaillant (1994) has shown that paranoid personality is associated with projection to a striking degree. In terms of treatment, psychotherapy is usually the treatment of choice. However, because clients are suspicious and have difficulty trusting others, rapport and intimacy in the therapeutic relationship are difficult to build.

Schizoid Personality Disorder

ELUDING CAPTURE AIDED BY SCHIZOID PERSONALITY FEATURES OF UNABOMBER It took many years for authorities to track down and arrest Ted Kaczynski, the Unabomber, who killed many people over an 18-year period. Formerly a University of California, Berkeley, math professor, Kaczynski is believed to have a schizoid personality disorder and to have eluded capture because of his “hermitlike” existence. He was a loner and did not seem interested in socializing with people. He was finally arrested in his isolated cabin, where he had lived alone for many years.

schizoid personality disorder

a personality disorder characterized by social isolation, emotional coldness, and indifference to others schizotypal personality disorder

a personality disorder characterized by peculiar thoughts and behaviors and by poor interpersonal relationships

Schizoid personality disorder is marked primarily by social isolation, emotional coldness, and indifference to others. People with this disorder have a long history of impairment of social functioning. They are often described as being reclusive and withdrawn (American Psychiatric Association, 2000a). Many live alone in apartments or furnished rooms and engage in solitary recreational activities such as watching television, reading, or taking walks. They tend to neither desire nor enjoy close relationships; they have few activities that provide pleasure. Because of a lack of capacity or desire to form social relationships, people with schizoid disorder are perceived by others as peculiar and aloof and therefore inadequate as dating or marital partners. The disorder appears to be uncommon, and slightly more males are diagnosed with it, according to DSM-IV-TR. Members of different cultures vary in their social behaviors, and diagnosticians must consider the cultural background of individuals who show schizoid symptoms. People with schizoid disorder may be required to interact with others in the workplace and similar situations, but their relationships are superficial and frequently awkward. In such situations, people with this disorder tend to comply with the requests or feelings of others in an attempt to avoid extensive involvement, conflicts, and expressions of hostility. They prefer a hermit-like existence (Stone, 2001). Ted Kaczynski (the Unabomber) is reported to have been diagnosed with schizoid personality disorder and lived like a hermit alone for many years as he planned and carried out his attacks on others. In general, individuals with this disorder prefer social isolation and the single life rather than marriage. When they do marry, their spouses are often unhappy in the marital relationships. For example, a man may marry primarily to please his parents, but his inability to show affection, lack of interest in sex, and lack of participation in family activities may cause marital problems. The relationship between schizoid personality disorder and schizophrenia (described in Chapter 13) is unclear. One view is that the disorder is a beginning stage of schizophrenia. Another is that schizophrenia may develop as a complication of the schizoid personality disorder. Some studies have shown that schizoid personality disorder is associated with a cold, unempathic, and emotionally impoverished childhood (Marmar, 1988). Whether there is a genetic predisposition to the disorder is not clear. With respect to treatment, as with most personality disorders, individual psychotherapy is preferred. However, persons with this disorder usually seek treatment only if they are experiencing stress or a crisis. The intervention should then be directed at resolving the crisis.

Schizotypal Personality Disorder People who have schizotypal personality disorder manifest peculiar thoughts and behaviors and have poor interpersonal relationships. Many believe they possess

Disorders Characterized by Odd or Eccentric Behaviors

magical thinking abilities or special powers (“I can predict what people will say before they say it”), and some are subject to recurrent illusions (“I feel that my dead father is watching me”). Speech oddities, such as frequent digression or vagueness in conversation, are often present. The disorder occurs in approximately 3 percent of the population (American Psychiatric Association, 2000a), more frequently among men than women. Again, the evaluation of individuals must take into account their cultural milieu. Superstitious beliefs, delusions, and hallucinations may be condoned or encouraged in certain religious ceremonies or other cultures. The peculiarities seen in schizotypal personality disorder stem from distortions or difficulties in cognition (Goodman et al., 2007). That is, these people seem to have problems in thinking and perceiving. People with this disorder often show social isolation, hypersensitivity, and inappropriate affect (emotions). They seem to lack pleasure from social interactions (Blanchard et al., 2000). The prevailing belief is that the disorder is defined primarily by cognitive distortions, however, and that affective and interpersonal problems are secondary. Research has demonstrated some cognitive processing abnormalities in individuals with this disorder that help to explain many of the symptoms (Goodman et al., 2007; Stone, 2001). The man described in the following case was diagnosed as having schizotypal personality disorder:

Case Study A forty-one-year-old man was referred to a community mental health center’s activities program for help in improving his social skills. He had a lifelong pattern of social isolation, with no real friends, and spent long hours worrying that his angry thoughts about his older brother would cause his brother harm. On interview, the patient was distant and somewhat distrustful. He described in elaborate and often irrelevant detail his rather uneventful and routine daily life. . . . For two days he had studied the washing instructions on a new pair of jeans—Did “Wash before wearing” mean that the jeans were to be washed before wearing the first time, or did they need, for some reason, to be washed each time before they were worn? . . . He asked the interviewer whether, if he joined the program, he would be required to participate in groups. He said that groups made him very nervous because he felt that if he revealed too much personal information, such as the amount of money that he had in the bank, people would take advantage of him or manipulate him for their own benefit. (Spitzer et al., 1994, pp. 289–290)

The man’s symptoms included absence of close friends, magical thinking (worrying that his thoughts might harm his brother), being distant in the interview, and social anxiety. These symptoms are associated with schizotypal personality disorder. As is true of schizoid personality disorder, many characteristics of schizotypal personality disorder resemble those of schizophrenia, although in less serious form. For example, people with schizophrenia exhibit problems in personality characteristics, psychophysiological responses, and information processing—deficits that have also been observed among persons with schizotypal personality disorder (Goodman et al, 2007; Lenzenweger, 2001). Some evidence is consistent with a genetic interpretation of the link between the two disorders. Kendler (1988) found a higher risk of schizotypal personality disorder among relatives of people diagnosed with schizophrenia than among members of a control group. In general, family, twin, and adoption studies support the genetic relationship between schizophrenia and schizotypal personality disorder. Despite the possibility of genetic influence in the disorder, early environmental enrichment for children (two years of enhanced nutrition, education, and physical exercise) has been found to reduce schizotypal personality disorder and symptoms compared with a nonenriched group of children (Raine et al., 2003). Various psychotherapies have been used to treat schizotypal personality disorder, such as dynamic therapy, supportive therapy, and cognitive-behavioral approaches, as well as group psychotherapy. For clients who are experiencing a great deal of anxiety, small doses of anxiolytics (a class of antianxiety drugs) may be used (Stone, 2001).

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Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors The group of disorders characterized by dramatic, emotional, or erratic behaviors includes four personality disorders: antisocial, borderline, histrionic, and narcissistic.

Antisocial Personality Disorder Chronic antisocial behavioral patterns, such as a failure to conform to social or legal codes, a lack of anxiety and guilt, and irresponsible behaviors, indicate antisocial personality disorder. If you recall our opening case study of Robert T., who has an antisocial personality disorder, you will have a thumbnail sketch of the characteristics associated with this disorder. People with this disorder show little guilt for their wrongdoing, which may include lying, using other people, and aggressive sexual acts. Their relationships with others are superficial and fleeting and involve little loyalty. The following case presents another example of antisocial personality disorder in the teenage years:

Case Study

Did You Know?

H

istorically, people have been interested in antisocial personalities. An early nineteenth-century British psychiatrist, J. C. Prichard (1837), described it this way: The moral and active principles of the mind are strongly perverted or depraved; the power of selfgovernment is lost or greatly impaired; and the individual is found to be incapable, not of talking or reasoning upon any subject proposed to him . . . but of conducting himself with decency and propriety in the business of life. (p. 15)

antisocial personality disorder

a personality disorder characterized by a failure to conform to social and legal codes, by a lack of anxiety and guilt, and by irresponsible behaviors

Roy W. was an eighteen-year-old high school senior who was referred by juvenile court for diagnosis and evaluation. He was arrested for stealing a car, something he had done on several other occasions. The court agreed with Roy’s mother that he needed evaluation and perhaps psychotherapy. During his interview with the psychologist, Roy was articulate, relaxed, and even witty. He said that stealing was wrong but that none of the cars he stole was ever damaged. The last theft occurred because he needed transportation to a beer party (which was located only a mile from his home) and his leg was sore from playing basketball. When the psychologist asked Roy how he got along with young women, he grinned and said that he was very outgoing and could easily “hustle” them. He then related the following incident: “About three months ago, I was pulling out of the school parking lot real fast and accidentally sideswiped this other car. The girl who was driving it started to scream at me. God, there was only a small dent on her fender! Anyway, we exchanged names and addresses and I apologized for the accident. When I filled out the accident report later, I said that it was her car that pulled out from the other side and hit my car. How do you like that? Anyway, when she heard about my claim that it was her fault, she had her old man call me. He said that his daughter had witnesses to the accident and that I could be arrested. Bull, he was just trying to bluff me. But I gave him a sob story—about how my parents were ready to get a divorce, how poor we were, and the trouble I would get into if they found out about the accident. I apologized for lying and told him I could fix the dent. Luckily he never checked with my folks for the real story. Anyway, I went over to look at the girl’s car. I really didn’t have any idea of how to fix that old heap so I said I had to wait a couple of weeks to get some tools for the repair job. “Meanwhile, I started to talk to the girl. Gave her my sob story, told her how nice I thought her folks and home were. We started to date and I took her out three times. Then one night I laid her. The crummy thing was that she told her folks about it. Can you imagine that? Anyway, her old man called and told me never to get near his precious little thing again. She’s actually a slut. “At least I didn’t have to fix her old heap. I know I shouldn’t lie but can you blame me? People make such a big thing out of nothing.”

The irresponsibility, disregard for others, and disregard for societal rules and morals evident in this interview indicated to the psychologist that Roy had antisocial personality disorder. Cleckley’s (1976) classic description of the disorder included the following characteristics: 1. Superficial charm and good intelligence 2. Shallow emotions and lack of empathy, guilt, or remorse 3. Behaviors indicative of little life plan or order 4. Failure to learn from experiences and absence of anxiety 5. Unreliability, insincerity, and untruthfulness

Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors

Some of these characteristics are apparent in Roy’s case. For example, he felt no guilt for his actions or for manipulating the young woman and her family. In fact, he was quite proud of his ability to seduce her and to avoid responsibility for the car repair. The ease with which Roy related his story to the psychologist demonstrated his lack of concern for those who were hurt by his behaviors. Roy showed no anxiety during the interview. DSM-IV-TR criteria for the disorder differ somewhat from Cleckley’s description, which is based on clinical observations of various cases. For example, DSM-IV-TR criteria do not include lack of anxiety, shallow emotions, failure to learn from past experiences, and superficial charm. They do include a history before age fifteen of failing to conform to social norms with respect to lawful behaviors, irritability and aggressiveness, impulsivity, lack of remorse, and deceitfulness. For the diagnosis to be made, the individual must be at least eighteen years old. DSM-IV-TR criteria, however, fail to convey the conceptual sense of the disorder that was clearly outlined in Cleckley’s original description. Some research now suggests that psychopathy is composed of three factors: arrogant and deceitful interpersonal style, deficient affective experience, and impulsive and irresponsible behavioral style (Cooke & Michie, 2001). The distinction between Cleckley’s conceptualization and DSM-IV-TR criteria is important because sole use of DSM-IV-TR may not capture the “personality” aspect or the underlying construct of the disorder. Because they overemphasize behavioral manifestations and criminality, the DSM-IV-TR criteria make rendering a diagnosis easier and more reliable, but they may fail to capture the essence of the disorder. Thus Cleckley’s conceptualization and the research on psychopathy are more likely to emphasize personality components than is the description of antisocial personality disorder in DSM-IV-TR. Antisocial behaviors may arise from a multitude of causes, of which personality pathology is only one (Cooke & Michie, 2001). Furthermore, only a minority of patients with antisocial personality disorder have severe psychopathy (Meloy, 2001). In the United States, the incidence of antisocial personality disorder is estimated to be about 2.0–3.6 percent overall; rates differ by gender, with more men than women diagnosed with the disorder (American Psychiatric Association, 2000a; Grant et al., 2004). Overall estimates vary from study to study, however, which may be due to differences in sampling, diagnostic, and methodological procedures. The disorder is much more frequent in urban environments than in rural ones and in lower socioeconomic groups than in higher ones. Rates of antisocial personality disorder appear comparable among whites, African Americans, and Latino Americans (Robins, Tipp, & Przybeck, 1991), although one study in the United Kingdom suggests significantly lower rates among African Caribbeans than whites (Mikton & Grounds, 2007). Although African Americans had a higher rate of incarceration for crimes, their rate of antisocial personality disorder is either equal to or lower than that of the general population.

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CRIME BOSSES AND ANTISOCIAL PERSONALITY DISORDERS Vito Corleone (played by Marlon Brando) in The Godfather and Boss Tony Soprano (played by James Gandolfini) in the TV series The Sopranos are both men who exhibit many of the traits of an antisocial personality disorder. Both men evidenced a callous disregard for the rights of others and showed little regret or remorse for cheating, lying, breaking the law, or even murder. However, they also revealed characteristics that are at odds with the diagnosis. Both had deep family relationships, revealed intense loyalty and emotional commitment to their families, evidenced flashes of guilt; Tony Soprano even sought psychiatric help for his anxiety attacks.

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BEHAVIOR PATTERNS, CONTEXT, AND DIAGNOSIS Individuals who engage in social protest or civil disobedience are rarely regarded as having antisocial personality disorder. Although some may break the law, the other features of antisocial personality disorder—chronic lack of remorse and deceitfulness, for example—are usually absent. In this photo, a group of individuals demonstrate to rally support against the war in Iraq. Are social protests, as well as antisocial personality disorders, more common among young adults than older adults?

The behavior patterns associated with antisocial personality disorder are different and distinct from behaviors involving social protest or criminal lifestyles. People who engage in civil disobedience or violate the conventions of society or its laws as a form of protest are not, as a rule, persons with antisocial personalities. Such people can be quite capable of forming meaningful interpersonal relationships and of experiencing guilt. They may perceive their violations of rules and norms as acts performed for the greater good. Similarly, engaging in delinquent or adult criminal behavior is not a necessary or sufficient condition for diagnosing antisocial personality. Although many convicted criminals have been found to have antisocial characteristics, many others do not. They may come from a subculture that encourages and reinforces criminal activity; hence in perpetrating such acts they are adhering to group mores and codes of conduct. As mentioned earlier, DSM-IV-TR criteria tend to emphasize criminality, but the appropriateness of this emphasis is being questioned. People with antisocial personalities are a difficult population to study because they do not voluntarily seek treatment. Only one out of seven will ever discuss their problems with a doctor, and concurrent problems are the reason for their participation in treatment (Meloy, 2001). Consequently, investigators often seek research participants in prison populations, which presumably harbor a relatively large proportion of psychopaths. Some research suggests, however, that psychopaths in prison do differ from the nonimprisoned psychopathic population (Widom, 1977). Although they share similarities, antisocial personalities in the general community tended to have higher levels of education, and, although often arrested, they were infrequently convicted of crimes.

Borderline Personality Disorder

borderline personality disorder

a personality disorder characterized by intense fluctuations in mood, self-image, and interpersonal relationships

Borderline personality disorder is characterized by intense fluctuations in mood, self-image, and interpersonal relationships. Persons with this disorder are impulsive, have chronic feelings of emptiness, and form unstable and intense interpersonal relationships (Goodman et al., 2007). They may be quite friendly one day and quite hostile the next. Many perceive their early childhoods as having malevolent others—others who were hostile or physically violent (Nigg et al., 1992). Many exhibit recurrent suicidal behaviors or gestures (Yen et al., 2003), and the probability of suicide is higher than average among those who have this disorder (Duberstein & Conwell, 1997). Self-destructive behaviors such as suicide attempts are often triggered by interpersonal conflicts and events (Welch, Shaw, & Linehan, 2002). Sexual difficulties, such as sexual preoccupation, dissatisfaction, and depression, have also

Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors

Did You Know?

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any well-known individuals have been described as having borderline personality disorder—Adolph Hitler, Marilyn Monroe, and even Princess Diana. Biographer and journalist Sally Bedell-Smith (1999) consulted a psychologist, who agreed that Princess Diana’s rapid mood swings, preoccupation with real or imagined abandonment, dissatisfaction, depression, and suicide attempts fit the category well. It is important to note, however, that people with personality disorders may also suffer from Axis I disorders.

Princess Diana, smiling happily in this picture, was known to suffer from rapid mood swings, depression, and suicide attempts. Her emotional and behavioral traits, such as impulsiveness, marked fluctuations in mood, chronic feelings of emptiness, and unstable and intense interpersonal relationships, are consistent with a diagnosis of borderline personality disorder. Why do women receive this diagnosis far more frequently than do men?

been observed (Zanarini et al., 2003). Although no single feature defines borderline personality disorder, its essence can be captured in the capriciousness of behaviors and the lability of moods (Millon et al., 2004). According to DSM-IV-TR, the prevalence is about 1.4–2.0 percent of the population, with females three times as likely as males to receive the diagnosis (Lenzenweger et al., 2007). This is the most commonly diagnosed personality disorder in both inpatient and outpatient settings (Oldham, 2006). Some researchers believe that the prevalence of the disorder is increasing because our society makes it difficult for people to maintain stable relationships and a sense of identity. The following example illustrates some of the many facets of borderline personality disorder.

Case Study Bryan was a twenty-three-year-old graduate student majoring in sociology at a prestigious university. He was active in student government and was viewed as charismatic, articulate, and sociable. When he met other students for the first time, he could often persuade them to participate in the campus activities that interested him. Women were quite attracted to him because of his charm and self-disclosing nature. They described him as exciting, intense, and different from other men. Bryan could form close relationships with others very quickly. Bryan could not, however, maintain his social relationships. Sometimes he would have a brief but intense affair with a woman and then abruptly and angrily ask himself what he ever saw in her. At other times, the woman would reject him after a few dates because she thought Bryan was moody, self-centered, and demanding. He often called his friends after midnight because he felt lonesome, empty, and bored and wanted to talk. Several times he threatened to commit suicide. He gave little thought to the inconvenience he was causing. Once he organized a group of students to protest the inadequate student parking the university provided. The morning of the planned protest demonstration, he announced that he no longer supported the effort. He said he was not in the right mood for the protest, much to the consternation of his followers, who had spent weeks preparing for the event. Bryan’s intense but brief relationships, the marked and continual shifts in moods, and boredom with others in spite of his need for social contacts all point to borderline personality disorder.

People who have borderline personality disorder may exhibit psychotic symptoms, such as auditory hallucinations (for example, hearing imaginary voices that tell them to commit suicide), but the symptoms are usually transient. They also

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usually have an ego-dystonic reaction to their hallucinations (Oldham, 2006). That is, they recognize their imaginary voices or other hallucinations as being unacceptable, alien, and distressful. By contrast, a person with a psychotic disorder may not realize that his or her hallucinations are pathological. Some researchers (Trull et al., 1997) have found that individuals with borderline personality features are more likely to show dysfunctional moods, interpersonal problems, poor coping skills, and cognitive distortions than are people without borderline personality characteristics. However, it is important to note that, using taxometric methods, some researchers have found that borderline personality disorder may be better viewed as a continuous rather than a categorical disorder (Rothschild et al., 2003; Widiger & Mullins-Sweatt, 2005). That is, rather than either having or not having the disorder, people differ in the degree of borderline personality characteristics they exhibit. Although diverse models have been used to conceptualize borderline personality disorder, most of the literature comes from researchers with psychodynamic perspectives. For example, Kernberg (1976) proposed the concept of object splitting—that people with borderline personality disorder perceive others as all good or all bad at different times. This split results in emotional fluctuations toward others. Another perspective looks at the disorder from a social learning viewpoint. One view (Millon et al., 2004) is that borderline personality is caused by a faulty self-identity, which affects the development of consistent goals and accomplishments. As a result, persons with this disorder have difficulty coping with their own emotions and with life in general. They then develop a conflict between the need to depend on others and the need to assert themselves. A similar model (Sable, 1997) views the conflict as a desire for proximity and attachment versus a dread and avoidance of engagement, but it attributes the conflict to traumatic attachment experiences that occurred early in life, not to a faulty self-identity. A third possibility is that the fluctuations in emotions or dysfunctions in emotional regulation are at the core of the disorder (Linehan, 1987). Such emotional dysregulations have been observed in different populations of people with this disorder, including adolescents (Santisteban et al., 2003). An interesting aspect of this approach is the idea that biological factors may be responsible for the emotional dysregulation among individuals with borderline personality disorder. In fact, MRI and PET scans reveal structural abnormalities in the prefrontal cortex and a different pattern of activation in the amygdala in the working brain of people with borderline personality disorder (Goodman et al., 2007). Both are implicated in mood and motor disinhibition. Cognitive-oriented approaches have also been used. There appear to be two core aspects of borderline personality: difficulties in regulating emotions and unstable and intense interpersonal relationships (Oldham, 2006). According to this approach, these two aspects are affected by distorted or inaccurate attributions (explanations for others’ behaviors or attitudes). Cognitive-behavioral therapy for borderline personality disorders, therefore, attempts to change the way clients think about and approach interpersonal situations (Beinenfeld, 2007a). Another cognitive theorist, Aaron Beck, argued that an individual’s basic assumptions (that is, thoughts) play a central role in influencing perceptions, interpretations, and behavioral and emotional responses (Beck et al., 1990). Individuals with borderline personality disorder seem to have three basic assumptions: (1) “The world is dangerous and malevolent,” (2) “I am powerless and vulnerable,” and (3) “I am inherently unacceptable.” Believing in these assumptions, individuals with this disorder become fearful, vigilant, guarded, and defensive. For these reasons, they are difficult to treat. Regardless of therapeutic approach, most individual psychotherapies end with the borderline patient’s dropping out of treatment (Gunderson & Links, 2001). Finally, Linehan (1993) has developed dialectical behavior therapy (DBT) specifically for clients with borderline personality disorder. Patients are taught skills that include emotional regulation, distress tolerance, and interpersonal effectiveness (Benjamin & Karpiak, 2002). Linehan’s goals, in descending order of priority, are to

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change (1) suicidal behaviors, (2) behaviors that interfere with therapy, (3) behaviors that interfere with quality of life, (4) behavioral skills acquisition, (5) posttraumatic stress behavior, and (6) self-respect behaviors. Thus she targets as priorities possible suicidal behaviors in clients and the therapist-client relationship. Her treatment has been found to decrease dropping out and suicidal behaviors and to be generally effective (Emmelkamp, 2004). Because of positive treatment outcomes, DBT has been increasingly used as a treatment procedure. These diverse theoretical perspectives on this disorder reflect the strong interest in borderline personality. In contrast to the theoretical contributions, empirical research is sparse. Some investigators have found that individuals with the disorder have a history of chaotic family environments, including physical and sexual abuse (Clarkin, Marziali, & Munroe-Blum, 1991; Golier et al., 2003; Phillips & Gunderson, 1999) and family history of mood and substance-use disorders (Morey & Zanarini, 2000). Such family experiences may affect perceptions of self and others. Benjamin and Wonderlich (1994) found in one study that individuals with borderline personality disorder viewed their mothers and others in their environment as more hostile than did a comparable group of people with mood disorders. Again, mood changes, intense and unstable interpersonal relationships, identity problems, and other characteristics associated with borderline personality disorder can be observed in all persons to a greater or lesser extent. In fact, although borderline personality disorder is associated with relationship dysfunctions and problems, so are other personality disorders (Daley, Burge, & Hammen, 2000). As is the case with other personality disorders, diagnosis is difficult, and formulations about the causes of the disorder must rely on what we know about personality development in general. We return to that topic later in this chapter.

Histrionic Personality Disorder People with histrionic personality disorder engage in self-dramatization, exaggerated expression of emotions, and attention-seeking behaviors. The desire for attention may lead to flamboyant acts or flirtatious behaviors (Phillips & Gunderson, 1999). Despite superficial warmth and charm, the histrionic person is typically shallow and egocentric. Individuals from different cultures vary in the extent to which they display their emotions, but the histrionic person goes well beyond cultural norms. In the United States, about 1 to 3 percent of the population may have this disorder (Grant et al., 2004). Gender differences are not evident (Corbitt & Widiger, 1995). Histrionic behaviors were evident in a female client seen by one of the authors, as shown in the following case.

Case Study The woman was a thirty-three-year-old real estate agent who entered treatment for problems involving severe depression. Her boyfriend had recently told her that she was a self-centered and phony person. He found out that she had been dating other men, despite their understanding that neither would go out with others. The woman claimed that she never considered “going out with other men” as actual dating. Once their relationship was broken, her boyfriend refused to communicate with her. The woman then angrily called the boyfriend’s employer and told him that unless the boyfriend contacted her, she would commit suicide. He never did call, but instead of attempting suicide, she decided to seek psychotherapy. The woman was attractively dressed for her first therapy session. She wore a tight and clinging sweater. Several times during the session she raised her arms, supposedly to fix her hair, in a very seductive manner. Her conversation was animated and intense. When she was describing the breakup with her boyfriend, she was tearful. Later, she raged over the boyfriend’s failure to call her and, at one point, called him a “son of a bitch.” Near the end of the session, she seemed upbeat and cheerful, commenting that the best therapy might be for the therapist to arrange a date for her.

None of the behaviors exhibited by this client alone warrants a diagnosis of histrionic personality disorder. In combination, however, her self-dramatization,

histrionic personality disorder

a personality disorder characterized by self-dramatization, exaggerated expression of emotions, and attention-seeking behaviors

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incessant drawing of attention to herself via seductive movements, angry outbursts, manipulative suicidal gesture, and lack of genuineness point to this disorder. Both biological factors, such as autonomic or emotional excitability, and environmental factors, such as parental reinforcement of a child’s attention-seeking behaviors and the existence of histrionic parental models, may be important influences in the development of histrionic personality disorder (Millon et al., 2004). The lack of research on the effectiveness of treatments with personality disorders in general makes it difficult to definitively designate a treatment of choice. Research on histrionic personality disorder is practically nonexistent (Weston & Riolo, 2007). As noted by Horowitz (2001), psychodynamic therapies have been aimed at establishing a therapeutic alliance with the client and providing insight into resistance to change. Cognitive-behavioral therapy has focused on changing the client’s irrational cognitions and assumptions.

Narcissistic Personality Disorder

narcissistic personality disorder

a personality disorder characterized by an exaggerated sense of selfimportance, an exploitative attitude, and a lack of empathy

The clinical characteristics of narcissistic personality disorder are an exaggerated sense of self-importance, an exploitative attitude, and a lack of empathy. People with this disorder require attention and admiration and have difficulty accepting personal criticism. In conversations, they talk mainly about themselves and show a lack of interest in others. Many have fantasies about power or influence, and they constantly overestimate their talents and importance. Individuals diagnosed with this disorder show reflective responses and idealization involving unlimited success, a sense of entitlement, and a sense of self-importance (Hilsenroth et al., 1997). Owing to their sense of self-importance, people with narcissistic personality disorder expect to be the superior participants in all relationships. For example, they may be impatient and irate if others arrive late for a meeting but may frequently be late themselves and think nothing of it. One narcissistic client reported, “I was denied promotion to chief executive by my board of directors, although my work was good, because they felt I had poor relations with my employees. When I complained to my wife, she agreed with the board, saying my relations with her and the children were equally bad. I don’t understand. I know I’m more competent than all these people” (Masterson, 1981, p. ix). The client was depressed and angry about not being promoted and about the suggestion that he had difficulty in forming social relationships. His wife’s confirmation of his problems further enraged him. During therapy, he was competitive and sought to devalue the observations of the therapist. Many persons with this disorder exhibit arrogance and grandiosity (Groopman & Cooper, 2001). In a study that evaluated the kinds of defense mechanisms used by individuals with different personality disorders, narcissistic personality disorder was strongly associated with the use of dissociation as a defense mechanism (Vaillant, 1994). People with this disorder may use denial and dissociation to ward off feelings of inferiority developed from early childhood (Kernberg, 1975; Marmar, 1988), and they may attempt to maintain their inflated self-concept by devaluing others (Kernberg, 1975). Narcissistic traits are common among adolescents and do not necessarily imply that a teenager has the disorder (American Psychiatric Association, 2000a). However, it was found that people later diagnosed with this disorder were more likely to experience feelings of invulnerability, to display risk taking behavior, and to have strong feelings of uniqueness as adolescents (Weston & Riolo, 2007). The prevalence of narcissistic personality disorder is about 1 to 2 percent, although some studies have found lower rates (Grant et al., 2004). More males than females are given the diagnosis. As in the case of most of the personality disorders, no controlled treatment studies for narcissistic personality disorder have been conducted, and treatment recommendations are therefore based on clinical experience (Groopman & Cooper, 2001). Individual psychotherapy and group therapy have been used and are generally recommended.

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NARCISSISTIC BEHAVIOR Miranda Priestly (Meryl Streep) in the movie The Devil Wears Prada illustrates some of the symptoms of narcissistic personality disorder, including an exaggerated sense of self-importance, an excessive need for admiration, and an inability to accept criticism or rejection. Do you think that narcissistic personality disorder is increasing among young people?

Disorders Characterized by Anxious or Fearful Behaviors Another cluster of personality disorders is characterized by anxious or fearful behaviors. This category includes the avoidant, dependent, and obsessive-compulsive personality disorders.

Avoidant Personality Disorder The essential features of avoidant personality disorder are a fear of rejection and humiliation and a reluctance to enter into social relationships. Persons with this disorder tend to have low self-esteem and to avoid social relationships without a guarantee of uncritical acceptance by others. A study of childhood antecedents of persons with avoidant personality disorder revealed that they engaged in fewer extracurricular activities, hobbies, and leadership roles, had less athletic ability, and were less popular in school (Rettew, Zanarini, & Yen, 2003; Weston & Riolo, 2007). Unlike persons with schizoid personalities, who avoid others because they lack interest, and unlike persons who are shy because of their cultural background, people with avoidant personality disorder do not desire to be alone. On the contrary, they crave affection and an active social life. They want—but fear—social contacts, and this ambivalence may be reflected in different ways. For example, many people with this disorder engage in intellectual pursuits, wear fine clothes, or are active in the artistic community. Their need for contact and relationships is often woven into their activities. Thus an avoidant person may write poems expressing the plight of the lonely or the need for human intimacy. A primary defense mechanism is fantasy, whereby wishes are fulfilled to an excessive degree in the person’s imagination (Millon et al., 2004). Avoidant personality disorder occurs in less than 1 percent of the population, and no gender differences are apparent (American Psychiatric Association, 2000a). People with this disorder are caught in a vicious cycle: because they are preoccupied with rejection, they are constantly alert to signs of derogation or ridicule. This concern leads to many perceived instances of rejection, which cause them to avoid others. Their social skills may then become deficient and invite criticism from others. In other words, their very fear of criticism may lead to criticism. People with avoidant personality disorder often feel depressed, anxious, angry at themselves, inferior, and inadequate into their elderly years (Mahgoub & Hossain, 2007).

avoidant personality disorder

a personality disorder characterized by a fear of rejection and humiliation and a reluctance to enter into social relationships

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Case Study Jenny L., an unmarried twenty-seven-year-old bank teller, showed several features of avoidant personality disorder. Although she functioned adequately at work, Jenny was extremely shy, sensitive, and quiet with fellow employees. She perceived others as being insensitive and gross. If the bank manager joked with other tellers, she felt that the manager preferred them to her. Although Jenny tried to be friendly, she did not interact much with anyone because of the possibility of them criticizing or rejecting her. Jenny had very few hobbies. A great deal of her time was spent watching television and eating chocolates. As a result, she was about forty pounds overweight. Television romances were her favorite programs; after watching one, she tended to daydream about having an intense romantic relationship. Jenny eventually sought treatment for her depression and loneliness.

Some researchers believe that the disorder is on a continuum with the Axis I disorder social phobia, whereas others see it as a distinct disorder that simply has features in common with social phobia (Sutherland, 2001). Little research has been conducted on the etiology of avoidant personality disorder. One suggestion (Marmar, 1988) is that a complex interaction of early childhood environmental experiences and innate temperament produce the disorder. Parental rejection and censure, reinforced by rejecting peers, have been proposed as factors in the disorder (Phillips & Gunderson, 1999). Because of the fear of rejection and scrutiny, clients may be reluctant to disclose personal thoughts and feelings. It is important for the therapist to establish rapport and a therapeutic alliance, or the client may fail to return for treatment. A number of different therapies have been used, such as cognitive-behavioral, psychodynamic, interpersonal, and psychopharmacological treatments (Sutherland, 2001).

Dependent Personality Disorder

dependent personality disorder

a personality disorder characterized by reliance on others and an unwillingness to assume responsibility

People who rely on others and are unwilling to assume responsibility show dependent personality disorder. These people lack self-confidence, and they subordinate their needs to those of the people on whom they depend. Nevertheless, casual observers may fail to recognize or may misinterpret their dependency and inability to make decisions. Friends may perceive dependent personalities as understanding and tolerant, without realizing that they are fearful of taking the initiative because they are afraid of disrupting the relationship. In addition, a dependent personality may allow his or her spouse to be dominant or abusive for fear that the spouse will otherwise leave. Beck and associates (1990) believe that the dependency is not simply a matter of being passive and unassertive, problems that can be treated with assertiveness training. Rather, dependent personalities have two deeply ingrained assumptions that affect their thoughts, perceptions, and behaviors. First, they see themselves as inherently inadequate and unable to cope. Second, they conclude that their course of action should be to find someone who can take care of them. Depression, helplessness, and suppressed anger are often present in dependent personality disorder. The individual’s environment must be considered before rendering a diagnosis of dependent personality disorder. The socializing process that trains people to be independent, assertive, and individual rather than group oriented is not equally valued in all cultures (Sue & Sue, 2008a). Nor do all people manifest dependency all the time in the cultures that do value it. Some individuals, such as hospitalized patients, typically develop some degree of dependency during confinement. According to Grant and colleagues (2004), the prevalence of this disorder is about 2.5 percent. The prevalence by gender is unclear. Bornstein (1997) finds evidence that it is found more often among men than among women, Torgersen and colleagues (2001) believe that rates are higher among women, and Corbitt and Widiger (1995) believe that there are no gender differences in this disorder. The following case illustrates a dependent personality disorder that cannot be attributed to cultural or situational factors.

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Case Study Jim was fifty-six, a single man who was living with his seventy-eight-year-old widowed mother. When his mother was recently hospitalized for cancer, Jim decided to see a therapist. He was distraught and depressed over his mother’s condition. Jim indicated that he did not know what to do. His mother had always taken care of him, and, in his view, she always knew best. Even when he was young, his mother had “worn the pants” in the family. The only time that he was away from his family was during his six years of military service. He was wounded in the Korean War, was returned to the United States, and spent a few months in a Veterans Administration hospital. He then went to live with his mother. Because of his service-connected injury, Jim was unable to work full time. His mother welcomed him home, and she structured all his activities. At one point, Jim met and fell in love with a woman, but his mother disapproved of her. During a confrontation between the mother and Jim’s woman friend, each demanded that Jim make a commitment to her. This was quite traumatic for Jim. His mother finally grabbed him and yelled that he must tell the other woman to go. Jim tearfully told the woman that he was sorry, but she must go, and the woman angrily left. While Jim was relating his story, it was clear to the therapist that Jim harbored some anger toward his mother, though he overtly denied any feelings of hostility. Also clear were his dependency and his inability to take responsibility. His life had always been structured, first by his mother and then by the military. His mother’s illness meant that his structured world might crumble.

People clearly differ in the degree to which they are dependent or submissive. How dependency is explained varies according to theoretical perspective. From the psychodynamic perspective, the disorder is a result of maternal deprivation, which causes fixation at the oral stage of development (Marmar, 1988). Behavioral learning theorists believe that a family or Did You Know? social environment that rewards dependent behaviors and These are the primary differences and similarities between punishes independence may promote dependency. Some cogOCPD and OCD: nitive theorists attribute dependent personality disorder to Characteristics OCPD OCD the development of distorted beliefs about one’s inadequaRigidity in personality Yes Not usual cies and helplessness that discourage independence. Research findings (Bornstein, 1997) show that dependency is associated Preoccupation in thinking Yes Yes with overprotective, authoritarian parenting styles. PresumOrderliness in general Yes Not usual ably, these parenting styles prevent the child from developControl Yes Not usual ing a sense of autonomy and self-efficacy. Different forms of Perfectionism Yes Not usual treatment (including individual and group) have been found to be beneficial, although the effectiveness of medications has Indecisiveness Yes Not usual not been well researched. In general, dependent personality Intrusive thoughts/behaviors Not usual Yes disorder is successfully treated more often than other personNeed to perform acts Not usual Yes ality disorders, such as borderline or antisocial personality disorder (Perry, 2001). Recognition of irrationality Not usual Yes

Obsessive-Compulsive Personality Disorder The characteristics of obsessive-compulsive personality disorder (OCPD) are perfectionism, a tendency to be interpersonally controlling, devotion to details, and rigidity. Again, these traits are found in many normal people. Unlike normal people, however, individuals with obsessive-compulsive personality disorder show marked impairment in occupational or social functioning. Their relationships with others may be quite stiff, formal, and distant (McCullough & Maltsberger, 2001). Further, the extent of the character rigidity is greater among people who have this disorder. OCPD, as presented in this chapter, is distinct from obsessive-compulsive disorder (OCD), as discussed in the chapter on anxiety disorders. The two disorders have similar names, but the clinical manifestations of these disorders are quite different. OCPD is not characterized by the presence of obsessions (intrusive and repetitive anxiety-arousing thoughts) or compulsions (a need to perform acts or to dwell on mental acts repetitively). Rather, OCPD involves a preoccupation with orderliness,

obsessive-compulsive personality disorder a personality disorder

characterized by perfectionism, a tendency to be interpersonally controlling, devotion to details, and rigidity

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perfectionism, and control. Persons with OCD experience tremendous anxiety related to specific preoccupations, which are perceived as threatening. They usually recognize that their obsessions or compulsions are irrational or senseless. In OCPD, it is one’s dysfunctional philosophy that produces anxiety, discomfort, and frustration. OCPD is a pervasive characterological disturbance. People with the disorder genuinely see their way of functioning as the “correct” way. Their overall style of relating to the world around them is processed through their own strict standards. Research also shows that OCPD symptoms are related to anger and depression and that those with these symptoms are more prone to suppress their anger (Whiteside & Abramowitz, 2004). The preoccupation with details, rules, and possible errors leads to indecision and an inability to see “the big picture.” There is an overconcern with being in control, not only over the details of their lives but also over their emotions and other people (Phillips & Gunderson, 1999). Coworkers may find individuals with this disorder too demanding, inflexible, miserly, and perfectionistic. They may actually be ineffective on the job, despite long hours of devotion, as in the following case.

Case Study Cecil, a third-year medical student, was referred for therapy by his graduate adviser. The adviser told the therapist that Cecil was in danger of being expelled from medical school because of his inability to get along with patients and other students. Cecil often berated patients for failing to follow his advice. In one instance, he told a patient with a lung condition to stop smoking. When the patient indicated he was unable to stop, Cecil angrily told the patient to go for medical treatment elsewhere—that the medical center had no place for such a “weak-willed fool.” Cecil’s relationships with others were similarly strained. He considered many members of the faculty to be “incompetent old deadwood,” and he characterized fellow graduate students as “partygoers.” The graduate adviser told the therapist that Cecil had not been expelled only because several faculty members thought that he was brilliant. Cecil studied and worked sixteen hours a day. He was extremely well read and had an extensive knowledge of medical disorders. Although he was always able to provide a careful and detailed analysis of a patient’s condition, it took him a great deal of time to do so. His diagnoses tended to cover every disorder that each patient could conceivably have, on the basis of all possible combinations of symptoms.

AS GOOD AS IT GETS Jack Nicholson in As Good As It Gets tries to woo Helen Hunt, a woman he finds very attractive. Suffering from OCPD, however, his preoccupation with details and rules and overconcern with being in control interferes with his emotions toward Ms. Hunt. Many find people with obsessive-compulsive personality disorders to be too demanding, inflexible, miserly, and perfectionistic.

Obsessive-compulsive personality disorder occurs in about 1 percent of the population according to DSM-IV-TR, but a more recent study places it at 7.9 percent (Grant et al., 2004). It is about twice as prevalent among males as females, according to DSM-IV-TR. Cognitive-behavioral therapy, as well as supportive forms of psychotherapy, have helped some clients (Barber et al., 1997; Beck et al., 1990). No medications specific to obsessivecompulsive personality disorder are currently available (McCullough & Maltsberger, 2001). The diversity of personality disorders makes it difficult to do justice in exploring the etiology of each. In many cases, we simply do not possess enough knowledge of these disorders to engage in a proper and informed explanation of their causes. Yet it is clear that personality disorders are influenced by biological, psychological, social, and sociocultural forces. In the next section, we use our multipath model to discuss one of the better researched personality disorders: antisocial personality disorder.

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Multipath Analysis of One Personality Disorder: Antisocial Personality Disorder Research on personality disorders has been quite limited, although anecdotal, clinical, and theoretical speculation abound (Millon et al., 2004). As mentioned previously, research on antisocial personality disorder (APD) is perhaps more developed because of its higher visibility and association with criminality. Thus, to give you a broader view and an appreciation of the wide range of explanatory views that can be proposed for personality disorders in general, we have chosen to concentrate our etiological analysis on APD. Using our multipath model, we survey how the four dimensions (biological, psychological, social, and sociocultural) explain APD development and their possible interacting contributions, as shown in Figure 8.1. In this way, we hope to provide a prototype for understanding the multidimensional development of other personality disorders, as well.

Biological Dimension An extraordinary amount of research has been devoted to trying to uncover the biological basis of APD. Indeed, early researchers concentrated primarily on using genetics, central nervous system abnormalities, and autonomic nervous system abnormalities to explain the disorder. Genetic Influences Throughout history, many people have speculated that some individuals are born to “raise hell.” It is not uncommon for casual observers to remark that antisocials, criminals, and sociopaths appear to have an inborn temperament toward aggressiveness, sensation seeking, impulsivity, and a disregard for others. These speculations are difficult to test because of the problems involved in distinguishing between the influences of environment and heredity on behavior. For example, APD is five times more common among first-degree biological relatives of males with APD and ten times more common among first-degree biological relatives of females with APD than among the general population (American Psychiatric Association, 1987, 2000a). But is this due to heredity or environment?

8.1

FIGURE MULTIPATH MODEL FOR ANTISOCIAL PERSONALITY DISORDER The dimensions interact with one another and combine in different ways to result in antisocial personality disorder.

Biological Dimension • Genetic (inherited predisposition) • Central nervous system abnormality (frontal lobe implication) • Autonomic nervous system abnormality (underarousal explanations)

Sociocultural Dimension • Gender influences • Cultural values (individualism, competitiveness and assertiveness)

ANTISOCIAL PERSONALITY DISORDER

Social Dimension • Poor parental supervision and involvement • Hostile home and family environment • Role modeling especially by antisocial father

Psychological Dimension • Psychodynamic theory: weakened superego • Cognitive theory: extreme core beliefs

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Support for the former is found in studies comparing concordance rates for identical or monozygotic (MZ) twins with those for fraternal or dizygotic (DZ) twins. MZ twins share exactly the same genes, whereas DZ twins are genetically no more alike than any two siblings. Most studies show that MZ twins do tend to have a higher concordance rate than DZ twins for antisocial tendencies, delinquency, and criminality (Eley, Lichtenstein, & Moffitt, 2003; Gottesman & Goldsmith, 1994). Further, adoptees who were separated from their biological parents who have APD and were raised by parents without APD still exhibited higher rates of antisocial characteristics (Cadoret & Cain, 1981). Although this body of evidence seems to show a strong causal pattern, it should be examined carefully, for several reasons. First, many of the studies fail to clearly distinguish between antisocial personalities and criminals; as we noted earlier, they may draw research participants only from criminal populations. Truly representative samples of people with APD should be investigated. Second, the evidence supporting a genetic basis for antisocial tendencies does not preclude the environment as a factor. Antisocial personality is undoubtedly caused by environmental, as well as genetic, influences (Slutske et al., 1997). The fact that crime has increased fivefold or more in most industrialized western countries over the past fifty years has to be attributed to environmental influences, because gene pools cannot change that quickly (Rutter, 1997). As noted in our multipath model, heredity and environment may interact in complex ways. For example, one study found that ineffective parenting was unrelated to conduct problems in children with antisocial temperamental characteristics, but for children without such characteristics, ineffective parenting increased conduct disorders (Wootton et al., 1997). Third, studies indicating that genetic factors are important do not provide much insight into how APD is inherited. What exactly is transmitted genetically? Genetic factors do not influence crime and antisocial behavior directly, but they seem to affect the probability that such behavior will occur (Rutter, 1997). Hence there is no specific “gene for crime.”

Myth vs Reality Myth: Antisocial personality problems are primarily caused by genetic factors. Some people seem born to “raise hell.” Reality: Although genetic factors are related to antisocial personality disorder, a wide range of family patterns can influence the development of the disorder. For example, dysfunctional aspects of family life, such as severe parental discord, a parent’s maladjustment or criminality, overcrowding, and even large family size, can predispose a child to antisocial personality disorder, especially if the child does not have a loving relationship with at least one parent (Millon et al., 2004).

Central Nervous System Abnormality Some investigators suggest that adults with antisocial personalities tend to have abnormal brain wave activity similar to that of young children (Elliott & Gillett, 1992; Hare, 1993). Perhaps these abnormalities indicate brain pathology, especially in the frontal lobes (Deckel, Hesselbrock, & Bauer, 1996; Goodman et al., 2007). MRI and PET scans of brains of individuals with APD reveal structural and activity abnormalities in the prefrontal portion of the brain and the limbic amygdala circuitry. These regions are known to underlie emotional processing (Brambilla et al., 2004; Frankle, Lombardo, & New, 2005). Such pathology could inhibit the capacity of people with APD to learn how to avoid punishment and could render them unable to learn from experience. This explanation is plausible, but there simply is not enough evidence to support its acceptance. Many persons diagnosed with APD do not show activity abnormalities in these regions of the brain (Milstein, 1988). In addition, the electroencephalogram (EEG) is an

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imprecise diagnostic device, and abnormal brain wave activity in people with antisocial personalities may simply be correlated with, rather than a cause of, disturbed behavior. Autonomic Nervous System Abnormalities Other interesting research points to the involvement of the autonomic nervous system (ANS) in the prominent features of APD: the inability to learn from experience, the absence of anxiety, and the tendency to engage in thrillseeking behaviors. Two lines of investigation can be identified, both based on the assumption that people with APD have ANS deficiencies or abnormalities. The first states that ANS abnormalities make antisocial personalities less susceptible to anxiety and therefore less likely to learn from their experiences in situations in which aversive stimuli (or punishment) are involved. The second explanation suggests that ANS abnormalities could keep antisocial people emotionally underaroused. To achieve an optimal level of arousal or to avoid boredom, underaroused individuals might seek excitement and thrills and fail to conform to conventional behavioral standards. The two premises—lack of anxiety and underarousal—may, of course, be related because underarousal could include underaroused anxiety. Genetic Predisposition to Fearlessness or Lack of Anxiety Lykken (1982) maintained that because of genetic predisposition, people vary in their levels of fearlessness. APD develops because of fearlessness or low anxiety levels. People who have high levels of fear avoid risks, stress, and strong stimulation; relatively fearless people seek thrills and adventures. Fearlessness is associated with heroes (such as those who volunteer for dangerous military action or who risk their lives to save others), as well as with individuals with antisocial personalities who may engage in risky criminal activities or impulsively violate norms and rules. Lykken’s (1957) classic research suggested that, because psychopaths do not become conditioned to aversive stimuli as readily as nonpsychopaths do, they fail to acquire avoidance behaviors, experience little anticipatory anxiety, and consequently have fewer inhibitions about engaging in antisocial behavior. More recent studies have also demonstrated that low anxiety among psychopaths is associated with more errors in learning tasks (Newman & Schmitt, 1998).

SENSATION SEEKING AND ANTISOCIAL PERSONALITY Lykken theorized that people with low anxiety levels are often thrill seekers. The difference between the psychopath who takes risks and the adventurer may largely be a matter of whether the thrill-seeking behaviors are channeled into destructive or constructive acts. In this picture, we see a female skier launching herself from an almost vertical cliff. It is believed, however, that men are more likely to be risk takers than women. Do you believe there are gender differences in thrill-seeking behaviors? If so, what can account for the gender differences?

Arousal, Sensation-Seeking, and Behavioral Perspectives These studies by Lykken and others suggest that individuals with APD may have deficiencies in learning because of lower anxiety. Another line of research proposes that they simply have lower levels of ANS reactivity and are underaroused. According to this view, the sensitivity of individuals’ reticular cortical systems varies, although there is an optimal level for each person. The system regulates the tonic level of arousal in the cortex, so that some people have high and some have low levels of arousal. Those with low sensitivity need more stimulation to reach an optimal level of arousal (Goma, Perez, & Torrubia, 1988). If psychopaths are underaroused, it may take a more intense stimulus to elicit a reaction in them than in nonpsychopaths. The lowered levels of reactivity may cause psychopaths to show impulsive, stimulus-seeking behaviors to avoid boredom. Zuckerman (1996) believes that a trait he calls impulsive unsocialized sensation seeking can help explain not only APD but also other disorders. Those with this trait want to seek adventures and thrills, are disinhibited, and are susceptible to boredom. Psychopaths score high for this trait. Similarly, Farley (1986) proposed that people vary in their degree of thrill-seeking behaviors. At one end of the thrillseeking continuum are the “Big T’s”—the risk takers and adventurers who seek excitement and stimulation. Because of their low levels of CNS or ANS arousal,

Did You Know?

I

s it possible that heroes and psychopaths are two sides of the same coin? Both share one characteristic: fearlessness. They tend to choose frightening or challenging situations, push the boundaries of acceptable behavior, and may use deception to attain goals. The difference seems to be that heroes channel their fearlessness into socially approved activities and are socialized in families that emphasize loving relationships rather than punishment. Psychopaths come from punitive and hostile family environments (Lykken, 1982).

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Big T’s need stimulation to maintain an optimal level of arousal. On the other end of the continuum are “Little t’s”—people with high arousal who seek low levels of stimulation to calm their hyped-up nervous systems. In contrast to Big T’s, Little t’s prefer certainty, predictability, low risk, familiarity, clarity, simplicity, low conflict, and low intensity.

Psychological Dimension Psychological explanations of personality disorders and specifically APD tend to fall into three camps: psychodynamic, cognitive, and social learning.

Did

Psychodynamic Perspectives According to psychodynamic approaches, the psychopath’s absence of guilt and frequent violation of moral and ethical standards are the result of faulty superego development (Fenichel, 1945). Although the ego develops adequately, the personalities of people with APD are dominated by id impulses that operate primarily from the pleasure principle in seeking immediate (impulsive) gratification with minimal regard for others (egocentricity). Because the infantile id is dominated primarily by sex and aggression, so are people with APD who act out these impulses on others (Millon et al., 2004). People exhibiting antisocial behavior patterns presumably You Know? did not adequately identify with their parents and thus did not internalize the morals and values of eck and colleagues (1990) have proposed psychological society. It is believed that frustration, rejection, or orientations (strategies) and beliefs that characterize a number inconsistent discipline resulted in fixation at an early of personality disorders. Do these make sense to you? stage of development.

B

Disorder

Strategy

Example of Belief

Antisocial

Predatory

“Others are patsies.”

Dependent

Help-eliciting

“I need people to survive.”

Narcissistic

Competitive

“I’m above the rules.”

Histrionic

Exhibitionistic

“I can go with my feelings.”

Schizoid

Autonomous

“Relationships are messy.”

Paranoid

Defensive

“Goodwill hides a hidden motive.”

Avoidant

Withdrawal

“People will reject the real me.”

Compulsive

Ritualistic

“Details are crucial.”

Cognitive Perspectives Cognitive explanations of APD stress the relationship of core beliefs that influence behavior (Beck et al., 1990). These core beliefs operate on a nonconscious level, occur automatically, and influence emotions and behaviors. For the antisocial person, the thoughts are “Others are patsies,” “The world is hostile,” “It’s okay to take advantage of others,” “Do unto others before they do unto you.” These thoughts arise from what Beck and colleagues (1990) refer to as a “predatory strategy.” It is built around a need to perceive oneself as strong and independent, necessary attributes for survival in a competitive, hostile, and unforgiving world.

Learning Perspectives Learning theories stress a number of different forces in explaining APD: (1) inherent neurobiological characteristics that delay or impede learning, (2) lack of positive role models in developing prosocial behaviors, or (3) presence of poor role models. In all cases, whether we are speaking about classical conditioning, operant conditioning, or social modeling, it is proposed that biology or social/developmental factors combine in unique ways to influence the development of APD. As we have seen earlier, some believe that learning deficiencies among individuals with APD are caused by the absence of anxiety and by lowered autonomic reactivity. If so, is it possible to improve their learning by increasing their anxiety or arousal ability? To test this idea, researchers designed two conditions in which psychopaths, a mixed group, and nonpsychopaths would perform an avoidance learning task, with electric shock as the unconditioned stimulus. Under one condition, participants were injected with adrenaline, which presumably increases arousal; under the other, they were injected with a placebo. Psychopaths receiving the placebo made more errors in avoiding the shocks than did nonpsychopaths; psychopaths receiving adrenaline, however, tended to perform better than nonpsychopaths. These findings imply that psychopaths do not react to the same amount of anxiety as do nonpsychopaths and that their learning improves when their anxiety is increased (Schachter & Latané, 1964).

Multipath Analysis of One Personality Disorder: Antisocial Personality Disorder

Social Dimension

.55 Mean avoidance learning

The kind of punishment used in avoidance learning is also an important consideration in evaluating psychopaths’ learning deficiencies (Schmauk, 1970). Whereas psychopaths may show learning deficits when faced with physical (electric shock) or social (verbal feedback) punishments, they learn as well as nonpsychopaths when the punishment is monetary loss. Figure 8.2 shows the effects of the three types of punishment for incorrect responses in Schmauk’s study of convicted psychopaths. The certainty of punishment may also influence the responsiveness of those with antisocial personality disorder to punishment. Psychopaths and nonpsychopaths do not seem to differ in responding when punishment is a near certainty (Siegel, 1978). When the probability of punishment is highly uncertain, however, psychopaths do not suppress their behaviors. Threats of punishment by themselves do not seem to be sufficient to discourage psychopaths. Social modeling or observational learning is a complex form of learning that involves the social dimension in our multipath model. As with our understanding of the reciprocal interaction between autonomous nervous system reactivity and learning processes, so too a strong relationship exists between how learning occurs through the social dimension of APD. It is impossible to discuss one without the other.

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.50

.45

.40

.35

.30

Control group

Physical punishment

FIGURE

Nonpsychopathic group Monetary punishment

8.2

Psychopathic group

Social punishment

EFFECT OF TYPE OF PUNISHMENT ON PSYCHOPATHS AND OTHERS The effects of three different types of punishment on an avoidance learning task are shown for three groups of participants. Although physical or social punishment had little impact on psychopaths’ learning, monetary punishment was quite effective.

Among the many factors that have been implicated in the development of personality disorders, relationships within the Source: Schmauk (1970). family—the primary agent of socialization—are paramount in the development of antisocial patterns. In a review of factors that predict delinquency and antisocial behaviors in children, it was found that a family’s socioeconomic status was a weak predictor, whereas other family characteristics, such as poor parental supervision and involvement, were good predictors (Loeber, 1990). Antisocial personality, according to this view, results from children who are exposed to family environments of neglect, hostility, indifference, and physical abuse (Millon et al., 2004). Children from such environments learn that the world is cold, unforgiving, and punitive. Struggle and survival become part of their outlook on life, and they respond in an aggressive fashion to control and manipulate the world. Rejection or deprivation by one or both parents may mean that the child has little opportunity to learn socially appropriate behaviors or that the value of people as socially reinforcing agents is diminished. There is also evidence that family structure, predictability of expectations, and dependability of family roles are related to lower antisocial tendencies (Tolan et al., 1997). Parental separation or absence and assaultive or inconsistent parenting are related to antisocial personality (Phillips & Gunderson, 1999). Children may have been traumatized or subjected to a hostile environment during the parental separation, or the hostility in such families may result in interpersonal hostility among the children (Benjamin, 1996; Kiesler, 1996). Such situations may lead to little satisfaction in close or meaningful relationships with others. Individuals with APD tend to misperceive the motives and behaviors of others and have difficulty being empathetic (Benjamin, 1996). It has been long established that people with antisocial personality disorder can learn and use social skills very effectively (Ullmann & Krasner, 1975), as shown in their adeptness at manipulation, lying, and cheating and their ease at being charming and sociable. The difficulty is that, in many areas of learning, these individuals do not pay attention to social stimuli, and their schedules of reinforcement differ from those of most other people. Perhaps this relatively diminished attention stems from inconsistent reinforcement from parents or inadequate feedback on behaviors.

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Children may also copy the behaviors of a parent who exhibits antisocial tendencies. In one major study, researchers examined the past records and statuses of nearly five hundred adults who had been seen about thirty years earlier as children in a child guidance clinic. More than ninety of the adults exhibited antisocial tendencies. These persons were compared with a group of one hundred adults who, as children, had lived in the same geographic area but had never been referred to the clinic. The researchers found the following (Robins, 1966): 1. There was little relationship between having antisocial personality disorder as an adult and participating in gangs as a youth. 2. Antisocial behavior (theft, aggression, juvenile delinquency, lying) in childhood was a predictor of antisocial behavior in adults. 3. The adjustment level of fathers, but not that of mothers, was significant—having a father who was antisocial was related to adult antisocial characteristics. 4. Growing up in a single-parent home was not related to psychopathy. This early study seemed to indicate that antisocial behavior is probably influenced by the presence of an antisocial father who either serves as a model for such behavior or provides inadequate supervision, inconsistent discipline, or family conflict. The father’s influence on antisocial behaviors in children may be a result of traditional gender role training. Males have traditionally received more encouragement to engage in aggressive behaviors than females have, and antisocial patterns are more prevalent among men than among women. As traditional gender roles change, one might reasonably expect that antisocial tendencies will increase among females and that mothers will play a greater role in the development of antisocial behaviors in children. Parental antisocial patterns, especially among fathers, have also been implicated in the development of child conduct disorders (Lahey et al., 1988). Interestingly, divorce among parents does not appear to be related to having children with conduct disorder, when parental antisocial background is controlled. That is, the association between divorce and increased conduct disorders of children was caused primarily by the fact that divorced parents were more likely to be antisocial than were married parents. It is unclear, however, whether the effects of having a psychopathic parent are genetic (parents transmitting a certain genetic makeup to children) or environmental (parents providing an antisocial role model). Consistent with our multipath model, a disturbed family background or disturbed parental model is neither a necessary nor a sufficient condition for the development of antisocial personality. Indeed, antisocial personality probably has multiple and interacting dimensional causes.

Sociocultural Dimension The study of culture and personality has always been of fascination to early anthropologists, who believed that culture shapes the development of personality or that culture represents an expanded extension of personality (Benedict, 1934; Kardiner, 1939; Mead, 1928). Little doubt exists that our lives are influenced by the values, traditions, and institutions of our society and that such factors as social class, race, gender, and other sociodemographic variables are important in both normal and abnormal development (American Psychiatric Association, 2000a; Sue & Sue, 2008a). Determining the relative impact of specific sociocultural factors, however, is a complicated procedure. We have already seen that socioeconomic class is a weak predictor of delinquency and APD but that gender and larger cultural values (individualism and collectivism) may have a profound impact (Ivey et al., 2007; Millon et al., 2004). Gender Because males are more likely to exhibit both conduct disorders and APD than females, there is a strong possibility that different pathways to development exist along gender lines. For example, although parental conflict and disharmony are often implicated in APD development, studies suggest that they do not predict

Treatment of Antisocial Personality Disorder

antisocial behavior for men but do predict it for women (Mulder et al., 1994). Further, the specific manner of expression of APD seems influenced by gender as well: men were found to exhibit job problems, violence, and traffic offenses, whereas women were more likely to report relationship problems, job problems, and violence. Because the sex role for women emphasizes a less assertive and more peoplefocused orientation, the term relational aggression has been coined to describe the behavior of females with APD (Millon et al., 2004). Whereas men are believed to engage in direct acting-out behaviors (physical aggression), women express themselves by more indirect or passive means (spreading rumors or false gossip and rejecting others from their social group). As gender role differences have narrowed, however, female antisocial behaviors have become progressively similar to those of their male counterparts. Cultural Values To be born and raised in the United States is to be exposed to the standards, beliefs, and values of United States society. One dominant value is that of “rugged individualism,” which is composed of two assumptions: (1) healthy functioning is equated with individualism and independence, and (2) people can and should master and control their own lives and the universe (Sue & Sue, 2008a). Striving, competition, and ability to manipulate the environment are considered pathways to success; achievements are measured by surpassing the attainment of others. In the extreme, this psychological orientation may fuel the aggressive and violent behavior of antisocials. Other societies, such as those in some Asian countries, possess values and beliefs that are often at odds with individualistic values: collectivism and interdependence are valued, concern is with group rather than self-development, and being in harmony with the universe is preferred over mastering it. Some have observed that antisocial behavior (crime and violence) is less likely to occur in Japan and China than in the United States because of these countries’ collectivistic orientation, in which harmony and relationship with others are valued (Ivey et al., 2007). Such findings also seem to be present among Asian Americans and Hispanic Americans in the United States. Because traditional Asian values, for example, value harmony, subtlety, and restraint of strong feelings, Asian American clients who seek therapy are less likely than their white European American counterparts to evidence actingout disorders (overt expressions of anger, physical aggression, verbal hostility, substance abuse, and criminal behavior; Sue & Sue, 2008a). Thus it is clear that the sociocultural dimension is a powerful determinant in the etiology and manifestation of personality disorders.

Treatment of Antisocial Personality Disorder As you have seen, evidence is growing that low anxiety and low autonomic reactivity characterize individuals with APD. But we still do not know whether these characteristics are products of inherited temperament, of an acquired congenital defect, or of social and environmental experiences during childhood. The theory that psychopaths have developed a defense against anxiety is intriguing, but the factors behind the development of such a defense have not been pinpointed. Because people with antisocial personality disorder feel little anxiety, they are poorly motivated to change themselves; they are also unlikely to see their behaviors as “bad” and may try to manipulate or “con” therapists. Thus traditional treatment approaches, which require the genuine cooperation of the client, may be ineffective for antisocial personality disorder. Few treatment outcome studies have been conducted for this disorder (Simon, 1998). In some studies, drugs with tranquilizing effects (phenothiazines and Dilantin) have been helpful in reducing antisocial behavior (Meyer & Osborne, 1982). People with antisocial personality disorder, however, are not likely to follow through with self-medication. Moreover, drug treatment is effective in only a few cases, and it can result in side effects such as blurred vision, lethargy, and neurological disorders.

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controversy

Impulse Control Disorders

D

efinitions of personality disorders include the characteristic of impulsivity. Yet DSM classifies certain impulse control disorders in a distinct category; these disorders occur in 8.9 percent of the population during any given year (Kessler, Chiu, et al., 2005). Although they may be long-standing and unvarying behavioral patterns, they are not considered personality disorders. People with impulse control disorders tend to share three characteristics: (1) they fail to resist an impulse or temptation, despite knowing the act is wrong or harmful to them or others; (2) they experience tension or arousal before the act; and (3) they feel a sense of excitement, gratification, or release after committing the act. Guilt or regret may or may not follow. The core feature of the disorder is the repeated expression of impulsive acts that lead to physical or financial damage to the individual or another person, often resulting in a sense of relief or release of tension (American Psychiatric Association, 2000a). Disorders in this category include intermittent explosive disorder, kleptomania, pathological gambling, pyromania, and trichotillomania. 1. Intermittent explosive disorder describes people who experience separate and discrete episodes of loss of control over their aggressive impulses, resulting in serious assaults on others or the destruction of property. The aggressiveness is grossly out of proportion to any precipitating stress that may have occurred. People with this disorder show no signs of general aggressiveness between episodes and may genuinely feel remorse for their actions. The disorder is apparently rare and believed to be much more common among males than females. 2. Kleptomania is characterized by a recurrent failure to resist impulses to steal objects. People with this disorder do not need the objects for personal use and do not steal them for their monetary value; indeed, they usually have enough money to buy the objects and typically discard, give away, or surreptitiously return them. The individual feels irresistible urges and tension before stealing or shoplifting and then an intense feeling of relief or gratification after the theft. The stealing is not committed to express anger or vengeance and is not in response to a delusion or hallucination. The disorder appears to be more common among females than among males. 3. Pathological gambling is a chronic and progressive failure to resist impulses to gamble. The gambling occurs despite the detrimental consequences that often accompany the behavior, such as financial ruin, turning to illegal activities to support gambling, disruptions of family or interpersonal relationships, and sacrificing obligations and responsibilities. Those afflicted with pathological

gambling constitute about 1 to 3 percent of adults, with the disorder more common among men than women (American Psychiatric Association, 2000a). 4. Pyromania is characterized by deliberate and purposeful fire setting on more than one occasion. Fire and burning objects fascinate people with this disorder, who get intense pleasure or relief from setting the fires, watching things burn, or observing firefighters and their efforts to put out fires. Their fire-setting impulses are driven by this fascination rather than by motives involving revenge, sabotage, or financial gains. Fire setters have been reported to have high rates of mood and substance use disorders (McElroy & Arnold, 2001). 5. Trichotillomania is a disorder characterized by an inability to resist impulses to pull out one’s own hair. Although trichotillomania principally involves the hairs in the scalp, a person with this disorder may pull hair from other parts of the body, such as eyelashes, beard, or eyebrows. Skin inflammation, itch, or other physical conditions do not provoke the hair pulling. Rather, the person simply cannot resist the impulse, which begins with a feeling of tension that is replaced by a feeling of release or gratification after the act. Initially, the hair pulling may not disturb the follicles, and new hair will grow. In severe cases, new growth is compromised and permanent balding results. Although some of the impulse control disorders, such as pathological gambling and pyromania, have gained much public attention, we know very little about their specific causes. There is some debate about whether impulse control disorders are more appropriately considered symptoms and manifestation of some other disturbance, such as obsessivecompulsive disorders. For example, the characteristics of impulse control disorders seem similar to those found in this OCD in three ways: (1) the disorders have an obsessivecompulsive quality in that the person feels a compulsion to perform certain acts; (2) the impulse control disorders also have a compulsive feature that is found in substance abusers or addicts who must maintain their habits; (3) to some extent, the behaviors of people with impulse control disorders resemble those of people with sexual disorders (such as exhibitionism and fetishism) in that tension, fascination, and release may precede or follow the acts. This controversy has been recently reinvigorated by a move to declare Internet addiction a new impulse control disorder in the 2012 edition of DSM-V. In one major survey, it was found that 15 percent of client youths described being addicted to the Internet and that they used the Internet so frequently that they isolated themselves from family and friends (Cynkar, 2007). Many children and adults not only feel a compulsion to constantly surf

Treatment of Antisocial Personality Disorder the Internet but also describe the cyberworld as their new social environment, in which they enter chat rooms, instant-message one another, post their profiles on MySpace, visit YouTube or pornography sites, and play virtual games (Bishop, 2005; DeAngelis, 2007), to the detriment of relationships with significant others and of their education or jobs. Opponents of including Internet addiction as a disorder believe the move is unwarranted because it represents a form of compulsion or “self-medication” from an existing disorder such as depression or loneliness. A lonely social isolate may be dependent on the Internet for vicarious companionship, but it is a compensatory response to an

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existing personal problem. An overly broad approach to the definition of addiction opens the floodgates to declaring every compensatory behavior an impulse control disorder, such as fingernail biting, frequent sexual activities, or even excessive use of the telephone. For Further Consideration 1. Can you make a case for and against the existence of impulse control disorders as distinct from other forms of compulsive activities? 2. What are your thoughts about Internet addiction? Have you ever found yourself so preoccupied with Internet use that other aspects of your life have suffered?

It may be that successful treatment can occur only in a setting in which behavior can be controlled. That is, treatment programs may need to provide enough control so that those with antisocial personalities cannot avoid confronting their inability to form close and intimate relationships and the effect of their behaviors on others. Such control is sometimes possible for psychopaths who are imprisoned for crimes or who, for one reason or another, are hospitalized. Intensive group therapy may then be initiated to help clients with antisocial personalities in the required confrontation. Some behavior modification programs have been tried, especially with delinquents who behave in antisocial ways. The most useful treatments are skill based and behavioral (Meloy, 2001). Money and tokens that can be used to purchase items have been given as rewards to young people who show appropriate behaviors (discussion of personal problems, good study habits, punctuality, and prosocial and nondisruptive behaviors). This use of material rewards has been fairly effective in changing antisocial behaviors (Van Evra, 1983). Once the young people leave the treatment programs, however, they are likely to revert to antisocial behavior unless their families and peers help them maintain the appropriate behaviors. Cognitive approaches have also been used. Because individuals with antisocial personalities may be influenced by dysfunctional beliefs about themselves, the world, and the future, they vary in skills for anticipating and acting on possible negative outcomes of their behaviors. Beck and colleagues (1990) have advocated that the therapist build rapport with the client, attempting to guide the patient away from thinking only in terms of self-interest and immediate gratification and toward higher levels of thinking. These higher levels would include, for example, recognizing the effects of one’s behaviors on others and developing a sense of responsibility. Because cognitive and behavioral approaches assume that antisocial behaviors are learned, treatment programs may target these behaviors by setting rules and enforcing consequences for rule violations, substituting new behaviors for undesirable ones, and learning to anticipate consequences of behaviors (Meloy, 2001). Because current treatment programs do not seem very effective, new strategies must be used. These strategies should focus on antisocial youths who seem amenable to treatment, and treatment programs should broaden the base of intervention to involve not only the young clients but also their families and peers. Because people with antisocial personality disorder may seek thrills (Big T’s), they may respond to intervention programs that provide the physical and mental stimulation they need (Farley, 1986). Longitudinal studies show that the prevalence of this disorder diminishes with age as these individuals become more aware of the social and interpersonal maladaptiveness of their social behaviors (Phillips & Gunderson, 1999).

impulse control disorder

a disorder in which the person fails to resist an impulse or temptation to perform some act that is harmful to the person or to others; the person feels tension before the act and release after it intermittent explosive disorder

impulse control disorder characterized by separate and discrete episodes of loss of control over aggressive impulses, resulting in serious assaults on others or destruction of property an impulse control disorder characterized by a recurrent failure to resist impulses to steal objects

kleptomania

pathological gambling

an impulse control disorder in which the essential feature is a chronic and progressive failure to resist impulses to gamble an impulse control disorder having as its main feature deliberate and purposeful fire setting on more than one occasion

pyromania

an impulse control disorder characterized by an inability to resist impulses to pull out one’s own hair

trichotillomania

Internet addiction a new impulse control disorder in the 2012 edition of DSM-V characterized by persons using the Internet so frequently that they isolate themselves from family and friends

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TREATING ANTISOCIAL BEHAVIORS Peers and family are critically important in the treatment of antisocial youths and in maintaining progress made in treatment. Here, a group led by a peer counselor is exploring some of the issues troubling these young people. What would you do as a peer counselor to help these youths open up and talk about their own problems?

I M P L I C AT I O N S

Although personality disorders have generated rich clinical examples and speculation, not much empirical research has been conducted to provide definitive insights into the causes of the disorders. Many researchers use the five-factor model of personality, which describes personality patterns in terms of neuroticism (emotional adjustment and stability), extraversion (preference for interpersonal interactions, being fun-loving and active), openness to experience (curiosity, willingness to entertain new ideas and values, and emotional responsiveness), agreeableness (being good-natured, helpful, forgiving, and responsive), and conscientiousness (being organized, persistent, punctual, and self-directed; Widiger, 2007). Individuals vary in the extent to which they exhibit any of these factors. For example, in terms of deliberation (the factor of conscientiousness), an individual with antisocial personality disorder would score low, whereas one with obsessivecompulsive personality disorder would score high. The five-factor model allows researchers and clinicians to assess personality disorders as a particular set of personality characteristics and to compare different disorders. It also views the etiology of personality disorders as a matter of discovering determinants of personality in general. Our review of the etiology of APD seems to suggest that other personality disorders are also the result of a multidimensional interaction of biological, psychological, social, and sociocultural factors. As we have seen, studies consistently indicate that genetic as well as environmental factors interact in many ways with differential outcomes. It appears, for example, that certain genetic characteristics of individual children may determine much of the environment they experience, so that the contributions of heredity and environment may be quite complex. Genetic characteristics may affect environmental factors, which in turn influence personality (Saudino, 1997). Individuals who inherit a disposition to be sociable may seek out certain social environments, joining social clubs and engaging in interpersonal activities. These environments may then further strengthen the personality’s tendency toward sociability. Again, our multipath model looks for explanations of personality disorders from a multidimensional rather than a singular perspective.

Summary histrionic personality disorder (self-dramatization and attention-seeking behaviors); and narcissistic personality disorder (sense of self-importance and lack of empathy).

1. What are personality disorders, and how are they viewed? ■

■

Personality disorders are enduring, inflexible, longstanding maladaptive personality traits that cause significant functional impairment, subjective distress, or a combination of both. DSM-IV-TR lists ten specific personality disorders; each causes notable impairment of social or occupational functioning or subjective distress for the person. They are usually manifested in adolescence and continue into adulthood, and they involve disturbances in personality characteristics. There are differences in thought as to whether personality disorders should be viewed categorically or in a dimensional manner (extremes on a continuum of normal personality traits). The personality disorders include a diversity of behavioral patterns in people who are typically perceived as being odd or eccentric; dramatic, emotional, and erratic; or anxious and fearful.

2. What personality disorders are considered odd or eccentric? ■ The three personality disorders in this cluster are paranoid personality disorder (suspiciousness, hypersensitivity, and mistrust); schizoid personality disorder (social isolation and indifference to others); and schizotypal personality disorder (peculiar thoughts and behaviors). 3. What personality disorders are considered dramatic, emotional, or erratic? ■ The four personality disorders in this cluster are antisocial personality disorder (failure to conform to social or legal codes of conduct); borderline personality disorder (intense mood and self-image fluctuations);

4. What personality disorders are considered anxious and fearful? ■

The three personality disorders in this cluster are avoidant personality disorder (fear of rejection and humiliation); dependent personality disorder (reliance on others and inability to assume responsibility); and obsessive-compulsive personality disorder (perfectionism and interpersonal control).

5. How does the multipath model explain antisocial personality disorder? ■ Because personality is at the core of the disorder, etiological explanations focus on factors that influence personality. Genetics and neurobiological factors (underarousal of ANS and low anxiety), psychodynamic, cognitive and learning formulations, social or parental and family environments, and sociocultural factors (gender, race, and culture) all seem to contribute in a highly complex fashion. 6. What types of therapy are used in treating antisocial personality disorder? ■ Traditional treatment approaches are not particularly effective with antisocial personalities. It may be that successful treatment can occur only in a setting in which behavior can be controlled. That is, treatment programs may need to provide enough control so that those with antisocial personalities cannot avoid confronting their inability to form close and intimate relationships and the effect of their behaviors on others.

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c h a p t e r

9

SubstanceRelated Disorders

J

chapter outline Substance-Use Disorders

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Etiology of Substance-Use Disorders 246 Intervention and Treatment of SubstanceUse Disorders

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IMPLICA TION S

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CONTROVERSY Is Drug

Addiction a Disease?

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CRITICAL THINKING Is Drug Use an Indicator of Disturbance?

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CONTROVERSY Controlled

Drinking

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im was a fifty-four-year-old alcoholic. He was well educated, having received a bachelor’s degree in engineering and a master’s degree in management. Until recently, he was employed as a middle manager in an aerospace firm. Because of federal defense industry budget cuts and because of his absenteeism from work caused by drinking, Jim lost his job. He decided to enter treatment. His drinking history was long. Jim clearly recalled the first time that he drank. At age fifteen, he attended a party at his friend’s house. Alcohol was freely served. Jim took a drink, and despite the fact that alcohol “tasted so bad,” he forced himself to continue drinking. Indeed, he became drunk and had a terrible hangover the next day. He swore that he would never drink again, but two weeks later he drank again at his friend’s house. Over the next several years, Jim acquired the ability to consume large amounts of alcohol and was proud of his drinking capacity. At social gatherings, he was uninhibited and the “life of the party.” His drinking continued during college, but it was confined primarily to his fraternity weekend parties. He was considered a very heavy drinker in the fraternity, but the drinking did not seem to affect his academic performance. He frequently drove his car during weekend binges, however, and was once caught and convicted of drunken driving. After graduate school, he got married and took a position in an aerospace firm. Katie, Jim’s wife, also drank but never as heavily as Jim. Although his drinking had been largely confined to weekends, Jim started drinking throughout the week. He attributed his increased drinking to pressures at work, company-sponsored receptions at which alcohol was served, and a desire to feel “free and comfortable” in front of company executives during the receptions. Over time, Jim was unable to complete work assignments on time and was frequently absent from work because of his drinking. The drinking continued despite frequent arguments with Katie over his drinking and a physician’s warning, after a routine physical examination, that alcohol had probably

FOCUSQUESTIONS

1 What are substance-use disorders? 2 Why do people develop substance-use disorders?

3 What kinds of interventions and treatments are available for substance-use disorders, and does treatment work?

caused the abnormal results of Jim’s liver-functioning tests. He could not control his alcohol consumption. Katie noticed that Jim was getting angrier and angrier over his work assignments. Jim felt that deadlines for him to complete assignments were unrealistic. She felt that he was increasingly difficult to be around. He drank now daily, usually in his office at the end of the workday. His colleagues knew Jim had a drinking problem, but because he was still functioning well at work, they kidded him about drinking rather than counseling him against consuming alcohol. They were, however, concerned about his absenteeism, frequent tardiness, and inability to get started in the morning, which were caused by his drinking. Over the years, Katie simply fell out of love with Jim. The arguments, Jim’s drinking, and his unwillingness to communicate with her finally led to a divorce. He was quite bitter over the divorce, although Katie could not see how he was getting anything out of the marriage. When awards for defense contracts had diminished, Jim’s company started to lay off workers. Jim was among the first to be asked to leave.

Problem drinking can develop in many different ways and can begin at almost any age. However, Jim’s history is typical in several respects. First, as is true of most people, he initially found the taste of alcohol unpleasant, and, after his first bout of drunkenness, he swore that he would never drink again. Nevertheless, Jim did return to drinking. Second, heavy drinking served a purpose: it reduced his anxiety, particularly at work. Third, consumption continued despite the obvious negative consequences. Fourth and finally, a preoccupation with alcohol consumption and the deterioration of social and occupational functioning are also characteristic of the problem drinker. Why did Jim force himself to drink when alcohol initially tasted so bad? Even though alcohol may have reduced some work anxieties, it also increased arguments with his wife and resulted in health problems. Why drink and become an alcoholic? Throughout history, people have swallowed, sniffed, smoked, or otherwise taken into their bodies a variety of chemical substances for the purpose of altering their moods, levels of consciousness, or behaviors. The widespread use of drugs in our society today is readily apparent in our vast consumption of alcohol, tobacco, coffee, medically prescribed tranquilizers, and illegal drugs such as cocaine, marijuana, and heroin. Compared with other societies, our society is generally permissive with regard to the use of these substances. As indicated in Figure 9.1, many people have tried substances, especially alcohol, at some time in their lives. The substances or drugs are psychoactive in that they alter moods, thought processes, or other psychological states. Substance-related disorders are ailments arising from the use of psychoactive substances that affect the central nervous system and cause significant social, occupational, psychological, or physical problems. DSM-IV-TR divides substancerelated disorders into two categories: (1) substance-use disorders that involve dependence and abuse and (2) substance-induced disorders, such as withdrawal and substance-induced delirium. The discussion in this chapter focuses primarily

substance-related disorder

ailment arising from the use of psychoactive substances that affect the central nervous system, causing significant social, occupational, psychological, or physical problems, and that sometimes result in abuse or dependence

233

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C H A P T E R 9 • SUBSTANCE-RELATED DISORDERS Alcohol

125

Tobacco Products

72.9

Marijuana

14.8

Illicit Drugs Other Than Marijuana

9.6

Psychotherapeutics

7.0

Pain Relievers

5.2

Cocaine

2.4

Tranquilizers

1.8

Stimulants

1.2

Hallucinogens

1.0

Inhalants

0.8

Methamphetamine

0.7

Crack

0.7

Ecstasy

0.5

Sedatives

0.4

Heroin

0.3

OxyContin®

0.3

LSD

0.1

PCP

0.0 0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

Numbers in millions

FIGURE

9.1

PERCENTAGE OF PERSONS WHO REPORTED USING SPECIFIC SUBSTANCES AT ANY TIME DURING THE PAST MONTH (AGE 12 AND OVER): 2006 The vast majority of Americans have used one substance or another, particularly alcohol and tobacco.

Source: SAMHSA (2007).

substance abuse maladaptive pattern of recurrent use that extends over a period of twelve months; leads to notable impairment or distress; and continues despite social, occupational, psychological, physical, or safety problems substance dependence

maladaptive pattern of use extending over a twelve-month period and characterized by unsuccessful efforts to control use despite knowledge of harmful effects; taking more of substance than intended; tolerance; and/or withdrawal tolerance condition in which

increased doses of a substance are necessary to achieve the desired effect

on the substance-use disorders represented in Table 9.1, rather than on substanceinduced disorders or maladaptive use of other substances such as anabolic steroids and nitrous oxide (“laughing gas”). Some substance-induced cognitive disorders are discussed in the chapter on cognitive disorders. DSM-IV-TR differentiates the substance-use disorders in two ways: (1) by the actual substance used and (2) by whether the disorder pattern is that of substance abuse or substance dependence. Regardless of the substance involved, the general characteristics of the abuse or dependence are the same. Substance abuse is a maladaptive pattern of recurrent use that extends over a period of twelve months, that leads to notable impairment or distress, and that continues despite social, occupational, psychological, physical, or safety problems. The abuse may cause legal problems (e.g., illegal activities to support a drug habit) or jeopardize the safety of the user or others (such as driving while intoxicated). It may affect the user’s ability to maintain meaningful social relationships or to fulfill major role obligations at work, school, or home. And need for the substance may lead to a preoccupation with its acquisition and use. In substance dependence, a person exhibits several of the following symptoms over a twelve-month period: 1. The user is unable to cut down or control use of the substance, despite knowledge of its harmful physical, psychological, or interpersonal effects. 2. The user takes increasingly larger amounts of the substance or continues to use it over a longer period than he or she intended. 3. The user devotes considerable time to activities necessary to obtain the substance, even though those activities mean that important social, occupational, and recreational activities must be sacrificed. 4. The user exhibits evidence of tolerance: increasing doses of the substance are necessary to achieve the desired effect, such as a “high.”

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9.1

DISORDERS CHART

SUBSTANCE-RELATED DISORDERS

SUBSTANCERELATED DISORDER

EFFECTS

Depressants or Sedatives (Nonalcohol)

Central nervous system depressant Sleep inducer Anxiety relief

PREVALENCE OF ABUSE/ DEPENDENCE %

GENDER DIFFERENCES

AGE OF ONSET

1.2

Higher in females for certain sedatives

Variable

Alcohol

8.0–14.0

5 times higher in males

First drink in mid-teens; peak in 20s/30s

Opiates

0.7

3 to 4 times higher in males

Any age but usually in late teens/early 20s

1.7

3 to 4 times higher in males

Teens or young adults

0.2

No gender differences observed

Young adults

0.4

3 times higher in males

Teens or young adults

4.4

Higher in males

Teens to young adults

Stimulants

Central nervous system energizer Euphoria Alertness

Cocaine Hallucinogens

Hallucinations Heightened awareness Increased insight

Marijuana, LSD, PCP

5. The user shows evidence of withdrawal: distress or impairment in social, occupational, or other areas of functioning or physical or emotional symptoms such as shaking, irritability, and inability to concentrate after reducing or ceasing intake of the substance. In diagnosing substance dependence, the clinician also specifies whether the dependence is physiological; evidence of either tolerance or withdrawal indicates physiological dependence. As can be readily noted, the criteria for substance dependence include those for abuse and withdrawal. Because dependence is considered the more severe disorder, people who meet the criteria for both dependence and abuse for a particular substance are diagnosed only as dependent, not as abusing. In this chapter, we first examine substance-use disorders, including the effects of the abuse of alcohol and various drugs. We also examine the degree to which different theories may increase our understanding of the causes and treatment of the abuse of alcohol and other substances.

Substance-Use Disorders A number of substances can result in abuse, dependence, intoxication, and withdrawal. Among them are prescription drugs such as Valium; legal substances such as alcohol and cigarettes; and illegal substances such as LSD (lysergic acid diethylamide), cocaine, and heroin. Alcohol and substance abuse is the second leading cause of disability in the United States, Canada, and western Europe, ahead of physical diseases and second only to mental illness (President’s New Freedom Commission on Mental Health, 2003). Each of the drugs discussed in this chapter can create an abuse or dependence disorder. Many are also associated with legal problems, because their use is expressly prohibited except under strict medical supervision. We discuss general categories of substances—depressants, stimulants, and hallucinogens—that contain many specific drugs, such as alcohol, narcotics, barbiturates, benzodiazepines,

withdrawal condition characterized by distress or impairment in social, occupational, or other areas of functioning or by physical or emotional symptoms such as shaking, irritability, and inability to concentrate after reducing or ceasing intake of a substance

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Did You Know? • About 18.7 million Americans, or 7.7 percent of the population, are alcohol dependent or abusers • About 3.6 million are dependent on drugs • About 23 percent of men and 18.5 percent of women are cigarette smokers • About 44.3 percent of young adults 18 to 25 years old use tobacco • The most widely used moodaltering drug is caffeine, which is consumed by about 80 to 90 percent of Americans Source: Lemonick (2007).

Did You Know? Each year: • 1,700 college students ages eighteen to twenty-four die from alcohol-related unintentional injuries, including car accidents. • 599,000 students ages eighteen to twenty-four are unintentionally injured under the influence of alcohol. • More than 696,000 students between the ages of eighteen and twenty-four are assaulted by another student who has been drinking. • More than 97,000 students ages eighteen to twenty-four are victims of alcohol-related sexual assault or date rape. • 2.1 million students ages eighteen to twenty-four drove under the influence of alcohol last year. Source: Hingson et al. (2002); Hingson et al. (2005).

depressant (sedative) substance

that causes generalized depression of the central nervous system and a slowing down of responses alcoholic person who abuses alcohol and is dependent on it alcoholism substance-related disorder characterized by abuse of, or dependency on, alcohol, which is a depressant

amphetamines, caffeine, nicotine, cocaine and crack, marijuana, LSD, and phencyclidine (PCP). Table 9.2 lists these substances, their effects, and their potential for dependency. In practice, some substances are not easily classified because they may have multiple effects.

Depressants or Sedatives Depressants (or sedatives) cause generalized depression of the central nervous system and a slowing down of responses. People taking such substances feel calm and relaxed. They may also become sociable and open because of lowered interpersonal inhibitions. Let’s examine in more detail one of the most widely used depressants— alcohol—and then discuss other depressants, such as narcotics, barbiturates, and benzodiazepines. Alcohol-Use Disorders Alcohol abuse and alcohol dependence are, of course, substance abuse and dependence in which the substance is alcohol. People who have either of these alcohol-related disorders are popularly referred to as alcoholics, and their disorder as alcoholism. Drinking problems can be exhibited in two major ways. First, the person may need to use alcohol daily to function; that is, he or she may be unable to abstain. Second, the person may be able to abstain from consuming alcohol for certain periods of time but fail to control drinking once it has started. This person is a “binge” drinker. Both patterns of drinking can result in deteriorating relationships, job loss, family conflicts, and violent behavior while intoxicated. Alcohol Consumption in the United States People drink considerable amounts of alcohol in the United States. Some interesting facts: • Slightly more than half (51 percent) of Americans age twelve or older reported being current drinkers of alcohol (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007). This translates to an estimated 125 million people. • Most of the alcohol is consumed by a small percentage of people—50 percent of the total alcohol consumed is drunk by only 10 percent of drinkers. • Drinking is widespread among young people. Among persons ages twelve to twenty, about 10.8 million (28.3 percent of this age group) reported drinking alcohol in the preceding month (SAMHSA, 2007). • Over 14 million American adults suffer from alcohol abuse or dependence (Nitzkin & Smith, 2004). • Early use of alcohol has been found to be a strong predictor of progression into serious problem drinking (Nelson, Heath, & Kessler, 1998). • Men drink two to five times as much as women, although gender differences in the use of alcohol are decreasing (Nelson et al., 1998). • Ethnic differences exist in consumption patterns (SAMHSA, 2007), with nonHispanic whites having among the highest rates, as indicated in Figure 9.2. Problems associated with alcohol consumption in the United States are apparent in terms of social, medical, physical, and financial costs. Alcohol consumption and alcoholism are associated with serious health-care costs; lowered productivity on the job; shortened life expectancy (by about ten to twelve years); and high rates of suicide, automobile accidents, spousal abuse, and divorce. Over seventy-five thousand deaths per year are due to excessive alcohol use, which is the third leading lifestyle-related cause of death in the United States (Centers for Disease Control and Prevention, 2006). Concern has also been directed at children of alcoholic parents, who are at risk for social maladjustment, self-depreciation, lower self-esteem, and alcoholism (Fields, 2004). In view of the problems associated with alcohol use, why do people continue drinking? Particularly ironic is the fact that, like Jim in our case description at the beginning of the chapter, most people consuming alcoholic beverages for the first time find the taste unpleasant. To better understand this puzzle, let’s consider the physiological and psychological effects of alcohol.

Substance-Use Disorders

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237

9.2

CHARACTERISTICS OF VARIOUS PSYCHOACTIVE SUBSTANCES SHORT-TERM EFFECTS a

POTENTIAL FOR DEPENDENCY

Alcohol

Central nervous system (CNS) depressant, loss of inhibitions

Moderate

Narcotics (codeine, morphine, heroin, opium, methadone)

CNS depressant, pain relief

High

Barbiturates (amytal, nembutal, seconal)

CNS depressant, sleep inducer

Moderate to high

Benzodiazepines (Valium)

CNS depressant, anxiety relief

Low

Amphetamines (Benzedrine, Dexedrine, Methedrine)

CNS energizer, euphoria

High

Caffeine

CNS energizer, alertness

Low

Nicotine

CNS energizer

High

Cocaine and crack

CNS energizer, euphoria

High

Marijuana

Relaxant, euphoria

Moderate

LSD

Hallucinatory agent

Low

PCP

Hallucinatory agent

Moderate

DRUGS

Depressants (Sedatives)

Stimulants

Hallucinogens

a

Specific effects often depend on the quality and dosage of the drug, as well as on the experience, expectancy, personality, and situation of the person using the drug.

Percent using in past month

The Effects of Alcohol Alcohol has both physiological and psychological effects, which can be further broken down into short-term and long-term effects. We consider short-term effects first. Once swallowed, alcohol is absorbed into the blood without digestion. When it reaches the brain, its short-term physiological effect is to 60 depress central nervous system functioning. Alcohol use (not binge) When the alcohol content in the bloodstream Binge use (not heavy) 50 (the blood alcohol level) is about 0.1 percent Heavy alcohol use (the equivalent of drinking five ounces of 40 whiskey or five glasses of beer), muscular coordination is impaired. The drinker may 30 have trouble walking a straight line or pronouncing certain words. At the 0.5 percent 20 blood alcohol level, the person may lose consciousness or even die. 10 The short-term physiological effects of alcohol on a specific person are determined by 0 Native Two or White Black or Hispanic American Asian the individual’s body weight, the amount of More African or Latino Indian or Hawaiian food present in the stomach, the drinking rate or Other Races American Alaska over time, prior drinking experience, heredPacific Native Islander ity, personality factors, and the individual’s environment and culture. The short-term psyETHNIC DIFFERENCES IN ALCOHOL CONSUMPTION PATTERNS chological effects of alcohol often include feel- F I G U R E ings of happiness, loss of inhibitions (because Source: SAMHSA (2007).

9.2

238

C H A P T E R 9 • SUBSTANCE-RELATED DISORDERS

alcohol depresses the inhibitory brain centers), poor judgment, and reduced concentration. Depending on the situation or context in which drinking occurs, other effects, such as negative moods and anger, may also be experienced. Reactions also depend on the expectancy that individuals have developed with respect to alcohol (Witkiewitz & Marlatt, 2004). Some people behave differently in the presence of others simply because of their perception that they have been drinking, not because of the effects of the alcohol (as, for example, when an individual has only a few sips of beer and begins to act hostile). Heavy and prolonged drinking often impairs sexual performance and produces a hangover. Ironically, because of the loss of inhibitions, people mistakenly believe that alcohol is a stimulant rather than a depressant. The long-term psychological effects of heavy drinking are more serious. Although THE COST OF DRINKING At a press conference, a mother talks about the death there is no single type of alcoholic, Jellinek of her son Dustin Church, 18, who was killed in an alcohol-related car accident. (1971) observed certain patterns among indiDo you know of anyone who has been injured or killed because of alcohol? viduals who develop alcohol dependence. The case of Jim is an example of this pattern. Most people begin to drink in social situations. Because the alcohol relieves tension, the drinkers tend to drink more and to drink more frequently. Tolerance levels may increase over a period of months or years. Because of stress, inability to adequately cope, or biological predisposition to alcoholism, some drinkers become preoccupied with thoughts of alcohol. They may Did You Know? worry about whether there will be enough alcohol at a party; they may try to drink he mouthwash Listerine inconspicuously or furtively. They begin to consume large amounts and may “gulp” contains enough alcohol to their drinks. Such drinkers frequently feel guilty; they are somewhat aware that be intoxicating. A fifty-year-old their drinking is excessive. Heavy, sustained drinking may lead to blackouts, periMichigan woman who admitted to ods of time for which drinkers have no memory of their activities. Jellinek believed drinking three glasses of Listerine that sustained drinking could then lead to a loss of control over alcohol intake and was found to have a blood-alcohol to frequent periods of intoxication. Individuals may then drink only to become content several times the legal limit intoxicated. after she ran into the rear of another The long-term physiological effects of alcohol consumption include an increase vehicle. The woman was charged in tolerance as the person becomes used to alcohol, physical discomfort, anxiety, with operating under the influence and hallucinations. Chronic alcoholism destroys brain cells and is often accompaand may be charged with having an nied by poor nutritional habits and physical deterioration. Other direct or indirect open container in the car, as police consequences generally attributed to chronic alcoholism are liver diseases such as found an open bottle of Listerine. cirrhosis, in which an excessive amount of fibrous tissue develops and impedes the circulation of blood; heart failure; hemorrhages of capillaries, particularly those on Source: “Listerine Drinker Arrested for DUI” the sides of the nose; and cancers of the mouth and throat. Alcohol consumption in (2005). pregnant women may affect their unborn children: children who suffer fetal alcohol syndrome are born mentally retarded and physically deformed. Interestingly, the moderate use of alcohol (one or two drinks a day), especially red wine, in adults has been associated in some studies with lowered risk of heart disease. The precise reasons for this effect are unknown, although antioxidant compounds in the wine may be beneficial. What is clear is that chronic heavy consumption has serious negative consequences, for the drinker and sometimes also for socinarcotic drug such as opium and ety at large. its derivatives—morphine, heroine,

T

and codeine—that depresses the central nervous system; acts as a sedative to provide relief from pain, anxiety, and tension; is addictive

Narcotics (Opiates) Like alcohol, the organic narcotics, which include opium and its derivatives morphine, heroin, and codeine, depress the central nervous system; act as sedatives to provide relief from pain, anxiety, and tension; and are addictive. Feelings

Substance-Use Disorders

239

RISKY BUSINESS In the movie Maria Full of Grace, actress Catalina Sandino Moreno stars as Maria, a Colombian girl who tries to smuggle 60 heroin pellets in her stomach in order to escape her country for the United States. Many couriers attempt to transport drugs internally, by swallowing balloonlike packets filled with a drug, risking potential death by overdose should a balloon rupture and the drug be absorbed by the body before it can be removed. How much money do you think is generated each year by the production, trafficking, and sales of illicit drugs worldwide?

of intense euphoria and well-being (and sometimes negative reactions such as nausea) often accompany narcotics use. Opium and its derivatives (especially heroin) result in dependency. Tolerance for narcotics builds rapidly, and withdrawal symptoms are severe. Opiates such as heroin are usually administered intravenously, causing puncture marks on the extremities of the body and spreading diseases such as AIDS, which can be transmitted through needle sharing. Over 25 percent of AIDS cases involve persons who abuse intravenous drugs (Centers for Disease Control and Prevention, 2007b). According to a recent report, about 0.3 percent of persons age twelve or older used heroin during the preceding month (SAMHSA, 2007), and 0.7 percent of the adult population has shown opioid abuse or dependence at some time during their lives. The prevalence of addiction decreases with age, and males are more affected than females by a ratio of 1.5:1 for opioids other than heroin (that is, those available by prescription) and 3:1 for heroin (American Psychiatric Association, 2000a). Because dependency is likely to occur after repeated use, narcotics addicts are usually unable to maintain normal relationships with family and friends or to pursue legitimate careers. They live to obtain the drug through any possible means. Nonmedical use of narcotics is illegal, and many addicts have little choice but to turn to criminal activities to obtain the drug and to support their expensive habits. Overdosing can occur and can result in death. Barbiturates Synthetic barbiturates, or “downers,” are powerful depressants of the central nervous system, and, like alcohol, can reduce inhibitions and become intoxicating. They are used to induce relaxation and sleep, although they are not often prescribed because of the availability of less powerful tranquilizers and sleeping pills. They are quite dangerous for several reasons. First, psychological and physical dependence can develop. Second, although their legal use as a tranquilizer and sleeping aid is restricted, their availability in the illegal drug market makes it difficult to control misuse or abuse. More than 1 million individuals—primarily middle-aged and older people—are now estimated to be barbiturate addicts. Third, users often experience harmful physical effects. Excessive use of either barbiturates or heroin can be fatal, but barbiturates are the more lethal. Constant heroin use increases the amount of the drug required for a lethal dosage. The lethal dosage of barbiturates does not increase with prolonged use, so accidental overdose and death can easily occur. And combining alcohol with barbiturates can be especially dangerous because alcohol compounds the depressant effects of the barbiturates, as it did in the following case.

Did You Know?

H

eavy barbiturate users or addicts included Adolph Hitler, Marilyn Monroe, Johnny Cash, and Elvis Presley.

CELEBRITY USER Actress Marilyn Monroe in a scene from the movie Bus Stop was a heavy barbiturate user.

barbiturate substance that is a powerful depressant of the central nervous system, is commonly used to induce relaxation and sleep, and is capable of inducing psychological and physical dependency; also called “downers”

240

C H A P T E R 9 • SUBSTANCE-RELATED DISORDERS

Case Study Kelly M., a seventeen-year-old girl from an upper-middle-class background, lived with her divorced mother. Kelly was hospitalized after her mother found her unconscious from an overdose of barbiturates, consumed together with alcohol. She survived the overdose and later told the therapist that she had regularly used barbiturates for the previous year and a half. The overdose was apparently accidental and not suicidal. For several weeks following the overdose, Kelly openly discussed her use of barbiturates with the therapist. She had been introduced to the drugs by a boy in school who told her they would help her relax. Kelly was apparently unhappy over her parents’ divorce. She felt that her mother did not want her, especially because her mother spent a lot of time away from home building a real estate agency. And although she enjoyed occasional visits with her father, Kelly felt extremely uncomfortable in the presence of the woman who lived with him. The barbiturates helped her relax and relieved her tensions. Arguments with her mother would precipitate heavy use of the drugs. Eventually she became dependent on barbiturates and always spent her allowance to buy them. Her mother reported that she had no knowledge of her daughter’s drug use. She did notice, though, that Kelly was increasingly isolated and sleepy. The therapist informed Kelly of the dangers of barbiturates and of combining them with alcohol. Kelly agreed to undergo treatment, which included the gradual reduction of barbiturate use, as well as psychotherapy with her mother.

Kelly’s practice of polysubstance use, or the use of more than one chemical substance at the same time, can be extremely dangerous. For example, heavy smokers who consume a great deal of alcohol run an increased risk of esophageal cancer. Chemicals taken simultaneously may exhibit a synergistic effect, interacting to multiply one another’s effects. For example, when a large dose of barbiturates is taken along with alcohol, death may occur because of a synergistic effect that depresses the central nervous system. Furthermore, one of the substances (such as alcohol) may reduce the person’s judgment, resulting in excessive (or lethal) use of

POLYSUBSTANCE ABUSE Using one psychoactive drug can be dangerous in itself, but mixing two or more chemical substances at the same time can be deadly. Each of these talented performers—Jim Morrison, Janis Joplin, John Belushi, and River Phoenix—died from polydrug use. How common is polydrug use?

Substance-Use Disorders

241

the other drug. Equally dangerous is the use of one drug to counteract the effect of another. For instance, a person who has taken a stimulant to feel euphoric may later take an excessive amount of a depressant (such as a barbiturate) in an attempt to get some sleep. The result can be an exceedingly harmful physiological reaction. According to DSM-IV-TR, polysubstance dependence may be diagnosed if (1) a person has used at least three substances (not including nicotine and caffeine) for a period of twelve months and (2) during this period, the person meets the criteria for substance dependence for the substances considered as a group but not for any single specific substance. Benzodiazepines One member of this category of drugs is Valium, which is one of the most widely prescribed drugs in the United States (Substance Abuse and Mental Health Services Administration [SAMHSA], 2002). Like other sedatives, Valium is a central nervous system depressant; it is often used to reduce anxiety and muscle tension. People who take the drug seem less concerned with and less affected by their problems. Some side effects may occur, such as drowsiness, skin rash, nausea, and depression, but the greatest danger in using Valium is in abusing it. Because life stressors are unavoidable, many people use Valium as their sole means of dealing with stress; then, as tolerance develops, dependence on the drug may also grow. The female-to-male and white-to-African American use ratios are about 3:1 (Franklin & Frances, 1999). Benzodiazepines are more likely to be prescribed for older adults, so there is special concern for this population (SAMHSA, 2002; U.S. Surgeon General, 1999).

Stimulants A stimulant is a substance that is a central nervous system energizer, inducing elation, grandiosity, hyperactivity, agitation, and appetite suppression. Commonly used stimulants are amphetamines, caffeine, nicotine, and cocaine and crack. Amphetamines Amphetamines, also known as “uppers,” speed up central nervous system activity and bestow on users increased alertness, energy, and sometimes feelings of euphoria and confidence. They increase the concentration of the neurotransmitter dopamine in synapses, which exposes the postsynaptic cells to high levels of dopamine. Increased concentration of dopamine may amplify nerve impulses in the brain that are associated with pleasure (Brower, 2006; Wise, 1988). Amphetamines inhibit appetite and sleep, and some are used as appetite suppressants or diet pills. These stimulants may be physically addictive and become habit forming, with a rapid increase in tolerance. They are taken orally, intravenously, or nasally (“snorting”). “Speed freaks” inject amphetamines into their blood vessels and become extremely hyperactive and euphoric for days. Another immediate and powerful effect is obtained by smoking a pure, crystalline form (“ice”) of the substance (American Psychiatric Association, 2000a). Assaultive, homicidal, and suicidal behaviors can occur during this time. Heavy doses may trigger delusions of persecution, similar to those seen among people with paranoid schizophrenia. Overdoses are fatal, and brain damage has been observed among chronic abusers. About 2 percent of U.S. adults have suffered from amphetamine abuse or dependence at some time during their lives. It is more common among persons from lower socioeconomic groups and among men than women by a ratio of two or three to one (American Psychiatric Association, 2000a; SAMHSA, 2007). Amphetamine is closely related chemically to methamphetamine, an even more powerful stimulant. Methamphetamines and other stimulants, such as Ecstasy (methylenedioxymethamphetamine), are often called “club drugs,” which is a term that comes from the popular use of certain drugs at dance clubs and “raves.” Other substances, such as the hallucinogen LSD (d-lysergic acid diethylamide), GHB (gamma hydroxybutyrate), Ketamine, Roofies or Rohypnol (flunitrazepam), alcohol, marijuana, and cocaine, may also be taken at raves. The substances tend to induce energy and excitement, feelings of well-being and connection with others

polysubstance dependence

substance dependence in which dependency is not based on the use of any single substance but on the repeated use of at least three substances (not including caffeine and nicotine) for a period of twelve months stimulant substance that is a central nervous system energizer, inducing elation, grandiosity, hyperactivity, agitation, and appetite suppression amphetamine a drug that speeds up central nervous system activity and produces increased alertness, energy, and, sometimes, feelings of euphoria and confidence; also called “uppers”

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C H A P T E R 9 • SUBSTANCE-RELATED DISORDERS

and one’s environment, and loss of inhibitions. After the substances are ingested, the effects of well-being may last for hours. The aftereffects may last for twentyfour hours or more, and users may experience lethargy, low motivation, and fatigue. Some experience severe effects, such as depression and anxiety, as well as physical changes in blood pressure, convulsions, and even death. In the case of Ecstasy, longlasting damage can occur to brain areas that are critical for thought and memory. Roofies (Rohypnol) are short-acting benzodiazepines that interfere with shortterm memory. Rohypnol is known as the “date-rape” drug because unsuspecting individuals who are given the drug may feel uninhibited and not remember recent activities. It is a tasteless and odorless drug that dissolves easily in beverages. Because of psychological, cognitive, and biological dangers associated with their use, club drugs are considered unsafe.

Did You Know?

R

esearchers have found that once a teenager had tried cigarettes, very little they did afterward affected whether they became addicted or not. Feelings of being “relaxed” immediately after the first puff of a cigarette was the leading predictor of becoming dependent on cigarettes and then being unable to quit. About 29 percent of youngsters interviewed said they had experienced such a feeling after their first cigarette.

Source: DiFranza et al. (2007).

cocaine substance extracted from

the coca plant; induces feelings of euphoria and self-confidence in users

Caffeine Caffeine is a legal stimulant ingested primarily in coffee, chocolate, tea, and cola drinks. It is the most widely consumed psychoactive substance in the world, prized by almost every culture for its ability to perk people up and keep them awake. In North America, about 90 percent of adults report using caffeine every day, and the average American consumes approximately 200 milligrams (mg) of caffeine per day (Larson & Carey, 1998). Caffeine is considered intoxicating when, after recently ingesting 250 mg (about two cups of coffee) or more, a person shows several of the following symptoms: restlessness, nervousness, excitement, insomnia, flushed face, gastrointestinal disturbance, rambling speech, and cardiac arrhythmia. The consequences of caffeine intoxication are usually transitory and relatively minor. In some cases, however, the intoxication is chronic and seriously affects the gastrointestinal or circulatory system. Nicotine Nicotine is another widely used legal stimulant, and dependence on it is most commonly associated with cigarette smoking. Media campaigns periodically immerse the public in warnings that cigarette smoking is harmful to the body and that secondhand smoke is dangerous to others. Cigarette smoking accounts for nearly one-fifth of the deaths in the United States and is the single most preventable cause of death (American Cancer Society, 2007). The prevalence of smoking is decreasing slightly in most industrialized nations, but it is rising in developing areas. According to SAMHSA (2007), 29.6 percent of the U.S. population age twelve or older reported current use of a tobacco product. During the month, 25 percent of the population had smoked cigarettes, 5.6 percent had smoked cigars, 3.3 percent had used smokeless tobacco, and 0.9 percent had smoked tobacco in pipes. Some, of course, used more than one type of tobacco. The highest rate of use was reported by young adults ages eighteen to twenty-five (43.9 percent). In terms of gender, a higher proportion of males than females smoked cigarettes (27.8 vs. 22.4 percent). As it is estimated that between 80 and 90 percent of regular smokers are nicotine dependent, close to 25 percent of the U.S. population may be nicotine dependent (American Psychiatric Association, 2000a). It has long been shown that cigarettes are strongly addicting. Schachter (1977) noted that chronic smokers need their “normal” constant intake of nicotine. When heavy smokers are given low-nicotine cigarettes, they smoke more cigarettes and puff more frequently. The following symptoms are characteristic of nicotine dependence: • Attempts to stop or reduce tobacco use on a permanent basis have been unsuccessful. • Attempts to stop smoking have led to withdrawal symptoms, such as a craving for tobacco, irritability, difficulty in concentrating, sleep difficulties, and restlessness. • Tobacco use continues despite a serious physical disorder, such as emphysema, that the smoker knows is exacerbated by tobacco use. Cocaine and Crack A great deal of publicity and concern has been devoted to the use of cocaine, a substance that is extracted from the coca plant and that induces feelings of euphoria and self-confidence in users. A number of professional athletes,

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SMOKING EFFECTS ON THE LUNGS An actual view of healthy lungs and heart of a nonsmoker versus the blackened lungs and heart of a smoker at a New York City exhibit of real whole human body specimens and more than 260 organs and partial body parts. The human body specimens are preserved through a revolutionary technique called polymer preservation. All bodies were of people who died of natural causes.

film stars, political figures, and other notables use this drug regularly. Cocaine is a fashionable drug, especially among middle- and upper-class professionals, and its use is equally distributed between males and females. Cocaine has among the highest levels of past-year illicit drug dependence or abuse (1.7 million persons), according to SAMHSA (2007). In the late 1800s, cocaine was heralded as a wonder drug for remedying depression, indigestion, headaches, pain, and other ailments. It was often included in medicines, tonics, and wines; it was even used in cola drinks such as Coca-Cola. In the early 1900s, however, its use was controlled, and the possession of cocaine is now illegal. Cocaine can be eaten, injected intravenously, or smoked, but it is usually “snorted” (inhaled). Eating does not produce rapid effects, and intravenous use requires injection with a needle, which leaves needle marks and introduces the possibility of infection. When cocaine is inhaled into the nasal cavity, however, the person quickly feels euphoric, stimulated, and confident. Heart rate and blood pressure increase, and (according to users) fatigue and appetite are reduced. As in the case of amphetamines, cocaine appears to increase synaptic dopamine levels in the brain by inhibiting the reuptake of the dopamine. These actions may make the drug reinforcing and stimulating (Brower, 2006).

COCAINE ADDICTION FROM MOTHER TO CHILD Women who use drugs during pregnancy are likely to have drug-addicted, underweight babies at risk for serious development problems. Pictured here is a newborn “crack baby” being monitored as it goes through cocaine withdrawal symptoms.

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Users may become dependent on cocaine. That is, a user can develop an addiction and be unable to stop using it, sometimes after only a short period of time. Although users do not show gross physiological withdrawal symptoms, Gawin (1991) noted that the distinction between psychological and physical addiction is difficult to make and that chronic abuse of cocaine can produce neurophysiological changes in the central nervous system. The constant desire for cocaine can impair social and occupational functioning, and the high cost of the substance can cause users to resort to crime to feed their habit. In addition, side effects can occur. Feelings of depression and gloom may be produced when a cocaine high wears off. Heavy users sometimes report weight loss, paranoia, nervousness, fatigue, and hallucinations. Because cocaine stimulates the sympathetic nervous system, premature ventricular heartbeats and death may occur. Crack is a purified and potent form of cocaine produced by heating cocaine with ether (“freebasing”). Crack is sold as small, solid pieces or “rocks.” When smoked, crack produces swift and marked euphoria, followed by depression. About 0.3 percent of persons (0.7 million) twelve years of age or older used crack during the month before they were surveyed. Among full-time college students, the rate is 0.1 percent (SAMHSA, 2007). Crack is a major concern to society for four reasons. First, it is relatively inexpensive and readily obtainable, so large segments of the population have easy access to the substance. Second, the euphoria of the high from crack is quite intense and immediate compared with sniffing cocaine. Thus many people prefer crack. Third, users appear to develop a relatively rapid addiction to crack, and they continually seek the substance. Fourth, because of the increasing popularity of the drug and the crimes associated with crack, law enforcement resources have been expanded in the attempt to control its sale, distribution, and use.

Hallucinogens Hallucinogens are substances that produce hallucinations, vivid sensory awareness, heightened alertness, or perceptions of increased insight. Their use does not typically lead to physical dependence (that is, to increased tolerance or withdrawal reaction), although psychological dependency may occur. Common hallucinogens are marijuana, LSD, and PCP.

substance that produces hallucinations, vivid sensory awareness, heightened alertness, or perceptions of increased insight; use does not typically lead to physical dependence, although psychological dependence may occur

hallucinogen

the mildest and most commonly used hallucinogen; also known as “pot” or “grass”

marijuana

Marijuana The mildest and most commonly used hallucinogen is marijuana, also known as “pot” or “grass.” Although DSM-IV-TR does not technically consider marijuana a hallucinogen, it does have many of the same effects as hallucinogens. This substance is generally smoked in a cigarette, or “joint.” Among persons age twelve or older, the rate of preceding-month marijuana use was 6.0 percent (SAMHSA, 2007). About 40 percent of the U.S. population over age twelve has used marijuana, although it is an illegal substance. Marijuana use is most common in the age range of eighteen to thirty years and in the male population. As in the case of cigarettes, chronic smoking of marijuana can lead to lung cancer. The subjective effects of marijuana include feelings of euphoria, tranquility, and passivity. Once the drug has taken effect, subjective time passes slowly, and some users report increased sensory experiences, as well as mild perceptual distortions. Individual reactions vary according to prior experience with marijuana, expectancy of its effects, and the setting in which it is used. Simons and colleagues (1998) found that the enhancement of perceptual and cognitive experiences was an important motive in marijuana use. Although much controversy has raged over the effects of marijuana, many states have now decriminalized the possession of small quantities of this substance. Marijuana has been helpful in treating some physical ailments, such as certain forms of glaucoma (an eye disorder), and in reducing the nausea of patients being treated with chemotherapy for cancer. Lysergic Acid Diethylamide (LSD) LSD or “acid” gained notoriety as a hallucinogen in the mid-1960s. Praised by users as a potent psychedelic consciousness-expanding

Substance-Use Disorders

A JOINT FOR WHAT AILS YOU The evidence of marijuana’s effectiveness in treating patients with certain problems—such as glaucoma, AIDS-related loss of appetite, nausea due to chemotherapy, and multiple sclerosis—continues to grow. Still, marijuana is not readily available for medicinal purposes. Until the federal government lifts the ban on the medical use of marijuana, patients will continue to rely on such operations as Oakland’s Cannabis Buyers Club (shown here), an underground network that supplies marijuana to the sick. Do you believe marijuana should be available to patients with these problems?

drug, LSD produces distortions of reality and hallucinations. “Good trips” are experiences of sharpened visual and auditory perception, heightened sensation, convictions that one has achieved profound philosophical insights, and feelings of ecstasy. “Bad trips” include fear and panic from distortions of sensory experiences, severe depression, marked confusion and disorientation, and delusions. Some users report “flashbacks,” the recurrence of hallucinations or other sensations days or weeks after taking LSD. Fatigue, stress, or the use of another drug may trigger a “flashback.” LSD is considered a psychotomimetic drug because, in some cases, it produces reactions that mimic those seen in acute psychotic reactions. It does not produce physical dependence, even in users who have taken the drug hundreds of times. Aside from its psychological effects, no substantial evidence supports the belief that LSD is dangerous in and of itself. Large doses do not cause death, although there are reports of people who have unwittingly committed suicide while under the influence of LSD. Initially researchers believed that LSD caused chromosomal damage and spontaneous abortions, but such events are probably attributable to impurities in the drug, the use of other drugs, or the unhealthy lifestyles of many users. Phencyclidine (PCP) Phencyclidine, also known as PCP, “angel dust,” “crystal,” “superweed,” and “rocket fuel,” has emerged as one of the most dangerous of the so-called street drugs. Originally developed for its painkilling properties, PCP is a hallucinatory drug that causes perceptual distortions, euphoria, nausea, confusion, delusions, and violent psychotic behavior. Reactions to the drug are influenced by dosage, the individual user, and the circumstances in which it is taken. One thing is clear: PCP has in many cases caused aggressive behavior, violence, or death from the taker’s recklessness or delusions of invincibility. The drug is illegal, but it is still widely used, often sprinkled on marijuana and smoked. Spitzer and coworkers (1994, pp. 121–122) described the effects of PCP on a chronic user. As you will see, one long-term effect may have been a personality change.

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eens are increasingly getting high with legal drugs such as painkillers and mood stimulants. They are also turning to cough syrup as well. While fewer teens overall drank alcohol or used illegal drugs in the past year, a small but growing number were popping prescription painkillers such as OxyContin and stimulants such as Ritalin. As many as one in every fourteen high school seniors said they used cold medicine “fairly recently” to get high. Source: Johnston et al. (2006).

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Case Study The patient was a twenty-year-old male who was brought to the hospital, trussed in ropes, by his four brothers. This was his seventh hospitalization in the past two years, each for similar behavior. One of his brothers reported that he “came home crazy” late one night, threw a chair through a window, tore a gas heater off the wall, and ran into the street. The family called the police, who apprehended him shortly thereafter as he stood naked, directing traffic at a busy intersection. He assaulted the arresting officers, escaped them, and ran home screaming threats at his family. There his brothers were able to subdue him. On admission the patient was observed to be agitated, his mood fluctuating between anger and fear. His speech was slurred, and he staggered when he walked. He remained extremely violent and disorganized for the first several days of his hospitalization, then began having longer and longer lucid intervals, still interspersed with sudden, unpredictable periods in which he displayed great suspiciousness, a fierce expression, slurred speech, and clenched fists. After calming down, the patient denied ever having been violent or acting in an unusual way (“I’m a peaceable man”) and said he could not remember how he got to the hospital. He admitted to using alcohol and marijuana socially but denied phencyclidine (PCP) use except for once, experimentally, three years previously. Nevertheless, blood and urine tests were positive for phencyclidine, and his brother believed “he gets dusted every day.”

Myth vs Reality Myth: Smoking marijuana or taking one drug does not lead to the use of more serious drugs. Reality: Although some individuals can abuse or become dependent on only one drug, others are susceptible to polysubstance use. This pattern of use seriously increases risks for mental and physical deterioration. For example, in emergency medical visits for club drug use, over 70 percent of the cases involved more than one drug. Alcohol was the most frequent substance associated with most club drugs, and marijuana was frequently found in combination with LSD (Clay, 2001).

Etiology of Substance-Use Disorders Why do people abuse substances, despite the knowledge that alcohol and drugs can have devastating consequences in their lives? The answer to this question is complicated by the number of different kinds of substances that are used and the number of factors that interact to account for the use of any one substance. In general, progression from initial substance use to abuse or dependence follows a typical sequence (Walter, 2001). First, for a variety of reasons, persons may experiment with alcohol or drugs in order to gain experience, feel high, enhance self-confidence, rebel against authorities, imitate others, conform to social pressure from users of drugs, and so forth. Second, because the drug may begin to serve an important purpose (reduce tension or anxiety; produce feelings of pleasure; make one feel “grown up,” especially for adolescents; enhance social relations with other users; and so forth), consumption increases. Third, tolerance may increase, and abuse or dependency develops. Bodily or brain processes may be altered with repeated drug use. The individuals crave the substance and may suffer withdrawal symptoms without it. Fourth, lifestyle changes occur with abuse or dependence. These changes may include preoccupation with how to get the substance; loss of interest in previous activities, hobbies, and social relationships; and planning of activities around opportunities to use the drug (see Figure 9.3). In the case of illicit drugs, criminal acts may be necessary to hide the drug habit or to finance and obtain the drug. Consistent with the multipath model, in all four phases, biological, psychological, social, and sociocultural factors are involved (see Figure 9.4). Let’s now turn to research involving these factors.

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Typical Progression Toward Drug Abuse or Dependence STEP POSSIBLE REASONS

FIGURE

Initial Use

Increasing Use

Heavy Use

Drug Lifestyle

Curiosity Role modeling Rebelling Gaining social status Yielding to pressure Subcultural norms

Reducing tension Feeling “high” Feeling “grown up” Participating with others Norms concerning use

Avoiding withdrawal Feeling “high” Increased tolerance Formation of habit

Changed goals in life Preoccupation with drugs Finding drug sources Reduction of previous activities Possible criminal activities

9.3 TYPICAL PROGRESSION TOWARD DRUG ABUSE OR DEPENDENCE

Biological Dimension Because alcohol and drugs affect metabolic processes and the central nervous system, investigators have explored the possibility that heredity or congenital factors increase susceptibility to addiction. In the case of alcoholism, there is evidence that it “runs in families” (Piasecki et al., 2005). Persons with a family history of alcoholism have an increased lifetime risk of 4.5 times or greater of developing alcoholism relative to the general population (Lovallo et al., 2006). Because family members usually share both genetic and environmental influences, researchers face the challenge of somehow separating the contributions of these two sets of factors. Many investigators have attempted to isolate genetic and environmental factors through the use of adoption studies and twin studies. Several studies have indicated that children whose biological parents were alcoholics but who were adopted and raised by nonrelatives are more likely to develop drinking problems than are adopted children whose biological parents were not alcoholics (Franklin & Frances, 1999; Goodwin, 1979; Kanas, 1988). In one study of alcohol abuse among adopted individuals, Cadoret and Wesner (1990) found clear-cut evidence of a genetic factor operating from biological parent to adopted child. However, they also found evidence of environmental influences: having an alcoholic in the adoptive home also increases the risk of alcohol problems in the adopted person. Investigators studying the concordance rates for alcoholism among MZ (monozygotic or identical) and DZ (dizygotic or fraternal) twins have reported similar

• Religious differences • National norms and values • Gender differences

SUBSTANCE ABUSE DISORDER

Social Dimension • Parental and peer models • Social pressures

A

ddiction may also extend to compulsive behaviors such as kleptomania and overeating. Drug addictions at the cellular level involve changes to the synapse structure, cell shape, and the way nerve cells communicate with each other (Kalivas & Volkow, 2005). People with compulsive behaviors have brain patterns and changes that are similar to those of people with drug addictions (Brower, 2006).

FIGURE

9.4

MULTIPATH MODEL FOR SUBSTANCE ABUSE DISORDERS The dimensions interact with one another and combine in different ways to result in a substance abuse disorder.

Biological Dimension • Hereditary influences • Dopamine reward/stress pathways • Brain activity levels

Sociocultural Dimension

Did You Know?

Psychological Dimension • Tension and anxiety reduction • Loss of inhibitions • Expectancy and cognition

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FAMILY TIES Drew Barrymore entered rehab at the age of thirteen to deal with her addiction to drugs and alcohol. Although it is difficult to separate environmental and genetic influences in cases of alcohol abuse, both were likely operating in Drew’s case. Not only did she experience the stress of young stardom, but she also had a family history of alcohol abuse—her grandfather drank himself to death and her father abused alcohol and drugs. Does this mean that drug abuse is inherited?

variables related to, or etiologically significant in, the development of a disorder

risk factors

findings. Concordance rates indicate the likelihood that both cotwins have a disorder. MZ twins generally have a higher concordance rate of alcoholism than DZ twins. The concordance rate for DZ twins is about the same rate as in other nontwin sibling pairs (Kendler et al., 1992; McGue, Pickens, & Svikis, 1992). One study of twins found not only a strong genetic component in alcohol consumption but also a gender difference in that males are more likely to be influenced by biological factors than are females (King et al., 2005). Collectively, findings suggest that heredity is important in alcoholism, although relatively little progress has been made in identifying the specific genes involved (Wall et al., 2005). However, environmental factors are also important, as illustrated in the twin studies in which MZ twins are not 100 percent concordant. It is possible that two types of alcoholism may exist: familial and nonfamilial. Familial alcoholism shows a family history of alcoholism, suggesting genetic predisposition. This type of alcoholism develops at an early age (usually by the late twenties), is severe, and is associated with an increased risk of alcoholism (but not other mental disorders) among blood relatives (Emmelkamp, 2004). Nonfamilial alcoholism does not show these characteristics and is presumably influenced more by environment. Researchers have attempted to find risk factors or markers for alcoholism. Risk factors are variables related to, or etiologically significant in, the development of a disorder. Biological markers involving neurotransmitters in the brain have been found to be related to alcoholism (Kranzler & Anton, 1994; Tabakoff, Whelan, & Hoffman, 1990). Another risk factor appears to be sensitivity or responsiveness to alcohol (Schuckit, 1990). Individuals who are not sensitive to alcohol may be able to consume large amounts of it before feeling its effects, and they may therefore be more susceptible to alcoholism. As mentioned earlier, being a child of an alcoholic and coming from a family with a history of alcoholism are risk factors. Noble (1990) compared two groups: high-risk sons of alcoholic fathers and low-risk sons of social-drinking fathers. The boys in the two groups were matched for demographic background, and at the start of the study none had ever consumed alcohol or used drugs. The researchers compared central nervous system functioning, using behavioral, neuropsychological, and electrophysiological measures. The central nervous system functioning of both the high-risk boys and their alcoholic fathers differed from that of the low-risk boys and their fathers. Furthermore, the high-risk boys were more likely than low-risk boys to begin drinking. The researcher also studied family environments to see whether highrisk boys had disturbed family backgrounds. No differences in family background and environment were found. Noble (1990) concluded that hereditary factors may be important in alcoholism. If children of alcoholics have an increased risk for developing substance use problems, can biological markers be found that account for this increased risk? Studies have shown that the A1 allele of the D2 dopamine receptor (DRD2) gene may be a causal mechanism for alcoholism, as well as for nicotine, cocaine, and opium dependence. In one study of adolescent boys who were children of alcoholics, substance use was assessed. Boys with the A1+ allele tried and got intoxicated on alcohol more often, tried and used more substances overall, developed a tobacco habit more often, and experienced a marijuana high at an earlier age than boys with the A1− allele (Conner et al., 2005). How might altered neurotransmitter transporters or brain functions affect the addiction process? An integrated model of drug addiction has developed in which drug addiction causes changes in the brain that in turn alter reward systems and cognitive functioning. In this view, alcohol and drugs in vulnerable individuals wreak havoc with brain chemistry and structure (Brower, 2006). Chronic substance abuse alters the normal dopamine reward and stress pathways, thus flooding the brain with far more dopamine than is secreted normally. Feelings of euphoria or pleasure may ensue. Eventually, the drug crowds out other pleasures and turns into an allconsuming, compulsive desire. As addiction develops, the chronic flooding of dopamine eventually results in the depletion and deregulation of dopamine and other

Etiology of Substance-Use Disorders

neurotransmitters (e.g., glutamate and GABA) involved in stress and reward. Consequently, by the time an addiction is established, the drug may bring little pleasure and only helps the user to feel temporarily “normal” (Brower, 2006). In other words, the pleasurable effects of the substance are dampened, and more and more of the substance is needed (Nestler & Malenka, 2004). The brain and neurotransmitter changes may interfere with judgment and decision making. Persons with drug addiction may be unable to make good decisions in the face of temptations or urges. This may be particularly true in relapse, which is the resumption of the drug habit after a period of voluntary abstinence. Using brain imaging, Paulus, Tapert, and Schuckit (2005) found that it was possible to accurately predict which methamphetamine addicts in a rehabilitation program would relapse and which would be abstinent on the basis of brain activity in certain parts of the brain. Those who relapsed showed reduced brain activity in those parts of the brain involved in decision making and analytic processes. Presumably, they were less able to prevent relapses or to avoid temptations. Is it possible that once someone is addicted and physiologically dependent on a substance, continued use is caused by the person trying to avoid the pain of withdrawal? Many researchers and clinicians formerly believed that addiction to other substances, such as heroin, could be best explained by biological factors such as physical dependence and the attempt to avoid withdrawal symptoms. However, we now know that drug use is a complex phenomenon and that explanatory models must also incorporate the role of learning, expectancy, and situational factors. Consider heroin withdrawal, for example. Some have characterized heroin withdrawal reactions as no more agonizing than a bad case of the flu (Ausubel, 1961). Heroin addicts who enter a hospital and receive no heroin while hospitalized will stop having withdrawal symptoms in a week or two. Yet the vast majority who have lost their bodily need for the drug resume heroin use after hospitalization. Many researchers believe that withdrawal symptoms do not motivate relapse and measures of the severity of withdrawal do not predict who is likely to relapse (Baker et al., 2006). There appear to be many factors that maintain drug use and drug dependence. In summary, genetics appears to be important in determining dopamine and dopamine receptor levels that are involved in the addiction. However, neurotransmission processes themselves may be influenced by consumption behavior, and social environment factors are important in the initiation and practice of drug use. In other words, a multipath model is needed to explain substance addiction and abuse.

Psychological Dimension Psychological research on alcohol and drug use has largely focused on tension-reducing properties, pleasurable feelings, expectancies from substance use, or the possibility that certain personality types become addicts and abusers. Tension and Anxiety Reduction Early behavioral explanations for alcohol abuse and dependence were based on two assumptions: (1) that alcohol temporarily reduces anxiety and tension and (2) that drinking behavior is learned. In a classic experiment, researchers induced an “experimental neurosis” in cats (Masserman, Yum, Nicholson, & Lee, 1944). After the cats were trained to approach and eat food at a food box, they were given an aversive stimulus (an air blast to the face or an electric shock) whenever they approached the food. The cats stopped eating and exhibited “neurotic” symptoms—anxiety, psychophysiological disturbances, and peculiar behaviors. When the cats were given alcohol, however, their symptoms disappeared, and they started to eat. As the effects of the alcohol wore off, the symptoms began to reappear. The experimenters also found that these cats now preferred “spiked” milk (milk mixed with alcohol) to milk alone. Once the stressful shocks were terminated and the fear responses extinguished, however, the cats no longer preferred spiked milk. Alcohol apparently reduced the cats’ anxieties and was used as long as the anxieties were present.

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mokers with brain damage involving the insula, a region implicated in conscious urges, were more likely than smokers with brain damage not involving the insula to undergo a disruption of smoking addiction. They were able to quit smoking easily, immediately, without relapse, and without persistence of the urge to smoke. This result suggests that the insula is critical in the addiction to smoking. Source: Naqvi et al. (2007).

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controversy

Is Drug Addiction a Disease?

I

n the past, alcohol and drug addicts were seen as weak-willed persons who should be condemned for their voluntary choice to start and continue a drug habit. The American Psychological Association, American Medical Association, and National Association of Social Workers have policies that assume that addictive processes represent a disease state. Alcoholics Anonymous views alcohol and drug addiction as a disease and illness. Consequently, drug addicts should not be viewed as somehow immoral or weak in character. But what is a disease? The American Heritage Dictionary (2007) considers disease “a pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms.” Wollschlaeger (2007) states that the disease concept includes (1) a clear biological basis; (2) unique, identifiable signs and symptoms; (3) a predictable course and outcome; and (4) the inability to control the cause of the disease. He believes that addiction satisfies these criteria. Leshner (2001) has also argued that addictions are a disease. The essence of addiction is uncontrollable, compulsive drug craving, seeking, and use, even in the face of negative health and social consequences. Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways, and more of the substance is needed (Nestler & Malenka, 2004). However, drug addiction seems to defy popular notions of a disease because it involves voluntary behaviors (i.e., consuming a drug) over which a person has choice. Furthermore, Wyatt (2001) notes that if changes in brain

structure and function are the evidence for brain disease, then the following are also brain diseases: reading, riding a bicycle, memorizing lines in a play, learning not to touch a hot stove, and dribbling a basketball. They all involve brain changes. For decades, Szasz (2007) has battled the notion that addiction and mental disorders are illnesses or diseases. The debate is not trivial. Many of those who favor a disease concept have opposed controlled intake of substances among addicts. Under this view, for example, alcoholics should never take a drink. Consumption even in small amounts will set off the disease process and drunkenness will occur. The opposing view is that alcoholics can be trained to moderate their drinking. What seems to be clear is that reciprocity exists in that behaviors can change brain structures and processes and that brain processes affect behaviors. Three points should be considered. First, whether one wants to consider addiction as a disease depends on one’s definition and the usefulness of that definition. Second, the issue of whether addicts are weak-willed or immoral is more of a moral judgment than a scientific finding. Finally, there is the possibility that addiction may be a heterogeneous condition in which some experience more of a disease process than others. For Further Consideration 1. Should addictive behaviors and compulsions that are voluntary (e.g., drinking alcohol) be considered diseases? 2. If drug and alcohol addictions are considered diseases, should we consider compulsive overeating or compulsive gambling diseases?

As illustrated in experimental neurosis, the tension-reducing model assumes that alcohol reduces tension and anxiety and that the relief of tension reinforces the drinking response. Although it makes intuitive sense, the model has produced conflicting findings in alcoholics. In fact, prolonged drinking is often associated with increased anxiety, distress, and depression (McNamee, Mello, & Mendelson, 1968; Steffen, Nathan, & Taylor, 1974). In a study of smokers, contrary to expectations, smoking after experiencing negative moods did not reduce the negative affect, although smokers increased their puffing (Conklin & Perkins, 2005). Other evidence supports the idea that the tension-reducing model is too simplistic. Steele and Josephs (1988, 1990) found that alcohol can either increase or decrease anxiety, depending on the way alcohol affects perception and thought. When confronted with a stressful situation, people who drank alcohol in the experiment experienced anxiety reduction if they were allowed to engage in a distracting activity. When faced with a stressor, however, those who drank and did not have a distracting activity experienced an increase in anxiety. The investigators argued that the distracting activity allowed drinkers to divert attention from the stressor. Without the distraction, drinkers’ attention may have focused on the stressor, which served to magnify their anxiety. The tension-reduction model has difficulty accounting for the two phases of alcohol effects, in which blood alcohol levels initially rise and then fall. Giancola

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and Zeichner (1997) found that increases in aggression tended to occur during the ascending phase (when blood alcohol level is increasing) rather than the descending phase (when blood alcohol level is decreasing) of blood alcohol levels. That is, despite having similar blood alcohol levels, individuals exhibited more aggression during the ascending rather than during the descending phase. The tension-reduction model has a problem explaining this two-phase effect because the blood alcohol levels, tensions, and expectations are presumably similar regardless of the phase. This research raises the possibility that the concept of tension reduction is too simple to explain the effects of alcohol. Expectancy and Cognitive Influences A number of researchers have focused less on tension reduction and more on the expectancies that are learned in substance use. Individuals who use drugs may come to expect feeling relaxed, confident, high, less anxious, and so on. In a study of marijuana and cocaine use among college students, Schafer and Brown (1991) showed the importance of expectancies. Their survey of positive and negative expectancies (for example, relaxation, social facilitation, and cognitive impairment) for the use of marijuana and cocaine showed that students who used these drugs also expected strong positive experiences. Cooper, Russell, and George (1988) found that stress is related to drinking when individuals expect positive effects from drinking and have coping styles that avoid dealing with anger. In contrast, stress and drinking were negatively correlated among those with little positive expectancy for alcohol and a tendency to actively deal with their anger. Other investigators (Stacy, Newcomb, & Bentler, 1991) found that expectancy is also predictive of drug use. In a classic experiment, Marlatt, Demming, and Reid (1973) provided evidence that learned expectations also affect consumption. In the process, they challenged the notion that alcoholism is a disease in which drinking small amounts of alcohol leads, in an alcoholic, to involuntary consumption to the point of intoxication. In their study, alcoholics and social drinkers were recruited to participate in what was described as a “tasting experiment.” Alcoholics and social drinkers were led to believe that they would be given alcohol or tonic in mixed drinks and actually were given alcohol and tonic regardless of what they were told. What happens if they think they are receiving (or not receiving) alcohol and actually are given (or not given) alcohol? Participants who were told that they would receive alcohol drank more than those who were told that they would receive tonic, and those who actually consumed alcohol did not drink more than those who consumed tonic. The participants’ expectancy had a stronger effect than the actual content of their drinks on how much they consumed. In fact, several people who were given tonic when they believed they were imbibing alcohol acted as though they were “tipsy” from the drinks! Expectancy and cognitive factors may also be important in relapse, in which there is a failure to maintain abstinence. For persons attempting to abstain from using substances after addiction, relapse is common. Risk of relapse for alcohol, heroin, tobacco, and other substances is greatest during the first three months following treatment, becoming less and less likely over time. By the end of three years, relapse is unlikely. Factors associated with relapse include younger age at onset of drug use, more extensive involvement with substances, antisocial behavior, comorbid psychiatric disorder, less involvement in school or work, and less support from drug-free family and peers (Walter, 2001). Earlier we had mentioned that relapse is associated with certain brain activity. Some researchers have also found that negative emotional states (such as depression, interpersonal conflict, and anxiety) are highly associated with relapse (Cooney et al., 1997). They account for 53 percent of relapses among alcoholics trying to quit drinking (Hodgins, El-Guebaly, & Armstrong, 1995). Negative emotional states tended to play a role in major relapse (substantial use of the substance), whereas social pressure led to minor relapse (taking just a beer). Negative physical states, urges and temptations, and positive emotional states did not strongly predict relapse. Interestingly, there was a gender difference in the states reported. Women were more

Did You Know?

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ome drinkers now snort vodka through their noses to get drunk more quickly. The snorting is done through a straw or from a thin glass tube. Some people were in tears after trying the fad, whereas others reacted so quickly they were seen falling to the floor. This practice is dangerous and can cause damage to the nose.

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likely than men to cite interpersonal conflict and less likely to report emotional states such as depression. This suggests that women may be more vulnerable to social influences than men are in the context of alcohol use and relapse. A person can obviously stop drinking after one drink. To explain the full-blown resumption of drinking that so often follows an alcoholic’s first drink, Marlatt (1978; Witkiewitz & Marlatt, 2004) proposed a cognitive interpretation involving the notion of an abstinence violation effect. That is, once drinking begins, the person senses a loss of personal control. He or she feels weak-willed and guilty and gives up trying to abstain. The abstinence violation effect may also apply to other relapse behaviors, such as overeating, masturbating, and smoking. In a test of the abstinence violation effect, Shiffman and his colleagues (1996) asked participants in a smoking-cessation program to record any instances of relapse (smoking) and their reactions. The investigators then followed the participants’ progress for three months to assess their subsequent smoking after an instance of relapse. They found that psychological demoralization after an initial instance of relapse played a role in progression to another relapse. Personality Characteristics Is it possible that certain personality types become addicts? In reviews of research on personality and alcoholism, Nathan (1988), Franklin and Frances (1999), and Sher and Trull (1994) have concluded that there is no single alcoholic personFEELING HIGH Alcohol consumption can result in ality. Nathan found only two personality characteristics—antisocial feelings of happiness, loss of inhibitions, and poor judgment. Alcohol depresses the inhibitory centers of behavior (especially during youth) and depression—associated with the brain. Sandra Bullock stars in the movie 28 Days, drinking problems. However, many alcohol abusers do not show antiin which she has had a few drinks. How often over the social histories, and many antisocial people do not drink excessively. past month have you seen people who are high or Furthermore, depression may well be a consequence rather than an uninhibited because of drinking? antecedent of alcohol abuse (that is, problem drinking may cause people to feel depressed). Similarly, in the case of other drugs, no personality types have emerged. Some general personality tendencies, such as impulsive sensation seeking or behavioral disinhibition (too little control), have been found to be related to substance-use disorders (Sher, Bartholow, & Wood, 2000). It is highly unlikely that addiction is caused by a single personality type.

Social Dimension In almost all explanations of substance use, social or interpersonal factors are considered important. For example, one may try drinking and maintain drinking because of pressures from peers, modeling oneself after parents who drink, pressures from peers to drink, expecting to feel less anxious in social situations, and so forth. A review of the literature on adolescent drinking led researchers to conclude that teenage problem drinkers are exposed first to parents who are themselves heavy drinkers and then to peers who act as models for heavy consumption (Braucht, 1982). The parents not only consumed a great deal of alcohol but also showed inappropriate behaviors, such as antisocial tendencies and rejection of their children. When such children loosened their parental ties, they tended to be strongly influenced by peers who may be heavy drinkers (Bray et al., 2003). In addition to acting as role models, parents who consume a great deal of alcohol have been shown to exhibit reduced parental monitoring of the activities of adolescent children and to produce stress and negative affect. These, in turn, make the adolescent more likely to associate with alcohol and drug-using peers and to increase substance usage (Chassin et al., 1993). There is evidence to indicate that adolescents who are exposed to peer and adult drinkers tend to develop positive expectancies over the use of alcohol (for example, believing that drinking alcohol makes it easier to be part of a group; Cumsille, Sayer, & Graham, 2000).

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critical thinking

Is Drug Use an Indicator of Disturbance?

M

any individuals believe that drug users are maladapted and have higher rates of emotional disturbance than non-drug users. Indeed, research shows that psychological disturbances (for example, depression or other emotional problems) and drug abuse or dependence co-occur. Among the 24.6 million adults with serious psychological distress, 21.3 percent were dependent on or abused illicit drugs or alcohol. Only 7.7 percent of adults without serious psychological distress had substance dependency or abuse (SAMHSA, 2007). Antisocial personality characteristics are often associated with drug use. Depression is associated with cigarette smoking and nicotine dependence (Windle & Windle, 2001) and other substance use disorders (Sobell & Sobell, 2007). As many as half of people with severe mental disorders develop alcohol or other substance abuse problems at some point in their lives (U.S. Surgeon General, 1999). Does this mean that drug use causes a person to become antisocial or maladjusted? Or is a person maladjusted and therefore prone to drug use? When two characteristics— such as drug use and antisocial personality patterns—are related, what kinds of causal inferences can be made? One way of examining these issues is to conduct a longitudinal study. As mentioned in Chapter 4, longitudinal research evaluates the behaviors of individuals over a period of time. If longitudinal research shows that a characteristic or behavior occurs before drug use, we can be certain that drug use did not cause the behaviors. For example, Sher, Bartholow, and Wood (2000) evaluated the personality characteristics of students and then determined their subsequent degree of substance use. They found that sensation seeking or behavioral disinhibition predicts substance-use disorders. Because the sensation-seeking behaviors occurred before substance use, we are confident that substance use did not cause sensation seeking. In practice, however, interpreting cause and effect is not easy.

In another longitudinal study, psychological evaluations (including personality, adjustment, and parent-child assessments) were made of boys and girls at different ages, beginning at age three and continuing to age eighteen. At age eighteen, they were interviewed about the frequency of drug use. The investigators, Shedler and Block (1990), wanted to see whether certain psychological characteristics were associated with drug use—characteristics that were present before drug use and therefore could not be caused by drug use. The results were quite striking: those who frequently used marijuana and had tried at least one other drug were maladjusted, demonstrating alienation, poor control over impulses, and emotional distress. These psychological characteristics were present before and during drug use. Do the results also imply that adolescents who do not use drugs are better adjusted than those who do? In addition to studying frequent users, the investigators also examined abstainers—adolescents who had never tried marijuana or other drugs—and they studied experimenters, those who had used drugs only a few times. Interestingly, the abstainers were relatively anxious, emotionally constricted, and lacking in social skills. Those who had experimented with drugs occasionally were better adjusted than either the adolescents who used drugs frequently or those who had never used drugs! Parents of abstainers and frequent users also exhibited greater personality problems. Given the finding that those who experiment with drugs are the best adjusted, should we advocate that adolescents occasionally try drugs? Such a position would be inconsistent with the results. Recall from the data that adjustment patterns preceded drug use, so experimenting with drugs will not necessarily cause one to be better adjusted. The point is that we often make mistakes in drawing inferences about cause and effect, and we must be careful not to base practices or policies on these erroneous inferences.

Studies also indicate that both peer selection and peer socialization influence druguse patterns. Frequency of alcohol and drug use reported by African American adolescents was significantly related to both peer pressure and peer drug use (Farrell & White, 1998). In a study of adolescents who did not initially smoke, those who had more friends who smoked were subsequently more likely to smoke (Killen et al., 1997). Sussman and his colleagues (1994) also found that a good predictor of subsequent smoking in adolescents was their identification with groups in which members smoked. However, smoking did not predict subsequent group identification. Curran, Stice, and Chassin (1997) note that the association between peer use and self-use of drugs appears to be a two-way street: a drug user tends to choose friends who are users, and friends who use drugs tend to influence an individual to take drugs. The importance of social expectations in substance use was demonstrated in a study of adolescents over a two-year period (Smith et al., 1995). Their drinking pattern was best characterized by a positive feedback model: those who expected social benefits (such as feelings of confidence and comfort) from drinking drank more.

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CULTURAL VARIATIONS IN DRINKING Drinking behavior varies from country to country and culture to culture. In “wet” cultures, alcohol is integrated into daily life and is widely available. Most people drink freely during meals and throughout the day. Italy is considered a wet culture. Here, we see a celebration festival for wine in Impruneta, Chianti.

They then endorsed even more positive social benefits, which made even greater consumption more likely. Finally, the presence or absence of social supports is related to consumption. Hussong and colleagues (2001) found that young adults with less intimate and supportive friendships, as compared with their peers, showed risk for greater drinking following emotional states such as sadness and hostility.

Sociocultural Dimension Drinking varies according to sociocultural factors, such as gender, age, socioeconomic status, ethnicity, religion, and country. As mentioned previously, males and young adults consume more alcohol than females and older adults, respectively. Interestingly, consumption tends to increase with socioeconomic status, although alcoholism is more frequent in the middle socioeconomic classes (SAMHSA, 2007). In terms of religious affiliation, heavier drinking is found among Catholics than among Protestants or Jews. Furthermore, drinking behavior varies from country to country. In “wet” cultures, alcohol is integrated into daily life and activities (for example, is consumed with meals) and is widely available and accessible. In these cultures, abstinence rates are low, and wine is the beverage of preference. Individuals are more likely to drink during meals and freely during the day. European countries bordering the Mediterranean have traditionally exemplified wet cultures. In “dry” cultures, alcohol consumption is not common during everyday activities (for example, it is less frequently a part of meals), and access to alcohol is more restricted. Abstinence is more common, but when drinking occurs it is more likely to result in intoxication; furthermore, wine consumption is less common. The United States, Canada, and Scandinavian countries are considered dry cultures (Bloomfield et al., 2003). Asians appear to have a lower rate of consumption. The low prevalence rates among Asians may be caused by cultural practices that discourage drunkenness or solitary drinking (Sue & Nakamura, 1984). Recent research suggests that the prevalence rates may also be affected by variations of an enzyme—aldehyde dehydrogenase (ALDH). Alcohol is metabolized in the body and results in acetaldehyde, which is a toxic substance. An accumulation of acetaldehyde is associated with dysphoria, face flushing, and palpitations, as well as a lower risk for alcoholism. Thus Asians who have variations of ALDH may either metabolize alcohol more quickly or metabolize acetaldehyde more slowly. In both cases, acetaldehyde accumulates in the body and causes adverse reactions and lower risk for alcoholism (Eng, Luczak, & Wall, 2007).

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Ethnic differences in the United States are also found, with a higher percentage of heavy drinkers among non-Hispanic whites and Native Americans than among Asians, African Americans, or Hispanics, as shown in Figure 9.2. These findings suggest that cultural values play an important role in drinking patterns. The values affect not only the amount consumed and the occasions on which drinking takes place but also the given culture’s tolerance of alcohol abuse.

Intervention and Treatment of Substance-Use Disorders Treatment of substance abusers and addicts depends on both the individual user and the type of drug being used. Most alcohol and drug treatment programs have two phases: first, the removal of the abusive substance, and second, long-term maintenance without it. In the first phase, which is also referred to as detoxification, the user is immediately or eventually prevented from consuming the substance. The removal of the substance may trigger withdrawal symptoms that are opposite in effect to the reactions produced by the drug. For instance, a person who is physically addicted to a central nervous system depressant such as a barbiturate will experience drowsiness, decreased respiration, and reduced anxiety when taking the drug. When the depressant is withdrawn, the user experiences symptoms that resemble the effects of a stimulant—agitation, restlessness, increased respiration, and insomnia. Helping someone successfully cope during withdrawal has been a concern of many treatment strategies dealing with various drugs, particularly in treating heroin addicts. Sometimes, addicts are given medication to alleviate some of the withdrawal symptoms. For example, tranquilizers may be helpful to alcoholics experiencing withdrawal. In the second phase, intervention programs attempt to prevent the person from returning to the substance (in some rare cases, controlling or limiting the use of the substance). These programs may be community programs, which include sending alcoholics or addicts to hospitals, residential treatment facilities, or halfway houses, where support and guidance are available in a community setting. Family therapy has consistently been successful in treating adolescent substance abusers (Sexton, Alexander, & Mease, 2004). Whatever the setting, the treatment approach may be chemical, cognitive-behavioral, or multimodal. In this section, we discuss these approaches to the treatment of various substance-use disorders and review their effectiveness. We also take a quick look at prevention programs.

Pharmacological Approach To keep addicts from using certain substances, some treatment programs dispense other chemical substances. Antabuse, naltrexone, and Campral, each with different effects on alcoholics, have been tried. Antabuse (disulfiram) has been used for decades. It produces an aversion to alcohol. A person who consumes alcohol one to two days after taking Antabuse suffers a severe reaction, including nausea, vomiting, and discomfort. Antabuse has the effect of blocking the progressive breakdown of alcohol so that excessive acetaldehyde accumulates in the body; acetaldehyde causes dysphoria (depression or distress). Most alcoholics will not consume alcohol after ingesting Antabuse. Those who do risk not only discomfort but also, in some cases, death. While clients are taking Antabuse and are not drinking, as demonstrated in several studies (see Gallant, 2001), psychotherapy and other forms of treatment may be used to help them develop coping skills or alternative life patterns. The problem with Antabuse treatment is that alcoholic patients may stop taking the drug once they leave the hospital or are no longer being monitored. And some may drink anyway because they believe the effects of Antabuse have dissipated, because they have forgotten when they last took it, or because they are tempted to drink in spite of the Antabuse. Naltrexone has been used to reduce craving or the reinforcing effects of alcohol. The reduced craving appears specific to alcohol, not to just any drink (for example, fruit juices), as found in a study by Rohsenow, Monti, Hutchinson, and colleagues (2000). Campral (acamprosate) has most recently been approved by the FDA. It has

detoxification alcohol or drug treatment phase characterized by removal of the abusive substance; after that removal, the user is immediately or eventually prevented from consuming the substance

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A TOTAL WRECK This wrecked 2003 Cadillac sits in front of a woman’s home after she was convicted for her third drunk-driving violation. The judge ordered the damaged car to remain there until the woman completes her three-year probation. Her last DUI accident seriously injured one man.

been found to be effective in some investigations, although a comparative study involving naltrexone, psychotherapeutic treatment, and Campral revealed that all but Campral were quite effective for alcoholics (Anton et al., 2006). Pharmacological agents such as clonidine and naltrexone have allowed some heroin addicts to be detoxified as outpatients (Franklin & Frances, 1999). Chemical treatment may also be used to reduce the intensity of withdrawal symptoms in heroin addicts who are trying to break the drug habit. The drug methadone is prescribed to decrease the intensity of withdrawal symptoms. Methadone is a synthetic narcotic chemical that reduces the craving for heroin without producing euphoria (the “high”). It was originally believed that reformed heroin addicts could then quite easily discontinue the methadone at a later date. Although methadone initially seemed to be a simple solution to a major problem, it has an important drawback: it can itself become addicting. The following case illustrates this problem, as well as other facets of the typical two-phase treatment program for heroin addiction.

Case Study After several months of denying the seriousness of his heroin habit, Gary B. finally enrolled in a residential treatment program that featured methadone maintenance, peer support, confrontational therapy, and job retraining. Although at first Gary responded well to the residential program, he soon began to feel depressed. He was reassured by the staff that recovering heroin addicts frequently experience depression and that several treatment options existed. A fairly low dose of tricyclic antidepressant medication was prescribed, and Gary also began supportive-expressive (psychodynamic) therapy. Psychotherapy helped Gary identify the difficult relationships in his life. His dependence on these relationships and his dependence on drugs were examined for parallels. His tendency to deny problems and to turn to drugs as an escape was pointed out. The therapy then focused on the generation of suitable alternatives to drugs. He worked hard during his therapy sessions and made commendable progress. For the next three months Gary enjoyed his life in a way that previously had been foreign to him. He was hired by a small restaurant to train as a cook. He was entirely satisfied with the direction in which his life was going until the day he realized that he was eagerly looking forward to his daily methadone dose. Gary knew of people who had become addicted to methadone, but it was still a shock when it happened to him. He decided almost immediately to terminate his methadone maintenance program. The withdrawal process was physically and mentally painful, and Gary often doubted his ability to function without methadone. But by joining a support group composed of others who were trying to discontinue methadone, he was eventually able to complete methadone withdrawal. Gary had never imagined that the most difficult part of his heroin treatment would be giving up methadone.

In smoking cessation programs, one tactic has been the use of nicotine replacement therapy. Because smokers become addicted to the nicotine in cigarettes, the aim of nicotine replacement therapy (NRT) is to provide an alternate way of ingesting nicotine. This reduces withdrawal symptoms associated with smoking cessation, thus helping resist the urge to smoke cigarettes. Nicotine is delivered using a transdermal nicotine patch, inhaler, nasal spray, gum, sublingual tablet, or lozenge. NRT has been found to be fairly effective in smoking cessation (Silagy

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et al., 2003). Evidence that NRT is effective is that people on the treatment are three to five times less likely to move from a smoking lapse to a full-blown relapse than people not having NRT (Shiffman et al., 2006). That is, it helps to prevent further smoking even after one who wants to quit has succumbed to smoking.

Cognitive and Behavioral Approaches Cognitive and behavioral therapists have devised several strategies for treating alcoholism and other substance-use disorders. Aversion therapy, which is based on classical conditioning principles, has been used for many years. Aversion therapy is a conditioning procedure in which the response to a stimulus is decreased by pairing the stimulus with an aversive stimulus. For example, alcoholics may be given painful electric shocks while drinking alcohol, or they may be given emetics (agents that induce vomiting) after smelling or tasting alcohol or when they get the urge to drink. After several sessions in which the emetic is used, alcoholics may vomit or feel nauseated when they smell, taste, or think about alcohol. Another aversive conditioning strategy is to have smokers rapidly puff and inhale cigarette smoke, which may make them sick. Imagery has been used as part of covert sensitization, an aversive conditioning technique in which the individual imagines a noxious stimulus in the presence of a behavior. Alcoholic patients, for example, are trained to imagine nausea and vomiting in the presence of alcoholic beverages (Cautela, 1966). PUFFING SO FAST YOUR STOMACH CHURNS This fifteenCovert sensitization has also been used with drug addicts. One year-old is undergoing aversive conditioning in an attempt difficulty with this technique is the inability of some patients to generalize the treatment—that is, to pair the learned aversive to help her stop smoking. The technique involves having the person puff their cigarettes at a very rapid pace, which usually reaction (nausea and vomiting) with the stimulus (taking a parbrings on nausea. Repeated pairing of rapid smoking and ticular drug) outside the clinic or hospital setting. Both aversion feelings of nausea may result in an aversion to smoking. therapy and covert sensitization have had some success with alcoholics (Hester & Miller, 2003). Skills training has also been used in drug-cessation programs. A wide range of coping strategies or skills have been found to be helpful in reducing temptations and aversion therapy conditioning urges in smoking (O’Connell et al., 2007). These skills may involve techniques for procedure in which the response to a refusing to give in to peer pressures or temptations, for resolving emotional conflicts stimulus is decreased by pairing the or problems, and for more effective communication. Smith, Meyers, and Delaney stimulus with an aversive stimulus (1998) found that skills training was effective in reducing alcohol consumption among homeless alcohol-dependent individuals. Reinforcing abstinence, or contin- covert sensitization aversive gency management, was effective for opioid-dependent individuals (Bickel et al., conditioning technique in which the individual imagines a noxious 1997; Carroll & Onken, 2005). The individuals received either reinforcement (such stimulus occurring in the presence of as vouchers for cash) for being abstinent, as measured by urinalysis, or standard forms of counseling used in methadone clinics. Results indicated that the behavioral a behavior method was more effective than the counseling method in promoting abstinence. skills training teaching skills Another treatment for cigarette smoking is nicotine fading (Foxx & Brown, for resisting peer pressures or 1979). In this method, the client attempts to withdraw gradually from nicotine by temptations, resolving emotional progressively smoking cigarette brands that contain less and less nicotine. When conflicts or problems, or for more clients reach the stage at which they are smoking cigarettes that contain only 0.1 mileffective communication ligrams of nicotine, their reduced dependence should enable them to stop altogether. reinforcing abstinence However, some individuals who smoke low-nicotine cigarettes may simply inhale (contingency management) more deeply or smoke more rapidly, thus defeating the purpose of smoking lownicotine cigarettes. A more familiar method is simply to smoke less and less—increas- treatment technique in which ing the interval between cigarettes. Cinciripini and his colleagues (1995) found that the individual is given behavioral systematically increasing the amount of time between using cigarettes was a more reinforcements for abstinence from effective way of achieving abstinence one year later than were other methods, such substance use

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as going “cold turkey” (abruptly ceasing smoking) or gradually reducing smoking without any fixed and systematic plan. The scheduledinterval method also appeared to be superior in decreasing tension and withdrawal symptoms. The investigators suggest that individuals using this method could plan and bring to bear coping mechanisms to deal with urges to smoke. Other Cognitive-Behavioral Treatments Relaxation and systematic desensitization may be useful in reducing anxiety. Almost any aversive conditioning procedure may be effective in treating alcoholism if there is also a focus on enhanced social functioning, resistance to stress, and reduction of anxiety. Some programs incorporate social learning techniques. Cox and Klinger (1988) developed a motivational approach in which alcoholics LIMITED TIME A man lights up a cigarette in a shop just two days before a set important and realistic goals they would smoking ban comes into effect. Do you think such bans in bars, restaurants, and like to accomplish. The therapist helps alcoeven parks will reduce cigarette smoking and the number of tobacco addicts? holics achieve these goals and develop a satisfying life without alcohol. Motivational approaches have been used for other substances, such as marijuana, and their success is enhanced if they are a part of a larger package that includes other treatment strategies (Carroll & Onken, 2005). Finally, virtual-reality therapy has been used on addictions such as smoking. Smokers may wear head-mounted displays, 3-D earphones, or wired gloves to experience a smoking environment. Smokers in such therapy perceive other smokers, smells of smoke and coffee, alcoholic drinks, or other cues that are associated with smoking. Their craving to smoke dramatically increased during exposure to the virtual-reality experience (Bordnick et al., 2005). The purpose of the therapy is to understand the circumstances in which cravings occur, the brain reactions during craving, and the effects of behavioral training or medication in reducing cravings even during the virtual experience. Cognitive-behavioral treatments, based on analyses of why addicts experience relapse, have also been tried. Niaura and colleagues (1988) believe that certain cues are strongly associated with substance use (smoking while having coffee, drinking alcohol at a party, and so forth). They suggested that addicts be placed in these situations or in the presence of the cues and prevented from using the substance. In this way, the consumption response to these cues is extinguished. To prevent relapse, some treatment programs help addicts restructure their thoughts about the pleasant effects of drug use (Cooper et al., 1988). Addicts are taught to substitute negative thoughts for positive ones when tempted to drink. For example, instead of focusing on the euphoria felt from taking cocaine, a person might be taught to say, “I feel an urge to take the substance, but I know that I will feel depressed later on, that many of my friends want me to stop taking it, and that I may get arrested.” Rohsenow, Monti, Martin, and their colleagues (2000) found that training cocaine users to cope with temptations and high-risk situations was beneficial not only in lowering cocaine use but also in lowering the amount of cocaine used during a relapse.

Self-Help Groups Alcoholics Anonymous (AA) is a self-help organization composed of alcoholics who want to stop drinking. Perhaps a million or more alcoholics worldwide participate in the AA program, which is completely voluntary. There are no fees, and the only membership requirement is the desire to stop drinking. AA assumes that once a person is an alcoholic, he or she is always an alcoholic—an assumption based on

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controversy

Controlled Drinking

A

great deal of debate has been generated by the suggestion that it is possible for alcoholics to control their intake and learn to become social drinkers. Proponents of controlled drinking assume that, under the right conditions, alcoholics can learn to limit their drinking to appropriate levels. The finding that alcoholics tend to gulp drinks rather than sip them (as social or moderate drinkers do), to consume straight rather than mixed drinks, and to drink many rather than a few drinks gave investigators clues to behaviors that require modification. Alcoholics were then trained to drink appropriately. In a setting resembling a bar, they were permitted to order and drink alcohol, but they were administered an aversive stimulus for each inappropriate behavior. For example, alcoholics who gulped drinks or ordered too many were given painful electric shocks. There is evidence that controlled drinking may work for some alcohol abusers (Emmelkamp, 2004). However, one problem with this technique is that patients need to receive periodic retraining or to learn alternative responses to drinking. Otherwise, they tend to revert to

their old patterns of consumption on leaving the treatment program (Marlatt, 1983). The major task is to discover the conditions under which controlled drinking or abstinence interventions work. Opponents of controlled drinking generally believe that total abstinence should be the goal of treatment, that controlled drinking cannot be maintained over a period of time, and that alcoholism is a genetic-physiological problem. Furthermore, by trying to teach alcoholics that they can resume and control drinking, proponents are unwittingly contributing to the alcoholics’ problems. There have even been questions about the validity of the findings in controlled drinking programs (Pendery, Maltzman, & West, 1982). For Further Consideration 1. Do you think alcoholics can become social drinkers? Why or why not? 2. Can you design a research study to determine whether alcoholics can become social drinkers?

the disease model of alcoholism. Members must recognize that they can never drink again and must concentrate on abstinence, one day at a time. As a means of helping members abstain, each may be assigned a sponsor who provides individual support, attention, and help. Group meetings encourage fellowship, spiritual awareness, and public self-revelations about past wrongdoings because of alcohol. Some people believe that membership in AA is one of the most effective treatments for alcoholism. A few studies with methodological limitations have found an association between AA attendance and positive treatment outcome (McCrady, 1994), although the success rate of AA is probably not as high as AA members claim it is (Brandsma, 1979). Approximately one-half of the alcoholics who stay in the organization are still abstinent after two years (Alford, 1980), but many drop out of the program and are not counted as failures. In one of the most rigorous studies of AA, Morganstern et al. (1997) investigated the effects of affiliation with AA among individuals who had undergone treatment for alcoholism. Greater affiliation with AA did predict better treatment outcomes. However, the involvement with AA was associated with increased feelings of self-efficacy, active coping, and motivation to stop drinking, which were, in turn, predictors of outcome. Finally, in a direct comparison of the effects of AA compared with mental health treatment, Moos and Moos (2006) found that people with alcohol-use disorders who were professionally treated or who participated in AA had better outcomes during a sixteen-year followup period than those who were untreated. Given the success of AA, spinoffs of AA, such as Al-Anon and Alateen, have been established, and they appear to be valuable in providing support for adults and teenagers living with alcoholics (Kanas, 1988). There are similar self-help groups for drug abuse (Narcotics Anonymous), although they have not gained the widespread attention and participation seen in AA.

Multimodal Treatment In view of the many factors that maintain drug-use disorders, some treatment programs make systematic use of combinations of approaches, especially with approaches that have been shown to be effective (Haaga, McCrady, & Lebow, 2006). For example, alcoholics may be detoxified through Antabuse treatment and

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simultaneously receive behavioral training (via aversion therapy, biofeedback, or stress management), as well as other forms of therapy. In one outpatient treatment program, alcohol-dependent men were given standard care (life-skills training, relapse prevention and coping skills, after-care meetings, and counseling). A group of these men was randomly assigned to another condition, the contingency management group. In this group, the men were given the opportunity to win prizes (ranging from small gift certificates to larger gifts, such as a television) if they tested negative for alcohol consumption on a Breathalyzer. Those patients who had the combined treatment involving contingency management and standard care were more likely to be abstinent than patients who were exposed solely to standard care (Petry et al., 2000). Other therapies may include combinations of Alcoholics Anonymous, educational training, family therapy, group therapy, and individual psychotherapy. For example, opioid-dependent patients have been helped by the use of behaviorally oriented family counseling, individual psychotherapy, and daily ingestion of naltrexone, an opioid antagonist that blocks the subjective reinforcing properties of opioid-based drugs (Fals-Stewart & O’Farrell, 2003). Gulliver and his colleagues (2007) also found that broadspectrum interventions that include different treatment modalities were more effective than confining treatment to a single modality. Proponents of multimodal approaches recognize that no single kind of treatment is likely to be totally effective and that successful outcomes often require major changes in the lives of alcoholics. The combination of therapies that works best for a particular person in his or her particular circumstances is obviALL IN THE FAMILY This postcard called “Group ously the most effective treatment. from Recovery Is Everywhere” attempts to show In the case of an amphetamine abuser, the individual may initially be that addicts are often family members and friends. admitted to an inpatient facility for approximately thirty days. There he or Addiction affects people regardless of social class, religion, gender, race, intelligence, and other she receives individual and group therapy, takes part in occupational and characteristics. The postcard points to the fact that recreational therapy and stress management counseling, and perhaps is everyone is vulnerable and that a concerted effort introduced to a support group modeled after Alcoholics Anonymous. The must be made to overcome addiction. patient’s spouse may also be asked to participate in the group sessions. Once the patient has successfully completed this inpatient phase, he or she is scheduled for outpatient treatment. As part of this treatment, the patient is asked to agree to unannounced urine screenings to test for the presence of drugs. The patient is encouraged to continue attending the support group, along with his or her spouse, and to become involved in individual outpatient therapy. Family therapy is the treatment of choice for adolescent substance users (Haley, 1980; Reilly, 1984; Rueger & Liberman, 1984), and it is highly recommended for adults as well. The outpatient program typically continues for about two years. One multimodal project involved six hundred youths being treated for marijuana use, the largest experiment ever conducted on outpatient adolescent treatment (Clay, 2001). The youths were exposed to a number of different treatments that included the adolescents, their families, schools, and other systems. Preliminary results showed dramatic changes in the adolescents’ drug use. For example, the percentage of youths reporting no marijuana abuse or dependence in the previous month increased from 19 percent before treatment to 61 percent six months after treatment. Problems with the criminal justice system, their families, and schools also decreased.

Prevention Programs Prevention programs have been initiated to discourage drug and alcohol use before it begins or to reduce consumption among users (Brown et al., 2005). Campaigns to educate the public about the detrimental consequences of substance use, to reestablish norms against drug use, and to give coping skills to others who are tempted by drug use are waged in the media. Other prevention programs take place in schools, places of worship, youth groups, and families. Such programs are having some effect. For example, Marlatt and others (1998) assigned heavy-drinking college students to either a brief intervention group or a

Intervention and Treatment of Substance-Use Disorders

no-intervention control group for three months of the first year of college. The intervention consisted of providing students with feedback on the extent of their drinking and on possible consequences, without confrontation or direct advice. The investigators conducted one-year and two-year follow-up assessments of drinking, which indicated that the intervention was successful. Students receiving the intervention reported lower alcohol consumption and fewer problems resulting from drinking, and the self-reports from students were consistent with those of friends of the students who were also asked to provide ratings of the students. In another study, Dent and his colleagues (1995) evaluated the outcome of a junior high school smoking-prevention program. A group of students received one of four possible training programs: (1) resistance to social influence (for example, resisting peer pressure to smoke), (2) information (such as correcting misperceptions of the social image of smokers), (3) the physical consequences of smoking, or (4) a combination of the three other approaches. A control group of students was not involved in the training program. The participants received three initial training sessions and a booster training session given a year later. Two years after the initial three sessions, the students exposed to the training were generally less likely to show increases in smoking or in trying smoking than were students not exposed to the training. The investigators warn that longer term success may depend on additional training in high school or at some other future time. Attitudes toward drug use can be altered. Cruz and Dunn (2003) exposed fourthgrade students to one-session alcohol prevention presentations that emphasized the sedating effects of alcohol, challenged the positive effects of alcohol, or alerted them to the dangerous consequences of consumption. Compared with students assigned to a no-prevention group, those who participated in the alcohol presentations had less favorable attitudes toward alcohol use. Because of the public’s constant exposure to television, radio, and newspapers, some researchers have used these media as a means to prevent drug use, as noted earlier. Jason (1998) has found that media programs to prevent or reduce drug use and to maintain abstinence have been very successful. Finally, interventions using the Internet seem quite promising. Munoz and his colleagues (2006) used the Internet to gain the participation of individuals in a smoking cessation program. The program, using a Web-based brochure, covered reasons to stop smoking, how to prepare to quit, what to do in case of relapse, how to refuse cigarettes from friends and family, and information on pharmacological aids such as nicotine replacement agents and bupropion. Additional advice for smoking cessation was individually tailored based on responses to the baseline questionnaires. In their random controlled study, the abstinence rates from the program were similar to those found in traditional interventions (for example, psychotherapy). Even more striking was the fact that more than four thousand smokers from seventy-four countries participated. The study raises the possibility that it may be possible to devise Internet interventions that can affect the lives of a large number of people in different parts of the world.

Effectiveness of Treatment Research evidence indicates that treatment programs are effective in reducing substance abuse and dependence, although outcomes have been small to moderate (Sussman, Sun, & Dent, 2006) and estimates vary from study to study. Currently, approximately half a million Americans are under treatment for alcoholism (Nitzkin & Smith, 2004). About one-third of alcoholic clients remain abstinent one year after treatment. Most opiate-dependent clients and heroin addicts become readdicted within the first year following treatment. The majority of treated smokers return to smoking within one year. Again, relapse occurs most frequently during the first several months of abstinence, and the type of substance is important to consider. Part of the problem in delivering effective treatment is that many individuals with substance-use disorders do not continue treatment (Stark, 1992). In an analysis of a treatment program for teen smokers, Sussman and colleagues (2006) found that smokers in programs that required more than four treatment sessions were more likely to quit than were smokers in programs with fewer sessions. It should be noted that some individuals recover on their own, without treatment. Other individuals

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who relapse after treatment subsequently undergo treatment again and become abstinent or develop an ability to control their intake. The research suggests that treatment can be helpful. In a review of the treatment outcomes for adolescents, Williams and Chang (2000) and Carroll and Onken (2005) found that treatment for substance abuse was generally beneficial, especially if the adolescents completed treatment and if parental and peer support for nonuse was available. Read, Kahler, and Stevenson (2001) conclude that there is probably no single “best” treatment for substance use disorders, although a number of different treatment approaches exist and are helpful. The task is to find the best combination of treatments for particular individuals with substance use disorders.

I M P L I C AT I O N S

All human beings consume substances that alter moods, affect performance and skills, and change body and brain processes. In substance-use disorders, individuals cannot refrain from using drugs or use them despite harmful effects. We now know that drugs alter brain processes and functioning in long-lasting ways. These altered processes include changing brain reward systems and cognitive functioning in ways that affect cravings for the substance. In turn, behaviors such as repeated drug use and finding ways to obtain the substances become dominant. As can be seen, the behaviors and repeated consumption then affect the brain further, so that a vicious cycle occurs. Substance use and dependence are clearly multipath phenomena. Research is continuing to search for brain changes in substance use. The difficulty is finding such changes and then determining whether they cause addiction or whether they are simply byproducts or correlates of addiction. Interesting research is also needed in discovering possible commonalities across different addictions (drugs and compulsive behaviors such as gambling and overeating), the means by which behaviors can change brain processes, and the efficacy of medication, psychological and behavioral treatments, and prevention of drug abuse and dependence.

Summary 1. What are substance-use disorders? ■ People often use chemical substances that alter moods, levels of consciousness, or behaviors. The use of such substances is considered a disorder when abuse or dependence occurs. Substance abuse is defined as a maladaptive pattern of recurrent use over a twelvemonth period, during which the person is unable to reduce or cease intake of a harmful substance, despite knowledge that its use causes social, occupational, psychological, medical, or safety problems. Substance dependence is a more serious disorder, involving not only excessive use but also tolerance and withdrawal in many cases. ■ Substances are largely classified on the basis of their effects. Three major categories have been created: depressants, stimulants, and hallucinogens. ■ Alcohol, which is widely used, is considered a depressant. Other depressants include narcotics, barbiturates, and benzodiazepines. They can cause psychological, physiological, or legal problems. ■ Stimulants energize the central nervous system, often inducing elation, grandiosity, hyperactivity,

■

agitation, and appetite suppression. Amphetamines and cocaine/crack cocaine, as well as widely used substances such as caffeine and nicotine, are considered stimulants. Hallucinogens, another category of psychoactive substances, often produce hallucinations, altered states of consciousness, perceptual distortions, and sometimes violence. Included in this category are marijuana, LSD, and PCP.

2. Why do people develop substance-use disorders? ■ There appears to be no single factor that can account for drug abuse or for dependence on other substances, such as depressants, stimulants, and hallucinogens. Biological/genetic, psychological, social, and sociocultural factors are all important. ■ In terms of biological factors, research has demonstrated that heredity is important in abuse and dependency of some substances such as alcohol. Chronic drug use seems to alter brain chemistry, and it crowds out other pleasures, reduces good decisions, and produces a consuming, compulsive desire for the drug.

Summary ■

■

■

prescribed for drug users depends on the type of drug and on the user. Heroin addicts usually undergo detoxification, followed by methadone maintenance and forms of treatment such as residential treatment programs, psychotherapy, cognitive or behavior therapy, and group therapy. Many alcoholics are helped by treatment, and some achieve abstinence by themselves. For addiction to cigarette smoking, aversive procedures such as “rapid smoking,” nicotine fading (the use of brands containing less and less nicotine), and transdermal nicotine patches have had some success. Prevention programs have also been extensively used in an attempt to discourage substance use.

Psychological approaches to substance-use disorders have emphasized learning about drug-use patterns, the tension- and anxiety-reducing properties of drugs, and expectancies about the effects of drug use. Social or interpersonal factors are important in the consumption of substances. Teenagers and adults have been found to use drugs because of parental models, social pressures from peers, and increased feelings of comfort and confidence in social relationships. Sociocultural factors such as gender, ethnicity, and culture are related to alcohol and drug use. Cultural norms, attitudes, and practices affect the availability of, access to, and tolerance of substances.

3. What kinds of interventions and treatments are available for substance-use disorders, and does treatment work? ■ A variety of treatment approaches have been used, including detoxification, drug therapies, psychotherapy, and behavior modification. The treatment

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Treatment for substance-use disorders has had mixed success. Multimodal approaches (the use of several treatment techniques) are probably the most effective. Evidence indicates that relapse is particularly likely during the first three months after treatment. The risk of relapse decreases as a function of time.

c h a p t e r

10

Sexual and Gender Identity Disorders

C

chapter outline What Is “Normal” Sexual Behavior?

265

Sexual Dysfunctions

270

Etiology of Sexual Dysfunctions

276

Treatment of Sexual Dysfunctions

280

Homosexuality

283

Aging, Sexual Activity, and Sexual Dysfunctions 284 Gender Identity Disorder

286

Paraphilias

288

Rape

296

IMP LIC AT IONS

301

CONTROVERSY Is Compulsive Sexual Behavior an Addiction?

267

CRITICAL THINKING Why

Do Men Rape Women?

264

300

hristina and Jeremiah had been referred for sex therapy by their primary care physician after only eight months of marriage. Both were extremely dissatisfied with their lovemaking: (1) Jeremiah complained that Christina never initiated sex, found excuses to avoid it, and appeared to fake her orgasms during intercourse, and (2) Christina complained that Jeremiah’s lovemaking was often brief, perfunctory, and without affection. During the sessions, it became clear that Christina had never had a strong desire for sex and would seldom become aroused during intercourse. Although Jeremiah had never had difficulty with maintaining an erection, sex with Christina had become progressively worrisome, as he often had difficulty getting hard enough for penetration. Prior to initiating sex, Jeremiah drank heavily to give him “courage” to approach Christina and to alleviate his guilt in “forcing her to have sex.” These encounters were often humiliating, as he felt that Christina only agreed to sex due to pity and sufferance. In 2007, Yvonne Buschbaum, a German pole-vaulter who took third place in the European Championships and sixth in the Sydney Olympics, announced that she was going to undergo sex-reassignment therapy to become a man. As a young child, she had always seemed more interested in “boy” activities. Yvonne often believed she was a boy, played like a boy, and had no interest in girls’ games. On her website she stated: “I feel as if I am a man and have to live my life in the body of a woman.” Yvonne believes that nature played a cruel hoax on her, that she was a man trapped in a woman’s body. On her website, she announced her decision to “come out” by stating “I am aware of the fact that transsexuality is a fringe issue, and I do not want to be responsible for it remaining on the fringe.” From early childhood, Peter F, a forty-one-year-old man, had fantasies of being mistreated, humiliated, and beaten. He recalls how he would become sexually excited

FOCUSQUESTIONS

1 What are normal and abnormal sexual behaviors? 2 What does the normal sexual response cycle tell us about sexual dysfunctions?

3 What causes sexual dysfunctions? 4 What types of treatments are available for sexual dysfunctions?

5 Is homosexuality a mental disorder?

6 How does aging affect the sexual activity of the elderly?

7 What causes gender identity disorder, and how is it treated?

8 What are the paraphilias, what causes them, and how are they treated?

9 Is rape an act of sex or aggression?

when envisioning such activities. As he grew older, he experienced difficulty achieving an orgasm unless he was able to experience pain inflicted by his sexual partners. He was obsessed with masochistic sexual acts, which made it difficult for him to concentrate on other matters. He had been married and divorced three times because of his proclivity for demanding that his wives engage in “sex games” that involved having them hurt him. These games involved being bound spread-eagled on his bed and tortured by whippings, biting of his upper thighs, the sticking of pins into his legs, and other forms of torture. During these sessions, he could ejaculate.

These cases illustrate some of the sexual dysfunctions and disorders we present in this chapter. We discuss the following categories listed in DSM-IV-TR (American Psychiatric Association, 2000a): • Sexual dysfunctions, which involve problems in the normal sexual response cycle that affect sexual desire, arousal, and response. The case of Christina and Jeremiah seems to fall into this category. • Gender-identity disorder, which involves an incongruity or conflict between one’s anatomical sex and one’s psychological feeling of being male or female. Buschbaum had such a conflict. • Paraphilias, which involve sexual urges and fantasies about situations, objects, or people that are not part of the usual arousal pattern leading to reciprocal and affectionate sexual activity. Peter F.’s activities place him in this category. Before we begin these discussions, however, let’s consider another question: How do we decide what constitutes “normal” sexual functioning?

What Is “Normal” Sexual Behavior? Of all the psychological or psychiatric disorders discussed in this text, sexual dysfunctions and disorders present the greatest difficulty for those attempting to distinguish between “abnormal” (maladaptive) behavior and nonharmful variations that reflect personal values and tastes markedly different from social norms (Balon, Segraves, & Clayton, 2007). The definitions of normal sexual behavior vary widely and are influenced by both moral and legal judgments. For example, the laws of some states define oral-genital sex as a “crime against nature.” This view is reflected in a California statute that was repealed as late as 1976: Oral Sex Perversion—Any person participating in an act of copulating the mouth of one person with the sexual organ of another is punishable by incarceration in the state prison for a period not exceeding fifteen years, or by imprisonment in the county jail not to exceed one year.

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CULTURAL INFLUENCES AND SEXUALITY Sexuality is influenced by how it is viewed in different cultures. Some societies have very rigid social, cultural, and religious taboos associated with exposure of the human body, whereas other societies are more open. Note the contrast between the teens from Muslim and American societies shown here.

Did You Know?

S

exual activities vary widely among people of different ages, marital status, and nationalities. • People across the world have sex an average of 97 times a year. • 59 percent claim to have sex at least once a week; 4 percent claim to have sex every day. • 21- to 34-year-olds have sex the most (113 times/year) compared with 70 for those over 45. • Unmarried people living together have more sex (113 times/year) than those married (100) or single (86). • One in 10 people have never had sex. Source: Durex (2001, 2005).

sexual addiction a popular term referring to a person’s desire and need to engage in constant and frequent sexual behavior (frequently labeled compulsive sexual behavior) compulsive sexual behavior

a term used by many sex therapists to describe individuals who seem to crave constant sex at the expense of relationships, work productivity, and daily activities

It would be difficult today to justify the classification of oral sex as a “perversion.” The pioneering work of Alfred Kinsey and colleagues revealed that oral sex is widespread, especially among the more highly educated part of the population (Kinsey, Pomeroy, Martin, & Gebhard, 1953). Surveys (Andersen & Cyranowski, 1995; Mosher, Chandra, & Jones, 2005) have found that among adults 25 to 44 years of age, 97 percent of men and 88 percent of women have engaged in oral sex with an opposite-sex partner. The codification of sexual behavior into law is often based on lack of information regarding normal sexual practices. For example, in the 1943 Dittrick v. Brown County Minnesota Supreme Court ruling, the court upheld the conviction of a father of six as a sexual psychopath because he had an “uncontrollable craving for sexual intercourse with his wife.” This “craving” amounted to three or four times a week. If he were tried today, Mr. Dittrick could base his defense on the views of some current researchers who believe that not having sex often enough indicates a sexual desire disorder. Classification of normal and abnormal behavior becomes especially difficult when one compares western and nonwestern cultures or different time periods within a particular culture (Rathus, Nevid, & Fichner-Rathus, 2005). For example, the Japanese have significantly less sexual intercourse than Americans (70 percent less), as is the case in many Asian countries (Durex, 2005). Should we conclude that Asians are more prone to sexual desire disorders, or do cultural factors account for the lower rate? In ancient Greece, homosexuality was not only accepted but encouraged (Arndt, 1991). In many countries, sex with animals is fairly common among rural youths but is rare among urban boys. Thus it is clear that definitions of sexual disorders are also strongly influenced by cultural norms and values. If legal, moral, and statistical models fall short of the viable definition of normal sexual behavior that is needed, can we resolve the controversy by simply stating that sexual behavior is deviant if it is a threat to society, causes distress to participants, or impairs social or occupational functioning? Using this definition, there would be no objection to our considering rape as deviant behavior; it includes the elements of nonconsent, force, and victimization. But what about sexual arousal to an inanimate object (fetishism), or low sexual drive, or gender identity conflict? These conditions are not threats to society, they may not cause distress to people who experience them, and they may not result in impaired social or occupational functioning. They are deviant simply because they do not fall within “normal arousal and activity patterns.” And they are considered deviant even though what constitutes a normal sexual pattern is the subject of controversy (Balon et al., 2007; Gierhart, 2006). In short, ambiguities surround all the classification systems, and the controversies will

What Is “Normal” Sexual Behavior?

267

controversy

Is Compulsive Sexual Behavior an Addiction?

I

s there such a thing as sexual addiction? Can a person be oversexed and have a sexual appetite that requires frequent sex in order to be satisfied? Over 4 percent of people claim to have sex every day; 2 percent of married men and 1 percent of married women have intercourse more than once a day (Durex, 2001, 2005; Laumann, Gagnon, Michael, & Michaels, 1994). By statistical standards, would these people be considered abnormal? The term compulsive sexual behavior (CSB) is used by many sex therapists to describe individuals who seem to crave constant sex at the expense of relationships, work productivity, and daily activities. DSM-IV-TR does not recognize the existence of sexual addiction; otherwise, it might be logically classified as a sexual desire disorder. Yet most sex therapists are in agreement that some individuals seem obsessed with sex, feel compelled to engage in frequent sexual activity, and find their behavior causing them personal distress (Holloway, 2003; Money, 1996). Even the Masters and Johnson Therapy Clinic has a residential treatment center for sexual addiction, and sexual scientists have used such terms as hypersexuality, erotomania, nymphomania, and satyriasis to refer to this phenomenon. Arguments against creating a sexual disorder category called “sexual addiction” come from several directions. 1. In his early work, Carnes (1983) popularized the concept of CSB as an addiction when he concluded that it is possible for people to become addicted to sex as they would to alcohol, cigarettes, and drugs. The Masters and Johnson Residential Center in St. Louis even uses the 12-step recovery model (similar to that of Alcoholics Anonymous) to treat “sexual addicts.” Many psychologists, however, do not believe that the comparison between sexual addiction and substance addiction is analogous. For one thing, drug usage, alcohol intake, and cigarette smoking are not basic expressions of life, as sex is. They also caution that labeling “extreme” behaviors, such as “workaholism,” is not based on scientific criteria and implies a distinct category that cannot be accounted for by a more appropriate classification. For example, although CSB may exist, it is unclear whether it is an impulse-control disorder or an obsessive-compulsive disorder. An equally strong case can be made that it is an obsessive-compulsive disorder that fulfills the criteria of obsessions and compulsions. The symptoms of CSB—compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships, or compulsive sex in a relationship—may

be little different from the intrusive-recurrent sexual thoughts or frequent hand washing found in OCD (Holloway, 2003). 2. Individuals vary considerably in the frequency of their sexual activity. Some have sex several times a day and others a few times a year (Rathus et al., 2005). Interestingly, a strong sexual libido is often valued by our society because it connotes potency, power, attractiveness, sensual pleasure, and health. Indeed, the search for aphrodisiacs in the form of powdered animal genitals, herbs, secret concoctions, and even drugs such as Viagra is a multibillion-dollar industry. So there are many in our society who would value a strong sex drive, especially if they do not experience personal distress over their behaviors and if it does not interfere with their ability to function in their many roles in life. Adolescents are known for being “obsessed” with sex for long periods of time, and adults in the early stages of a romance can become obsessed with their partners, seek out their company, and express their sexual feelings quite often. These thoughts and activities are normal and healthy developmental processes and must be distinguished from CSB. 3. The diagnosis of CSB is often fraught with the danger that the clinician may overpathologize sexual behaviors that are driven by antisexual attitudes or a conflict over values. A clinician who is not comfortable with the wide range of normal sexual expression (frequency and practice) must distinguish between his or her own internal standards of normality and abnormality and the sexual behavior of others. At one time, homosexuality was considered a sexual disorder; many people continue to see sadomasochistic practices, oral sex, and even masturbation as abnormal. Likewise, clients can often diagnose their own sexual thoughts and feelings as abnormal because they are in conflict with their own restrictive values. Many adolescents, for example, feel guilty about masturbating. It is their discomfort with their sexual behavior and internal values, not the possibility of CSB, that should be the focus of treatment. For Further Consideration 1. Do you believe there is such a thing as a sexual addiction? How does one determine normal sexual desires from abnormal sexual desires? 2. How often do you think about sex? Has it ever become so problematic that you find yourself unable to concentrate on other life duties?

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MEN

WOMEN

Level of arousal

Orgasm g

Orgasm

Resolution

Arousal

Resolution

Arousal

Appetitive (desire)

Appetitive (desire)

10.1

FIGURE HUMAN SEXUAL RESPONSE CYCLE The studies of Masters and Johnson reveal similar normal sexual response cycles for men and women. Note that women may experience more than one orgasm. Sexual disorders may occur at any of the phases, but seldom at the resolution phase. become more obvious as we discuss the three groups of sexual disorders and sexual aggression in the remainder of this chapter.

The Study of Human Sexuality Because sexual behavior is such an important part of our lives and because so many taboos and myths surround it, people have great difficulty dealing with the topic in an open and direct manner (Ohl, 2007). To some extent, Freud made the discussion of sexual topics more acceptable when he made sex (libido) an important part of psychoanalytic theory. His knowledge of sexual practices and behavior, however, was largely confined to his clinical cases and his speculations from the understanding of social mores. Our contemporary understanding of human sexual physiology and sexual practices and customs is based on the works of Alfred Kinsey and his colleagues (Kinsey, Pomeroy, & Martin, 1948; Kinsey et al., 1953), of William Masters and Virginia Johnson in their seminal works Human Sexual Response (1966) and Human Sexual Inadequacy (1970), on the Janus Report (Janus & Janus, 1993), and on the work of other contemporary sex researchers. Although the nature of the subject matter and the means used to obtain the information proved controversial and provocative, these studies dispelled myths and provided explicit evidence of human sexual responsiveness, attitudes, and practices.

The Sexual Response Cycle

HELEN SINGER KAPLAN In her book Disorders of Sexual Desire (1979), renowned sexuality researcher Dr. Helen Singer Kaplan proposed an alternative to the Masters and Johnson model of human sexual response, employing a four-stage psychophysical model: (1) desire, (2) excitement, (3) orgasm, and (4) resolution. By including desire as the first stage, Dr. Kaplan broadened our understanding of the role emotions play in the sexual experience.

Treating human sexual dysfunction requires an understanding of the normal sexual response cycle, which consists of four stages: appetitive (desire), arousal, orgasm, and resolution (see Figure 10.1). Originally, Masters and Johnson (1966) proposed only three stages; they included the appetitive stage with the arousal phase. The work of sex therapist Helen Singer Kaplan (1974) gave us an understanding of how important it is for a person to desire and to be sexually ready, thus legitimizing the addition of another distinct (appetitive or desire) stage of sexual response (“Study Confirms Importance of Sexual Fantasies,” 2007). 1. The appetitive phase is characterized by the person’s desire for sexual activity. The person begins to have thoughts or fantasies surrounding sex. He or she may begin to feel attracted to another person and to daydream increasingly about sex.

What Is “Normal” Sexual Behavior?

269

Cowper's gland secretion Full erection

Pubic bone

Color deepens

Partially stimulated state

Prostate enlarges Scrotum thickens

Testes elevated

Partial elevation of testes

Unstimulated state

Cowper's gland becomes active

Desire

Marked increase in size of testes

Arousal

Penile contractions Internal sphincter of bladder closes Seminal vesicles contract Urethral contractions

Erection disappears

Contractions force the seminal fluid through the urethra

Prostate gland contracts Rectal sphincter contracts

Testes descend Unstimulated state Scrotum thins

Orgasm

10.2

Loss of testicular congestion

Resolution

FIGURE GENITAL CHANGES ASSOCIATED WITH STAGES OF THE HUMAN MALE SEXUAL RESPONSE CYCLE Although we often focus on the differences between men and women, Masters and Johnson found that the physiological responses of both to sexual stimulation are quite similar (compare this figure with Figure 10.3).

2. The arousal phase moves out of the appetitive phase when specific and direct—but not necessarily physical—sexual stimulation occurs. Heart rate, blood pressure, and respiration rate increase. In the male, blood flow increases in the penis, resulting in an erection (see Figure 10.2). The ridge around the head of the penis turns deep purple, and the testes enlarge and elevate in preparation for ejaculation. In the female, the breasts swell, nipples become erect, blood engorges the genital region, and the clitoris expands (see Figure 10.3). Vaginal lubrication reflexively occurs, and a sex flush may appear on the skin (usually later in this phase). 3. The orgasm phase is characterized by involuntary muscular contractions throughout the body and the eventual release of sexual tension. In the man, muscles at the base of the penis contract, propelling semen through the penis. In the woman, the outer third of the vagina contracts rhythmically. Following orgasm, men enter a refractory period during which they are unresponsive to sexual stimulation for a period of time. However, women are capable of multiple orgasms with continued stimulation. 4. The resolution phase is characterized by relaxation of the body after orgasm. Heart rate, blood pressure, and respiration return to normal.

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CHAPTER 10 • SEXUAL AND GENDER IDENTITY DISORDERS Uterus

Uterus elevates

Bladder

Vagina expands Pubic bone

Clitoris enlarges

Labia swell

Vaginal lubrication appears

Desire

Clitoris retracts Color changes in labia

Orgasmic platform

Arousal

Contractions in uterus

Uterus lowers

Seminal point Vagina returns to normal Rhythmic contractions in orgasmic platform

Rectal sphincter contracts

Orgasm

FIGURE

Orgasmic platform disappears

Resolution

10.3 GENITAL CHANGES ASSOCIATED WITH STAGES OF THE HUMAN FEMALE SEXUAL RESPONSE CYCLE Problems may occur in any of the four phases of the sexual response cycle, although they are rare in the resolution phase. If problems related to arousal, desire, or orgasm are recurrent and persistent, they may be diagnosed as dysfunctions.

Sexual Dysfunctions

sexual dysfunction a disruption of any part of the normal sexual response cycle that affects sexual desire, arousal, and response

A sexual dysfunction is a disruption of any part of the normal sexual response cycle that affects sexual desire, arousal, and response. Problems in sexual functioning, such as premature ejaculation, low sexual desire, and difficulties in achieving orgasm, are quite common in our society. Epidemiological data suggest that 40 to 45 percent of adult women and 20 to 30 percent of adult men suffer from at least one sexual dysfunction (Lewis et al., 2004). Lifetime prevalence of sexual problems in young adults at some time in their lives is summarized in Table 10.1. To be diagnosed as a dysfunction, the disruption must be recurrent and persistent. DSM-IV-TR also requires that such factors as frequency, chronicity, subjective distress, and effect on other areas of functioning be considered in the diagnosis. As indicated in Table 10.2, the DSM-IV-TR categories for sexual dysfunctions are sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. Prevalence of the sexual dysfunctions is summarized here as well.

Sexual Dysfunctions

TA B L E

271

10.1

LIFETIME PREVALENCE OF SEXUAL DISORDERS BY WOMEN AND MEN DISORDER

WOMEN

MEN

Reduced libido

40%

30%

Arousal difficulties

60%

50%

Reaching orgasm too soon

10%

15%

Inability to have orgasm

35%

2%

Dyspareunia

15%

5%

Source: Haas & Haas (1993).

Sexual Desire Disorders Sexual desire disorders are related to the appetitive phase and are characterized by a lack of sexual desire. There are two types: hypoactive sexual desire disorder, characterized by little or no interest in sexual activities, either actual or fantasized, and sexual aversion disorder, characterized by an avoidance of and aversion to sexual intercourse. Both of these disorders can be lifelong or acquired and may be due to psychological factors or a combination of psy- UNDERSTANDING SEXUALITY Through their chological and biological factors (Perlman, Martin, Hirdes, & Curtin-Telegdi, clinical research and well-known publications, 2007). Some people may report low sexual desire because of inexperience. Human Sexual Response (1966) and Human Many of these people may not have learned to label or identify their own Sexual Inadequacy (1970), William Masters and Virginia Johnson have done much to further arousal levels, may not know how to increase their arousal, and may have a understanding and dispel myths of human limited expectation for their ability to be aroused (LoPiccolo, 1995). sexuality. About 20 percent of the adult population (20–35 percent of women and 15 percent of men) are believed to be suffering from hypoactive sexual desire disorder (American Psychiatric Association, 1994; LoPiccolo, 1995; Rosen & Leiblum, 1995; Spector & Carey, 1990). Some clinicians estimate that 40 to 50 percent of all sexual dysfunctions involve deficits in desire, and it is now the most common complaint of couples seeking sex therapy (McAnulty & Burnette, 2004; Spector & Carey, 1990). Although people with sexual desire disorders are often capable of experiencing orgasm, they claim to have little interest in, or to derive no pleasure from, sexual activity. In the following case, relationship problems contributed to the sexual dysfunction:

Case Study A thirty-six-year-old woman and her thirty-eight-year-old husband were referred by her psychotherapist for sex therapy. The couple had had little or no sexual contact over the preceding three years, and the sexual relationship had been troubled and unsatisfactory since the day they met. Kissing and gentle fondling were enjoyable to both of them, but as their relationship progressed to genital caressing, the woman became more anxious, despite her being easily orgasmic. . . . She explained the difficulty as being due to conflict in the relationship. She saw him as angry, controlling, and demanding and very critical of her. Naturally, she did not feel loving or sexually receptive. Correspondingly, he felt angry, resentful, and cheated of a “normal sex life.” (Golden, 1988, p. 304)

In this case, the woman was diagnosed as having inhibited sexual desire. According to DSM-IV-TR, a sexual dysfunction should be diagnosed in such cases because the interpersonal problem is the primary cause of the disturbed functioning. Many people question the legitimacy of these criteria and of the categories themselves, however. They challenge the idea that sexual problems stemming from a troubled relationship or from job or academic stress are sufficient to indicate a disorder (Balon et al., 2007).

sexual desire disorder sexual dysfunction that is related to the appetitive phase of the sexual response cycle and is characterized by a lack of sexual desire

272 TA B L E

CHAPTER 10 • SEXUAL AND GENDER IDENTITY DISORDERS

10.2

DISORDERS CHART SEXUAL DYSFUNCTION

Sexual Desire Disorders

SEXUAL DYSFUNCTIONS

SYMPTOMS

—Problems during the appetitive phase —Hypoactive sexual desire disorder Absent or low sexual interest/desire —Sexual aversion disorder Avoidance of/aversion to sexual intercourse

Sexual Arousal Disorders

—Problems of sexual pleasure or physiological changes involving sexual excitement —Male erectile disorder (ED) Inability to attain/maintain an erection sufficient for sexual intercourse and/or psychological arousal during sexual activity

PREVALENCE

AGE OF ONSET

COURSE

20% of adult population; women have higher rates (20–35%) than men (15%)

Usually noticed in adulthood by a partner who complains

May be lifelong or acquired; treatment may help

10% of men report ED; some 50% have experienced “transient” conditions; 10–50% of women suffer from arousal lubrication problems

Can occur at age of sexual maturity but increases with age, especially in men

Most can be helped by psychological or medical treatment

Premature ejaculation estimates from 30–50%; 3–10% of nonclinical population suffer from inhibited male orgasm; 10% of women have never experienced an orgasm

At age of sexual maturity

In men, often related to performance anxiety; in women, lack of foreplay is most frequent reason

Dyspareunia is relatively rare in men but more common in women (17–19%); vaginismus occurs in less than 1% of females

Can occur because of medical problems (such as injury to the pelvis) or traumatic event

Most have physical causes and can be treated

—Female sexual arousal disorder Inability to attain/maintain physiological response and/or psychological arousal during sexual activity Orgasmic Disorders

—Problems with the orgasm phase —Female/male orgasmic disorder Persistent delay or inability to achieve orgasm after reaching excitement phase —Premature ejaculation Ejaculation with minimal sexual stimulation before, during, or shortly after penetration

Sexual Pain Disorders

—Dyspareunia Genital pain in a man or woman not primarily due to lack of lubrication in the vagina or vaginismus. —Vaginismus Involuntary spasm of the outer third of the vaginal wall that prevents or interferes with sexual intercourse

Source: Data from American Psychiatric Association (2000a); Spector & Carey (1990); LoPiccolo (1995, 1997); Hooper (1998); Paik & Laumann (2006).

There is an even larger issue in diagnosing these problems. As noted earlier in this chapter, we do not really know what constitutes “normal” sexual desire, and we know little about what frequency of sexual fantasies or what activities are “normal.” Kinsey and colleagues (1948) found tremendous variation in reported total sexual outlet, or release. One man reported that he had ejaculated only once in thirty years; another claimed to have averaged thirty orgasms per week for thirty years. However, using some average frequency of sexual activity does not seem appropriate for categorizing people as having inhibited sexual desire. One person may have a high sex drive but not engage in sexual activities; another may not have sexual interest or fantasies but may engage in frequent sexual behaviors for the sake of his or her partner.

Sexual Dysfunctions

Furthermore, using number of orgasms (intercourse or masturbation) or desire for orgasms may introduce gender bias into the definition of “normal” sexual desire. The Janus Report indicated that, for all age groups, men masturbate and experience orgasms more than women do (Janus & Janus, 1993). Does this mean that women’s sexual desire is less than that of men? Until we can decide on a normal range of sexual desire, we can hardly discover the causes of sexual desire disorders or develop treatment programs for them.

273

Did You Know? Men think about sex significantly more often than women.

Thoughts of Sex Men Women

Once or Several Times a Day 54%

Weekly or Monthly 43%

Less Than Once a Month/Never 4%

19%

67%

14%

Adapted from Michael, Gagnon, Laumann, & Kolata (1994).

Sexual Arousal Disorders Sexual arousal disorders are problems that occur during the excitement phase and that relate to difficulties with feelings of sexual pleasure or with the physiological changes associated with sexual excitement. Male Erectile Disorder In men, inhibited sexual excitement takes the form of male erectile disorder (ED), an inability to attain or maintain an erection sufficient for sexual intercourse and/or psychological arousal during sexual activity. The man may feel fully aroused, but he cannot finish the sex act. In the past, such a dysfunction has been attributed primarily to psychological causes (“it’s all in the head”). Masters and Johnson (1970), for example, estimated that only about 5 percent of erectile dysfunctions were due to physical conditions. However, studies indicate that from 30 percent to as many as 70 percent of erectile dysfunctions are caused by some form of vascular insufficiency, such as diabetes, atherosclerosis, or traumatic groin injury, or by other physiological factors (Hooper, 1998; Lewis et al., 2004). A primary reason that DSM-IV-TR includes general medical conditions as a factor in sexual dysfunctions is that a man may also have a minor organic impairment that makes him more vulnerable to experiencing ED because of other psychological, social, or sexual stressors. Distinguishing between erectile dysfunctions that are primarily biological and those that are primarily psychological has been difficult (see Table 10.3). For example, one procedure involves recording nocturnal penile tumescence (NPT). During sleep, men have frequent erections. If, however, they suffer from an organic problem,

TA B L E

10.3

SOME POSSIBLE PHYSICAL CAUSES OF ERECTILE DISORDER • Alcoholism (neuropathy) • Diabetes mellitus • Arterial disease (e.g., Leriche syndrome) • Renal failure • Carcinomatosis • Neurosyphilis • Hypothalamo-pituitary dysfunction

sexual arousal disorder disorder characterized by problems occurring during the excitement phase of the sexual response cycle and relating to difficulties with feelings of sexual pleasure or with the physiological changes associated with sexual excitement

• Liver failure male erectile disorder • Multiple sclerosis • Many others Source: Haas & Haas (1993).

an inability to attain or maintain an erection sufficient for sexual intercourse and/or psychological arousal during sexual activity

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they are not able to have erections during the waking state. Psychological distress is minimized during sleep and should not impair erections. Thus men who do not display adequate spontaneous erections during sleep suffer from an organic impairment, and psychological causes are thought to predominate in men who have such erections. Unfortunately, considerable overlap in NPT scores has been found between samples of diabetic men with erectile difficulties and normally functioning men in control groups (LoPiccolo & Stock, 1986). Therefore, some people diagnosed with organic impotence may actually have a psychologically based impotence. The reverse could also be true. Primary erectile dysfunction is the diagnosis for a man who has never been able to engage successfully in sexual intercourse. This difficulty often has a clear psychological origin, because many men with this dysfunction can get an erection and reach orgasm during masturbation and can show erection during the REM (rapid eye movement) phase of sleep. In secondary erectile dysfunction, the man has had at least one successful instance of sexual intercourse but is currently unable to achieve an erection and penetration in 25 percent or more of his sexual attempts (Masters & Johnson, 1970).

Case Study A twenty-year-old college student was suffering from secondary erectile dysfunction. His first episode of erectile difficulty occurred when he attempted sexual intercourse after drinking heavily. Although to a certain extent he attributed the failure to alcohol, he also began to have doubts about his sexual ability. During a subsequent sexual encounter, his anxiety and worry increased. When he failed in this next coital encounter, even though he had not been drinking, his anxiety level rose even more. The client sought therapy after the discovery that he was unable to have an erection even during petting.

The prevalence rate of ED is difficult to determine because it is often unreported. Clinicians estimate that approximately 50 percent of men have experienced transient impotence (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994). Of 448 men with sexual dysfunctions treated at the Masters and Johnson sex clinic, 32 were suffering from primary ED and 213 from secondary ED. Prior to the introduction of drugs such as Cialis, Levitra, and Viagra, the generally accepted figure of ED among men was between 10 million and 15 million (Leary, 1992). Current estimates of erectile problems place the figure at approximately 30 million (Hooper, 1998). Several factors may be contributing to this increase in the number of reported cases: (1) an increasing acceptance that the dysfunction may be caused by some physical condition and not by feelings of “psychological inadequacy”; (2) the availability of drugs such as Viagra as a nonintrusive successful treatment; (3) an increasing willingness among men to talk about this problem; and (4) a greater acceptance of women’s right to expect satisfaction in sexual relationships.

female sexual arousal disorder

the inability to attain or maintain physiological response and/or psychological arousal during sexual activity

Female Sexual Arousal Disorder Female sexual arousal disorder is an inability to attain or maintain physiological response and/or psychological arousal during sexual activity. It is characterized by a lack of physical signs of excitement, such as vaginal lubrication or erection of the nipples, or complaints of a lack of pleasure during sexual interactions (American Psychiatric Association, 2000a). As with other sexual dysfunctions, this disorder may be lifelong or acquired and is often the result of negative attitudes about sex or early sexual experiences. Receiving negative information about sex, having been sexually assaulted or molested, and having conflicts with a sexual partner can contribute to the disorder (Perlman et al., 2007). Estimates of this disorder vary widely, from 10 to 50 percent of the female population; accurate numbers are difficult to obtain because it is extremely difficult to distinguish this condition from other sexual disorders (Laumann et al., 1994; LoPiccolo, 1997). Indeed, female sexual arousal disorder is rarely diagnosed alone and usually is accompanied by or submerged with other desire or orgasmic disorders.

Sexual Dysfunctions

275

Orgasmic Disorders An orgasmic disorder is an inability to achieve an orgasm after entering the excitement phase and receiving adequate sexual stimulation. Female Orgasmic Disorder A woman with female orgasmic disorder, or inhibited female orgasm, experiences persistent delay or inability to achieve an orgasm with stimulation that is “adequate in focus, intensity, and duration” after entering the excitement phase. Whether the lack of orgasm is categorized as a dysfunction or as a “normal variant” is left to the judgment of the clinician. Again, the criteria that define adequate functioning during sexual intercourse are quite controversial. Inhibited female orgasm may be termed primary, to indicate that orgasm has never been experienced, or secondary, to show that orgasm has been experienced. Primary orgasmic dysfunction is considered relatively common in women: approximately 10 percent of all women have never achieved an orgasm (Rosen & Lieblum, 1995; Spector & Carey, 1990). This disorder is not equivalent to primary orgasmic dysfunction in males, who often can achieve orgasm through masturbation or by some other means. Male Orgasmic Disorder Male orgasmic disorder, or inhibited male orgasm, is the persistent delay or inability to achieve an orgasm after the excitement phase has been reached and sexual activity has been adequate in focus, intensity, and duration. The term is usually restricted to the inability to ejaculate within the vagina, even with full arousal and penile erection. As noted, men who have this dysfunction can usually ejaculate when masturbating. Inhibited orgasm in males is relatively rare, and little is known about it (McAnulty & Burnette, 2004). Treatment is often urged by the wife, who may want to conceive or who may feel (because of the husband’s lack of orgasm) that she is unattractive. An examination of the backgrounds of men with this disorder may reveal either the occurrence of some traumatic event or a severely restrictive religious background in which sex is considered evil. Masters and Johnson (1970) gave an example of a man who discovered that his wife had engaged in sexual intercourse with another man. Although they remained married, he could no longer ejaculate during intercourse. Premature Ejaculation The inability to satisfy a sexual partner is a source of anguish for many men. Premature ejaculation is ejaculation with minimal sexual stimulation before, during, or shortly after penetration. It is believed to be the most common type of male sexual dysfunction, affecting 21 to 33 percent of men (Walling, 2007). Sex researchers and therapists, however, differ in their criteria for prematurity. Kaplan (1974) defined prematurity as the inability of a man to tolerate high (plateau) levels of sexual excitement without ejaculating reflexively. Kilmann and Auerbach (1979) suggested that ejaculation less than five minutes after coital entry is a suitable criterion of prematurity. Masters and Johnson (1970) contended that a man who is unable to delay ejaculation long enough during sexual intercourse to produce an orgasm in the woman 50 percent of the time is a premature ejaculator. The difficulty with the latter definition is the possibility that a man may be “premature” with one partner but entirely adequate for another. From the perspective of males, approximately one in three men admit to occasional premature ejaculation problems (Spector & Carey, 1990).

Sexual Pain Disorders Sexual pain disorders can be manifested in both males and females in a condition termed dyspareunia, which is a recurrent or persistent pain in the genitals before, during, or after sexual intercourse. Table 10.4 identifies possible biological or medical reasons for both men and women. It is estimated that the lifetime prevalence rate is 17 to 19 percent (Paik & Laumann, 2006). Dyspareunia is not caused exclusively by lack of lubrication or by vaginismus, which is an involuntary spasm of the outer third of the vaginal wall, preventing or interfering with sexual intercourse. The incidence

an inability to achieve an orgasm after entering the excitement phase and receiving adequate sexual stimulation.

orgasmic disorder

female orgasmic disorder

a sexual dysfunction in which the woman experiences persistent delay or inability to achieve an orgasm with stimulation that is adequate in focus, intensity, and duration after entering the excitement phase; also known as inhibited female orgasm male orgasmic disorder

persistent delay or inability to achieve an orgasm after the excitement phase has been reached and sexual activity has been adequate in focus, intensity, and duration; usually restricted to an inability to ejaculate within the vagina; also known as inhibited male orgasm premature ejaculation

ejaculation with minimal sexual stimulation before, during, or shortly after penetration dyspareunia recurrent or persistent pain in the genitals before, during, or after sexual intercourse vaginismus involuntary spasm of the outer third of the vaginal wall, preventing or interfering with sexual intercourse

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TA B L E

10.4

SOME POSSIBLE CAUSES OF DYSPAREUNIA Female • Failure of vaginal lubrication • Failure of vasocongestion • Failure of uterine elevation and vaginal ballooning during arousal • Estrogen deficiency leading to atrophic vaginitis • Radiotherapy for malignancy • Vaginal infection (e.g., trichomonas or herpes) • Vaginal irritation (e.g., sensitivity to creams or deodorants) • Abnormal tone of pelvic floor muscles • Scarring after episiotomy or surgery • Bartholin’s gland cysts or abscess • Rigid hymen, small introitus Male • Painful retraction of the foreskin • Herpetic and other infections • Asymmetrical erection due to fibrosis or Peyronie’s disease • Hypersensitivity of the glans penis Source: Haas & Haas (1993).

of vaginismus is not known, but it is considered very rare. Several causal factors have been identified in vaginismus. Masters and Johnson (1970) found one or more of the following conditions among many women with this dysfunction: (1) a husband or partner who was impotent; (2) rigid religious beliefs about sex; (3) prior sexual trauma, such as rape or childhood molestation; (4) prior homosexual identification; and (5) painful intercourse. DSM-IV-TR also recognizes the diagnoses of sexual dysfunction due to a general medical condition and substance-induced sexual dysfunction. For example, a man may suffer from an erectile disorder caused by a general medical condition, such as diabetes, as noted earlier, or by a substance-induced condition, such as alcohol abuse.

Etiology of Sexual Dysfunctions There is perhaps no other group of mental disorders in which the interaction of biological, psychological, social, and sociocultural dimensions are as clearly demonstrated as in the etiology of sexual dysfunctions. Nor are there disorders that so directly illustrate how these dimensions can interact with one another to create sexual problems (Heiman, 2002; Ohl, 2007). Let’s return to the case of Jeremiah and Christina in our chapter opener to illustrate how various etiological factors can contribute to sexual dysfunctions. (You may wish to reread the case in order to follow our multipath analysis.) Recall that both came for sex therapy because Christina did not seem to desire nor enjoy sex and Jeremiah was experiencing erection difficulties during their lovemaking. Christina was diagnosed as suffering from a hypoactive sexual desire disorder

Etiology of Sexual Dysfunctions

10.4

FIGURE MULTIPATH MODEL FOR SEXUAL DYSFUNCTIONS The dimensions interact with one another and combine in different ways to result in a specific sexual dysfunction. The importance and influence of each dimension varies from individual to individual.

Biological Dimension • Physical and medical conditions (chronic illness, vascular diseases, medication, substance abuse, etc.) • Hormonal deficiencies • Autonomic nervous system reactivity to anxiety

Sociocultural Dimension • Cultural scripts • Gender roles • Age-related changes

Psychological Dimension

SEXUAL FUNCTI

• • • •

277

Situational or coital anxiety or guilt Performance anxiety Negative attitudes toward sex Fear of pregnancy, HIV infection, or venereal disease

Social Dimension • Relational problems with partner • Negative parental attitudes toward sex in childhood • Rape or sexual molestation/abuse • Strict religious and moralistic upbringing

and Jeremiah from a male erectile disorder. The possibility that Christina could also be suffering from an arousal or orgasmic disorder was entertained but eliminated as therapy progressed. It appeared that she was quite capable of being aroused and orgasmic under the right conditions. Studies suggest that sexual desire is due to a combination of biological, psychological, social, and sociocultural factors (Heard-Davison, Heiman, & Briggs, 2004). On the biological level, hormones such as prolactin, testosterone, and estrogen affect high or low levels of sexual desire (Hyde, 2005). On a psychological level, negative childhood experiences such as sexual abuse, strict moralistic upbringing, and positive or negative attitudes toward sex affect fantasy and desire (“Study Confirms Importance of Sexual Fantasies,” 2007). Likewise, social and sociocultural factors such as a dysfunctional partner or marital relationships that are full of anger or resentment and gender scripts (“good girls do not initiate sex” or “they enjoy it as much as men”) can affect desire. A similar analysis can be applied to Jeremiah and his problems with maintaining an erection during intercourse. His past sexual history revealed no significant erectile problems until his marriage to Christina. Although his increasing ED seems more related to psychological causes, his heavy drinking affects his biological sexual response cycle. Although consumption of alcohol might decrease inhibition (and thereby increase his courage), it is a central nervous system suppressant that makes it more difficult for any man to achieve an erection. For Jeremiah, it is clear that he is also suffering from guilt, humiliation, and anger toward Christina, whom he may blame for his problem. As a man, he may also operate from a cultural script—a social and cultural belief and expectation that guides our behaviors regarding sex—that equates masculinity with sexual potency. Given these facts, the following multipath explanation of the couple’s sexual difficulties might be operative (see also Figure 10.4).

Case Study Jeremiah and Christina’s sexual disorders are intertwined in their relationship (social) and cannot be viewed in isolation (interactive). Christina’s low sexual desire (biological) makes Jeremiah doubt his own sexual attractiveness (psychological) and increases his anxiety levels so that it affects his ability to achieve an erection. He drinks heavily to reduce his anxiety and to decrease his inhibitions about initiating sex. Alcohol and his anxiety affect his ability to achieve and maintain

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an erection (biological). When he does achieve an erection, he quickly enters Christina for fear of losing it (psychological), and in turn becomes “brief and perfunctory in lovemaking.” The brevity of the sexual encounter does not allow Christina to become sexually aroused, to become sufficiently lubricated (biological; intercourse becomes painful), or to achieve an orgasm, so she “fakes it” in order to please him. Jeremiah, however, knows it is faked and not only blames himself for the failure (psychological) but feels humiliated by her “pity.” He may begin to equate his inability to satisfy Christina with “not being a real man” (sociocultural). Both find the encounter unpleasant (social). The cycle then repeats itself.

Biological Dimension As has been indicated, lower levels of testosterone or higher levels of estrogens such as prolactin (or both) have been associated with lower sexual interest in both men and women and with erectile difficulties in men (Hyde, 2005; Kresin, 1993). Drugs that suppress testosterone levels appear to decrease sexual desire in men (Schiavi & Segraves, 1995). Conversely, the administration of androgens is associated with reports of increased sexual desire in both men and women. However, the relationship between hormones and sexual behavior is complex and difficult to understand. Many people with sexual dysfunctions have normal testosterone levels (Hyde, 2005). Medications given to treat ulcers, glaucoma, allergies, and convulsions have also been found to affect the sex drive. Drugs such as hypertensive medication and alcohol are also associated with sexual dysfunctions, as are illnesses and other physical conditions (McAnulty & Burnette, 2003, 2004). Indeed, some believe that alcohol abuse is the leading cause of erectile disorders, as well as of premature ejaculation (Arackal & Benegal, 2007). But again, not everyone who takes hypertensive drugs, consumes alcohol, or is ill has a sexual dysfunction. In some people these factors may combine with a predisposing personal history or current stress to produce problems in sexual function. A complete physical workup—including a medical history, physical exam, and laboratory evaluation—is a necessary first step in assessment before treatment decisions are made. For some, a lack of sexual desire may be physiological (Paik & Laumann, 2006). In one early study (Wincze, Hoon, & Hoon, 1978), a group of women who reported no feelings of anxiety about or aversion to sexual intercourse showed significantly lower sexual arousal during exposure to erotic stimuli than did sexually active women and no increase in responsiveness after participation in therapy. The researchers concluded that the absence of sexual arousal in these women was biological and that the appropriate treatment for this condition was unknown. Hypersensitivity to physical stimulation may also affect sexual functioning. Men who ejaculate prematurely may have difficulty determining when ejaculation is inevitable once the sympathetic nervous system is triggered. The amount of blood flowing into the genital area is also associated with orgasmic potential in women and erectile functioning in men. In women, masturbation training and Kegel exercises (tightening muscles in the vagina) may increase vascularization of the labia, clitoris, and vagina. In men, vascular surgery to increase blood flow to the penis is successful when used appropriately. Unfortunately, if the problem is due to arteriosclerosis, which affects a number of the small blood vessels, vascular surgery meets with little success (Hooper, 1998).

Psychological Dimension Sexual dysfunctions may be due to psychological factors alone or to a combination of psychological and biological factors. They may be mild and transient or lifelong and chronic. Studies indicate that neurological, vascular, and hormonal factors are important in many cases of sexual dysfunctions, and they may also render sexual functioning more susceptible to psychological or social stresses. Psychological causes for sexual dysfunctions may include predisposing or historical factors, as well as more current problems and concerns. Guilt, anger, or resentment toward a partner, fear of pregnancy, fear of catching a sexually transmitted disease, and anxiety can all interfere with sexual performance (Westheimer & Lopater, 2005).

Etiology of Sexual Dysfunctions

Traditional psychoanalysts have stressed the role of unconscious conflicts in sexual dysfunctions. For example, erectile difficulties and premature ejaculation represent a man’s hostility to women due to unresolved early developmental conflicts involving his parents. Likewise, a woman’s lack of desire or arousal may also represent repressed hostility toward her partner or an attempt to punish him. Cognitive theorists stress the interaction of performance anxiety and the spectator role in the etiology of sexual dysfunctions. For example, a man may experience a rare erection problem and begin to worry that it will happen again. Instead of enjoying the next sexual encounter and becoming aroused, he monitors or observes his own reactions (“Am I getting an erection?”) and becomes a spectator who is anxious and detached from the situation. The result is potential failure and greater anxiety for future sexual encounters. Men with psychological erectile dysfunction often report anxiety over sexual overtures, including a fear of failing sexually, a fear of being seen as sexually inferior, and anxiety over the size of their genitals. One early study found that patients with ED reported marked increases in subjective anxiety and displayed somatic symptoms, such as sweating, trembling, muscle tension, and heart palpitations, when asked to imagine engaging in sexual intercourse (Cooper, 1969). In a sample of 275 college men, sexual pressure from a partner was associated with sexual dysfunction (Spencer & Zeiss, 1987). The men most affected were those who identified most heavily with the traditional masculine role. Situational or coital anxiety can also interrupt sexual functioning in women. Factors associated with orgasmic dysfunction in women include having a sexually inexperienced or dysfunctional partner; a crippling fear of performance failure, of never being able to attain orgasm, of pregnancy, or of venereal disease; an inability to accept the partner, either emotionally or physically; and misinformation or ignorance about sexuality or sexual techniques.

Social Dimension Social upbringing and current relationships have been identified as important in sexual functioning. It seems plausible that the attitudes parents display toward sex and affection and toward each other can influence their children’s attitudes. For example, women with sexual desire disorders rated their parents’ attitudes toward sex more negatively than did women without sexual desire disorders (Stuart, Hammond, & Pett, 1987). Being raised in a strict religious environment is also associated with sexual dysfunctions in both men and women (Masters & Johnson, 1970). Traumatic sexual experiences involving incestuous molestations during childhood or adolescence or rape are also factors to consider (Burgess & Holmstrom, 1979; LoPiccolo & Stock, 1986). As we saw in the case study of Jeremiah and Christina, current marital or relationship problems may interfere with sexual function. A relationship problem is often a contributing factor, even in the apparent absence of predisposing factors. In a study of fifty-nine women with sexual desire disorders, only eleven had had the problem before marriage; the other forty-eight had developed it gradually after being married. The women voiced dissatisfaction about their relationships with their husbands, complaining that their spouses did not listen to them. Marital dissatisfaction may have caused them to lose their attraction toward their husbands (Leiblum & Rosen, 1991).

Sociocultural Dimensions From our earlier discussion, it is clear that sexual behavior and functioning are influenced by gender, age, cultural scripts, educational level, and country of origin. Although the human sexual response cycle is similar for women and men, gender differences are clearly present: women (1) are capable of multiple orgasms, (2) entertain different sexual fantasies than men, (3) have a broader arousal pattern to sexual stimuli, (4) are more attuned to relationships in the sexual encounter, and (5) take longer than men to become aroused (Safarinejad, 2006; “Study Suggests Difference Between Female and Male Sexuality,” 2003; “Study Confirms Importance of Sexual Fantasies,” 2007). Likewise, sexual dysfunctions differ because of biological

279

Did You Know?

F

requency of yearly sex varies among countries, nationalities, and regions: • Americans have the most sex (124 times/year), followed by Greeks (117 times/year), South Africans and Croatians (116 times/year), and New Zealanders (115 times/year). • People in Japan (36 times/year), Hong Kong (63 times/year), Taiwan (65 times/year), and China (72 times/year) have sex the least. Source: Durex (2001, 2005).

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CHAPTER 10 • SEXUAL AND GENDER IDENTITY DISORDERS

differences and gender role expectations: women are more likely than men to suffer from sexual desire disorders, and they differ as to the manifestation of an arousal disorder (erectile disorder for men vs. lubrication problems for women). In our society, men are taught to be the sexual aggressors, whereas women are taught not to initiate sex directly but in a more subtle and indirect manner. Earlier, we mentioned how cultural scripts, the social and cultural beliefs and expectations that guide our behaviors regarding sex, can have a major impact on sexual functioning (Gagnon, 1990). This perspective states that most of us are socialized into both domestic and international cultural scripts that vary from being quite explicit to being implicit. Some domestic scripts for men in the United States may be “sexual potency in men is a sign of masculinity,” implying that “impotence” is a sign of not being a “real man”; “the bigger the sex organ, the better”; and “strong and virile men do not show feelings.” For women, scripts include “nice women don’t initiate sex”; “nice women are restrained and proper in lovemaking”; and “it is the woman’s responsibility to take care of contraception.” Likewise, nations also vary in the cultural scripts they communicate to their citizens. For example, people in Asian countries consistently report the lowest frequency of sexual intercourse. It would be a serious mistake to believe that an entire nation can suffer from a sexual desire disorder. Rather, some suggest that these countries are more conservative, restrained, and restrictive in their attitudes toward sex (Sue & Sue, 2008a). In conclusion, it is clear that sexual functioning (and dysfunction) may be strongly influenced by sociocultural forces.

Treatment of Sexual Dysfunctions Many approaches have been used to treat sexual dysfunctions, including biological interventions and psychological treatment approaches.

Biological Interventions Biological interventions may include hormone replacement and special medications or mechanical means to improve sexual functioning. For example, men with organic erectile dysfunction may be treated with vacuum pumps, suppositories, or penile implants. The penile prosthesis is an inflatable or semirigid device that, once inflated, produces an erection sufficient for intercourse and ejaculation (see Table 10.5). It has been found that approximately 89 percent of men and 70 percent of their partners expressed satisfaction with penile implants (Center for Male Reproductive Medicine and Microsurgery, 2005) and that 90 percent would choose the treatment again (Steege, Stout, & Carson, 1986). As indicated in the following case, however, some men report dissatisfaction with the procedure and minimal improvement in their desire for sex.

Case Study Mr. F was a fifty-four-year-old recovered alcoholic who had received a surgical implant following a diagnosis of organic impotence. Despite the patient’s newfound ability to perform intercourse at will, in the two years following surgery he made infrequent use of the prosthesis. His wife became increasingly distressed by his disinclination to either initiate or respond with any enthusiasm to her overtures for sexual contact. In reviewing the history, it became apparent that Mr. F ’s loss of sexual desire had preceded the erectile failure and that the absence of desire appeared to be the primary problem for treatment. Unfortunately, both the urologist and the patient’s wife had assumed that once the capacity for intercourse was restored, sexual interest would reemerge unassisted. (Rosen & Leiblum, 1987, p. 153)

Another form of medical treatment for ED is the injection of substances into the penis (Mohr & Beutler, 1990). Within a very short time the man will obtain a very stiff erection, which may last from one to four hours. Although men and their mates have reported general satisfaction with the method, it does have some side effects. There is often bruising of the penis and the development of nodules. Some men find the prolonged erection disturbing in the absence of sexual stimulation.

Treatment of Sexual Dysfunctions

TA B L E

281

10.5

TREATING ERECTILE DISORDERS: MEDICAL INTERVENTIONS TREATMENT

PRIMARY AGENT

EFFECTS

DRAWBACKS

Oral medication

Viagra (sildenafil)

Taken as a pill. Some 70 to 80% of users achieve erections normal for their ages. Viagra enhances blood flow and retention by blocking an enzyme found primarily in the penis. The drug must be taken an hour before sex, and stimulation is needed for an erection.

Possible headaches and diarrhea. A drop in blood pressure. Temporary bluegreen-tinted vision.

Surgery

Vascular surgery

Corrects venous leak from a groin injury by repairing arteries to boost blood supply in the penis. Restores the ability to have a normal erection.

Minimal problems when used appropriately with diagnosed condition.

Suppository

Muse (alprotadil)

A tiny pellet is inserted into the penis by means of an applicator 5 to 10 minutes before sex. Erections can last an hour. Some 65% of users show some tumescence.

Penile aching, minor urethral bleeding or spotting, dizziness, and legvein swelling.

Injection therapy

Vasodilating drugs, including Caverject (alprotadil), Edex (alprostadil), and Invicorp (VIP and phentolamine)

Drug is injected directly into the base of the penis 10 minutes to 2 hours before sex, depending on the drug. The drug helps relax smooth-muscle tissues and creates an erection in up to 90% of patients. Erection lasts about an hour.

Pain, bleeding, and scar tissue formation. Erections may not readily subside.

Devices

Vacuum pump

Creates negative air pressure around the penis to induce the flow of blood, which is then trapped by an elastic band encircling the shaft. Pump is used just before sex. Erection lasts until band is removed.

Some difficulty in ejaculation. Penis can become cool and appear constricted in color. Apparatus can be clumsy to use.

Penile implants

Considered a court of last resort. A penile prosthesis is implanted in the penis, enabling men to literally “pump themselves up” by pulling blood into it.

Destruction of spongy tissue inside the penis.

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Oral medications such as Viagra, Levitra, and Cialis have been found to be an attractive alternative in minimizing the negative effects of injection therapy. Viagra made headlines in 1998 as a “miracle cure” for the 30 million men suffering from erectile dysfunctions (Tuller, 2004). The early clinical trials on 4,500 men indicated between 50 and 80 percent effectiveness; users’ testimony of its “instantaneous success” has added to the hype (Hooper, 1998; Leland, 1997). There have even been reports that, by increasing blood flow to the genital areas, the pill can increase sexual desire in women. Recently, Pfizer reported that Viagra has not proven effective for women. Unlike injectables, Viagra and its competitors do not produce an automatic erection in the absence of sexual stimuli. If a man becomes aroused, the drugs enable the body to follow through the sexual response cycle to completion. Urologists claim that for individuals with no sexual dysfunction, taking Viagra, for example, will not improve their erections; in other words, Viagra will not provide physiological help that will enable normally functioning men to improve their sexual functioning, nor will it lead to a stiffer erection. These drugs may aid sexual arousal and performance by stimulating men’s expectations and fantasies; this psychological boost may then lead to subjective feelings of enhanced pleasure.

Psychological Treatment Approaches PENILE IMPLANTS In this picture, a physician shows a patient how inflatable penile implants work. Because of its intrusive nature, implants are usually considered a last resort.

•

•

In addition to biological forms of treatment, most general psychological treatment approaches include the following components: • Education The therapist replaces sexual myths and misconceptions with accurate information about sexual anatomy and functioning. • Anxiety reduction The therapist uses procedures such as desensitization or graded approaches to keep anxiety at a minimum. The therapist explains that constantly “observing and evaluating” one’s performance can interfere with sexual functioning. Structured behavioral exercises The therapist gives a series of graded tasks that gradually increase the amount of sexual interaction between the partners. Each partner takes turns touching and being touched over different parts of the body except for the genital regions. Later the partners fondle the body and genital regions without making demands for sexual arousal or orgasm. Successful sexual intercourse and orgasm is the final stage of the structured exercises. Communication training The therapist teaches the partners appropriate ways of communicating their sexual wishes to each other and also teaches them conflict resolution.

Some specific nonmedical treatments for other dysfunctions are as follows: 1. Female orgasmic dysfunction The general approach just described has been successful in treating sexual arousal disorders in women and erectile disorders in men. Masturbation appears to be the most effective way for orgasmically dysfunctional women to have an orgasm. The procedure involves education about sexual anatomy, visual and tactile self-exploration, using sexual fantasies and images, and masturbation, both individually and with a partner. Success rates of 95 percent have been reported with this procedure for women with primary orgasmic dysfunction (LoPiccolo & Stock, 1986). This approach does not necessarily lead to the woman’s ability to achieve orgasm during sexual intercourse. 2. Premature ejaculation In one technique, the partner stimulates the penis while it is outside the vagina until the man feels the sensation of impending ejaculation. At this point, the partner stops the stimulation for a short period of time and then continues it again. This pattern is repeated until the man can tolerate increasingly greater periods of stimulation before ejaculation. Masters and Johnson (1970) and Kaplan (1974) used a similar procedure, called the “squeeze

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technique.” They reported a success rate of nearly 100 percent. The treatment is easily learned. Although the short-term success rate for treating premature ejaculation is very high, relapses were very common. 3. Vaginismus The results of treatment for vaginismus have been uniformly positive (Kaplan, 1974; LoPiccolo & Stock, 1986). The involuntary spasms or closure of the vaginal muscle can be deconditioned by first training the woman to relax and by then inserting successively larger dilators while she is relaxed, until insertion of the penis can occur.

Homosexuality Although the American Psychiatric Association and the American Psychological Association no longer consider homosexuality to be a mental disorder, some individuals still harbor this belief. In 1998 Trent Lott, then the U.S. Senate majority leader, described homosexuality as a disorder akin to alcoholism and kleptomania—a condition that should be treated (Mitchell, 1998). Jerry Falwell, on the Pat Robertson program, stated that the September 11, 2001, terrorist attack that took thousands of lives was punishment for the growing influence of gay and lesbian groups. Falwell was later forced to apologize for his remarks. It is clear from the tone of these statements that homophobia—the irrational fear of homosexuality—continues to be a major part of these objections. Given the level of public misunderstanding and misinformation, we believe it is important to discuss briefly what homosexuality is not. Is homosexuality a mental disorder? The answer is no. The American Psychiatric Association did not include homosexuality as a disorder in DSM-III-R or in any future editions. This view of homosexuality stems from two main views (Halderman, 2002). First, many clinicians felt that heterosexual sexuality should not be the standard by which other sexual behaviors are judged. Second, many gays and lesbians argue that they are mentally healthy and that their sexual orientation reflects a normal variant of sexual expression. Research supports these views. Studies on male and female homosexuals suggest that most accepted their sexual orientation and indicated no regrets at being homosexual (Croteau, Lark, Lidderdale, & Chung, 2005; Greenan & Tunnell, 2003). In a move indicative of changing international views of homosexuality as well, the Chinese Psychological Association in 2001 removed it as an illness. This move is even more meaningful because China has always been conservative toward sexual orientation matters, and its recognition that homosexuality is not an illness may mean that the estimated 30 million gays and lesbians may become increasingly visible in Chinese society. It is also important to note that although the human sexual response cycle appears equally applicable to a homosexual population, the sexual issues may differ quite dramatically. For example, problems among heterosexuals most often focus on sexual intercourse, whereas gay and lesbian sexual concerns focus on other behaviors (aversion toward anal eroticism and cunnilingus). Lesbians and gay men must also deal with societal or internalized homophobia, which often inhibits open expression of their affection toward one another (Schneider, Brown, & Glassgold, 2002). Finally, gay men are forced to deal with the association between sexual activity and HIV infection. These broader contextual issues may create diminished sexual desire, sexual aversion, and negative feelings toward sexual activity. In summary, the overwhelming available studies (Croteau et al., 2005; Greenan & Tunnell, 2003; Hu, Pattatucci, & Patterson, 1995; Laird & Green, 1996; Masters & Johnson, 1979; Strong & DeVault, 1994; Turner, 1995) on homosexuals and heterosexuals lead to the following conclusions: • There are no physiological differences in sexual arousal and response between homosexuals and heterosexuals. • On measures of psychological disturbance, homosexuals and heterosexuals do not differ significantly from each other.

Did You Know?

I

n a national survey of eighteen- to forty-four-year-olds, 90 percent of men identified themselves as heterosexual, 2.3 percent homosexual, 1.8 percent bisexual, and 3.9 percent something else; 1.8% did not respond. For women the responses were nearly identical: 90 percent heterosexual, 1.3 percent homosexual, 2.8 percent bisexual, and 3.8 percent something else; 1.8% did not answer. With respect to same-sex activity that included vaginal penetration, anal penetration, and oral sex, however, the figures calculated over their lifetimes were much higher than the percentage identifying themselves as homosexual (6 percent for males and 11 percent for females). Source: Mosher et al. (2005).

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GAY MARRIAGE AND FAMILY LIFE Jessie and Stacey Harris were married in Massachusetts in 2004 where samesex couples have a right to marry. Here they are shown with Zion, their adopted 5-year-old son, and 2-year-old Torin, the biological daughter of Jessie. Note the obvious joy of each sharing time as a family.

• Homosexuals do not suffer from gender identity confusions; rather, any gender conflicts they experience are due to societal intolerance to their lifestyles. • Because of the societal context in which they live (homophobia, health concerns, and other such issues), the sexual concerns of homosexuals may differ significantly from those of heterosexuals. • Research suggests that homosexuality is not simply a lifestyle choice but is rather a naturally occurring phenomenon linked to a biological disposition. Nothing more need be said. Homosexuality is not a psychological disorder.

Aging, Sexual Activity, and Sexual Dysfunctions In the most comprehensive study of sexuality and health among older adults in the United States ages fifty-seven to eighty-five, 3,005 participants (1,550 women and 1,455 men) were surveyed, with the following findings (Lindau et al., 2007): • Sexual activity declined with age (73 percent among fifty-seven- to sixty-fouryear-olds; 53 percent among sixty-five- to seventy-four-year-olds; 25 percent among seventy-five- to eighty-five-year-olds). • Women were far more likely to report less sexual activity at all ages. • Among men and women who were sexually active, approximately 50 percent reported at least one bothersome sexual problem. • The most frequently reported sexual problems for women included low sexual desire (43 percent), problems with vaginal lubrication (39 percent), and inability to climax (34 percent). • Among men the most frequent problems were erectile difficulties (37 percent). It is important for us to understand how the aging process affects sexuality. When women reach menopause, estrogen levels drop, and women may experience vaginal dryness and thinning of the vaginal wall. This may result in discomfort during sexual activity. Likewise, older men are at higher risk for prostate problems that may increase the risk of ED. Both sexes are also at higher risk for illnesses that affect sexual performance and interest (diabetes, high blood pressure, rheumatism, and heart disease). Hormone replacement therapy, drugs (Cialis, Levitra, and Viagra), and other medical procedures may help minimize the effects of these organic problems

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on sexual activity. For example, older men and women who rate their health as poor are less likely to be sexually active, and 14 percent of men report using medication to improve their sexual performance (Lindau et al., 2007).

Myth vs Reality Myth: Sex is unimportant to the elderly. They are averse to being sexually active, become asexual beings, and are conservative in sexual behavior. Reality: Although sexual activity does decline with age, a 2007 major survey of adults ages fifty-seven to eighty-five found that many older people are sexually active well into their sixties, seventies, and eighties. Fifty-four percent reported having sex at least twice a month, and 23 percent reported once a week or more. Approximately 50 percent of men and women under age seventy-five had engaged in oral sex in the previous two months.

Some additional findings reported by the American Association of Retired Persons (AARP, 1999) were the following: • Although most men and women report that satisfying sex is important in their lives, they found relationships to be more important than sex. • Sexual activity is affected by the “partner gap.” Whereas 80 percent of those surveyed between the ages of forty-five and fifty-nine have partners, only 58 percent of men and 21 percent of women seventy-five and older do. • Both men and women report that sexual activity declines with advancing age due to health problems; yet 64 percent of men and 68 percent of women with sexual partners report being satisfied with their sex lives. Sexuality during old age is an area of intolerance in our youth-oriented society, in which sexual activity is simply not associated with the elderly. Nevertheless, a large percentage of older Americans clearly have active sex lives. In one study (Diokno, Brown, & Herzog, 1990), investigators found a clear relationship between the reported frequency of intercourse at younger ages and at the present time among sixty- to seventy-nine-year-old married men. The most active respondents reported a present frequency that was 61 percent of their frequency between ages forty and fifty-nine, whereas the least active reported a present frequency of only 6 percent of that between ages forty and fifty-nine. The most active also indicated that they became aroused on seeing women in public situations and in response to visual stimuli. The vast majority (69 percent) felt that sex was important for good health, and most (63 percent) looked on masturbation as an acceptable outlet. Sexual dysfunctions were also more prevalent in the older groups than in younger ones, and the prevalence was affected by the individuals’ prior and present sexual activity levels. Of the least active, 21 percent suffered from premature ejaculation, and 75 percent were either impotent or had erectile difficulties. For the most active group, the corresponding percentages were 8 and 19 percent. The results of this study are summarized in Figure 10.5. A comprehensive survey (Janus & Janus, 1993) suggested that sexual activity and enjoyment among the older population remains surprisingly high. The Januses’ survey found that (1) the sexual activity of people ages sixty-five and older declined little from that of their thirty- to forty-yearold counterparts, (2) their ability to reach orgasm and have sex diminished very little from their early years, and (3) their desire to continue a relatively active sex life was unchanged. These findings are supported by a recent poll of 1,292 Americans (534 men and 758 women) ages sixty or older who reported that their interest in sex remains high, that over half engage in

SEXUAL BEHAVIOR AMONG SENIORS Contrary to the belief that the elderly lose their sexual desire, studies reveal that sexual desire, activity, and enjoyment remain high in the older population.

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Text not available due to copyright restrictions

sexual activity at least once a month, and that half rated their sexual activity to be physically better now than in their youth (National Council on Aging, 1998). Aside from sexual outlook and behavior, physiologically based changes in patterns of sexual arousal and orgasm have been found in people over age sixty-five (Masters & Johnson, 1966). For both men and women, sexual arousal takes longer (McAnulty & Burnette, 2003). Erection and vaginal lubrication are slower to occur, and the urgency for orgasm is reduced. Both men and women are fully capable of sexual satisfaction if no physiological conditions interfere. Many elderly individuals felt that such changes allowed them to experience sex more fully. They reported that they had more time to spend on a seductive buildup, felt positively about their ability to experience unhurried sex-for-joy, and experienced more warmth and intimacy after the sex act (Janus & Janus, 1993).

Gender Identity Disorder

gender identity disorder (transsexualism) disorder

characterized by conflict between a person’s anatomical sex and his or her gender identity, or selfidentification as male or female

In contrast to the sexual dysfunctions, which involve any disruption of the normal sexual response cycle, gender identity disorder (GID)—often called transsexualism— is characterized by conflict between a person’s anatomical sex and his or her gender identity, or self-identification as male or female. It is important to note that gender identity and sexual orientation are not the same thing—the sexual orientation of a transsexual can thus be heterosexual, homosexual, or bisexual (Selvin, 1993). GID involves the person experiencing strong and persistent cross-gender identification and persistent discomfort with his or her anatomical sex, creating significant impairment in social, occupational, or other important areas of functioning. People with this disorder hold a lifelong conviction that nature has placed them in the body of the wrong gender. This feeling produces a preoccupation with eliminating the “natural” physical and behavioral sexual characteristics and acquiring those of the opposite sex. People with GID tend to exhibit gender-role conflicts at an early age and to report transsexual feelings in childhood, some as early as two years old (Beers & Berkow, 1999; McAnulty & Burnette, 2004). A boy may claim that he will grow up to be a woman, may demonstrate disgust with his penis, and may be exclusively preoccupied with interests and activities considered “feminine.” Boys with this disorder are frequently labeled “sissies” by their male peers. They prefer playing with girls and generally avoid the rough-and-tumble activities in which boys are traditionally encouraged to participate. They are more likely than normal boys to play with “feminine” toys. Girls with a GID may insist that they have a penis or will grow one and may exhibit an avid interest in rough-and-tumble play. Female transsexuals report being labeled

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“tomboys” during their childhoods. Although it is not uncommon for girls to be considered tomboys, the strength, pervasiveness, and persistence of the crossgender identification among those with a gender identity disorder are the distinguishing features. Children who may engage in traditional opposite sex role activities (feminine or masculine) should not be prematurely diagnosed as GID. Nonconformity to stereotypical sex role behavior should not, for example, be confused with the pervasiveness of the cross-gender wishes, interests and activities of GID.

Etiology of Gender Identity Disorder The etiology of GID is unclear. Because the disorder is quite rare, investigators have focused more attention on other sexual disorders. GID appears to be more common in males than in females and may appear in both adults and children (Laumann et al., 1994). In all likelihood, a number of variables interact to produce GID. Again, a multipath analysis would reveal multiple influences, but biological factors seem to be strongly implicated.

A CASE OF SEX REASSIGNMENT Dr. Ben Barres is a renowned neurobiologist at Stanford University who obtained a B.S. from MIT, an M.D. from Dartmouth, and a Ph.D. from Harvard. In 1997, he became a transgendered person, undergoing sex reassignment. Dr. Barres recalls that as a young child he wanted to join the Boy Scouts and to ditch sewing and cooking classes for woodworking, mechanical engineering, and “boy stuff.” People observed that he was always uncomfortable with being a woman.

Biological Influences The research in this area suggests that neurohormonal factors, genetics, and possible brain differences may be involved in the etiology of GID. In one oft-cited study (Ellis & Ames, 1987), male rats were castrated perinatally. This procedure reduces the production of testosterone, which appears to influence the organization of brain centers that govern sexual orientation. The male rats subsequently displayed female-like gender behaviors. In human females, early exposure to male hormones has resulted in a more masculine behavior pattern. Thus it does appear that gender orientation can be influenced by a lack or excess of sex hormones. Genetics and differences in areas of the hypothalamus have also been found to correlate with the development of GID (Henningsson et al., 2005; Zhou, Hofman, Gooren, & Swaab, 1995). These studies suggest that GID may run in families and that there are differences in the size of brain clusters in regions of the hypothalamus between men with and men without GID. It is important to note, however, that limited research in this area makes conclusions about hormonal, genetic, and brain structure explanations very hazardous. Some researchers believe that gender identity is malleable. For example, most transsexual children have normal hormone levels, and their opposite-sex orientation raises doubt that biology alone determines male-female behaviors. Although neurohormonal levels are important, their degree of influence on gender identity in human beings may be minor. Psychological and Social Influences Psychological and social explanations of GID must also be viewed with caution. In psychodynamic theory, all sexual deviations symbolically represent unconscious conflicts that began in early childhood (Meyers, 1991). They occur because the Oedipus complex is not fully resolved. The male or female child has a basic conflict between the wish for and the dread of maternal reengulfment (Meyer & Keith, 1991). The conflict results from a failure to deal successfully with separation-individuation phases of life, which creates a gender identity problem. While psychodynamic theorists adhere to such an explanation, research support is lacking. Some researchers have hypothesized that childhood experiences influence the development of GID (Green, 1987). Factors thought to contribute to the disorder in

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boys include parental encouragement of feminine behavior, discouragement of the development of autonomy, excessive attention and overprotection by the mother, the absence of an older male as a model, a relatively powerless or absent father figure, a lack of exposure to male playmates, and encouragement to cross-dress (Marantz & Coates, 1991).

Treatment of Gender Identity Disorder Psychotherapy and hormone therapy have been used for many persons with GID. For some, however, sex reassignment surgery is chosen. According to DSM-IV, 1 in 30,000 adult males and 1 in 100,000 adult females seek sex-reassignment surgery. For men, the surgery involves altering the male genitalia to be more similar to the opposite sex through what can be described as “penis inversion.” Then plastic surgery constructs female genitalia, including a vagina and clitoris. The skin of the penis is used in this construction because the sensory nerve endings that are preserved enable most transsexuals to experience orgasm. The male-to-female operation is nearly perfected, and affirms the gender identity of the individual. Research suggests that genital surgery can produce happier lives. Women who want to become men generally request operations to remove their breasts and some ask for an artificial penis to be constructed. This procedure is much more complicated and expensive than the male-to-female conversion. Some studies of transsexuals indicate positive outcomes for sex reassignment surgery (Bradley, 1995). Most females who “changed” to males express satisfaction over the outcome of surgery, although males who “changed” to females are less likely to feel satisfied (Arndt, 1991). It has been suggested that adjusting to life as a man is easier than adjusting to life as a woman, or perhaps others may react less negatively to woman-to-man changes than man-to-woman changes (APA, 2000).

Is GID a Valid Psychiatric Diagnosis? With the DSM being revised (fifth edition), some experts have advocated the removal of GID as a psychiatric diagnosis. They cite the following in support of their contention: (a) lack of reliability and validity supporting the GID diagnostic criteria in DSM-IV-TR, (b) the psychological distress experienced by sons and daughters are often created by parental and societal negative reactions and not the result of pathology, (c) some therapeutic approaches are often similar to “reparative therapies”, and (d) there is little evidence of pathology in GID children (Hausman, 2003). Finally, there are some who believe that gender identity can best be conceptualized along a spectrum rather than a bimodal curve. In conclusion, gender identity is a basic and important aspect of our total being. Gender identity disorders challenge our basic notions of the dichotomy between male and female identities.

Paraphilias

paraphilia sexual disorder of at least six months’ duration in which the person has either acted on or is severely distressed by recurrent urges or fantasies involving nonhuman objects, nonconsenting persons, or suffering or humiliation

Paraphilias are sexual disorders of at least six months’ duration in which the person has either acted on or is severely distressed by recurrent urges or fantasies involving any of the following three categories (see Table 10.6): (1) nonhuman objects, as in fetishism and transvestic fetishism; (2) nonconsenting others, as in exhibitionism, voyeurism, frotteurism (rubbing against others for sexual arousal), and pedophilia; and (3) real or simulated suffering or humiliation, as in sadism and masochism. A person who is highly distressed by paraphiliac urges or fantasies but has not acted on them would be diagnosed as having a mild case of the paraphilia. All of these acts are considered deviant because they are obligatory for sexual functioning (erection, for example, cannot occur without the stimulus). It is not unusual for people in this category to possess multiple paraphilias (Langstrom & Zucker, 2005). In one study of sex offenders, researchers found that nearly 50 percent had engaged in a variety of sexually deviant behaviors, averaging between three and four paraphilias, and had committed more than five hundred

Paraphilias

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10.6

DISORDERS CHART PARAPHILIA CATEGORY

Nonhuman Objects

Nonconsenting Persons

Pain or Humiliation

PARAPHILIAS

SYMPTOMS

PREVALENCE

AGE OF ONSET

COURSE

Fetishism Sexual attraction and fantasies involving nonliving objects such as female undergarments

Primarily a male disorder; rare in women; exact figures unavailable

Usually adolescence

Causes are difficult to pinpoint; conditioning and learning seem likely

Transvestic fetishism Intense sexual arousal by crossdressing

Exact figures difficult to obtain because crossdressing often goes unreported and is acceptable in many societies

Begins as early as puberty

Cross-dressing is not usually associated with major psychiatric problems

Exhibitionism Urges, acts, or fantasies involving exposure of genitals to a stranger

Almost exclusively a male activity; exact figures lacking

Begins in teens; exhibitionist is most likely in 20s

Most likely to have doubts about his masculinity; likes to shock; many have an erection during act; most masturbate after exposure

Voyeurism Urges, acts, or fantasies of observing an unsuspecting person disrobing or engaging in sexual activity

Difficult to determine; most are men

Begins around age 15; tends to be chronic

Voyeurs tend to be young males; they may masturbate during or after the episode

Frotteurism Urges, acts, or fantasies of touching or rubbing against a nonconsenting person

Difficult to determine; most are men

Begins in adolescence or earlier

Usually decreases after age 25

Pedophilia Urges, acts, or fantasies involving sexual contact with a prepubescent child

Primarily men; exact figures not available

Must be at least 16; pedophiles tend to be in late 20s/30s

Prefer children who are at least 5 years younger than they are and usually less than 13 years old; pedophiles often have poor social skills

Sadism Sexually arousing urges, fantasies, or acts associated with inflicting physical or psychological suffering

Usually male; rates unknown, however, 22% of men and 12% of women in one study report some sexual arousal from sadistic stories

Begins in early childhood with sexual fantasies

Fantasies begin in childhood; sadistic acts usually develop in adulthood and can stay at the same level of cruelty or, more rarely, increase to problematic proportions

Masochism Sexual urges, fantasies, or acts associated with being humiliated, bound, or made to suffer

Precise figures difficult to obtain

Males report first interests around 15 and women at 22

Not all suffering arouses; usually it must be produced in a specific way; classical conditioning strongly implicated as causal

Source: Data taken from American Psychiatric Association (2000a); Tsoi (1993); Kinsey et al. (1953); Spector & Carey (1990); Allgeier & Allgeier (1998).

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deviant acts (Rosenfield, 1985). Men who had committed incest, for example, had also molested nonrelatives, exposed themselves, raped adult women, and engaged in voyeurism and frotteurism. In most cultures, paraphilias seem to be much more prevalent in males than in females (Beers & Berkow, 1999). This finding has led some to speculate that biological factors may account for the unequal distribution.

Paraphilias Involving Nonhuman Objects Under this category, two forms of paraphilias are evident: an attraction or arousal related to a nonliving object (the “fetish”) or transvestic fetishism that involves cross-dressing. Fetishism Fetishism comprises an extremely strong sexual attraction to and fantasies involving inanimate objects such as female undergarments. The fetish is often used as a sexual stimulus during masturbation or sexual intercourse. The disorder is rare among women.

Case Study Mr. M met his wife at a local church. Some kissing and petting took place but never any other sexual contact. He had not masturbated before marriage. Although he and his wife loved each other very much, he was unable to have sexual intercourse with her because he could not obtain an erection. However, he had fantasies involving an apron and was able to get an erection while wearing an apron. His wife was described as upset over this discovery but was persuaded to accept it. The apron was kept hanging somewhere in the bedroom and it allowed him to consummate the marriage. He remembers being forced to wear an apron by his mother during his childhood years. (Kohon, 1987)

Most males find the sight of female undergarments sexually arousing and stimulating; this does not constitute a fetish. An interest in such inanimate objects as panties, stockings, bras, and shoes becomes a sexual disorder when the person is often sexually aroused to the point of erection in the presence of the fetish item, needs this item for sexual arousal during intercourse, chooses sexual partners on the basis of their having the item, or collects these items. In many cases, the fetish item is enough by itself for complete sexual satisfaction through masturbation, and the person does not seek contact with a partner. Common fetishes include aprons, shoes, undergarments, and leather or latex items. As a group, people diagnosed with fetishism are not dangerous, nor do they tend to commit serious crimes. Transvestic Fetishism A diagnosis of fetishism is not made if the inanimate object is an article of clothing used only in cross-dressing. In such cases, the appropriate diagnosis would be transvestic fetishism—intense sexual arousal obtained through crossdressing (wearing clothes appropriate to the opposite gender). This disorder should not be confused with gender identity disorder (transsexualism), in which one identifies with the opposite gender. Although some transsexuals and homosexuals cross-dress, most transvestites are exclusively heterosexual and married. Some research, however, suggests that transvestites may be fairly hostile and self-centered, with high levels of marital discord and a limited capacity for intimacy (Wise, Fagan, Schmidt, & Ponticas, 1991). Several aspects of transvestism are illustrated in the following case study: fetishism sexual attraction and fantasies involving inanimate objects such as female undergarments transvestic fetishism intense sexual arousal obtained through cross-dressing (wearing clothes appropriate to the opposite gender); not to be confused with transsexualism

Case Study A twenty-six-year-old graduate student referred himself for treatment following an examination failure. He had been cross-dressing since the age of ten and attributed his exam failure to the excessive amount of time that he spent doing so (four times a week). When he was younger, his cross-dressing had taken the form of masturbating while wearing his mother’s high-heeled shoes, but it had gradually expanded to the present stage, in which he dressed completely as a woman, masturbating in front of a mirror. At no time had he experienced a desire to obtain a sex-change operation. He had neither homosexual experiences nor homosexual fantasies. Heterosexual contact had been restricted to heavy petting with occasional girlfriends. (Lambley, 1974, p. 101)

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Sexual arousal while cross-dressing is an important criterion in the diagnosis of transvestic fetishism. If arousal is not present or has disappeared over time, a more appropriate diagnosis may be gender identity disorder. This distinction, however, may be difficult to make. Some transsexuals show penile erections to descriptions of cross-dressing (Blanchard, Racansky, & Steiner, 1986). The occurrence of sexual arousal in cross-dressing, therefore, may not serve as a valid distinction between transsexualism and transvestic fetishism. If the cross-dressing occurs only during the course of a gender identity disorder, the person is not considered in the category of transvestic fetishism. Many transvestites believe that they have alternating masculine and feminine personalities. In a feminine role, they can play out such behavior patterns as buying nightgowns and trying on fashionable clothes. They may introduce their wives to their female personalities and urge them to go on shopping trips together as women. Other transvestites cross-dress only for the purposes of sexual arousal and masturbation and do not fantasize themselves as members of the opposite sex. Male transvestites often wear feminine garments or undergarments during sexual intercourse with their wives.

Paraphilias Involving Nonconsenting Persons This category of disorders involves persistent and powerful sexual fantasies about unsuspecting strangers or acquaintances. The victims are nonconsenting in that they do not choose to be the objects of the attention or sexual behavior. Exhibitionism Exhibitionism is characterized by urges, acts, or fantasies of exposing one’s genitals to a stranger, often with the intent of shocking the unsuspecting victim:

NOT NECESSARILY WHAT YOU MIGHT THINK The etiology and behavioral symptoms of gender identity disorder go far beyond enjoying dressing as the opposite sex; more important is persistent crossgender identification and discomfort with one’s own anatomical sex.

Case Study A nineteen-year-old single white college man reported that he had daily fantasies of exposing and had exposed himself on three occasions. The first occurred when he masturbated in front of the window of his dormitory room when women would be passing by. The other two acts occurred in his car; in each case he asked young women for directions and then exposed his penis and masturbated when they approached. He felt a great deal of anxiety in the presence of women and dated infrequently. (Hayes, Brownell, & Barlow, 1983)

Exhibitionism is relatively common. The exhibitionist is most often male and the victim female. A high number of young women have been victims of exhibitionists, although most women did not report any long-lasting psychological traumas associated with the episodes. It is more likely to cause moderate distress, although a smaller number believed the incidents had negatively affected their attitudes toward men (Cox & McMahon, 1978). The main goal of the exhibitionist seems to be the sexual arousal he gets by exposing himself; most exhibitionists want no further contact. Exhibitionists may expect to produce surprise, sexual arousal, or disgust in the victim. The act may involve exposing a limp penis or masturbating an erect penis. Most exhibitionists are in their twenties—far from being the “dirty old men” of popular myth. Most are married. Their exhibiting has a compulsive quality to it, and they report that they feel a great deal of anxiety about the act. A typical exposure sequence involves the person first entertaining sexually arousing memories of previous exposures and then returning to the area where previous exposures took place. Next, the person locates a suitable victim, rehearses the exposure mentally, and finally exposes himself. As the person moves through his sequence, his self-control weakens and disappears. Many men use alcohol before exposing themselves, perhaps to reduce inhibitions (Arndt, 1991).

Did You Know?

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ome social scientists believe that the United States is an exhibitionistic and voyeuristic society that contributes to such disorders. Reality TV and access to the Internet (MySpace, Facebook, etc.) encourage people to reveal intimate aspects of their lives to strangers. Some even claim that modern architecture reflects the “peek-a-boo effect” such that “glass walled” condominiums and office buildings allow residents to see out and be seen in a webcam manner.

disorder characterized by urges, acts, or fantasies about the exposure of one’s genitals to strangers

exhibitionism

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JERRY LEE LEWIS: PEDOPHILIAC OR SOMETHING ELSE? When musician Jerry Lee Lewis married a thirteen-yearold girl in the 1950s, it created a furor in Great Britain, where many considered him a pedophiliac. The public’s outrage resulted in the cancellation of many of his concerts, forcing him to return to New York. Lewis was twenty-two at the time of this marriage and not yet divorced from his second wife.

voyeurism urges, acts, or fantasies involving observation of an unsuspecting person disrobing or engaging in sexual activity frotteurism disorder characterized by recurrent and intense sexual urges, acts, or fantasies or touching or rubbing against a nonconsenting person pedophilia disorder in which an adult obtains erotic gratification through urges, acts, or fantasies involving sexual contact with a prepubescent child

a form of pedophilia; can also be sexual relations between people too closely related to marry legally

incest

Voyeurism Voyeurism comprises urges, acts, or fantasies of observing an unsuspecting person disrobing or engaging in sexual activity. “Peeping,” as voyeurism is sometimes termed, is considered deviant when it includes serious risk, is done in socially unacceptable circumstances, or is preferred to coitus. The typical voyeur is not interested in looking at his wife or girlfriend; an overwhelming number of voyeurism acts involve strangers. Observation alone produces sexual arousal and excitement, and the voyeur often masturbates during this surreptitious activity. The voyeur is like the exhibitionist in that sexual contact is not the goal; viewing an undressed body is the primary motive. However, a voyeur may also exhibit or use other indirect forms of sexual expression (American Psychiatric Association, 2000a). Because the act is repetitive, arrest is predictable. Usually an accidental witness or a victim notifies the police. Potential rapists or burglars who behave suspiciously are often arrested as voyeurs. The proliferation of sexually oriented television programs, “romance” paperbacks, explicit sexual magazines, and NC-17-rated movies all point to the voyeuristic nature of our society. The growing number of “night clubs” featuring male exotic dancers and attended by women may indicate women’s increasing interest in men’s bodies and their acknowledgment that it is all right to be sexual. Frotteurism Whereas physical contact is not the goal of voyeurism, contact is the primary motive in frotteurism. Frotteurism involves recurrent and intense sexual urges, acts, or fantasies of touching or rubbing against a nonconsenting person. The touching, not the coercive nature of the act, is the sexually exciting feature. As in the case of the other paraphilias, the diagnosis is made when the person has acted on the urges or is markedly distressed by them. Pedophilia Pedophilia is a disorder in which an adult obtains erotic gratification through urges, acts, or fantasies of sexual contact with a prepubescent child. According to DSM-IV-TR, to be diagnosed with this disorder, the person must be at least sixteen years of age and at least five years older than the victim. Pedophiles may victimize their own children (incest), stepchildren, or those outside the family. Most pedophiles prefer girls, although a few choose prepubertal boys. Sexual abuse of children is common (Phillips & Daniluk, 2004). Between 20 and 30 percent of women report having had a childhood sexual encounter with an adult man. And, contrary to the popular view of the child molester as a stranger, most pedophiles are relatives, friends, or casual acquaintances of their victims (Morenz & Becker, 1995). In most cases of abuse, only one adult and one child are involved, but cases involving several adults or groups of children have been reported. Child victims of sexual abuse show a variety of physical symptoms, such as urinary tract infections, poor appetite, and headaches. Reported psychological symptoms include nightmares, difficulty in sleeping, decline in school performance, acting-out behaviors, and sexually focused behavior. Some child victims show the symptoms of posttraumatic stress disorder. The effects of sexual abuse can become lifelong. One study of women who were victims of childhood sexual abuse revealed a “contaminated identity” characterized by self-loathing, shame, and powerlessness (Phillips & Daniluk, 2004). Incest DSM-IV-TR considers childhood incest to be a form of pedophilia. Incest, however, can also occur between adults too closely related to marry legally; it is nearly universally taboo in society. The cases of incest most frequently reported to law enforcement agencies are those between a father and his daughter or stepdaughter. However, the most common incestuous relationship is brother-sister incest, not parent-child incest. Mother-son incest seems to be rare. Sexual activities between siblings are relatively frequent: 15 percent of women and 10 percent of men reported that they had had sexual involvement with their siblings. In 75 percent of these cases, mutual consent was involved. About half considered the experience positive; the other half, negative (Finkelhor, 1980). Although brother-sister incest is more common, most research has focused on father-daughter incest (Masters, Johnson, & Kolodny, 1992). This type of incestuous

Paraphilias

relationship generally begins when the daughter is between six and eleven years old, and it continues for at least two years (Stark, 1984). Unlike sex between siblings, father-daughter incest is always exploitative. The girl is especially vulnerable because she depends on her father for emotional support. As a result, the victims often feel guilty and powerless. Their problems continue into adulthood and are reflected in their high rates of drug abuse, sexual dysfunction, and psychiatric problems (McAnulty & Burnette, 2003). Studies suggest that incestuous fathers are lower in intelligence than other fathers (Williams & Finkelhor, 1990) and often shy (Masters et al., 1992). Three types of incestuous fathers have been described (Herman & Hirschman, 1981). The first is a socially isolated man who is highly dependent on his family for interpersonal relationships; his emotional dependency gradually evolves (and expands) into a sexual relationship with his daughter. The second type of incestuous father has a psychopathic personality and is completely indiscriminate in choosing sexual partners. The third type has pedophilic tendencies and is sexually involved with several children, including his daughter. In addition, incest victims have reported family patterns in which the father is violent and the mother is unusually powerless. Williams and Finkelhor (1990) noted that some studies have shown that incestuous fathers were more likely than nonincestuous fathers to have experienced childhood sexual abuse themselves, although such abuse is absent in many cases. They also found that incestuous fathers tend to have difficulties with empathy, nurturance, caretaking, social skills, and masculine identification.

293

TOOLS OF THE SADOMASOCHISTIC TRADE Pain and humiliation are associated with sexual satisfaction in sadism and masochism. Sadism involves inflicting pain on others; masochism involves receiving pain. Instruments used in sadomasochistic activities include handcuffs, whips, chains, and sharp objects.

Paraphilias Involving Pain or Humiliation Pain and humiliation do not appear to be related to normal sexual arousal. In sadism and masochism, however, they play a prominent role. Sadism is a form of paraphilia in which sexually arousing urges, fantasies, or acts are associated with inflicting physical or psychological suffering on others. The word sadism was coined from the name of the Marquis de Sade (1740–1814), a French nobleman who wrote extensively about the sexual pleasure he received by inflicting pain on women. The marquis himself was so cruel to his sexual victims that he was declared insane and jailed for twenty-seven years. Sadistic behavior may range from the pretended or fantasized infliction of pain through mild to severe cruelty toward partners to an extremely dangerous pathological form of sadism that may involve mutilation or murder. Masochism is a paraphilia in which sexual urges, fantasies, or acts are associated with being humiliated, bound, or made to suffer. The word masochism is derived from the name of a nineteenth-century Austrian novelist, Leopold von Sacher-Masoch, whose fictional characters obtained sexual satisfaction only when pain was inflicted on them. Because of their passive roles, masochists are not considered dangerous. For some sadists and masochists, coitus becomes unnecessary; pain or humiliation alone is sufficient to produce sexual pleasure. As with other paraphilias, DSMIV-TR specifies that to receive the diagnosis the person must have acted on the urges or must be markedly distressed by them. Most sadomasochists (men and women) engage in and enjoy both submissive and dominant roles (Moser & Levitt, 1987). Only 16 percent were exclusively dominant or submissive. Many engaged in spanking, whipping, and bondage (see Table 10.7). Approximately 40 percent engaged in behaviors that caused minor pain using ice, hot wax, biting, or face slapping. Fewer than 18 percent engaged in more harmful procedures, such as burning or piercing. Nearly all respondents reported sadomasochistic (S&M) activities to be more satisfying than “straight” sex. Most sadomasochists who have been studied report that they do not seek harm or injury but that they find the sensation of utter helplessness appealing (Baumeister, 1988). S&M activities are often carefully scripted and involve role playing and mutual consent by the participants. In addition, fantasies involving sexual abuse, rejection, and forced sex are not uncommon among both male and female college students. Most sadomasochistic behavior among college students involves very mild forms of pain (such as in biting or pinching) that are accepted in our society.

form of paraphilia in which sexually arousing urges, fantasies, or acts are associated with inflicting physical or psychological suffering on others

sadism

masochism a paraphilia in which sexual urges, fantasies, or acts are associated with being humiliated, bound, or made to suffer

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TA B L E

10.7

SADOMASOCHISTIC ACTIVITIES, RANKED BY SELECTED SAMPLES OF MALE AND FEMALE PARTICIPANTS ACTIVITY

MALE (percentage)

FEMALE (percentage)

Spanking

79

80

Master-slave relationships

79

76

Oral sex

77

90

Bondage

67

88

Humiliation

65

61

Restraint

60

83

Anal sex

58

51

Pain

51

34

Whipping

47

39

Use of rubber or leather

42

42

Enemas

33

22

Torture

32

32

Golden showers (urination)

30

37

Note: These sadomasochistic sexual preferences were reported by both male and female respondents. Many more men express a preference for S&M activities, but women who do so are likely to engage in this form of sexual behavior more frequently and with many more partners. Source: Data from Brewslow, Evans, & Langley (1986).

Sadomasochistic behavior is considered deviant when pain, either inflicted or received, is necessary for sexual arousal and orgasm. According to Kinsey and his associates (1953), 22 percent of men and 12 percent of women reported at least some sexual response to sadomasochistic stories. Janus and Janus (1993) reported that 14 percent of men and 11 percent of women have had at least some sadomasochistic experiences. Some cases of sadomasochism appear to be the result of an early experience associating sexual arousal with pain. One masochistic man reported that as a child he was often “caned” on the buttocks by a school headmaster as his “attractive” wife looked on (Money, 1987). He reported, “I got sexual feelings from around the age of twelve, especially if she was watching” (p. 273). He and some of his schoolmates later hired prostitutes to spank them. Later yet, he engaged in self-whipping. In addition to the paraphilias covered here, DSM-IV-TR lists many others under the category of “not otherwise specified” paraphilias. They include telephone scatalogia (making obscene telephone calls) and sexual urges involving corpses (necrophilia), animals (zoophilia), or feces (coprophilia).

Etiology and Treatment of Paraphilias All etiological theories for the paraphilias attempt to answer three questions: (1) What produced the deviant arousal pattern? (2) Why does the person not develop a more appropriate outlet for his or her sexual drive? (3) Why is the behavior not deterred by normative and legal prohibitions? As the multipath model suggests, there are multiple contributing causes, but the state of our knowledge provides only partial answers.

Paraphilias

Earlier, we noted that investigators have attempted to find genetic, neurohormonal, and brain anomalies that might be associated with sexual disorders. Some of the research findings conflict; others need replication and confirmation (Nevid, Fichner-Rathus, & Rathus, 1995). There is evidence, however, that some men may be biologically predisposed to pedophilia (“Are Some Men Predisposed to Pedophilia?” 2007), as they have been found to have deficits in brain activation and less white matter. In any event, researchers need to continue applying advanced technology in the study of the biological influences on sexual disorders. Even if biological factors are found to be important in the causes of sexual disorders, psychological factors are also likely to contribute in important ways. Among early attempts to explain paraphilic disorders, psychodynamic theorists proposed that all sexual deviations symbolically represent unconscious conflicts that began in early childhood (Schrut, 2005). Castration anxiety is hypothesized to be an important etiological factor underlying transvestic fetishism, exhibitionism, sadism, and masochism. It occurs because the Oedipal complex is not fully resolved. Because the boy’s incestuous desires are only partially repressed, he fears retribution from his father in the form of castration. If this is the case, many sexual deviations can be seen as attempts to protect the person from castration anxiety. For example, in transvestic fetishism, acknowledging that women lack a penis raises the fear of castration. To refute this possibility, the male transvestite “restores” the penis to women through cross-dressing. In this manner, he unconsciously represents a “woman who has a penis” and therefore reduces the fear of castration. An item of clothing or a particular fetish is selected because it represents a phallic symbol (Arndt, 1991). Similarly, according to psychodynamic theorists, an exhibitionist exposes to reassure himself that castration has not occurred. The shock that registers on the faces of others assures him that he still has a penis. A sadist may protect himself from castration anxiety by inflicting pain (power equals penis). A masochist may engage in self-castration through the acceptance of pain, thereby limiting the power of others to castrate him. Because castration anxiety stems from an unconscious source, the fear is never completely allayed, however, and so the person feels compelled to repeat deviant sexual acts. The psychodynamic treatment of sexual deviations involves helping the patient understand the relationship between the deviation and the unconscious conflict that produced it. Learning theorists stress the importance of early conditioning experiences in the etiology of sexually deviant behaviors. For example, if a person with poor social skills masturbates while engaged in sexually deviant fantasies, the conditioning may hamper the development of normal sexual patterns. A young boy may develop a fetish for women’s panties after he becomes sexually excited watching girls come down a slide with their underpants exposed. He begins to masturbate to fantasies of girls with their panties showing and may develop a fetish into adulthood. In another example, two young men became sexually aroused when female passersby surprised them as they were urinating in a semiprivate area. The accidental association between sexual arousal and exposure resulted in exhibitionism (McGuire, Carlisle, & Young, 1965). Another researcher (Rachman, 1966), however, did use controlled research to demonstrate the possible role of conditioning in the development of a fetish. The investigators showed three men a picture of a pair of women’s black boots, followed by slides of nude women, which produced sexual arousal (as measured by penile volume). Initially, the picture of boots did not elicit any increases in penile volume. But after slides of boots and nude women were paired several times (classical conditioning), all three participants developed conditioned sexual arousal at the sight of the boots alone. Although the conditioned responses were weak, they could have been strengthened if the participants had masturbated while the boots were shown. Learning approaches to treating sexual deviations have generally involved one or more of the following elements: (1) weakening or eliminating the sexually inappropriate behaviors through processes such as extinction or aversive conditioning;

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(2) acquiring or strengthening sexually appropriate behaviors; and (3) developing appropriate social skills. The following case illustrates this multiple approach:

Case Study A twenty-seven-year-old man with a three-year history of pedophilic activities (fondling and cunnilingus) with four- to seven-year-old girls was treated through the following procedure. The man first masturbated to orgasm while exposed to stimuli involving adult females. He then masturbated to orgasm while listening to a relaxation tape, and then masturbated (but not to orgasm) to deviant stimuli. The procedure allowed the strengthening of normal arousal patterns and lessened the ability to achieve an orgasm while exposed to deviant stimuli (extinction). Measurement of penile tumescence when exposed to the stimuli indicated a sharp decrease to pedophilic stimuli and high arousal to heterosexual stimuli. These changes were maintained over a twelvemonth follow-up period. (Alford, Morin, Atkins, & Schuen, 1987)

One of the more unique treatments for exhibitionism is the aversive behavior rehearsal (ABR) program (Wickramasekera, 1976), in which shame or humiliation is the aversive stimulus. The technique requires that the patient exhibit himself in his usual manner to a preselected audience of women. During the exhibiting act, the patient must verbalize a conversation between himself and his penis. He must talk about what he is feeling emotionally and physically and must explain his fantasies regarding what he supposes the female observers are thinking about him. One premise of the ABR program is that exhibitionism often occurs during a hypnoticlike state, when the exhibitionist’s fantasies are extremely active and his judgment is impaired. The ABR method forces him to experience and examine his act while being fully aware of what he is doing (Kilmann, Sabalis, Gearing, Bukstel, & Scovern, 1982). The results of behavioral treatment have been generally positive, but the majority of the studies involved single participants. Few control groups were included. Another problem in interpreting the results of these studies becomes apparent when we examine the approaches that were employed. For the most part, several different behavioral techniques were used within each study, so evaluation of a particular technique is impossible.

Rape Did You Know?

E

arly explanations attributed rape to an unusually quick sexual arousal response and impulsivity that was considered a natural reaction. Thus excuses were made for men: “Boys will be boys.” Conversely, women were often blamed for enticing rape through flirtatious behaviors and/or revealing dress. In reality, rape is an act of aggression and control, not sex. Most rapists are deliberate and often plan their attacks.

rape a form of sexual aggression that refers to sexual activity (oralgenital sex, anal intercourse, and vaginal intercourse) performed against a person’s will through the use of force, argument, pressure, alcohol or drugs, or authority

Although it is not considered a DSM-IV-TR disorder, we believe that the magnitude and seriousness of problems related to rape in our society warrant such discussion. Public awareness of these problems has heightened in the wake of highly publicized allegations of assault or sexual harassment made against such public figures as basketball player Kobe Bryant, boxer Mike Tyson, conservative talk show host Bill O’Reilly, Supreme Court Justice Clarence Thomas, and former president Bill Clinton. Rape is a form of sexual aggression that refers to sexual activity (oral-genital sex, anal intercourse, and vaginal intercourse) performed against a person’s will through the use of force, argument, pressure, alcohol or drugs, or authority (McAnulty & Burnette, 2004). With a child younger than a certain age who may consent, however, the law recognizes what is called statutory rape—sexual intercourse with a child younger than a certain age. Rape is an act surrounded by many myths and misconceptions (see Table 10.8). Considerable controversy exists over whether rape is primarily a crime of violence or of sex (Marsh, 1988). Feminists have challenged the belief that rape is an act of sexual deviance; they make a good case that it is truly an act of violence and aggression against women. The principal motive, they believe, is that of power, not sex. FBI statistics reveal that the number of rapes in the United States has risen dramatically, with an average of one rape every five minutes (Federal Bureau of Investigation [FBI], 1996; U.S. Senate Committee on the Judiciary, 1991). However, in past decades, only about 16 percent of reported cases resulted in a conviction for rape, with another 4 percent of those cases producing convictions for lesser offenses. This low conviction rate and the humiliation and shame of a rape trial keep many women from reporting rapes, so the actual incidence of the crime is probably much higher than reported.

Rape

TA B L E

297

10.8

WHAT HAVE YOU BEEN TOLD ABOUT RAPE? WAS IT THIS? 1. Anyone can be raped. This includes women, men, girls, boys, infants, grandmothers, and teenagers. 2. Rape is an act of violence. It is not about sex but about the abuse of power. 3. Rape is never the fault of the victim. It is painful, humiliating, and hurtful. No one ever enjoys being raped. 4. Most rapes happen between people of the same race. 5. You are more likely to be raped by someone you know than by a stranger. 6. You can be raped by someone you’ve had sex with before. Each time you are asked to have sex, you have the right to say no, even if you’ve said yes before. 7. Most rapists do not use weapons to force someone into having sex. Threats or emotional and physical force are more commonly used. 8. If you say no and someone forces you to have sex, it’s rape. 9. Most rapists plan their attacks and test their victim’s tolerance of abuse over a period of time. This includes husbands, someone you’re dating, and family members, as well as strangers. 10. Not only is rape always wrong; it’s also a crime. Rape is against the law. Source: San Francisco Women Against Rape, 3543 18th Street, San Francisco, CA 94110, 415-861-2024 (http://www.sfwar.org/facts.html, retrieved May 9, 2008).

Estimates based on surveys indicate that as many as one of every five women will be a rape victim at some time during her life (Sorenson & Siegel, 1992). Most rape victims are young women in their teens or twenties; in approximately one-half of all rape cases, the victim is at least acquainted with the rapist and is attacked in the home or in an automobile. About 90 percent of rapists attack persons of the same race; most rapes are planned and not impulsive (Beers & Berkow, 1999). The most frequent form of rape reported is “acquaintance” or “date” rape. Date rape may account for the majority of all rapes. Many victims may be reluctant to report such an attack; they feel responsible—at least in part—because they made a date with their attacker. Statistics vary as to the incidence of date rapes. Between 8 and 25 percent of female college students have reported that they had “unwanted sexual intercourse,” and studies have generally found that most college women had experienced some unwanted sexual activity (Craig, 1990). Men who try to coerce women into intercourse share certain characteristics (Craig, 1990; Hall, 1996; Hall, Windover, & Maramba, 1998). They tend to (1) actively create the situation in which sexual encounters may occur; (2) interpret women’s friendliness as provocation or their protests as insincerity; (3) try to manipulate women into sexual favors by using alcohol (some 70 percent of rapes are associated with alcohol intoxication) or “date rape drugs” such as rohypnol and GHB; (4) attribute failed attempts at sexual encounters to perceived negative features of the woman, thereby protecting their egos; (5) come from environments of parental neglect or physical or sexual abuse; (6) initiate coitus earlier than men who are not sexually aggressive; and (7) have more sexual partners than males who are not sexually aggressive. Many men who do not rape may also have these characteristics. Indeed, when asked to indicate the likelihood that they would rape if assured that they would not be caught and punished, about 35 percent of college males reported some likelihood and 20 percent indicated fairly high likelihood (Malamuth, 1981). Sexual aggression by men is quite common. Fifteen percent of a sample of college men reported that they did force intercourse at least once or twice. Only 39 percent of the men did not admit to any coerced sex (Rapaport & Burkhart, 1984). In a survey of students enrolled in thirty-two universities in the United States, more than 50 percent of women reported being the victims of sexual aggression, and

Did You Know?

I

n 2005, Jan Luedeckde of Toronto was tried for sexual assault for attempting to have sex with a female acquaintance against her will. His defense was that he suffered from a disorder called “sexsomnia” or “sleepsex.” Akin to sleepwalking, the perpetrator is unaware of his/her actions. There have been only 31 recorded cases in the medical literature of sexsomnia. All occurred during sleep, with individuals having no memory of their actions. Luedeckde was acquitted of rape, outraging many women’s organizations (Underwood, 2007).

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PROTESTING RAPE In South Africa it is reported that half a million women are victims of sexual violence, but only 1 in 9 women who are raped will report it. Antirape and crime activists stage a mock crucifixion in Johannesburg to protest the reported recent assault of a woman raped by 9 men and to highlight the unacceptable high numbers raped in the country.

8 percent of men admitted to committing sexual acts that met the legal definition of rape. Women seldom reported episodes of date rape (Hall, 1996; Koss, Gidycz, & Wisniewski, 1987). Many universities are conducting workshops for students to help them understand that intercourse without consent during a date or other social activity is rape.

Effects of Rape

rape trauma syndrome

a two-phase syndrome that rape victims may experience, including such emotional reactions as psychological distress, phobic reactions, and sexual dysfunction

Rape victims may experience a cluster of emotional reactions known as the rape trauma syndrome; they include psychological distress, phobic reactions, and sexual dysfunction (Koss, 1993). These reactions appear consistent with posttraumatic stress disorder. Two phases have been identified in rape trauma syndrome: 1. Acute Phase: Disorganization During this period of several or more weeks, the rape victim may have feelings of self-blame, fear, and depression. The victim may believe she was responsible for the rape (for example, by not locking the door or wearing provocative clothing or by being overly friendly toward the attacker). The victim may have a strange fear that the attacker will return and anxiety that she may again be raped or even killed. She may express these emotional reactions and beliefs directly as anger, fear, rage, anxiety, and/or depression, or she may conceal them, appearing amazingly calm. Beneath this exterior, however, are signs of tension, including headaches, irritability, restlessness, sleeplessness, and jumpiness (Nevid et al., 1995). 2. Long-Term Phase: Reorganization This second phase may last for several years. The victim begins to deal directly with her feelings and attempts to reorganize her life. Lingering fears and phobic reactions continue, especially to situations or events that remind the victim of the traumatic incident. A host of reactions may be present. Many women report one or more sexual dysfunctions as the result of the rape; fear of sex and lack of desire or arousal appear most common. Some women recover quickly, but others report problems years after the rape. Victims may experience selective fears involving things such as darkness and enclosed places—conditions likely to be associated with rape. Duration and intensity of fear also appear to be related to perceptions of danger. Many women drastically alter their feelings of safety and personal vulnerability; they feel unsafe in many situations and over an extended period of time. It is clear that the impact of rape has long-lasting consequences and that family, friends and acquaintances need to exercise patience and understanding of the victim as she goes through the healing process.

Rape

Etiology of Rape Rape is not specifically listed in DSM-IV-TR as a mental disorder because the act can have a variety of motivations. In an influential study of 133 rapists, Groth, Burgess, and Holstrom (1977) distinguished the three motivational types: 1. The power rapist, comprising 55 percent of those studied, is primarily attempting to compensate for feelings of personal or sexual inadequacy by trying to intimidate his victims. 2. The anger rapist, comprising 40 percent of those studied, is angry at women in general; the victim is merely a convenient target. 3. The sadistic rapist, comprising only 5 percent of those studied, derives satisfaction from inflicting pain and may torture or mutilate the victim. These findings tend to support the contention that rape has more to do with power, aggression, and violence than with sex. Researchers are raising questions about the effect that media portrayals of violent sex, especially in pornography, have on rape rates. Exposure to such material may affect attitudes and thoughts and influence patterns of sexual arousal. These media portrayals may reflect and affect societal values concerning violence and women. A “cultural spillover” theory—namely, that rape tends to be high in cultures or environments that encourage violence—has been proposed (Baron, Straus, & Jaffee, 1988). The investigators studied the relationship between cultural support for violence, as well as demographic characteristics and rates of rapes in all fifty states. Results indicated that cultural support for violence was significantly related to the rate of rape; when violence is generally encouraged or condoned, there is a “spillover” effect on rape.

Treatment for Rapists Many believe that sex offenders are not good candidates for treatment. High recidivism rates are often associated with sexual aggression, and the most frequent action is punishment (incarceration). Both conventional and more controversial treatments have been used or proposed. Conventional Treatment Imprisonment has been the main form of treatment for rapists. However, it is more accurate to describe it as punishment, as the majority of convicts receive little or no treatment in prison (Goleman, 1992). Behavioral treatment for sexual aggressors (rapists and pedophiles) generally involves the following steps: 1. Assessing sexual preferences through self-report and measuring erectile responses to different sexual stimuli 2. Reducing deviant interests through aversion therapy (the man receives electric shock when deviant stimuli are presented) 3. Orgasmic reconditioning or masturbation training to increase sexual arousal to appropriate stimuli 4. Social skills training to increase interpersonal competence 5. Assessment after treatment Treatments for sex offenders are becoming increasingly sophisticated. They involve identifying risk factors and attempting to develop intervention strategies directly attuned to them. These risk factors include (1) dispositional, such as psychopathic or antisocial personality characteristics; (2) historical, such as prior history of crime and violence and developmental trauma; (3) criminogenic, such as deviant social networks and lack of positive social supports; and (4) clinical, such as indicators of substance abuse, psychiatric problems, and poor social functioning (Ward & Stewart, 2003). Treatment as previously outlined attempts to use the most empirically sound strategies to alter or minimize the risk factors (Polaschek, 2003). For example, if a person has a deviant social network, attempts are made to remove the person from such an environment. Although treatment is becoming more sophisticated, questions remain about the effectiveness of these programs. Some treatment programs have been effective with child molesters and exhibitionists, but treatment outcomes have tended to be poor

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critical thinking

Why Do Men Rape Women?

I

n 1995, former world heavyweight boxing champ Mike Tyson was released from prison after serving a sentence for raping a beauty contestant in his hotel room. During his trial, “talk radio” and the print media were filled with speculations about his motives and responsibility for the event. Some claimed that Tyson was only minimally responsible because the woman had willingly gone to his hotel room. (This reasoning was also offered to excuse Kobe Bryant of the alleged rape of a young hotel worker.) Others placed the blame on certain sports such as boxing, saying the activity condones aggression, even sexual aggression. Still others speculated that Tyson was oversexed, that his testosterone levels were high, or that he acted out because of steroid use. Sociocultural Perspective A variety of views of the causes of rape have been proposed. Some researchers theorized that rape was committed by mentally disturbed men, and studies were initiated to find personality characteristics that might be associated with rape. The sociocultural view of rape gained favor with the finding that a significant proportion of men would consider rape if they could get away with it. The view that rapists were simply mentally disturbed individuals began to change. Many argued that rape was a means of control and dominance whereby men keep women in a perpetual state of intimidation. This view emphasized a “culture” of male dominance rather than a sexual motive as a primary reason for sexual assault (McAnulty & Burnette, 2004). Other theorists believe that social myths embedded in our culture reinforce themes that underlie rape: (1) that women have an unconscious desire to be overpowered and raped; (2) that women “ask for it” by dressing in provocative clothing, visiting a man’s room, or going where they should not go; (3) that women could avoid rape if they wanted to; (4) that only “bad girls” get raped; and (5) that women only “cry rape” for revenge. Sociobiological Perspective Another explanation of rape and sexual aggression is posited by sociobiological models. Sexual aggression, according to this view, has an evolutionary basis. Sex differences have evolved as a means of maximizing the reproduction of the human species: men have much more to gain in reproductive terms by being able to pass on their genes rapidly to a

large number of women, which increases their chances of having offspring (L. Ellis, 1991). Men’s advantage is women’s disadvantage, however. Because women must bear much more of the investment in each offspring before and after birth, natural selection would favor women whose mates are likely to supply a greater share of the investment in offspring. Therefore, it would be advantageous for women to avoid multiple partners and to seek male commitment. Ellis also argued that men’s sex drive is stronger than women’s and cited as evidence these three points: 1. Men in all societies have higher self-reported desires for copulation and other forms of sexual experiences. 2. Males (including males in other species of primates) masturbate more, especially in the absence of sex partners. 3. Women are more likely than men to report having sexual intercourse for reasons other than sexual gratification. Ellis took issue with the view that rape is not a sexual crime. He agreed that rapists often try to obtain sex by actions such as getting women drunk and falsely pledging love; that they use physical force only after these other tactics fail; and that fewer men than women believe rape is motivated by power and anger. Nevertheless, sociobiological theories have difficulty explaining differences in rates of rape in different societies or changes in rates of rape over time without references to cultural conditions or experiential factors. Ellis believes that the motivation for sexual assault is unlearned but that the behavior surrounding sexual assault is learned. Thus sexual motivation (including the drive to rape) is innate. If sexual aggression is reinforced (or not punished), forced copulatory attempts will persist. Isolating and testing different propositions concerning sexual assault have been difficult. Even so, no one—not even those who believe that men have a stronger biological sexual drive—can excuse or condone such behavior. Research findings suggest that changes in the way men and women relate to one another, attitudes toward violence, and cultural practices can reduce the incidence of rape. Can you give examples that support or disprove the sociocultural perspective? Does the sociocultural perspective seem accurate to you? Do you think punishment is an effective deterrent to rape? Does the sociobiological perspective seem accurate to you?

for rapists (Marshall, Jones, Ward, Johnston, & Barbaree, 1991). Public revulsion and outrage against incest offenders, pedophiles, and rapists have resulted in calls for severe punishment, although there is no agreement as to what this should entail. Controversial Treatments Surgical castration has been used to treat sexual offenders in many European countries, and results indicate that rates of relapse have been low (Marshall et al., 1991). An investigation of sex offenders (rapists, heterosexual

Summary

301

pedophiles, homosexual pedophiles, bisexual pedophiles, and a sexual murderer) who were surgically castrated reported a decrease in sexual intercourse, masturbation, and frequency of sexual fantasies. However, twelve of the thirty-nine were still able to engage in sexual intercourse several years after being castrated. The rapists constituted the group whose members were most likely to remain sexually active. Chemical therapy, usually involving the hormone Depo-Provera, reduces selfreports of sexual urges in pedophiles but not the ability to show genital arousal. Drugs appear to reduce psychological desire more than actual erection capabilities (Wincze, Bansal, & Malamud, 1986). The effectiveness of biological treatment such as surgery and chemotherapy is not known, and controversy obviously continues over the appropriate treatment for incest offenders, pedophiles, and rapists. Sexuality and the expression of sex are considered not only normal and pleasurable aspects of human existence but an intimate expression of life itself. Because human sexuality plays such an important role in our lives, sexual problems can cause great consternation. As a result, much public and scholarly interest and attention have been directed toward problematic sexual behaviors. Sex therapists now recognize that sexual dysfunctions are very common in people, that most will inevitably experience episodes in their lives, and that such incidents will be successfully resolved without professional intervention. Adequately dealing with them often involves realizing that they represent normal transitory situations of short duration and/or acquiring a greater understanding and acceptance of normal biological changes that affect sexual functioning. Most psychologists now recognize that the complex interaction of biological, psychological, social, and sociocultural forces influences the etiology, manifestation, and treatment of sexual dysfunctions. Research on sexual dysfunctions and the paraphilias has increased significantly, often using a multipath analysis. Unfortunately, the same cannot be said of gender identity disorder, for which research into its causes lags far behind, partly because of its rarity. Little doubt exists, however, that the general public is becoming increasingly knowledgeable and sophisticated in their understanding of sexual dysfunctions and disorders. It remains to be seen how increased public awareness will affect the study and treatment of sexual dysfunctions and disorders.

I M P L I C AT I O N S

Summary 1. What are normal and abnormal sexual behaviors? ■ One of the difficulties in diagnosing abnormal sexual behavior is measuring it against a standard of normal sexual behavior. No attempt to establish such criteria has been completely successful, but these attempts have produced a better understanding of the normal human sexual response cycle. 2. What does the normal sexual response cycle tell us about sexual dysfunctions? ■

■

The human sexual response cycle has four stages: the appetitive, arousal, orgasm, and resolution phases. Each may be characterized by problems, which may be diagnosed as disorders if they are recurrent and persistent. Sexual dysfunctions are disruptions of the normal sexual response cycle. They are fairly common in the general population and may affect a person’s ability to become sexually aroused or to engage in intercourse. Many result from fear or anxiety regarding

sexual activities; the various treatment programs are generally successful. 3. What causes sexual dysfunctions? ■ The multipath model illustrates how biological (hormonal variations and medical conditions), psychological (performance anxieties), social (parental upbringing and attitudes), and sociocultural (cultural scripts) dimensions contribute to sexual dysfunctions. 4. What types of treatments are available for sexual dysfunctions? ■ Depending on the specific dysfunction, treatments vary, from biological interventions such as hormone replacement in the treatment of low sexual desire to penile implants or drugs like Viagra for ED to education and communications training to combat negative attitudes or misinformation about sex to structured sexual exercises for learning new behaviors and warding off performance anxieties.

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5. Is homosexuality a mental disorder? ■ Many myths and misunderstandings continue to surround homosexuality. The belief that homosexuality is deviant seems to relate more to homophobia than to scientific findings. DSM-IV-TR no longer considers homosexuality to be a psychological disorder. 6. How does aging affect the sexual activity of the elderly? ■ Despite myths to the contrary, sexuality extends into old age. However, sexual dysfunction becomes increasingly prevalent with aging, and the frequency of sexual activity typically declines. 7. What causes gender identity disorder, and how is it treated? ■ Specified GID involves strong and persistent crossgender identification. Transsexuals feel a severe psychological conflict between their sexual self-concepts and their genders. Children with this problem identify with members of the opposite gender, deny their own physical attributes, and often cross-dress. ■

Some transsexuals seek sex-conversion surgery, although behavioral therapies are increasingly being used. For children, treatment generally includes the parents and is behavioral in nature.

8. What are the paraphilias, what causes them, and how are they treated? ■ The paraphilias are of three types, characterized by (1) a preference for nonhuman objects for sexual arousal, (2) repetitive sexual activity with nonconsenting partners, or (3) the association of real or simulated suffering with sexual activity. ■

Biological factors such as hormonal or brain processes have been studied as the cause of paraphilias, but the results have not been consistent enough to permit strong conclusions about the role of biological factors in the paraphilias. Psychological factors also play a role.

■

Treatments are usually behavioral and are aimed at eliminating the deviant behavior while teaching more appropriate behaviors.

9. Is rape an act of sex or aggression? ■ Rape is not listed in DSM-IV-TR, but it is a serious problem. There appears to be no single cause of rape, and rapists seem to have different motivations and personalities. ■

Some researchers feel that sociocultural factors can encourage rape and violence against women; others believe that biological factors coupled with sociocultural factors are important in explaining rape.

c h a p t e r

11

Mood Disorders

A

manda was a thirty-nine-year-old homemaker with three children, ages nine, eleven, and fourteen. Her husband, Jim, was the sales manager for an auto agency, and the family did well financially and lived comfortably. For years, family life was stable, and no serious problems existed between family members. The family could be described as cohesive and loving. However, Jim began to notice that his wife was becoming more and more unhappy and depressed. She constantly said that her life lacked purpose. Jim would try to reassure her, pointing out that they had a nice home and that she had no reason to be unhappy. He suggested that she find some hobbies or socialize more with their neighbors and friends. But Amanda became progressively more absorbed in her belief that her life was meaningless. She recalled that her mother also had bouts of depression and feelings of low self-esteem. After a while, Amanda no longer bothered to keep the house clean, to cook, or to take care of the children. At first Jim thought she was merely in a “bad mood” and that it would pass, but as her lethargy deepened, he became increasingly worried. He thought his wife was either sick or no longer loved him and the children. Amanda told him that she was tired and that simple household chores took too much energy. She said that she still loved Jim and the children but no longer had strong feelings for anything. Amanda did show some guilt about her inability to take care of the children and to be a wife, but everything was simply too depressing. Life was no longer important, and she just wanted to be left alone. At that point she began to cry uncontrollably. Nothing Jim said could bring her out of the depression or stop her from crying. He decided that she had to see a physician, and he made an appointment for her. Amanda is currently receiving medication and psychotherapy to treat her depression.

chapter outline Unipolar Depression

304

Etiology of Unipolar Depression

310

Treatment for Unipolar Depression

322

Bipolar Disorders

327

Etiology of Bipolar Disorders

329

Treatment for Bipolar Disorders

330

IMP LIC ATIONS

331

CONTROVERSY When

Is One Depressed?

308

CRITICAL THINKING Should We Increasingly Turn to Drugs in the Treatment of Depression? 324

As we shall see in this chapter, depression is often difficult to explain. In Amanda’s case, we cannot see a single event, traumatizing experience, or stressor that caused

303

FOCUSQUESTIONS

1 What are the symptoms of unipolar depression?

4 What are the symptoms of bipolar, or manicdepressive, disorder?

2 What causes unipolar depression? 3 What kinds of treatment are available for people with unipolar depression, and how effective are they?

5 What causes bipolar disorder? 6 What are the primary means of treating bipolar disorder?

her depression. Consistent with our multipath model, a combination of factors may be operating to cause depression. Such factors often involve genetic predisposition, particular early life events, and stressors. Mood disorders are disturbances in emotions that cause subjective discomfort, hinder a person’s ability to function, or both (see Table 11.1). Unipolar depression, in which only depression occurs, is characterized by intense sadness, feelings of futility and worthlessness, and withdrawal from others. Bipolar disorder is characterized by mania, a condition characterized by elevated mood, expansiveness, or irritability, often resulting in hyperactivity. It is usually accompanied by depression. Depression and mania, the two extremes of mood or affect, can be considered the opposite ends of a continuum that extends from deep sadness to wild elation. In this chapter, we first discuss unipolar depression and its symptoms, causes, and treatments. Then we turn our attention to bipolar disorders. In the next chapter, on suicide, we examine a very serious problem that has been strongly linked to depression.

Unipolar Depression

a disturbance in emotions that causes subjective discomfort, hinders a person’s ability to function, or both

mood disorder

a mood disorder in which only depression occurs and that is characterized by intense sadness, feelings of futility and worthlessness, and withdrawal from others

unipolar depression

a mood disorder in which depression is accompanied by mania, which is characterized by elevated mood, expansiveness, or irritability, often resulting in hyperactivity

bipolar disorder

mania characteristic of bipolar disorder, consisting of elevated mood, expansiveness, or irritability, often resulting in hyperactivity

304

We have all felt depressed or elated at some time during our lives. The loss of a job or the death of a loved one may result in depression; good news may make us manic (for example, ecstatic, hyperactive, and brazen). These reactions may be a sign of a mood disorder if the reactions pervade every aspect of our lives, persist over a long period of time, occur for little or no apparent reason, or are markedly out of proportion to a stressful situation.

Symptoms of Unipolar Depression Symptoms of depression can be seen in four domains, including affective, cognitive, behavioral, and physiological. Affective Symptoms The most striking affective symptom of depression is depressed mood, with feelings of sadness, dejection, and an excessive and prolonged mourning. Feelings of worthlessness and of having lost the joy of living are common. Wild weeping may occur as a general reaction to frustration or anger. Such crying spells do not seem to be directly correlated with a specific situation, as was the case for Amanda. To illustrate these affective characteristics, we present the following statements, made by a severely depressed patient who had markedly improved after treatment.

Case Study It’s hard to describe the state I was in several months ago. The depression was total—it was as if everything that happened to me passed through this filter which colored all experiences. Nothing was exciting to me. I felt I was no good, completely worthless, and deserving of nothing. The people who tried to cheer me up were just living in a different world.

Unipolar Depression

TA B L E

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11.1

DISORDERS CHART

MOOD DISORDERS

MOOD DISORDER

SYMPTOMS

Major Depressive Disorder

• Single episode: Single, major depressive episode

LIFETIME PREVALENCE (%)

GENDER DIFFERENCE

AGE OF ONSET

8.0–19.0

Much higher in females

Any age; average age in 20s

• Recurrent: Two or more major depressive episodes Dysthymic Disorder

• Depressed mood that is chronic and relatively continual in nature

6.0

Much higher in females

Often starts in childhood or adolescence

Bipolar I Disorder

• Single manic episode

0.4–1.6

No major difference

Any age; usually in early 20s

• Most recent episode hypomanic • Most recent episode manic • Most recent episode mixed • Most recent episode depressed • More recent episode unspecified Bipolar II Disorder

• Recurrent major depressive episodes with hypomania

0.5

Higher in females

Any age

Cyclothymic Disorder

• Manic and depressed moods that are chronic and relatively continual in nature

0.4–1.0

No difference

Often starts in adolescence

Source: Data from American Psychiatric Association (2000a).

Cognitive Symptoms Besides general feelings of futility, emptiness, and hopelessness, certain thoughts and ideas, or cognitive symptoms, are clearly related to depressive reactions. For example, the depressed person has profoundly pessimistic beliefs about what he or she can do, about what others can do to help, and about prospects for the future. Self-accusations of incompetence and general selfdenigration are common, as are thoughts of suicide. Other symptoms include difficulty in concentrating and in making decisions. Depression is often reflected in faulty thinking, such as holding irrational or unjustified beliefs. Ezra Pound, one of the most brilliant poets of the twentieth century, suffered a severe depression when he was in his seventies. He bitterly told an interviewer, “I have lived all my life believing that I knew something. And then a strange day came and I realized that I knew nothing, nothing at all. And so words have become empty of meaning. Everything that I touch, I spoil. I have blundered always” (Darrach, 1976, p. 81). Pound stopped writing for years; for days on end, he ceased to speak. Behavioral Symptoms A person with depression often shows behavioral symptoms such as social withdrawal and lowered work productivity. Amanda felt constantly tired and complained that she had no energy. This low energy level is one of the dominant behavioral symptoms of depression, and it has been found to distinguish depressed individuals from nondepressed individuals (Christensen & Duncan, 1995). Depressed persons often show little motivation and exhibit anhedonia, or a loss of the capacity to derive pleasure from normally pleasant experiences. Other symptoms include sloppy or dirty clothing, unkempt hair, and lack of concern for personal cleanliness. Speech is reduced and slow, and responses may be limited to short phrases. This slowing down of all bodily movements, expressive gestures, and

Did You Know?

D

epression is accompanied by anxiety 45 to 75 percent of the time (Gorman, 1996; Watson et al., 1995). Because anxiety and depression occur in family lines with high incidences of these disorders, mood disorders and anxiety may share genetic vulnerabilities and etiologies.

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spontaneous responses is called psychomotor retardation. Although psychomotor retardation is typical, some people suffering from depression manifest an agitated state and symptoms of restlessness. Physiological Symptoms The following physiological or somatic symptoms frequently accompany depression: 1. Appetite and weight changes. During depression, some people may experience either increased or decreased eating or weight changes. Those who constantly eat may do so even if they are not hungry. For others, a loss of appetite often stems from the person’s lack of interest in eating; food seems tasteless. In severe depression, weight loss can become life threatening. 2. Constipation. The person may not have bowel movements for days at a time.

DEPRESSION SLOWS A MUSE Ezra Pound (1885–1972), American poet and expatriate, developed severe depression later in life and at one point was institutionalized. During his depression, he became extremely pessimistic and derogated much of his own work. For a time, he even stopped speaking and writing.

3. Sleep disturbance. Difficulty in falling asleep, waking up early, waking up erratically during the night, insomnia, and nightmares leave the person exhausted and tired during the day. Many dread the arrival of night because it represents a major fatigue-producing battle to fall asleep. Some depressed people, however, show hypersomnia, or excessive sleep. They often feel continually tired despite excessive sleep. 4. Disruption of the normal menstrual cycle in women. The disruption is usually a lengthening of the cycle, and the woman may skip one or several periods. The volume of menstrual flow may decrease. 5. Aversion to sexual activity. Many people report that their sexual arousal dramatically declines. The core symptoms of severe unipolar depression are the same for children and adolescents, although the prominence of characteristic symptoms may change with age. In a longitudinal study of adolescents who experienced unipolar depression as they progressed into adulthood, depressive symptoms were found to vary considerably (Lewinsohn, Pettit, Joiner, & Seeley, 2003). However, certain symptoms, such as somatic complaints, irritability, and social withdrawal, are particularly common in children, whereas psychomotor retardation, hypersomnia, and delusions are more common in adolescence and adulthood (American Psychiatric Association, 2000a). Table 11.2 compares the symptoms for depression and mania. Mania is discussed more fully later in the chapter.

TA B L E

11.2

SYMPTOMS OF DEPRESSION AND MANIA DOMAIN

DEPRESSION

MANIA

Affective

Feelings of sadness, dejection, and worthlessness; apathy; anxiety; brooding; crying spells

Elation, grandiosity, irritability

Cognitive

Pessimism, guilt, inability to concentrate, faulty or negative thinking, loss of interest and motivation, suicidal thoughts

Flighty and pressured thoughts, lack of focus and attention, poor judgment

Behavioral

Social withdrawal, lowered productivity, low energy, anhedonia, neglect of personal appearance, psychomotor retardation, agitation

Overactive, speech difficult to understand, talkative

Physiological

Appetite and weight changes, constipation, sleep disturbance, disruption of the normal menstrual cycle in women, loss of sex drive

High levels of arousal, decreased need for sleep

Unipolar Depression

TA B L E

307

11.3

CRITERIA FOR DSM DIAGNOSIS OF MAJOR DEPRESSIVE DISORDER Presence of a major depressive (but not manic) episode, which includes: A. Five (or more) of the following symptoms present during the same two-week period with at least one that includes depressed mood or loss of pleasure: 1. depressed mood most of the day, almost every day 2. markedly diminished interest or pleasure in all, or nearly all, activities 3. significant weight loss when not dieting or weight gain or decrease or increase in appetite almost every day 4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation almost every day 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or inappropriate guilt nearly every day 8. reduced ability to think or concentrate, or indecisiveness, nearly every day 9. recurrent thoughts of death or suicidal ideation or a suicide attempt or a specific plan for committing suicide B. The symptoms cause clinically significant distress or impairment in social, occupational, or other functioning. Source: Adapted from American Psychiatric Association (2000a).

Diagnosis and Classification of Depressive Disorders In the DSM, depressive disorders are also called unipolar depression because of absence of mania. Depressive disorders are divided into major depressive disorder and dysthymic disorder. In order to receive the diagnosis of major depressive disorder, one must have experienced a major depressive episode or a major instance of depression. The criteria for major depressive episode are provided in Table 11.3. About one-half of those who experience a depressive episode eventually have another episode. In general, the earlier the age of onset, the more likely is a recurrence (Reus, 1988). If a disorder is characterized by depressed mood but does not meet the criteria for major depression, dysthymic disorder may be diagnosed. In dysthymic disorder (or dysthymia), the depressed mood is chronic and relatively continual. Typical symptoms include pessimism or guilt, loss of interest, poor appetite or overeating, low self-esteem, chronic fatigue, social withdrawal, or concentration difficulties. Unlike major depression, which may continue from a couple of weeks to several months, dysthymia may last for years, although the symptoms are often not as severe (Klein et al., 1998). Each year, about 10 percent of individuals with dysthymia go on to have a first major depressive episode. In dysthymia, the depressive symptoms are present most of the day and for more days than not during a two-year period (or, for children and adolescents, a one-year period). Symptom Features and Specifiers To be more precise about the nature of mood disorders, DSM-IV-TR has listed certain characteristics that may be associated with these disorders. Specifiers may be used to more precisely describe a major depressive episode. These specifiers may include references to the severity, presence or absence of psychotic symptoms (such as hallucinations or delusions), remission status, and other notable features of the depression—for example, (1) melancholia

depressive disorders disorders that include major depressive disorder and dysthymic disorder with no history of a manic episode; also called unipolar depression major depressive disorder

a major depressive episode whose symptoms include a depressed mood or a loss of interest or pleasure, weight loss or gain, sleep difficulties, fatigue, feelings of worthlessness, inability to concentrate, and recurrent thoughts of death dysthymic disorder (dysthymia)

depressed mood which is chronic and relatively continual and does not meet the criteria for major depression

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controversy

When Is One Depressed?

B

ecause of the high rates of mental disorders in general and depression in particular, a controversy exists over the very definition of whether a condition is a disorder or a mild, unpleasant feeling (“New Report Opens Old Debate,” 2005). For example, if a person fits the minimum five DSM criteria (see Table 11.3) for unipolar depression, the person is defined as having a disorder. However, if someone has met four but not five, is that person free of a mental disorder? In some cases, a person may be diagnosed as having dysthymia, which is milder but more chronic than unipolar depression. Those who favor inclusion of even mild conditions fear that ignoring and not treating less serious conditions is unwise. Mental disorders may be similar to physical health disorders. In physical health, one can have serious diseases (for example, cancer and heart disease), as well as less serious conditions that require attention and treatment (for example, colds and flu and skin diseases). Shouldn’t the same be true of mental disorders in which a person may not be clinically depressed (according to DSM criteria) but may have low self-esteem, may be unable to effectively work, may feel miserable, and so forth? Advocates of exclusion of mild cases, however, believe that the

field should not include the wide range of bad feelings, poor judgments, and faulty habits in the domain of mental disorders (“New Report Opens Old Debate,” 2005). The controversy is also fueled by findings that many of the DSM disorders are actually dimensional rather than categorical in nature (see Hankin, Fraley, Lahey, & Waldman, 2005; Prisciandaro & Roberts, 2005). That is, depression and depressive symptoms are a matter of degree rather than of being present or absent. Thus the DSM practice of categorizing behaviors as indicators of a disorder is arbitrary because people have the behaviors to varying degrees. The controversy has implications for research and science (what constitutes a disorder?) as well as for policy considerations (should mild disorders be covered in health-care plans?). For Further Consideration 1. Should the definition of mental disorders be narrow (that is, include only severe disorders) or broad (that is, include even mild disorders)? 2. What are the positive and negative consequences or strengths and weaknesses of using different definitions?

(loss of pleasure, lack of reactivity to pleasurable stimuli, depression that is worse in the morning, early morning awakening, excessive guilt, weight loss); (2) catatonia, characterized by motoric immobility (taking a posture and not moving), extreme agitation (excessive motor activity), negativism (resistance to changing positions), or mutism; (3) postpartum onset (occurring within four weeks of childbirth), or (4) seasonal pattern (occurring during certain times or seasons of the year). In a seasonal pattern, moods are accentuated during certain times. For example, many depressed people find the morning more depressing than the evening POSTPARTUM PSYCHOSIS “Postpartum onset” occurs in about 13 percent of mothers (O’Hara, 2003), and Andrea Yates, who drowned her five children, built her defense case on this mood disorder. Why do you think that postpartum psychosis occurs?

Unipolar Depression

309

(Lehmann, 1985). Many individuals also find winter, when days are shorter and darker, more depressing than summer. In seasonal affective disorder (SAD), serious cases of depression fluctuate according to the season. Proposed explanations include the possibility that SAD is an abnormal body response to seasonal changes in the length of the day, that the dark days of winter may bring about hormonal changes in the body that somehow affect depression levels, and that disruption of the body’s circadian rhythm produces mood fluctuations (Lee et al., 1998). SAD appears to be related to the photoperiod (hours from sunrise to sunset) rather than to daily hours of sunshine, mean daily temperature, or total daily radiation (Young, Meaden, Fogg, Cherin, & Eastman, 1997). In some cases of recurrent major depresSEASONAL PATTERNS OF DEPRESSION In seasonal affective disorder (SAD), sion, the onset, end, or change of an episode depressive symptoms vary with the seasons. One theory for this is that during coincides with a particular time of the year. For winter, reduced daylight affects hormone levels, which may induce depression. The example, one man regularly became depressed people in this photo are receiving light therapy at the Light Lounge, which exposes after Christmas. Interestingly, “light therapy” them to specially designed light boxes. The treatment appears to be helpful in (exposure to bright light) for several hours some cases of SAD. Do you believe that most people feel happier during the a day, especially during winter, appears to be summer than winter? helpful for many individuals with SAD (Oren & Rosenthal, 2001), as may vacations to sunny parts of the country. An analysis of randomized, controlled trials suggests that bright light treatment for SAD and bright light for nonseasonal depression are as beneficial as treatment with antidepressant medications (Golden et al., 2005).

Prevalence of Unipolar Depression

Prevalence

Depression is the most common complaint of individuals seeking mental health care (Gotlib, 1992; Strickland, 1992). It also ranks among the top ten causes of worldwide disability and is a leading cause of absenteeism and diminished productivity in the workplace (U.S. Surgeon General, 1999). Nearly 15 million Americans will experience unipolar depression this year. In the large-scale survey of more than 43,000 adults in the United States, twelve-month prevalence rates (the proportion of people having depression during a twelveBipolar One and Bipolar Two Unipolar month period) and lifetime prevalence rates (the proportion of 20 20 people who develop the disorder at some point in their lives) 16.2 were determined. The prevalences of twelve-month and life15 15 13.73 time major depression were 5.28 percent and 13.23 percent, respectively (Hasin, Goodwin, Stinson, & Grant, 2005). Being 10 10 female, Native American, middle aged, widowed, separated, or 6.6 divorced, or having a low income increased risk for depression. 5.28 5 5 Being Asian, Hispanic, or African American decreased risk. 1.0 1.1 Having major depression was significantly associated with .6 .8 0 0 other specific disorders, such as substance dependence, panic 12–month Lifetime 12–month Lifetime and generalized anxiety disorders, and several personality disorders. Another large-scale study found even higher prevaSources: (Hasin et al., 2005) Bipolar One (BP–I) lence rates: 6.6 percent for twelve-month and 16.2 percent for (Kessler et al., 2003) Bipolar Two (BP–II) lifetime prevalence (Kessler et al., 2003; see Figure 11.1). Source: Merikangas, 2007 After one episode of depression, the likelihood of another is 50 percent; after two episodes, 70 percent; and after TWELVE-MONTH AND LIFETIME FIGURE three episodes, 90 percent (Munoz et al., 1995). Moreover, PREVALENCE OF UNIPOLAR AND BIPOLAR DISORDERS I AND II depression has been found to be associated with the risk Source: Based on Hasin et al. (2005); Kessler et al. (2003); Merikangas of having a heart attack and a shortened life expectancy et al. (2007).

11.1

310

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(President’s New Freedom Commission on Mental Health, 2003). Among U.S. college students, one survey found that over half indicated that they had experienced depression, 9 percent had had thoughts of suicide, and 1 percent had attempted suicide since the beginning of college (Furr, Westefeld, McConnell, & Jenkins, 2001). In fact, the suicide risk of depressed persons is at least eight times higher than that of the general population (Nitzkin & Smith, 2004). Depression is also very costly. About $43 billion annually is spent on health-care services and lost workdays in the United States because of depression (Nitzkin & Smith, 2004).

Etiology of Unipolar Depression

Did You Know? You could be living in a “depressed” or a “happy” city. The following rankings were based on antidepressant sales, suicide rates, and the number of days residents reported being depressed (“Depressed? Could Be Where You Live,” 2005).

Depressed Cities

Happy Cities

1. Philadelphia

1. Laredo

2. Detroit 3. St. Petersburg (FL) 4. St. Louis

2. El Paso

5. Tampa

5. San Jose

3. Jersey City 4. Honolulu

Over the years, a number of different explanations have been proposed to account for depression. Consistent with our multipath approach, research seems to show that various biological, psychological, social, and sociocultural factors interact in complex ways to cause unipolar depression, as shown in Figure 11.2.

Biological Dimension Biological approaches to the causes of mood disorders generally focus on genetic predisposition, physiological dysfunction, or combinations of the two. The Role of Heredity There is now overwhelming evidence that mood disorders carry significant genetic components whose ultimate phenotypic expression is highly dependent on environmental factors (Leonardo & Hen, 2006). Compared with bipolar disorder (discussed later), major depression is much more heterogeneous (that is, symptoms and causes seem to vary a great deal), and the contribution of environmental factors is larger than that of genetic factors (Kato, 2007). Depression tends to run in families, and the same type of disorder is generally found among members of the same family (Goldberg, 2006). As we have noted in earlier chapters, one way to assess the role of heredity is to compare the incidence of disorders among the biological and adoptive families of people who were adopted early in life. If heredity is more important, then biological families (which contributed the genetic makeup) should show a high incidence of the disorders. If environment is more important, then adoptive families (which provided the early

11.2

FIGURE MULTIPATH MODEL FOR UNIPOLAR DEPRESSION The dimensions interact with one another and combine in different ways to result in unipolar depression.

Biological Dimension • Genetic predisposition • Dysfunctions in neurotransmission in the brain • Brain structure differences • Abnormal cortisol levels • REM sleep disturbances Psychological Dimension Sociocultural Dimension • Low socioeconomic status • Cultural differences • Gender differences (more common in women)

UNIPOLAR DEPRESSION

Social Dimension • Stress • Lack of social support/resources

• Inappropriate separation and anger response • Inadequate/insufficient reinforcers • Negative thoughts and specific errors in thinking • Learned helplessness/attributional style

Etiology of Unipolar Depression

environment) should show a high incidence. The results of such a comparison indicate that the incidence of mood disorders is significantly higher among the biological families than among the adoptive families; the latter showed an incidence similar to that of the general population (American Psychiatric Association, 2000a; Levinson, 2006). Finally, when one twin has unipolar depression, what is the likelihood that the cotwin will have the same disorder? Monozygotic or identical twins share 100 percent of their genes, whereas dizygotic twins share about 50 percent of their genes. Studies of monozygotic and dizygotic twins reveal a significantly higher concordance rate for depressive symptoms among monozygotic than among dizygotic twins (McGue & Christensen, 1997). Goodwin and Guze (1984) believe the concordance rate for unipolar depression is about 40 percent for monozygotic twins and 11 percent for dizygotic twins, which supports a genetic interpretation (Goodwin & Guze, 1984). Interestingly, concordance is higher for female than male twins, perhaps indicating gender differences in heritability (Goldberg, 2006). Neurotransmitters and Mood Disorders But how is heredity involved in major mood disorders? Research shows that dysfunctions in neurotransmission in the brain, perhaps influenced by heredity, are associated with depression. Neurotransmitter substances, including norepinephrine, dopamine, and serotonin, help transmit nerve impulses from one neuron to another. Nerve impulses are transmitted from neuron to neuron across synapses, which are small gaps between the axon (or transmitting end) of one neuron and the dendrites (or receiving end) of a receptor neuron. The amount of neurotransmitter substances affects transmission of the impulses from neuron to neuron. The availability of these substances for neurotransmission is affected by reuptake, or the reabsorption of the substances, and by chemical reactions that break down the substances. Thus reuptake and chemical depletion have the effect of reducing neural transmission. The evidence for the importance of the level of neurotransmitters in depression comes from a variety of sources. Some findings were made accidentally. For example, it was discovered that when the drug reserpine was used in treating hypertension, many patients became depressed. (Reserpine depletes the level of neurotransmitters in the brain.) Similarly, the drug iproniazid, given to tubercular patients, elevated the mood of those who were depressed. (Iproniazid inhibits the destruction of neurotransmitters.) More recently, studies of the effects of antidepressant medication also implicated neurotransmission. Antidepressant medications appear to increase the level of neurotransmitters. One group, the monoamine oxidase inhibitors (MAOIs), blocks the effects of monoamine oxidase (MAO) in breaking down the neurotransmitters. Another group, the tricyclic drugs, block the reuptake of certain transmitter substances. Fluoxetine (Prozac) seems to block the reuptake of serotonin, leaving more available serotonin. Several hypotheses have been proposed for problems in neurotransmission: 1. Depression may be caused by a deficit of specific neurotransmitters at brain synapses; similarly, mania is presumed to be caused by an oversupply of these substances (Bunney, Pert, Rosenblatt, Pert, & Gallaper, 1979). 2. To travel from one neuron to another, an electrical impulse must release neurotransmitters that stimulate the receiving neuron. The problem may not be the amount of neurotransmitter made available by the sending neuron but rather a dysfunction in the reception of the neurotransmitter by the receiving neuron (Sulser, 1979). 3. Drugs that raise the level of neurotransmitters in the synapse trigger such increases immediately, yet the alleviation of depressive symptoms may be delayed for several weeks after this increase. This delay may indicate that other factors, such as membrane responses to neurotransmitters, are also important in depression (Rivas-Vazquez & Blais, 1997). 4. Transporter proteins regulate the concentration of neurotransmitters in synapses and therefore have effects on a receiving neuron’s receptor. Reduced serotonin transporter and dopamine transporter proteins may decrease serotonin’s “feelgood” effects (Hariri & Brown, 2006).

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Brain Structures Davidson, Pizzagalli, Nitschke, and Putnam (2002) believe that persons with depression often display their depression in inappropriate contexts. It is not so much the reaction that is unusual but the context in which it occurs. For example, great sadness may be appropriate after the death of a loved one, but a severe period of mourning extending for years is an example of context-inappropriate emotional responding. Because the prefrontal region, amygdala, and hippocampus of the brain are involved in emotional regulation, investigators have been searching for possible leads. In depression, abnormalities in activation of prefrontal regions in depression have been frequently reported. Recent reports have documented decreased activation in these brain areas in patients with major depressive disorder. The reduction in activation appears to be at least partially a function of a reduction or shrinking of gray matter in the brain as revealed by magnetic resonance imaging-derived measures (Leonardo & Hen, 2006). It is also possible that depression disorders can be produced by abnormalities in many different parts of the circuitry of the brain. The specific subtype, symptom profile, and affective abnormalities may systematically vary with the brain location and nature of the abnormality (Davidson et al., 2002). Whether mood disorders are caused by a deficiency in the production of neurotransmitter substances, by a blunted receptor response, by a more general dysregulation in neurotransmission, or by other brain abnormalities cannot be resolved at this time. It is also possible that no one cause will be isolated, especially if depression is a heterogeneous collection of subtypes of disorders with differing biological and environmental precursors (Mann, 1989). Furthermore, the interaction effects between one’s genetic makeup and stress increase the complexities in etiological explanations. Abnormal Cortisol Levels Considerable interest has also focused on possible abnormalities in neuroendocrine regulation in depression. People experiencing depression tend to have high levels of cortisol, a hormone secreted by the adrenal cortex. Studies in different countries have shown that people with depression register higher blood levels of cortisol than are found in nondepressed people (World Health Organization, 1987) and that prognosis for recovery is poorer when these levels are not suppressed (Reus, 1988). Furthermore, in a study of rats that were given repeated injections of the hormone corticosterone, which is believed to simulate chronic stress, depression-like behaviors were found (Kalynchuk, Gregus, Boudreau, & Perrot-Sinal, 2004). The investigators believe that brain structure functioning particularly in the hippocampus area may be affected. Whether cortisol influences depression or is produced by depression or some other factor, however, is still unclear, especially because some studies do not show increased cortisol levels among depressed persons (Cowen, 2002). A somewhat different hypothesis has been proposed by Gillespie and Nemeroff (2007). They observe that many individuals with depression have had early life traumas or stressors such as child abuse, neglect, or loss of a parent. Their belief is that exposure to stress during early development affects the cortisol and the hypothalamicpituitary-adrenal (HPA) system. This makes one more prone to depression in later life, especially among those who have genetic vulnerability. Thus stress, time of onset of stress, and genetic predisposition may interact in causing depression. REM Sleep Disturbances Findings of a different sort have also aroused interest in the biological or physiological processes of depression. For example, the sleep patterns of adults with depression differ from those of other people, particularly during rapideye-movement (REM) sleep. (There are several stages of sleep; during REM sleep, the eyes move rapidly, and dreaming occurs.) Depression is linked with a relatively rapid onset of, and an increase in, REM sleep (Goodwin & Guze, 1984). Moreover, reducing the REM sleep of persons with depression seems to help (Vogel, Vogel, McAbee, & Thurmond, 1980). Why sleep patterns are linked to depression is unclear. Monroe, Thase, and Simons (1992) found that some patients in depression experienced severe, acute life stress, whereas others did not. REM latency (that is, the time before REM occurs during sleep) was short among the individuals who did not experience severe life stress. It may be that those with reduced REM latency have a lower threshold for the development of depression in that less stress is needed to affect depression.

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SLEEP DISTURBANCES AND DEPRESSION Sleep patterns have been linked to depression. For example, rapid eye movement during sleep occurs more often among those who have depression than among those who do not. The reasons for this are unclear. Here, a researcher is monitoring a man’s sleep. Can you find reasons for depression being associated with sleep disturbances?

In our discussion of how genetic effects may be reflected in neurotransmission, neuroendocrine regulation, or brain structure abnormalities, it must be kept in mind that the deviations found in persons with depression provide us with possible leads on causes of depression. However, these deviations may simply be a byproduct or correlate of depression and not the cause of depression. With the ongoing advances in research and technologies, we are continuing to find more precisely the biological contributors to depression.

Psychological Dimension The biological contributors we just discussed interact in some way with life experiences to cause depression. A number of psychological theories have been proposed to account for the life experiences that lead to depression. In this section we look at the psychodynamic, behavioral, and cognitive theories of depression. Psychodynamic Explanations The psychodynamic explanation of depression focuses mainly on two concepts: separation and anger. Separation may occur when a spouse, lover, child, parent, or significant other dies or leaves for one reason or another. But depression cannot always be correlated with the immediate loss of a loved one, and for those instances, Freud used the construct of “symbolic loss.” That is to say, the depressed person may perceive any form of rejection or reproach as symbolic of an earlier loss. For example, the withdrawal of affection or support or a rejection can induce depression. Freud (1917/1955) believed this was especially true because depressed people are fixated at the oral stage and excessively dependent. Freud also believed that a person in depression fails to follow through the normal process of mourning, which he called “grief or mourning work.” In this process, the mourner consciously recalls and expresses memories about the lost person in an attempt to undo the loss. In addition, the mourner is flooded with two strong sets of feelings: anger and guilt. The anger, which arises from the sense of being deserted, can be very strong. The mourner may also be flooded with guilt feelings about real or imagined sins committed against the lost person. Psychodynamic explanations of depression have strongly emphasized the dynamics of anger. Many patients in depression have strong hostile or angry feelings, and some clinicians believe that getting clients to express their anger reduces their depression. Such a belief has led some to speculate that depression is really anger turned against the self (Freud, 1917/1955). Freud suggested that, when a person experiences a loss (symbolic or otherwise), he or she may harbor feelings of resentment and hostility toward the lost person, in addition to feelings of love

SEPARATION AS A CAUSE OF DEPRESSION Harry and Margaret Harlow (1962) found that infant monkeys reacted with fear and despair when separated from their mothers. Even monkeys raised with surrogate mothers (in this case, a wire frame covered with terrycloth) exhibited anxiety and despair when separated from them. The psychodynamic perspective asserts that separation can be a cause of depression. Do you think separation anxiety and depression are genetically determined?

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and affection. Freud’s ideas seem to be important for several reasons. First, he stimulated the development of other psychodynamic approaches to depression. One such approach, interpersonal therapy, has been found to be effective in depression. Second, psychodynamic approaches may well specify some, but not all, of the conditions that elicit depression. Third, its emphasis on early life experiences as critical to depression appears to be important, as discussed later. There have been relatively few empirical tests of psychodynamic ideas. One longitudinal study (Stroebe & Stroebe, 1991) examined whether persons whose spouses had died were less depressed if they directly confronted the loss (that is, performed grief work) rather than avoided dealing with it. Results were equivocal in that performing grief work was inversely related to adjustment for LOSS AS A SOURCE OF DEPRESSION Mourning over the death of a loved widowers but not for widows. Other studies (such one occurs in all cultures and societies, as illustrated by these women mourning as Paykel, 1982) have shown that loss (death or at the funerals of 13 members of an Iraqi tae kwon do team, kidnapped and separation) of significant others in one’s life can killed in Iraq. However, in most cultures, severe and incapacitating depression rarely continues after the first three months. If it does continue longer, then a precipitate depression. However, stressors other depressive disorder may have developed. What other characteristics or symptoms than the loss of a significant other may bring about would help one to distinguish between “normal” grief and a depressive disorder? depression, and the loss of a significant other can lead to disorders other than depression, such as anxiety and substance abuse. Behavioral Explanations Behaviorists also see the separation or loss of a significant other as important in depression. However, behaviorists tend to see reduced reinforcement as the cause, rather than fixation or symbolic grief, which they view as untestable concepts. When a loved one is lost, an accustomed level of reinforcement (whether affection, companionship, pleasure, material goods, or services) is immediately withdrawn. The survivor can no longer obtain the support or encouragement of the lost person, and the survivor’s level of activity (talking, expressing ideas, working, joking, engaging in sports, going out on the town) diminishes markedly in the absence of this reinforcement. Thus many behaviorists view depression as a product of inadequate or insufficient reinforcers in a person’s life, leading to a reduced frequency of behavior that previously was positively reinforced (Lewinsohn, 1974; Wells, Sturm, Sherbourne, & Meredith, 1996). Lewinsohn’s model of depression is perhaps the most comprehensive behavioral explanation of depression (Lewinsohn, 1974; Lewinsohn, Hoberman, Teri, & Hautzinger, 1985). Along with the reinforcement view of depression, Lewinsohn suggested three sets of variables that may enhance or hinder a person’s access to positive reinforcement. 1. The number of events and activities that are potentially reinforcing to the person. This number depends very much on individual differences and varies with the biological traits and experiential history of the person. For example, age, gender, or physical attributes may determine the availability of reinforcers. Handsome people are more likely to receive positive attention than are nondescript people. 2. The availability of reinforcements in the environment. Harsh environments, such as regimented institutions or remote isolated places, reduce reinforcements. 3. The instrumental behavior of the individual. The number of social skills a person can exercise to bring about reinforcement is important. People in depression lack social behaviors that can elicit positive reinforcements. They interact with fewer people, respond less, have very few positive reactions, and initiate less conversation. They also feel more uncomfortable in social situations (Youngren &

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Lewinsohn, 1980), and they elicit depression in others (Hammen & Peters, 1978). A low rate of positive reinforcement in any of these three situations can lead to depression. The occurrence of stress also plays a strong role in the theory. Lewinsohn and his colleagues (1985) believe that an antecedent event such as stress disrupts the predictable and well-established behavior patterns of people’s lives. Such disruptions then reduce the rate of positive reinforcements or increase aversive experiences. If individuals are unable to reverse the impact of the stress, they begin to have a heightened state of self-awareness (for example, self-criticism, negative expectancies, and loss of self-confidence) and to experience depressed affect. With depressed moods, persons then have a more difficult time functioning appropriately, which makes them further vulnerable to depression. Thus Lewinsohn’s model attempts to cover not only behavioral elements but also cognitive and emotional consequences. Cognitive Explanations Cognitively oriented psychologists have proposed that the way people think, rather than low rates of positive reinforcement, can cause depression. In their view, depressed persons have negative thoughts and specific errors in thinking that result in pessimism, negative views of themselves, feelings of hopelessness, and depression (Emmelkamp, 2004). Depressed people often perceive themselves as inept, unworthy, and incompetent, regardless of reality. If they do succeed at anything, they are likely to dismiss it as pure MAGNIFICATION OF EVENTS According to cognitive luck or to forecast eventual failure. Hence a cognitive interpretation explanations for depression, people may become depressed because of the way they interpret situations. of oneself as unworthy may lead to thinking patterns that reflect selfblame, self-criticism, and exaggerated ideas of duty and responsibility. They may overly magnify, selectively abstract, or make Such beliefs are often exaggerated and irrational and are interpreted into catastrophes events that happen to them. In this photo, a male high school football player sits alone in a in a catastrophic manner (Ellis, 1989). Beck (1976) proposed one major cognitive theory that views locker room after losing a football game. depression as a primary disturbance in thinking rather than a basic disturbance in mood. How persons structure and interpret their experiences determines their affective states. If individuals see a situation as unpleasant, they will feel an unpleasant mood. According to Beck, patients with depression have Did You Know? schemas—cognitive frameworks that help organize and interpret information—that set them up for depression. In one study, for example, Crowson and Cromwell (1995) hat makes you happy? In a offered research participants the choice of listening to positive or negative tapesurvey of people ages 13 to 24, spending time with recorded messages. The researchers found that the group not suffering from depresfamily was the top answer, followed sion was more likely to choose positive messages, whereas the group with depression by time with friends and significant showed little preference in the messages. Perhaps depression involves schemas that others. Being sexually active did not perpetuate negative outlooks and attention to negative messages. rate as high, and taking alcohol/ According to Beck’s theory, depressed people operate from a cognitive or primary drugs was related to less happiness. triad of negative self-views, present experiences, and future expectations. Four Happier were whites than African characteristic errors in logic typify this negative schema:

W

1. Arbitrary inference. The person with depression tends to draw conclusions that are not supported by evidence. For example, a woman may conclude that “people dislike me” just because no one speaks to her on the bus or in the elevator. 2. Selected abstraction. The individual takes a minor incident or detail out of context and focuses on it, and these incidents tend to be trivial. A person corrected for a minor aspect of his or her work may take the correction as a sign of incompetence or inadequacy—even when the supervisor’s overall feedback is highly positive. 3. Overgeneralization. The individual tends to draw a sweeping conclusion about his or her ability, performance, or worth from one single experience or incident. A woman laid off from a job because of budgetary cuts may conclude that she is worthless.

Americans and Latinos, young people with nondivorced versus divorced parents, and those with stronger versus weaker religious/ spiritual orientation.

Source: Noveck & Tompson (2007).

schema a cognitive framework that helps organize and interpret information

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4. Magnification and minimization. The individual tends to exaggerate (magnify) limitations and difficulties and play down (minimize) accomplishments, achievements, and capabilities. Asked to evaluate personal strengths and weaknesses, the person lists many shortcomings or unsuccessful efforts but finds it almost impossible to name any achievements. People with low self-esteem may have experienced much disapproval in the past from significant others, such as parents. Their parents or significant others may have responded to them by punishing failures and not rewarding successes or by holding unrealistically high expectations or standards, as in the following case.

Case Study Paul was a twenty-year-old college senior majoring in chemistry. He first came to the student psychiatric clinic complaining of headaches and a vague assortment of somatic problems. Throughout the interview, Paul seemed severely depressed and unable to work up enough energy to talk with the therapist. Even though he had maintained a B+ average, he felt like a failure and was uncertain about his future. His parents had always had high expectations for Paul, their eldest son, and had transmitted these feelings to him from his earliest childhood. His father, a successful thoracic surgeon, had his heart set on Paul’s becoming a doctor. The parents saw academic success as very important, and Paul did exceptionally well in school. Although his teachers praised him for being an outstanding student, his parents seemed to take his successes for granted. In fact, they often made statements such as “You can do better.” When Paul failed at something, his parents would make it obvious to him that they not only were disappointed but also felt disgraced. This pattern of punishment for failures without recognition of successes, combined with his parents’ high expectations, led to the development of Paul’s extremely negative self-concept.

Evidence of a link between cognition and depression comes from studies of memory bias. When people with depression are given lists of words that vary in emotional content, they tend to recall more negative words than do their control group counterparts. This may indicate a tendency to attend to, and remember, negative and depressing events (Mineka & Sutton, 1992). Even individuals who have recovered from depression show a greater tendency toward negative cognitive styles than is found among individuals who have never been depressed (Hedlund & Rude, 1995). They presumably have developed negative schemas. Cognitive or perceptual bias was also found when individuals were asked to identify happy faces from a movie of morphed faces that varied in degrees of happiness (Joormann, 2006). Those with major depression, compared with nondepressed controls, required greater facial intensities to identify happy faces. Although the cognitive explanation of depression has merit, it seems too simple. At times, negative cognitions may be the result, rather than the cause, of depressed moods, as noted by Hammen (1985). That is, one may first feel depressed and then, as a result, have negative or pessimistic thoughts about the world. Hammen also found that a person’s schema tends to mediate the relationship between stress and depression. As discussed more fully later, stress can lead to depression if a person has developed a predisposing schema. Another criticism of cognitive explanations is that many people get depressed, but they do not feel depressed all the time. Yet negative cognitive styles are often hypothesized to be stable or enduring.

an acquired belief that one is helpless and unable to affect the outcomes in one’s life

learned helplessness

Cognitive-Learning Approaches: Learned Helplessness and Attributional Style Martin Seligman (1975; Nolen-Hoeksema, Girgus, & Seligman, 1992) proposed a unique view of depression based on cognitive learning theory. The basic assumption of this approach is that both cognitions and feelings of helplessness are learned and that depression is learned helplessness—an acquired belief that one is helpless and unable to affect the outcomes in one’s life. People who feel helpless make causal attributions, or speculations about why they are helpless. These attributions can be internal or external, stable or unstable, and global or specific.

Etiology of Unipolar Depression

For instance, suppose that a student in a math course receives the same low grades regardless of how much he or she has studied. The student may attribute the low grades to internal or personal factors (“I don’t do well in math because I’m scared of math”) or to external factors (“The teacher doesn’t like me, so I can’t get a good grade”). The attribution can also be stable (“I’m the type of person who can never do well in math”) or unstable (“My poor performance is due to my heavy workload”). Additionally, the attribution can be global or specific. A global attribution (“I’m a poor student”) has broader implications for performance than a specific one (“I’m poor at math but good in other subjects”). Abramson, Seligman, and Teasdale (1978) believe that a person whose attributions for helplessness are internal, stable, and global is likely to have more pervasive feelings of depression than someone whose attributions are external, unstable, and specific. Attributions have been found to be associated with many aspects of life. Both the learned helplessness model and the attributional style approach have generated a great deal of research. There is evidence that people with depression make “depressive” attributions and feel that their lives are less controllable than others do (Raps, Peterson, Reinhard, Abramson, & Seligman, 1982). One study has also shown that negative self-appraisals by children can predict subsequent changes in level of depression (Hoffman, Cole, Martin, Tram, & Seroczynski, 2000). Cognitions and attributions may be important factors in depression, but the disorder is complex; current models tend to include or explain only particular facets of depression (Dubovsky & Buzan, 1999; Hammen, 1985). Helplessness theory and attributions may explain only a certain type of depression (Abramson, Metalsky, & Alloy, 1989; DeVellis & Blalock, 1992). Interestingly, Lewinsohn, Joiner, and Rohde (2001) have comparatively tested the cognitive theories of Beck and Seligman. Both theories propose a diathesis-stress process. The diathesis involves vulnerability because of negative cognitions (Beck) or pessimistic attributional styles (Seligman). The vulnerability in the presence of stress (negative life events) results in depression, according to each theory. In a longitudinal study of adolescents, the investigators assessed (at Time 1) dysfunctional attitudes and negative attributional styles, as well as depressive symptoms, stressful life events, nondepressive diagnoses, past and family history of depression, and gender. Another assessment was conducted a year later (Time 2). The researchers wanted to find out which cognitive theory could better predict the onset of depression from Time 1 to Time 2. They wanted to control for initial level of depression (Time 1), family history of depression, and gender, because these three factors have been found to be related to the subsequent development of depression. Furthermore, it was important to assess nondepressive diagnosis because, according to both theories, the cognitive diathesis and stress should influence depression specifically, not just any disorder. Results tended to support Beck’s theory over that of Seligman. High levels of negative cognitions coupled with stress predicted subsequent depression. Negative attributional style did not result in greater depression at high levels of stress. Only at low levels of stress did negative attributional styles predict depression (which is somewhat counterintuitive). The diathesis-stress models did not predict nondepressive disorders. Because this was a first comparative test of the two theories, further tests are necessary, using different measures and participant samples.

Social Dimension As noted earlier, some investigators, such as Lewinsohn, have found that stress significantly affects the occurrence of depressive disorders. Also mentioned was the fact that exposure to chronic injections of the hormone corticosterone, which is believed to simulate chronic stress, resulted in depressive-like behaviors in rats (Kalynchuk et al., 2004). Because stress has been primarily associated with interpersonal situations, we focus on stress from social situations. Stress and Depression The importance of stress, especially stress that is interpersonal in nature, has been demonstrated for depression (Hammen, 2006). In a study of individuals’ self-reports of daily stress and depressive moods, stressors

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LEARNED HELPLESSNESS AND DEPRESSION According to Seligman, feelings of helplessness can lead to depression. However, if people can control their environment and believe in their ability to succeed, they can begin to lead productive lives again. California Angels’ one-handed baseball pitcher Jim Abbott fought feelings of helplessness and won his battle with depression. In Seligman’s theory, what can be done to alter feelings of helplessness?

Did You Know?

M

ore people are becoming depressed, especially in western countries. Why is this so? Seligman and his colleagues (Seligman, Reivich, Jaycox, & Gillham, 1995) argue that changes in the depression rate were affected by two cultural shifts in the 1960s and 1970s: a movement to achieve higher levels of personal satisfaction and freedom and a movement away from causes greater than the self (for example, parenthood, community, and God). As the self becomes more important, individuals have difficulty finding meaning in their lives and are more prone to depression.

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such as dependency (that is, having to depend on others) and interpersonal problems (such as having an argument with someone) tended to occur just before the onset of depressive symptoms (Stader & Hokanson, 1998). Other studies have shown that severe psychosocial stress, such as the death of a loved one, a lifethreatening medical condition, or frustration of major life goals, often precedes the onset of major depression (Brown & Harris, 1989; Lewinsohn, Hoberman, & Rosenbaum, 1988; Mazure, 1998; Paykel, 1982). Stress also appears to be important in relapse—the recurrence of depression after treatment (Krantz & Moos, 1988; Lewinsohn, Zeiss, & Duncan, 1989). These findings have led investigators to ask what kinds of stress lead to depression. Brown and Harris (1989) concluded that (1) severity is important. One severe stressor is more likely to cause depression than several minor stressors. In other words, several minor stressors do not seem to have the same effect as one very serious stressor. Moreover, in a survey of respondents in a study of stress and depressive symptoms, McGonagle and Kessler (1990) classified stress according to (2) chronicity. Chronic stress was defined as beginning more than twelve months before the study; acute stress was defined as stress beginning within twelve months of the study. The investigators found that chronic stress was more highly related to depression than was acute stress, even though respondents rated both types of stress as equally severe. Perhaps stress that persists for a long time is viewed as being uncontrollable and stable. There is also evidence that time of (3) onset, or when stress is experienced, is important. Experiences occurring during childhood may affect depression in later life. Harsh discipline in childhood is associated with levels of depression among people who experience a major depressive episode (Lara, Klein, & Kasch, 2000). Thus vulnerability may arise from early experiences in the family. Finally, the particular (4) type of stress is important to consider. For example, stressors such as loss and humiliation are associated with depression, whereas others, such as exposure to dangerous events, are more likely to be associated with anxiety (Kendler, Hettema, Butera, Gardner, & Prescott, 2003). Why do some people who encounter stress develop depression, whereas others do not? People may differ in their degrees of vulnerability to depression. The vulnerability may be caused by biological factors, psychosocial factors, or both. Hammen, Davilla, Brown, Ellicott, and Gitlin (1992) argue that the relationship between stress and depression is complex and interactive. In a longitudinal study of people with unipolar depression, the investigators found evidence that having dysfunctional parents who create stressful conditions in the family may influence an individual’s vulnerability to stress. Individuals from such families may fail to acquire adaptive skills and positive self-images, which in turn brings on more stress, which can trigger depression. Not only does stress cause depression, but depression can also cause stress. Hammen (2006) has found that individuals who are depressed, compared with those who are nondepressed, are more likely to have stressors that are within their control (for example, initiating an argument) rather than outside of their control (for example, cancer occurring in a sibling). She believes that depressed persons may create and generate stress for themselves. Thus the research suggests that stress and depression are bidirectional. Finally, stress itself may activate a genetic predisposition for depression. Having a gene for depression may not cause depression. Rather, certain hereditary and environmental influences (for example, stress) in combination can elicit major depression (Caspi et al., 2003). This explanation can also account for the facts that people with genetic predispositions may not show major depression (a certain stressor is absent) and that individuals encountering the same stressors as a depressed person do not suffer from depression (they do not have the hereditary predisposition). Adequate social support or resources may act as a buffer against depression when we are exposed to stress. To study the role of social resources in stress and depression, Holahan and Moos (1991) collected data on individuals at the beginning and end of a four-year period. Information was included on personality characteristics, family support (such as helpfulness of family members), stress, and depression. At the end

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MAJOR STRESSORS AND DEPRESSION Stress can lead to depression. The frustration of major life goals, financial insecurity, loss of social supports and relationships often precede depression. Here, people line up to attend a job fair in New York. New York’s financial community, hit by the subprime mortgage crisis, has suffered thousands of layoffs in 2008.

of the four-year period, persons with positive personality traits and family support had less depression than those without these characteristics, even when initial level of depression (during year one) was controlled. The researchers speculated that personal or family resources help individuals cope and adjust to stress. A ten-year follow-up of clients with depression (Moos, Cronkite, & Moos, 1998) showed that social resources (such as more helpful friends, fewer family arguments, and sharing activities with friends) were important in remission. Further evidence of the effects of social support was found in a study of gay men at risk for AIDS (Hays, Turner, & Coates, 1992), which assessed their levels of depression, social supports, and HIV-related symptoms over a one-year period. Results indicated that men who were more satisfied with their social supports were subsequently less likely to suffer from depression. Social supports that are more than just “psychological” and that meet specific needs (e.g., financial support) are especially beneficial in depression (Knowlton & Latkin, 2007).

Sociocultural Dimension Sociocultural factors include the influence of culture, race and ethnicity, institutions, social systems, social class and status, and group membership on depression. A number of sociocultural factors have been found to be related to depression. They include socioeconomic factors, culture, race and ethnicity, and gender. For example, individuals in communities that have high rates of poverty and that experience high social disorder, including delinquency and drug use, have increased risk for depression (Cutrona et al., 2005). Cultural Differences in Symptoms and Treatment As noted by Kleinman (2004), culture influences the nature of depressive symptoms, the idioms used to report them, decisions about treatment, doctor-patient interactions, the likelihood of outcomes such as suicide, and the practices of professionals. Consequently, some conditions are universal and some culturally distinct, but all are meaningful within particular contexts. People from different cultures differ in the extent to which they display the symptoms listed in DSM-IV-TR. In some cultures, depression may be experienced largely in somatic or bodily complaints, rather than in sadness or guilt. Complaints of “nerves” and headaches (in Latino and Mediterranean cultures), of weakness, tiredness, or “imbalance” (in Chinese and Asian cultures), of problems of the “heart” (in Middle Eastern cultures), or of being “heartbroken” (among the Hopi) may reveal the depressive experience (American Psychiatric Association, 2000a).

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CULTURAL DIFFERENCES IN SYMPTOMS AND TREATMENT People from different cultures differ in the extent to which they display the symptoms listed in DSM-IV-TR for disorders. Chinese people with depression often exhibit somatic or bodily complaints instead of depressive symptoms, such as sadness and depression. Chinese medicine and acupuncture, not psychotherapy, are often the preferred forms of treatment for this disorder. Are such treatments effective?

Cross-cultural studies of mood disorders have found that prevalence rates and manifestation of symptoms vary considerably among different cultural groups and societies (Goodwin & Guze, 1984). For example, Native Americans and Southeast Asians living in the United States appear to have higher rates of depression than are found among other Americans (Chung & Okazaki, 1991; Vega & Rumbaut, 1991). Why do reactions and symptoms differ from culture to culture? Some insight into this question was gained from a study by Greenberger, Chen, Tally, and Dong (2000). The investigators compared the correlates of depressed mood among adolescents in China and the United States. In both cultures, “culture general” stressors such as parents’ illness and family economic losses had similar effects on depressed mood. Cultural differences emerged for other variables. For instance, the correlations between depressed mood and poor relationships with parents, as well as poorer academic achievement, were higher for Chinese than for Americans, perhaps reflecting the Chinese cultural emphasis on family and achievements. Culture may even turn out to create distinctive environments for gene expression and physiological reaction in depression (Kleinman, 2004). Already, research has shown that one’s ethnicity is related to the way antidepressant drugs are metabolized in the body. Gender and Depression Besides culture, other important sociocultural factors, such as gender, have been associated with depression. Depression is far more common among women than among men, regardless of region of the world, race and ethnicity, or social class (Strickland, 1992). Although men and women have about the same rate of bipolar disorder, women’s rates of major depression are twice as high as those for men (Kessler, 2003). In addition, women are more likely than men to be seen in treatment and to be diagnosed with depression. Other explanations for this finding are noted in Table 11.4. First, women may simply be more likely than men to seek treatment when depressed; this tendency would make the reported depression rate for women higher, even if the actual male and female rates were equal. Second, women may be more willing to report their depression to other people. That is, the gender differences may occur in self-reported behaviors rather than in actual depression rates. Third, diagnosticians or the diagnostic system may be biased toward finding depression among women (Caplan, 1995). And fourth, depression in men may take other forms and thus be given other diagnoses, such as substance dependency.

Etiology of Unipolar Depression

TA B L E

11.4

EXPLAINING THE FINDINGS THAT RATES OF DEPRESSION ARE HIGHER AMONG WOMEN THAN AMONG MEN THE GENDER DIFFERENCES ONLY APPEAR TO BE REAL BECAUSE

• • • •

Women may be more likely to seek treatment. Women may be more willing to report their depression to other people. Diagnosticians or the diagnostic system may be gender biased. Men may exhibit depression in different ways and may be given other diagnoses.

THE GENDER DIFFERENCES ARE REAL BECAUSE

• Genetic or hormonal differences between genders may account for higher depression levels among women. • Women are subjected to gender roles that may be unfulfilling and that limit occupational opportunities. • Gender roles may lead to feelings of helplessness. • Traditional feminine roles may be less successful at eliciting positive reinforcement from others, compared with traditional male roles, which foster assertive and forceful behavior. • Women may have been subjected to childhood traumas (sexual abuse, child abuse, neglect) that lead to depression.

These four possibilities may account for only part of the gender difference in depression. Evidence indicates that women do have higher rates of depression than men and that the differences are real rather than an artifact of self-reports or biases (Rieker & Bird, 2005). The higher rates seem to occur regardless of age, although the gender gap appears to be the greatest during reproductive years. Attempts to explain these differences have focused on physiological or social psychological factors. Biological factors, such as genetic or hormonal differences between the sexes, may account for the gender differences in depression. Heritability of depression appears to be higher among women than men, as noted earlier (Goldberg, 2006). Hormonal changes occur in women during puberty, premenstrual periods, pregnancy, and menopause. These changes may affect systems associated with depression (for example, the neurotransporter system or hypothalamic-pituitary-adrenal system), although little research has been conducted on these factors. Social or psychological factors have also been proposed, one of which is women’s traditional gender role. Women have been encouraged to present themselves as attractive, sensitive to other people, and passive in relationships (Strickland, 1992). This subservience to men, combined with a lack of occupational opportunities, may have produced more depression in women (Bernard, 1976). Women who fulfill the genderrole expectations may be more likely than men to experience lack of control in life situations. They may then attribute their “helplessness” to an imagined lack of personal worth. Interestingly, women who are not employed outside the home and who are raising children are particularly vulnerable to depression (Gotlib, 1992). The traditional feminine gender role behaviors (gentleness, emotionality, and self-subordination) may not be so successful in eliciting reinforcement from others as the assertive and more forceful responses typically associated with males. Finally, sexual and child abuse has been associated with depression in later life, which may affect women more than men. In a review of different explanations for the gender differences in rates of depression, Nolen-Hoeksema (1987) concluded that none truly accounts for the observed differences. She hypothesized that the way a person responds to depressed moods contributes to the severity, chronicity, and recurrence of depressive episodes. In her view, women tend to ruminate and amplify their depressive moods, and men tend to dampen or find means to minimize dysphoria. Nolen-Hoeksema (1991) found that when individuals tracked their depressed moods and responses to these moods for

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GENDER AND DEPRESSION Among the Amish, men and women appear to have similar rates of depression. Egeland and Hostetter (1983) believe that gender roles may affect depression rates. Gender roles, such as working together in the fields, are similar for Amish men and women and may account for the lack of gender differences in rates of depression. What are the implications of the findings for a genetic or environmental explanation of depression?

one month, women were more likely than men to ruminate in response to depressed moods. Those who tended to ruminate had longer periods of depressed moods, and when tendency to ruminate was statistically controlled, gender differences in duration of depressed moods disappeared. Egeland and Hostetter (1983) also speculated that responses to depressive moods may affect observed rates of depression. In their study of an Amish religious community in Pennsylvania, they found that males and females have the same rates of depression. The researchers noted that because Amish men do not show alcoholism or antisocial behaviors, their depression cannot be masked. Additionally, Amish women, like the men, must work outside the home, so engaging in a sick (depressed) role is discouraged. Although role behavior may help explain some of the differences in rates of depression between women and men, it is not clear whether the explanation is enough to account for the vast differences that have been recorded. The findings suggest that some aspect of the environment may interact with a woman’s biology to account for the disproportionate incidence of depression among women (U.S. Surgeon General, 1999).

Treatment for Unipolar Depression What can be done to alleviate depression? We now turn to various treatment tactics aimed at depression.

Myth vs Reality Myth: Saint John’s wort has been proven to be effective in alleviating depression. Reality: Saint John’s wort (Hypericum perforatum plant) has been popularly used by consumers to treat depression. It can be found in the herbal supplement section of most pharmacies in the United States. Despite its popularity, little rigorous research has been conducted to establish its effectiveness or possible side effects. Research, primarily in Germany, has obtained positive results in alleviating mild to moderate depression with only mild gastrointestinal side effects. However, most of these studies have had methodological weaknesses, and basic questions concerning the mechanisms of action of the substance remain (U.S. Surgeon General, 1999). The National Center for Complementary and Alternative Medicine (2007) considers St. John’s wort to be an unproven treatment for depression.

Treatment for Unipolar Depression

Biomedical Treatments for Depressive Disorders Biomedical treatments are interventions that alter the physical or biochemical state of the patient. They include the use of medication and electroconvulsive therapy. Medication According to the U.S. Surgeon General (1999), antidepressant medications are effective across the full range of severity of depressive episodes, although effectiveness is greater with less severe depressive episodes. There are four kinds of antidepressant medication: tricyclic antidepressants (TCAs), heterocyclic antidepressants (HCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors (SSRIs). Each medication is designed to heighten the level of a target neurotransmitter at the neuronal synapse. This heightening can be accomplished by (1) boosting the neurotransmitter’s synthesis, (2) blocking its degradation, (3) preventing its reuptake from the synapse, or (4) mimicking its binding to postsynaptic receptors. For example, TCAs (for example, Elavil, or amitriptyline) seem to block the reuptake of norepinephrine, thereby leaving more norepinephrine at the synapses. These higher levels of residual norepinephrine seem to be linked with reduced depressive symptoms. The tricyclics, however, may cause side effects. Reactions include drowsiness, insomnia, agitation, fine tremors, blurred vision, dry mouth, and reduced sexual ability. MAOIs (e.g., Nardil, or phenelzine) also work by increasing the levels of norepinephrine at the brain synapses. Rather than blocking reuptake as the tricyclics do, the MAOIs prevent the MAO enzyme (which is normally found in the body) from breaking down norepinephrine that is already available at the synapse. Both MAOIs and tricyclic antidepressants may act in ways more complicated than previously believed. There is growing suspicion that these drugs may affect not only the levels of neurotransmitters at synapses but also the sensitivity of receptors on the receiving (postsynaptic) neurons. MAOIs are currently prescribed for patients with depression who have not responded well to treatment with tricyclics. But MAOIs also have many side effects, including insomnia, irritability, dizziness, constipation, and impotence. The most serious side effect, however, is tyramine-cheese incompatibility. One normal function of the MAO enzyme is to break down tyramine, a substance found in many cheeses, as well as in some beers, wines, pickled products, and chocolate. Because the MAOIs interfere with this function, people using these drugs must severely restrict their intake of tyramine. Failure to do so triggers the tyramine-cheese reaction, which begins with increased blood pressure, vomiting, and muscle twitching and can, if untreated, result in intracranial bleeding, followed by death. Such side effects are a major drawback of these antidepressant drugs, and careful monitoring of the patient’s reactions is thus absolutely necessary. Another drawback is that these antidepressant drugs are essentially ineffective during the first two weeks of use, which is a serious concern, particularly in cases in which suicide is a danger. As mentioned earlier, the effectiveness of antidepressant drugs may be caused by changes in the sensitivity of postsynaptic receptors. These changes in sensitivity, however, seem to require a couple of weeks to develop. Tricyclics and MAOIs were used primarily from the 1960s through the 1980s. They have subsequently fallen out of favor because of their side effects. SSRIs, which block the reuptake of serotonin, are now increasingly popular. The SSRIs include the drugs Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline). They seem to have fewer side effects and to be at least as effective as the other tricyclics. In fact, SSRIs are “favored” as the first-line medication for depression because of their ease of use, more manageable side effects, safety in overdose, and cost (U.S. Surgeon General, 1999). Many patients report much relief after taking the medication. However, it should be noted that SSRIs, as well as other drugs used to treat mood disorders, restore functioning of patients but may not “cure” them (Delgado & Gelenberg, 2001). One issue that has recently arisen over the use of certain SSRIs is whether suicide risk, especially among young people who take the drugs, is increased. Under investigation by the Federal Drug Administration is the charge that Paxil and other SSRIs can contribute to the number of young people committing suicide (Berenson, 2006).

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critical thinking

Should We Increasingly Turn to Drugs in the Treatment of Depression?

I

n October 2004, the Food and Drug Administration (FDA) warned physicians, patients, and the general public about the increased risk of suicide, particularly among children and teenagers, following the initiation of antidepressant treatment (Berenson, 2006). It ordered drug companies to add strong warnings to labels of antidepressants. Some feel that society is overly medicated because we have drugs for all sorts of conditions and people use medications, perhaps too freely. Others argue that medications have freed patients from the long hospital stays found in the past and that newer medications have been increasingly effective in treatments. What kinds of factors must be considered in addressing the question of whether people should take antidepressant medications? Try to answer the following questions. First, how prevalent is depression? Effective treatment must be found, especially for disorders that are very common versus those that rarely occur. Second, is depression a significant disorder that has serious consequences? Third, how effective is the treatment, and what are side effects from the treatment? Obviously, if treatment is not effective

or has major side effects, its value decreases. Fourth, is the treatment readily available and relatively inexpensive? All of these factors must be considered before recommending a particular treatment. With respect to the third question concerning side effects, one study with more than sixty-five thousand patients examined the risk of suicide after antidepressant medication was used to treat patients (Simon, Savarino, Operskalski, & Wang, 2006). Suicide attempts and deaths were analyzed before and after treatment. Results indicated that the risk of suicide was highest in the month preceding treatment, and there was no evidence that the risk increased after treatment started. Such a finding applies not only to drug treatment but also to psychotherapy (Simon & Savarino, 2007). Another study examined suicide rates for children and adolescents before and after the FDA warning about possible suicide risks following the use of SSRI drugs. The study found that prescriptions for SSRI drugs decreased whereas the suicide rate increased for children and youths after the FDA warning (Gibbons et al., 2007).

Electroconvulsive Therapy Electroconvulsive therapy (ECT) is generally reserved for patients with severe unipolar depression who have not responded to antidepressant medications. Also known as electroshock therapy, ECT is a treatment that consists of applying a moderate electrical voltage to the person’s brain for up to half a second. The patient’s response to the voltage is a convulsion (seizure) lasting thirty to forty seconds, followed by a five- to thirty-minute coma. Most patients with serious depression show at least a temporary improvement after about four ECT treatments (Campbell, 1981). The ECT mechanism is not fully understood; it may operate on neurotransmitters at the synapses, as do antidepressants. Some of the decrease in symptoms may also be due to the amnesia that develops for a short time after the treatment. One major advantage of ECT is that the response to treatment is relatively fast (Gangadhar, Kapur, & Kalyanasundaram, 1982). In fact, many clinicians believe that ECT is the most rapid and effective treatment for major depressive episodes (Weiner & Krystal, 2001), and the U.S. Surgeon General (U.S. Surgeon General, 1999) considers ECT among those treatments that are effective for severe depression. However, the treatment is not without side effects, including headaches, confusion, and memory loss. And many patients are terrified of ECT. In about one of every thousand cases, serious medical complications occur (Goldman, 1988). For these and other reasons, ECT is controversial, and critics have urged that it be banned as a form of treatment.

Psychotherapy and Behavioral Treatments for Depressive Disorders Because the use of antidepressant medication or ECT involves a number of disadvantages, clinicians have sought other approaches to either supplement or replace medical treatment of depression. A variety of psychological forms of treatment have been used, such as psychoanalysis, behavior therapy, group psychotherapy, and family therapies—all with some success. Treatment strategies reflect the theoretical orientation of the therapists. For example, psychodynamic therapists attempt to help their clients gain insight into

Treatment for Unipolar Depression

unconscious and unresolved feelings of separation or anger. To this end, the therapist interprets the client’s free associations and reports of dreams, resistances, and transferences (see Chapter 2). Psychodynamic therapies of depression have not been rigorously studied, but some investigations suggest that brief dynamic therapy appears to be effective in reducing the depressive symptoms of patients (Gabbard, 2001). In contrast to psychodynamic therapists, behavioral therapists may believe that reduced reinforcement is responsible for depression. They would attempt to teach clients to increase their exposure to pleasurable events and activities and to improve their social skills and interactions. One type of behavioral treatment, called behavioral activation, has been shown in one study to be as efficacious as medication and more efficacious than cognitive therapy (Dimidjian et al., 2006). Two types of treatment—interpersonal psychotherapy and cognitive-behavioral therapy—have been intensively examined for their effectiveness in depressive disorders. There is evidence that these two treatments are effective (and in some studies just as beneficial as, or more so than, antidepressant medications), particularly in the treatment of less severe cases of unipolar depression (Cardemil & Barber, 2001; Dubovsky & Buzan, 1999; Hollon, Stewart, & Strunk, 2006; President’s New Freedom Commission on Mental Health, 2003). Interpersonal Psychotherapy Interpersonal psychotherapy is a short-term, psychodynamic-eclectic (i.e., based on psychodynamic procedures but flexible in the use of therapeutic techniques) type of treatment for depression. It targets the client’s interpersonal relationships and uses strategies found in psychodynamic, cognitivebehavioral, and other forms of therapy (Klerman, Weissman, Rounsavelle, & Chevron, 1984). The assumptions underlying interpersonal psychotherapy are that depression occurs within an interpersonal context and, accordingly, that interpersonal relationship issues must be addressed. The focus is on conflicts and problems that occur in these relationships. Clients gain insight into conflicts in social relationships and strive to change these relationships. For example, by improving communications with others, by identifying role conflicts, and by increasing social skills, clients come to find relationships more satisfying and pleasant. Although interpersonal psychotherapy resembles psychoanalysis and psychodynamic approaches in acknowledging the role of early life experiences and traumas, it is oriented primarily toward present, not past, relationships. Cognitive-Behavioral Therapy As its name implies, cognitive-behavioral therapy combines cognitive and behavioral strategies. The cognitive component involves teaching the patient the following (Beck, Rush, Shaw, & Emery, 1979): • To identify negative, self-critical thoughts (cognitions) that occur automatically • To note the connection between negative thoughts and the resulting depression • To carefully examine each negative thought and decide whether it can be supported • To try to replace distorted negative thoughts with realistic interpretations of each situation Cognitive therapists believe that distorted thoughts cause psychological problems such as depression and that changing the distorted thoughts can eliminate the depression. At the outset of the cognitive therapy, the client is usually asked to begin monitoring his or her negative thoughts and to list them on a chart. It is important for the client to include all the thoughts and emotions associated with each distressing event that takes place each day. In an intensive study, clients suffering from depression were randomly assigned to one of four treatment conditions for four months: interpersonal psychotherapy, cognitive-behavioral therapy, imipramine (a tricyclic drug) plus clinical management, and pill-placebo plus clinical management (Elkin, 1994; Elkin et al., 1995). Imipramine was included in the design because its effectiveness has been studied

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and because the other treatments could be compared with it. The imipramine and pill-placebo conditions were paired with clinical management (in which minimal supportive therapy was provided) because of the ethical need to provide some therapy for clients in the pill-placebo and imipramine conditions. Results indicated that, in general, the interpersonal psychotherapy, cognitive-behavioral, and imipramine treatments were equally effective in reducing depression. All were significantly more effective than the pill-placebo condition. However, specific effects were influenced by the initial severity of disturbance. In addition, many of the clients who showed major improvement at the end of treatment (regardless of treatment condition) had relapsed and were suffering from depression again eighteen months following treatment. Thus interpersonal psychotherapy, cognitive-behavioral therapy, and imipramine all appear to be effective, although some of the effects diminish over time. Hollon, DeRubeis, and Seligman (1992) found that cognitive therapy may reduce the risk of episodes of depression occurring after treatment. Clients treated with cognitive therapy were less likely to develop subsequent symptoms of depression than were clients treated pharmacologically. The researchers believe that cognitive changes in explanatory styles and attributions among the clients in cognitive therapy may help prevent depressive symptoms. In fact, cognitive-behavioral techniques have been used in prevention programs. Munoz and his colleagues (1995) found that teaching cognitive-behavioral skills can be helpful in preventing depression. Indeed, the majority of programs that attempt to prevent depression have been cognitive-behavioral in orientation. The reason is not that other approaches cannot be effective. Rather, cognitive-behavioral orientations have been shown to be effective and can be used as an intervention for many people at the same time (Cardemil & Barber, 2001). In a review of depression-focused psychotherapies, Thase (2001) notes that behavioral, cognitive, and interpersonal therapies share common features: they are nontraditional (the focus is not on the unconscious) and short term in nature (two to four months of treatment), and their theoretical models of depression are linked with intervention tactics. These three therapies have demonstrated their effectiveness and practicality in the treatment of mild to moderately severe depressive disorders. Both psychotherapy and drug therapy are effective, with some evidence that antidepressant medications may be particularly advantageous with severe cases of depression (Lambert & Ogles, 2004). However, cognitive and behavioral treatments have enduring effects that reduce risk for subsequent symptom return following treatment. That is, the effects of psychological treatments tend to last, whereas medications relieve depression only during active treatment (Hollon et al., 2006). The kinds of changes in cognitive treatment (modifying schemas, correcting negative thoughts, cognitive restructuring) may enable patients to think differently, even after treatment has been terminated. Cognitive-behavioral treatment has also not only demonstrated reductions in symptoms but also shown effects in brain changes. After cognitive-behavioral treatment, the functioning of limbic and cortical regions of patients’ brains was changed, as revealed in PET scans (Goldapple et al., 2004). These affected brain sites are also affected after drug treatment using an SSRI such as paroxetine. Finally, neuronal changes in the brain were found to vary as a function of favorable or unfavorable responders to cognitive-behavioral treatment (Siegle, Carter, & Thase, 2006). Thus cognitive changes influence brain processes, and brain processes influence cognitions. Our understanding of how psychological treatments work must include cognitive, behavioral, emotional, and brain structure elements. There do appear to be advantages in combined treatments that involve medication and psychotherapy. Medication tends to produce rapid and reliable reductions in symptoms among chronic or severely depressed patients, and psychotherapy can enhance social functioning or reduce subsequent risk and relapse (Friedman et al., 2004; Hollon & Fawcett, 2001). Furthermore, research has indicated that if patients do not show significant improvement with one type of medication, they may respond to other types (Rush et al., 2006). This increases the overall effectiveness of medications.

Bipolar Disorders

Bipolar Disorders Earlier we defined mood disorders as disturbances in emotions that cause subjective discomfort, hinder a person’s ability to function, or both. Up to this point, we have discussed unipolar depression, in which only depression occurs. In this section, we discuss bipolar disorder, in which depression is usually accompanied by mania.

Symptoms and Characteristics of Bipolar Disorders As in depression, symptoms of bipolar disorders can be seen in four domains: affective, cognitive, behavioral, and physiological. Affective Symptoms In mania, affective symptoms include an elevated, expansive, or irritable mood. Social and occupational functioning is impaired, as shown in the following case.

Case Study Alan was a forty-three-year-old unmarried computer programmer who had led a relatively quiet life until two weeks before, when he returned to work after a short absence for illness. Alan seemed to be in a particularly good mood. Others in the office noticed that he was unusually happy and energetic, greeting everyone at work. A few days later, during the lunch hour, Alan bought a huge cake and insisted that his fellow workers eat some of it. At first everyone was surprised and amused by his antics. But two colleagues working with him on a special project became increasingly irritated because Alan didn’t put any time into their project. He just insisted that he would finish his part in a few days. On the day the manager had decided to tell Alan of his colleagues’ concern, Alan behaved in a delirious, manic way. When he came to work, he immediately jumped onto a desk and yelled, “Listen, listen! We aren’t working on the most important aspects of our data! I know, since I’ve debugged my mind. Erase, reprogram, you know what I mean. We’ve got to examine the total picture based on the input!” Alan then spouted profanities and made obscene remarks to several of the secretaries. Onlookers thought that he must have taken drugs. Attempts to calm him down brought angry and vicious denunciations. The manager, who had been summoned, also couldn’t calm him. Finally the manager threatened to fire Alan. At this point, Alan called the manager an incompetent fool and stated that he could not be fired. His speech was so rapid and disjointed that it was difficult to understand him. Alan then picked up a chair and said he was going to smash the computers. Several coworkers grabbed him and held him on the floor. Alan was yelling so loud that his voice was quite hoarse, but he continued to shout and struggle. Two police officers were called, and they had to handcuff him to restrain his movements. Within hours, he was taken to a psychiatric hospital for observation.

People with mania, like Alan, show boundless energy, enthusiasm, and self-assertion. If frustrated, they may become profane and quite belligerent, as he did. Cognitive Symptoms Cognitive symptoms of mania include grandiosity, flightiness, pressured (or intrusive) thoughts, lack of focus and attention, and poor judgment. The verbal processes of patients with mania reflect their cognitive state. For example, their speech is usually quite accelerated and pressured. They may change topics in mid-sentence or utter irrelevant and idiosyncratic phrases. Although much of what they say is understandable to others, the accelerated and disjointed nature of their speech makes it difficult to follow their train of thought. They seem incapable of controlling their attention, as though they are constantly distracted by new and more exciting thoughts and ideas. Behavioral Symptoms In terms of behavioral symptoms, individuals with mania are often uninhibited, engaging impulsively in sexual activity or abusive discourse. Two levels of manic intensity have been recognized—hypomania and mania (American Psychiatric Association, 2000a). In the milder form, hypomania-affected people seem to be “high” in mood and overactive in behavior. Their judgment is usually poor, although delusions are rare. They start many projects but complete few, if any. When they interact with others, people with hypomania dominate the conversation and are often grandiose.

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People who suffer from mania display more disruptive behaviors, including pronounced overactivity, grandiosity, and irritability. Their speech may be incoherent, and they do not tolerate criticism or restraints imposed by others. In the more severe form of mania, the person is wildly excited, rants, raves (the stereotype of a raving “maniac”), and is constantly agitated and on the move. Hallucinations and delusions may appear. Because these individuals may be uncontrollable and are frequently dangerous to themselves or to others, physical restraint and medication are often necessary. Physiological Symptoms The most prominent physiological or somatic symptom is a decreased need for sleep, accompanied by high levels of arousal. The energy and excitement these patients show may cause them to lose weight or to go without sleep for long periods. Whereas hypomania is not severe enough to cause marked impairment or hospitalization, the mood disturbance in mania is sufficiently severe to cause marked impairment in social or occupational functioning.

Classification of Bipolar Disorders In DSM, the essential feature of bipolar disorders is the occurrence of one or more manic or hypomanic episodes; the term bipolar is used because the disorders are usually accompanied by one or more depressive episodes. Criteria for diagnosing bipolar disorder in DSM specify that manic episodes last at least one week in the case of mania and four days in the case of hypomania. Bipolar disorders include subcategories that describe the nature of the disorder. Bipolar I subcategories include single manic episode, most recent episode hypomanic, most recent episode manic, most recent episode mixed, most recent episode depressed, and most recent episode unspecified. Bipolar II disorder includes recurrent major depressive episodes with hypomania. Persons in whom manic but not depressive episodes have occurred are extremely rare; in such cases, a depressive episode will presumably appear at some time. Table 11.5 lists the general criteria for mania. One specifier for bipolar disorders is whether the manic or depressive episodes have occurred four or more times during the previous twelve months. Such episodes may appear with periods of relative normality in between. In some cases, there may be only partial remission in between the episodes. One patient was reported to demonstrate manic behaviors for almost exactly twenty-four hours, immediately followed by depressive behaviors for twenty-four hours. At the manic extreme, the TA B L E

11.5

GENERAL CRITERIA FOR MANIA (CLASSIFICATION INTO BIPOLAR I OR II DEPENDS ON THE SPECIFIC OCCURRENCE OF MANIA, HYPOMANIA, AND DEPRESSION) A. A period of abnormally and persistently elevated or irritable mood, lasting for at least 1 week. B. During this period, three (or more) of the following symptoms occur: 1. inflated self-esteem or grandiosity 2. little sleep (e.g., feels rested after only 3 hours of sleep) 3. more talkative and pressured speech 4. flight of ideas or perceptions that thoughts are racing 5. easily distracted 6. increase in goal-directed activity or psychomotor agitation 7. unusual involvement in pleasing activities that can lead to undesirable consequences (e.g., engaging in outrageous buying sprees, sexual indiscretions, or reckless business investments) C. Marked impairment in occupational or social functioning Source: Adapted from American Psychiatric Association (2000a).

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patient was agitated, demanding, and constantly shouting; the next day, he was almost mute and inactive. The alternating nature of the disorder lasted eleven years (Jenner et al., 1967). Typical manic episodes appear suddenly and last from a few days to months. Depressive episodes tend to last longer.

Prevalence of Bipolar Disorders A large-scale national survey of bipolar disorders was conducted in order to determine prevalence rates (Merikangas, 2007). The twelve-month and lifetime prevalence rates were 0.6 percent and 1.0 percent, respectively, for bipolar I, and 0.8 percent and 1.1 percent, respectively, for bipolar II (see Figure 11.1). Thus bipolar disorders are less prevalent than major depression. Unlike depression, there appear to be no major overall gender differences in the prevalence of bipolar disorders (Dubovsky & Buzan, 1999). If differences do exist, they do not appear to be very marked (Merikangas, 2007), especially in comparison with gender differences for unipolar depression. Interestingly, although bipolar disorders are much less prevalent than unipolar depression, their costs are high. Bipolar disorder was associated with 65.5 annual lost workdays per ill worker and major depressive disorder with 27.2. The higher work loss was due to more severe and persistent depressive episodes in those with bipolar disorder than in those with major depressive disorder (Kessler et al., 2006). Furthermore, the course of bipolar disorder is characterized by frequent relapse and recurrence (Hollon, Stewart, & Strunk, 2006). Comorbidity is high (Leahy, 2007) because bipolar disorder is commonly associated with other medical conditions (heart disease, hypertension, diabetes, and so forth) and mental health problems (anxiety, smoking, drug abuse, suicides, and so forth). Some people have hypomanic episodes and depressed moods that do not meet the criteria for major depressive episode. If the symptoms have been present for at least two years, the individuals are diagnosed with cyclothymic disorder. (For children and adolescents, one year rather than two years is the criterion.) As in the case of dysthymia, cyclothymic disorder is a chronic and relatively continual mood disorder in which the person is never symptom free for more than two months. With lifetime prevalence between 0.4 and 1 percent, cyclothymia is less common than dysthymia. The risk that a person with cyclothymia will subsequently develop a bipolar disorder is 15 to 50 percent (American Psychiatric Association, 2000a).

Did You Know?

M

ichelangelo, Van Gogh, Tchaikovsky, F. Scott Fitzgerald, Ernest Hemingway, and Walt Whitman all experienced mood disorders. We do not know why an association between artists and mood disorders occurs, although it should be noted that most people with mood disorders are not especially creative. Perhaps the elevated energy, expansiveness, and uninhibited mood may contribute to productivity and novel ideas.

Comparison Between Depressive and Bipolar Disorders Several types of evidence seem to support the distinction between depressive (unipolar) and bipolar disorders (Dubovsky & Buzan, 1999; Goodwin & Guze, 1984). First, genetic studies have revealed that blood relatives of patients with bipolar disorders have a higher incidence of manic disturbances than do relatives of patients with unipolar disorders. In addition, stronger evidence of genetic or psychophysiological influences exists for bipolar disorders than for unipolar disorders. Second, the age of onset is somewhat earlier for bipolar disorders (the early twenties) than for unipolar disorders (the late twenties). Third, individuals with bipolar disorder display psychomotor retardation and a greater tendency to attempt suicide than do individuals with unipolar disorder, whose depressive symptoms often include anxiety. Fourth, bipolar disorders respond to lithium, whereas the drug has little effect on unipolar disorders. Finally, the prevalence of bipolar disorder is many times lower than that of major depression (see Figure 11.1).

Etiology of Bipolar Disorders As in the case of unipolar depression, a number of biological, psychological, social, and sociocultural theories have been proposed for bipolar disorders. The contribution of genetic factors to bipolar disorder is well established from twin, adoption, and family studies (Kato, 2007). For example, the concordance rates for bipolar disorders has been found to be 72 percent for identical (monozygotic—MZ) twins and 14 percent for fraternal (dizygotic—DZ) twins. The evidence suggests that heredity influences are important in bipolar disorders, and more strongly so than in unipolar

a chronic and relatively continual mood disorder in which the person is never symptom free for more than two months

cyclothymic disorder

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Did You Know?

E

xercise has been found to alleviate depression. Moderate to high-intensity workouts for thirty minutes two to four times a week are recommended (Stathopoulou, Powers, Berry, Smits, & Otto, 2006). They can also be used in conjunction with psychotherapy.

depression. However, the rate of bipolar disorders in the families of patients with unipolar depression is three to four times the rate in control families (Dubovsky & Buzan, 1999), and relatives of those with bipolar disorders have an increased chance of having not only bipolar disorders but also unipolar disorders (Faraone, Kremen, & Tsuang, 1990). These studies suggest that the two disorders are somehow related or under the influence of common factors. Some researchers believe, as in the case of unipolar depression, that bipolar disorders are caused by dysfunctions in neurotransmission. Tolmunen and his colleagues (2004) have found that mania was associated with elevated serotonin transporter availability and this availability declined with psychotherapy. However, among depressed controls, serotonin availability actually increased with psychotherapy. Others feel that dysregulation in the brain activation system results in inappropriate affect (Davidson et al., 2002). Consistent with a dysregulation model, Johnson and her colleagues (2000) found that individuals with bipolar disorders show elevated manic symptoms after experiencing goal-attainment life events (but not just any positive life events). They speculate that bipolar individuals cannot regulate motivation and that goal-attainment events trigger manic symptoms. In contrast, persons without the disorder tend to “coast” or decrease activation after these events. Behaviorists have made major contributions to the understanding of depression, but they and many other theorists have not really given much attention to mania. Although they acknowledge that biological factors may be important in bipolar disorders, Staats and Heiby (1985) believe that learning principles can contribute to the understanding of mania. They hypothesize that individuals may receive praise and admiration because of some behavior (such as performing well using social or interpersonal skills). The euphoria from receiving the praise may elicit further use of the skills, resulting in even more positive consequences. The behaviors then become accelerated, and euphoria increases even more—as in a manic state. At some point, however, the behaviors elicit negative reactions, which set up conditions for depression. In any case, much more is known about what causes unipolar depression than about what causes the bipolar disorders, and psychological-sociocultural perspectives focus primarily on depression rather than on mania. As indicated earlier, biological factors may play a more prominent role in the etiology of bipolar disorders than in unipolar disorders. Another possibility is that the category of unipolar disorders is more heterogeneous and that some of these disorders are caused by internal conditions within the organism, whereas others are caused by external precipitating events.

Treatment for Bipolar Disorders Although the drugs used for depressive disorders are also used for bipolar disorders (e.g., MAOIs and SSRIs), lithium and depakote are typically given to bipolar clients. Since it was introduced to the United States in 1969, lithium (in the form of lithium carbonate) has been the treatment of choice for bipolar and manic disorders. Response rates with lithium range from 60 to 80 percent in “classic” bipolar disorder (Delgado & Gelenberg, 2001). Lithium is also used as a mood-stabilizing drug to prevent or reduce future episodes of bipolar disorder (National Institute of Mental Health, 1985) and has an antisuicide effect (Goldberg, 2007). As noted, the manic phase of bipolar disorder may be caused by too much neurotransmitter (primarily norepinephrine) at brain synapses or by neurotransmitter dysfunction. Lithium decreases the total level of neurotransmitters in the synaptic areas by increasing the reuptake of norepinephrine into the nerve cells. Thus medication forms the core of treatment. Most patients are maintained indefinitely on lithium or other mood stabilizers to forestall symptom onset (especially mania), with antidepressants often included to deal with depressive symptoms (Hollon et al., 2006). The generally positive results achieved with lithium have been overshadowed somewhat by reports of distressing side effects (Dubovsky, Franks, Lifschitz, & Coen, 1982). The earliest danger signals are gastrointestinal complications (such as vomiting and diarrhea), fine tremors, muscular weakness, and frequent urination.

Treatment for Bipolar Disorders

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The more serious side effects, associated with excessive lithium in the blood, are loss of bladder control, slurred speech, blurred vision, seizures, and abnormal heart rate. Fortunately, accurate measurements of lithium blood levels are easily obtained, and dosages can be adjusted accordingly. Another problem associated with lithium is lack of patient compliance with the treatment program. For some reason, this problem is consistently worse with patients taking lithium for bipolar disorder than with any other group of patients taking any other drug. Patients with bipolar disorder often report that they have tried to adjust their lithium dosage by themselves so that they will experience the mania but not the depression of bipolar disorder. Unfortunately, lithium levels cannot be manipulated in this manner. When the dosage is decreased, the initial slightly manic state quickly OVERCOMING DEPRESSION Few people know that actor develops into either a severe manic state or depression. Some posi- Ben Stiller suffered from bipolar disorder, as did other tive results have been reported with anticonvulsant drugs, such as members of his family. Comedian Robin Williams also carbamazepine, valproate, lamotrigine, and gabapentin, in the treat- suffered from bouts of depression. ment of bipolar disorders. Although pharmacological treatments are often used in the treatment of bipolar disorders, psychotherapy and family therapy have also been helpful. For example, family-focused treatment involving psychosocial education about bipolar disorders, communication training, and problem-solving skills training were found to be a useDid You Know? ful adjunct to pharmacotherapy in decreasing the risk of relapse and hospitalizar. Norman Endler, a tion in patients with a bipolar disorder (Morris, Miklowitz, & Waxmonsky, 2007). prominent psychologist, had Finally, ECT has been successfully used with bipolar disorders. serious bouts of depression There is empirical evidence that psychoeducation, family-focused therapy, and mania. He offers advice to those interpersonal therapy, and cognitive-behavioral therapy reduce symptom severity, with bipolar disorder. (1) People prevent relapse, and enhance psychosocial functioning (Rizvi & Zaretsky, 2007). should seek treatment immediately Social rhythm therapy has also been successfully used. This treatment involves when they feel depressed. (2) Some the creation of routines in day-to-day life. Examples include setting daily times combinations of treatments, such for sleep, eating, and exercise in order to combat bodily rhythm changes (sleepas psychotherapy, antidepressants, ing and activity patterns) that may affect mood. Treatment adherence (e.g., foland ECT, may be effective. (3) A lowing through with treatment rather than dropping out) and selecting the most supportive family can help a person appropriate intervention at the different stages of a bipolar episode are critical survive this disorder. factors in the effectiveness of treatment. Finally, as noted by Hollon and colleagues (2006), teaching patients to detect early signs of a manic attack and to Source: From Endler (1982). seek prompt medical assistance have reduced the frequency of onset of full manic episodes, and interpersonal therapy has been found to reduce the frequency of depressive relapse.

D

We know that depression is relatively widespread and seriously affects people throughout the world. No single theory can adequately account for depression or bipolar disorder. Increasingly, researchers have proposed multipath explanatory models. They try to link genetic findings, brain-body functioning, and psychological, social, and sociocultural factors in mood disorders. For example, genetic predisposition coupled with critical early life stress and subsequent life experiences seems to affect depression. The interactions of various factors is also evident in the mind-body relationship found in studies that show changes in physiological and brain functioning indicators as a result of psychotherapy. The complexities in finding the causal linkages in depression are complicated by the real possibility that many different factors can cause depression and that depression may be a group of heterogeneous conditions. In the case of bipolar disorder, heredity seems to play a stronger role than in the case of depression. Finally, we also know that psychological and psychopharmacological treatment is effective, although treatment effects vary. Psychotherapy tends to prevent relapses, whereas medication appears to work well with seriously disturbed patients, but only if medication is continued.

I M P L I C AT I O N S

Summary treatment, which seeks to replace negative thoughts with more realistic (or positive) cognitions, and interpersonal therapy, which is a short-term treatment focused on interpersonal issues. Biomedical approaches to treating depression focus on increasing the amounts of neurotransmitters available at brain synapses or affecting the sensitivity of postsynaptic receptors through either medication or electroconvulsive therapy. Antidepressant medication is effective, but, unlike some psychological treatments, its effects last only as long as one continues with medication.

1. What are the symptoms of unipolar depression? ■

■

Depression involves affective, cognitive, behavioral, and physiological symptoms, such as sadness, pessimism, low energy, and sleep disturbances. Unipolar depression, the broad name for depressive disorders, involves the occurrence of depression without any history of mania. In DSM, two types of depressive disorders can be diagnosed: major depression, in which the depression is severe, and dysthymic disorder, in which the depression is less severe but long term.

2. What causes unipolar depression? ■ Evidence shows that biological factors, including heredity, are important in predisposing one to depression. The functioning of neurotransmitters, brain structure activities, and cortisol levels in the body are associated with depression. ■

■

■

Psychological theories of depression have been proposed by adherents of the psychodynamic, behavioral, cognitive, cognitive-learning, and sociocultural viewpoints. Psychodynamic explanations focus on separation and anger. Behavioral explanations focus on reduced reinforcement following losses. Cognitive explanations see low self-esteem as an important factor. According to the learned helplessness theory of depression, susceptibility to depression depends on the person’s experience with controlling the environment. The person’s attributional style—speculations about why he or she is helpless—is also important. Social explanations focus on relationships and interpersonal stressors and social supports that make one vulnerable to, or resilient against, depression. Sociocultural explanations have focused on cultural, demographic, and socioeconomic factors that influence the rates and symptoms of mood disorders. For example, women have a higher prevalence for depression than men, and various biological and social psychological factors have been proposed for this gender discrepancy.

3. What kinds of treatment are available for people with unipolar depression, and how effective are they? ■

Different forms of psychological and behavioral treatments have been found to be effective with depressive disorders. These include cognitive-behavioral

332

4. What are the symptoms of bipolar, or manic-depressive, disorder? ■ Bipolar disorder is characterized by the occurrence of mania, in which a person shows elation, lack of focus, impulsive actions, and almost boundless energy. ■ In bipolar mood disorders, manic episodes occur or alternate with depressive episodes. DSM-IV-TR recognizes two levels of manic intensity: hypomania and mania. Hypomania is the milder form, in which affected people seem to be “high” in mood and overactive in behavior. People suffering from mania display more disruptive behaviors, including pronounced overactivity, grandiosity, and irritability. Their behaviors may be so extreme as to require restraint and medication. 5. What causes bipolar disorder? ■ In finding the causes of bipolar disorders, researchers have also focused on biological, psychological, social, and sociocultural factors. However, much more research has been devoted to unipolar depression. Research has shown that bipolar disorders seem to have a stronger genetic basis and a smaller gender difference than those found in unipolar depression. Nevertheless, consistent with a multipath model, bipolar disorder is affected by a number of different factors. 6. What are the primary means of treating bipolar disorder? ■

The most effective treatment for bipolar and manic disorders is lithium, a drug that lowers the level of neurotransmitters at synapses by increasing the reuptake of norepinephrine, although other drugs are being tested for use in these disorders. Research has increasingly shown that psychotherapy is also effective in treating bipolar disorders.

c h a p t e r

12

Suicide

L

ate one evening, Carl Johnson, M.D., left his downtown office, got into his Mercedes 500 SL, and drove toward his expensive suburban home. He was in no particular hurry because the house would be empty anyway; the year before, his wife had divorced him and, with their two children, had moved back east to her parents’ home. Carl was deeply affected. Although he had been drinking heavily for two years before the divorce, he had always been able to function at work. For the past several months, however, his private practice had declined dramatically. He used to find his work rewarding, but now he found people boring and irritating. Although he had suffered from depressive episodes in the past, this time he knew things were different. The future looked bleak and hopeless. Carl knew he had all the classic symptoms of depression—he was, after all, a psychiatrist. The garage door opened automatically as he rolled up the driveway. Carl parked carelessly, not even bothering to press the switch that closed the door. Once in the house, he headed directly for the bar in his den; there he got out a bottle of bourbon and three glasses, filled the glasses, and lined them up along the bar. He drank them down, one after the other, in rapid succession. For a good half hour, he stood at the window staring out into the night. Then Carl sat down at his mahogany desk and unlocked one of the drawers. Taking a loaded .38-caliber revolver from the desk drawer, Dr. Carl Johnson held it to his temple and pulled the trigger.

chapter outline Correlates of Suicide

335

A Multipath Perspective of Suicide

343

Victims of Suicide

347

Preventing Suicide

350

The Right to Suicide: Moral, Ethical, and Legal Issues

354

IMP LIC ATIONS

357

CRITICAL THINKING Why Do People Kill Themselves? 336 CONTROVERSY Do People

Have a Right to Die?

356

Why would someone like Dr. Carl Johnson take his own life? Granted, he was depressed and obviously feeling the loss of his family, but most people under similar circumstances are able to cope and choose life over death. Unfortunately, we will never know the answer, but our multipath model, as shown in Figure 12.1, does offer clues: there is a strong possibility that the combined influence of biological, psychological, social, and sociocultural factors contributed to his suicide. Confining our explanations to only one factor would be a serious oversimplification

333

FOCUSQUESTIONS

1 What do we know about suicide?

4

How can we intervene or prevent suicides?

2

What are the major explanations of suicide?

5

3

Who are the victims of suicide?

Are there times and situations in which suicide should be an option?

12.1

FIGURE MULTIPATH MODEL FOR THE SUICIDE OF DR. CARL JOHNSON Here you see the interacting multipath dimensions that may have contributed to Dr. Carl Johnson’s suicide. Their precise relationship to and interaction with one another is difficult to ascertain, but clearly he was at high risk for suicide.

Biological Dimension • Possible genetic predisposition (history of depression) • Biochemical (5-HIAA)

Sociocultural Dimension • Male gender • Occupation (Psychiatrist)

SUICIDAL CORRELATES OF DR. CARL JOHNSON

Psychological Dimension • Alcohol abuse • Hopelessness • Depression

Social Dimension • Divorce • Loss of family life (wife and children) • Social isolation

suicide the intentional, direct, and

conscious taking of one’s own life

334

and mistake (Leenaars, 2008). First, there is evidence that Carl had a history of depression, and strong biological factors (biochemical or genetic) are implicated in suicide. For example, cerebrospinal fluid levels of people who kill themselves reveal that they have lower levels of 5-HIAA serotonin, found to predict a ten to twenty times higher rate of suicide (Leonardo & Hen, 2006; Roy, 1992). Second, psychological factors such as alcohol abuse (Bryan & Rudd, 2006), hopelessness, and depression are often associated with suicide (Jobes, 2006). Third, social factors were evident in Dr. Johnson’s pain; a divorce and loss of his family made his life no longer meaningful. As we shall see, people who are divorced and lack social relationships are more likely to commit suicide (Rudd, Joiner, & Rajab, 2004). Finally, there are major sociocultural correlates of Dr. Johnson’s decision to take his own life. His gender and occupation are significant factors. We know, for example, that men are more likely to kill themselves than women and that, occupationally, psychiatrists have among the highest rates of suicide (Comtois & Linehan, 2006; Klott & Jongsma, 2004). It is clear that Dr. Johnson was at high risk for suicide on a number of risk dimensions. How these four dimensions interact, however, is difficult to ascertain. Suicide—the intentional, direct, and conscious taking of one’s own life—is not only a tragic act, it is a baffling and confusing one as well. Most of us have been raised to believe in the sanctity of life, and we operate under strong moral, religious, and cultural sanctions against taking our own lives. Yet suicide is as old as human history itself, and its occurrence no longer seems a rarity. Although explanations abound for suicide, we can never be entirely certain why people knowingly and deliberately end their own lives (Leenaars, 2008; Rudd et al., 2004). The easy and most frequent explanation is that people who kill themselves are suffering from a mental disorder. Yet our increasing understanding of suicide suggests that a single explanation is simplistic. Suicide has many causes, and people kill themselves for many different reasons (Rosenfeld, 2004).

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We have chosen to provide a separate chapter on suicide for TA B L E several reasons. First, although suicide is not classified as a mental disorder in DSM-IV-TR, the suicidal person usually has clear LEADING CAUSES OF DEATH IN psychiatric symptoms. Many persons who suffer from depresTHE UNITED STATES sion, alcohol dependence, and schizophrenia exhibit suicidal 1. Diseases of the heart (heart disease) thoughts or behavior (Bryan & Rudd, 2006). Yet suicide does not fall neatly into one of the recognized psychiatric disorders. 2. Malignant neoplasms (cancer) There is evidence that suicide and suicidal ideation—thoughts 3. Cerebrovascular diseases (stroke) about suicide—may represent a separate clinical entity. The second reason for treating suicide as a separate topic 4. Chronic lower respiratory diseases is that increasing interest in suicide and the fact that it is the eleventh leading cause of death for all Americans (see 5. Accidents (unintentional injuries) Table 12.1) appears to warrant study of this phenomenon in 6. Diabetes mellitus (diabetes) its own right. In fact, every year, there are more deaths due to suicide in the United States than to homicide. However, 7. Alzheimer’s disease throughout history, people have traditionally avoided discuss8. Pneumonia and influenza ing suicide and have participated in a “conspiracy of silence” because of the shame and stigma involved in taking one’s life 9. Nephritis, nephrosis (kidney disease) (Maris, Berman, & Silverman, 2000; Rudd et al., 2004). Even some mental health professionals find the topic uncomfort10. Septicemia able and personally disturbing (Friedman, 2004; Shea, 2002). 11. SUICIDE Now, however, we are witnessing increased openness in discussing issues of death and dying, the meaning of suicide, and 12. Chronic liver disease and cirrhosis the right to take one’s own life. Some individuals have even 13. Essential hypertension and renal disease gone so far as to advocate a “right to suicide” and the legalization of “assisted suicide.” In May 2004, a federal court upheld 14. Parkinson’s disease the only law in the nation (in Oregon) authorizing doctors to 15. Homicide (assault) help their terminally ill patients commit suicide (Hastings & Robbennolt, 2004). Source: Centers for Disease Control and Prevention Web-based Injury And, finally, we need to recognize that suicide is an irreversStatistics Query and Reporting System (2005). ible act. Once the action has been taken, there is no going back, no reconsideration, and no reprieve. Regardless of the moral stand one takes on this position, the decision to commit suicide is often an ambivalent one, clouded by many personal and social stressors. Many mental health professionals believe that the suicidal person, if taught how to deal with personal and social crises, would not consciously take his or her own life. As a result, understanding the causes of suicide and what can be done to prevent such an act becomes extremely important to psychologists (Berman, 2006).

12.1

Correlates of Suicide People who commit suicide—who complete their suicide attempts—can no longer inform us about their motives, frames of mind, and emotional states. We have only indirect information, such as case records and reports by others, to help us understand what led them to their tragic act. The systematic examination of existing information for the purpose of understanding and explaining a person’s behavior before his or her death is called a psychological autopsy (Jacobs & Klein, 1993; Roberts, 1995). It is patterned on the medical autopsy, which is an examination of a dead body to determine the cause or nature of the biological death. The psychological autopsy attempts to make psychological sense of a suicide or homicide by compiling and analyzing case histories of victims, recollections of therapists, interviews with relatives and friends, information obtained from crisis phone calls, and messages left in suicide notes. Unfortunately, these sources are not always available or reliable. Only 12 to 34 percent of victims leave suicide notes, many have never undergone psychotherapy, and the intense feelings of loved ones often cloud their judgments (Black, 1993; Leenaars, 1992).

suicidal ideation thoughts about

suicide psychological autopsy

the systematic examination of existing information for the purpose of understanding and explaining a person’s behavior before his or her death

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critical thinking

Why Do People Kill Themselves?

I

t is a very common belief that people who choose to commit suicide are mentally disturbed and suffer from psychological factors such as depression. Studies do support a high correlation between depression and the presence of mental disorders in both those who attempt suicide and those who are successful in committing suicide. There are commonalities among those who kill themselves, but it is also true that people take their lives for many different reasons. Let’s look at four examples of individuals who committed suicide. 1. Kurt Cobain was the founder, lead singer, guitarist and songwriter for the band Nirvana. The band was in the forefront of grunge and alternative rock, and Cobain was considered the spokesman for Generation X. His marriage to Courtney Love was not well received by Cobain’s fans, who felt she had a negative influence over him and was using him to enhance her own fame. It is well known that the two heavily abused drugs during their marriage, and even when Love was pregnant with Cobain’s child. Throughout their courtship and marriage, Love and Cobain were under constant critical scrutiny by the media. Adding to the pressures he felt, Cobain had great difficulty reconciling his huge success and fame in the music world with his underground roots. He felt hounded by the media but was even more disturbed by fans who seemed not to understand his music. Throughout his childhood until his death, Cobain was prone to depression and drug abuse and suffered from medical problems. On April 5, 1994, after writing a suicide note, he killed himself by a self-inflicted shotgun wound to the head. 2. In 1990, the psychology community was shocked by the suicide of one of their very own, Bruno Bettelheim. Bettelheim was a renowned psychologist whose work on autism influenced the field of mental health and treatment immensely. In his personal and professional life he had dedicated himself to helping others and improving the quality of their lives, but he began to experience declining health. In a very personal interview with a reporter, Bettelheim expressed his thoughts on death and suicide. He stated that he did not fear death but was frightened at the prospect of suffering. At the age of eighty-six, he had lived a productive and enjoyable life and was fearful he would be kept alive without a purpose. Bettelheim had recently suffered a stroke, was fearful that he would suffer another, did not want to be a burden to his family or friends, and could no longer take part in many of the activities that had

brought joy and meaning to his life. He believed that he was living on borrowed time and met with a doctor in the Netherlands who was willing to give him a lethal injection. 3. Ten-year-old Tammy Jimenez was the youngest of three children—a loner who had attempted suicide at least twice in the previous two years. Tammy’s parents always seemed to be bickering about one thing or another and threatening divorce. She and her sisters were constantly abused by their alcoholic father. In February 1986, Tammy was struck and killed by a truck when she darted out into the highway that passed by her home. The incident was listed as an accident, but her older sister said Tammy had deliberately killed herself. On the morning of her death, an argument with her father had upset and angered her. Her sister said that, seconds before Tammy ran out onto the highway, she had said that she was unwanted and would end her own life. 4. On September 11, 2001, terrorists hijacked four planes; two of them destroyed the twin towers of the World Trade Center in New York City, one struck the Pentagon, and another crashed in Pennsylvania. Thousands of innocent lives were lost. All the terrorists also perished and were praised as martyrs by al-Qaeda leader Osama Bin Laden. In televised gloating, Bin Laden indicated that the Islamic extremists willingly gave their lives for a greater good, to combat the evil of the United States. He stated that those responsible for the heinous act were destined for an idyllic afterlife. The decision or impulse to take one’s life is a complex one. Suicidologists now accept the belief that no single explanation is sufficient to account for all types of suicide. Common sense alone leads to the conclusion that Kurt Cobain’s reasons for taking his life differ from those of Bruno Bettelheim, Tammy Jimenez, or the September 11th terrorists. Cobain had difficulty with the pressures of fame and battled depression; Bettelheim wanted to avoid further suffering, declining physical health, and being a burden to others; Tammy Jimenez believed she was escaping an unhappy family life and child abuse; and, although we may vigorously disagree, the 9/11 terrorists believed they sacrificed their lives for a greater good. Can you discern the motives that would lead each of these individuals to take their own lives? In what ways are they similar or different? Which of these suicides, if any, would you consider more acceptable than the other? What does your ranking tell you about your values and perspective on suicides?

Correlates of Suicide

337

Another strategy involves studying those who survive a suicide attempt. This method, however, assumes that people who attempt suicide are no different from those who succeed. Studies suggest that these two populations differ on many important dimensions: (1) attempters are more likely to be white female housewives in their twenties and thirties who are experiencing marital difficulties and use primarily barbiturates; and (2) those who succeed are more likely to be males in their forties or older who suffer from health and depression and shoot or hang themselves (Diekstra, Kienhorst, & de Wilde, 1995; Furr et al., 2001; Shea, 2002).

Myth vs Reality Myth: People who attempt suicide are not serious about ending their lives. They are usually manipulative, attention seeking, and have little intention of completing the act. Reality: Although this statement may hold some truth, it is dangerous to assume that people who attempt suicide are not serious. Indeed, most people who are successful have made attempts in the past. A suicide attempt is a danger signal that should not be taken lightly.

Facts About Suicide In seeking to understand suicide, researchers have focused on events, characteristics, and demographic variables that recur in psychological autopsies and that are highly correlated with the act (Comtois & Linehan, 2006; Lester, 2008). Our first example, Dr. Carl Johnson, fits a particular profile. Higher suicide rates are associated with divorce (Berman, 2006; Bryan & Rudd, 2006) and with certain professions (psychiatry in particular). Alcohol is frequently implicated (Canapary, Bongar, & Cleary, 2002; Rogers, 1992), and men are more likely to kill themselves using firearms than by other means (Centers for Disease Control and Prevention (CDC), 2007e). Profiles such as these, as well as others described later in this chapter, emerge from our increasing knowledge of facts that are correlated with suicide (Bryan & Rudd, 2006; CDC Web-based Injury Statistics, 2005; Karch, Cosby, & Simon, 2006; Leach, 2006; Shneidman, 1993). Let’s examine some of them in greater detail. But first, look at Table 12.2, which examines some of the characteristics shared by suicidal individuals.

Did You Know?

C

leopatra, Kurt Cobain, Ernest Hemingway, Adolf Hitler, Jim Jones (the People’s Temple leader), Marilyn Monroe, Freddie Prinze, Sr. (comedian), King Saul, and Virginia Woolf all have one thing in common. As you may have guessed, they all committed suicide—the intentional, direct, and conscious taking of one’s own life.

Frequency Every sixteen minutes or so, someone in the United States takes his or her own life. Approximately 31,000 persons kill themselves each year. Suicide is among the top eleven causes of death in the industrialized parts of the world; it is the eighth leading cause of death among American males and the third leading cause of death among young people ages fifteen to twentyfour (CDC Web-based Injury Statistics, 2005, 2007a). Some evidence shows that the number of actual suicides is probably 25 to 30 percent higher than that recorded. Many deaths that are officially recorded as accidental—such as single-auto crashes, drownings, or falling from great heights—are actually suicides. According to some estimates, eight to ten persons attempt suicide for every one person who completes the act. Children and Young People as Victims In 2004, suicide was the third leading cause of death for the following age groups: children ages ten to fourteen years (1.3 per 100,000); adolescents ages fifteen to nineteen (8.2 per 100,000), and young adults ages twenty to twenty-four (12.5 per 100,000; CDC, 2007e). Recent reports suggest that about twelve thousand children between the ages of five and twenty-four are admitted to psychiatric hospitals for suicidal behavior every year, and it is believed that twenty times that number actually attempt suicide. Suicides among young people ages fifteen to twenty-four have increased by more than 40 percent in the past decade (50 percent for males

CELEBRITY ATTEMPTS AT SUICIDE Actor Owen Wilson watches a basketball game between the Miami Heat and the Golden State Warriors on March 7, 2008. Less than a year earlier, on August 28, 2007, he attempted suicide with a drug overdose and slitting his wrists.

338 TA B L E

CHAPTER 12 • SUICIDE

12.2

TEN COMMON CHARACTERISTICS OF SUICIDE 1. The common purpose is to seek a solution. People may believe that suicide represents a solution to an insoluble problem. To the suicidal person, taking one’s life is not a pointless or accidental occurrence.

6. The cognitive state is one of ambivalence. Although the suicidal person may be strongly motivated to end his or her life, there is usually a desire (in varying degrees) to live as well.

2. The cessation of consciousness is a common goal. Consciousness represents constant psychological pain, but suicide represents a termination of distressing thoughts and feelings.

7. The cognitive state is also characterized by “tunnel vision.” The person has great difficulty seeing “the larger picture” and can be characterized as suffering from tunnel vision. People intent on suicide seem unable to consider other options or alternatives. Death is the only way out.

3. The stimulus for suicide is generally intolerable psychological pain. Depression, hopelessness, guilt, shame, and other negative emotions are frequently the basis of a suicide. 4. The common stressor in suicide is frustrated psychological need. The inability to attain high standards or expectations may lead to feelings of frustration, failure, and worthlessness. When progress toward goals is blocked, some individuals become vulnerable to suicide. 5. A common emotion in suicide is hopelessness/ helplessness. Pessimism about the future and a conviction that nothing can be done to improve one’s life situation may predispose a person to suicide.

8. The common action in suicide is escape. The goal is egression—escape from an intolerable situation. 9. The common interpersonal act in suicide is communication of intention. At least 80 percent of suicides are preceded by either verbal or nonverbal behavioral cues indicating their intentions. 10. The common consistency is in the area of lifelong coping patterns. Patterns or habits developed in coping with crisis generally are the same response patterns that are used throughout life. Some patterns may predispose one to suicide.

Source: Shneidman (1992).

Did You Know?

A

survey of 1,455 college students found the following contributing factors to suicidal ideation and behavior: • Hopelessness (49 percent) • Loneliness (47 percent) • Helplessness (37 percent) • Relationship problems with girlfriends/boyfriends (27 percent) • Money problems (27 percent) • Unspecified depression (26 percent) • Parental problems (20 percent) Source: Furr et al. (2001).

and 12 percent for females); suicide is now the second leading cause of death for whites in this age group. College students appear less at risk for suicide than their age-matched noncollege peers, although the recent rash of highly visible suicides on the Massachusetts Institute of Technology and New York University campuses may seem to contradict these statistics (Sontag, 2002; Swindler, 2004). Suicide Publicity and Identification with Victims Media reports of suicides, especially of celebrities, seem to spark an increase in suicide (Bailey, 2003). The twelve-month period following Marilyn Monroe’s suicide saw a 12 percent increase. Suicides by young people in small communities or schools seem to evoke copycat suicides in some students. Publicized murder-suicides also seem to be correlated with an increase in car accidents. It is hypothesized that group suicides involving two or more individuals represent an extreme form of personal identification with others. Studies suggest that group suicides are characterized by highly emotional involvements or settings that overcome the desire for self-preservation. Interestingly, publicized natural deaths (as opposed to suicides) of celebrities do not produce similar increases. Gender The completed suicide rate for men is about four times that for women, although recent findings suggest that the gap is closing, as many more women are now incurring a higher risk. Further, women are more likely to make attempts, but it appears that men are more successful because they use more lethal means. Among people older than sixty-five, the completed suicide rate for men is ten times that for women. However, women in the same age range attempt suicide three times as often as men. The age group beginning at age sixty-five has the highest suicide rate of all. Among younger people, males commit the majority of suicides.

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For example, among the fifteen-to-twenty-four age category, over 70 percent of suicides are men. Marital Status As Figure 12.2a, b, and c indicate, being widowed as compared to divorced appears to be associated with higher risk of suicide for white men and women and African American men. At older ages, however, divorce rather than widowhood increases the risk. Interestingly, the pattern reversal occurs much earlier among white women than among men (forty to forty-nine years vs. fifty-five to sixty-five years). Across the life span, the lowest incidence of suicide is found among people who are married (Luoma, Pearson, & Pearson, 2002). The suicide rates for single and widowed or divorced men are about twice those for women of similar marital status. Attempted and completed suicide rates are higher among those who are separated, divorced, or widowed. They are especially high among single adolescent girls and single men in their thirties (McIntosh, 1991). Occupation Physicians, lawyers, law enforcement personnel, and dentists have higher than average rates of suicide. Among medical professionals, psychiatrists have the highest rate and pediatricians the lowest. Because medical personnel have easy access to drugs and know what constitutes a fatal dose, they may be more likely to complete a suicide. Interestingly, the suicide rate of women physicians is four times higher than that of a matched general population. Such marked differences raise the question of whether the specialty influences susceptibility or whether a suicide-prone person is attracted to certain specialties. Socioeconomic Level Suicide is represented proportionately among all socioeconomic levels. Level of wealth does not seem to affect the suicide rate as much as do changes in that level. In the Great Depression of the 1930s, suicide was higher among the suddenly impoverished than among those who had always been poor. Choice of Weapon Over 50 percent of suicides are committed by firearms, and 70 percent of attempts are accounted for by drug overdose. Men most frequently choose firearms as the means of suicide; poisoning and asphyxiation via barbiturates are the preferred means for women. The violent means (which men are more likely to choose) are more certain to complete the act; this partially explains the disproportionately greater number of incomplete attempts by women. Recent studies indicate, however, that women are increasingly choosing firearms and explosives as methods (55.9 percent increase). Some have speculated that this change may be related to a change in role definitions of women in society. Among children younger than fifteen, the most common suicide method tends to be jumping from buildings and running into traffic. Older children try hanging or drug overdoses. Younger children attempt suicide impulsively and thus use more readily available means. Religious Affiliation Religious affiliation is correlated with suicide rates. Although the U.S. rate is 12.2 per 100,000, in countries in which Catholic Church influences are strong—Latin America, Ireland, Spain, and Italy—the suicide rate is relatively low (less than 10 per 100,000). Islam, too, condemns suicide, but the increase in suicide attacks in the Middle East may affect rates in Arab countries, which are generally low. Where religious sanctions against suicide are absent or weaker—for example, where church authority is weaker, as it is in Scandinavian countries, in the former Czechoslovakia, and in Hungary—higher rates are observed. Indeed, Hungary has the highest recorded rate of suicide, at 40.7 per 100,000, and the former Czechoslovakia’s rate was 22.4 per 100,000. Ethnic and Cultural Variables Suicide rates vary among ethnic minority groups in the United States. As shown in Figure 12.3, American Indian groups have the highest rate, followed by white Americans, Mexican Americans, African Americans, Japanese Americans, and Chinese Americans. American Indian youngsters have frighteningly high rates (26 per 100,000) as compared with white youths (14 per 100,000). For this group, suicide is the second leading cause of death (CDC Webbased Injury Statistics, 2005). High rates of alcoholism, a low standard of living, and an invalidation of their cultural lifestyles may all contribute to this tragedy.

Did You Know? Suicide Methods Firearms: 51.6% Suffocation/Hanging: 22.6% Poisoning: 17.9% Cut/pierce: 1.8% Drowning: 1.1% Other: 5% Source: CDC Web-based Injury Statistics (2007a).

340 200

CHAPTER 12 • SUICIDE 381a

264

251

Never married, single

Suicide rate per 100,000 (adult white males)

180

Married Widowed

160

Divorced

140

120

100

80

60

40

20

0

20–24

25–29

30–34

35–39

40–44

45–49

50–54

55–59

60–64

65–69

70–74

75–79

80–84

> 85

–

Years of age aExtrapolated

census estimate using five years of available data

25

Never married, single

Suicide rate per 100,000 (adult white females)

Married Widowed 20

Divorced

15

10

5

0

20–24

25–29

30–34

35–39

40–44

45–49

50–54

55–59

60–64

65–69

70–74

75–79

80–84

> 85

–

Years of age

12.2

FIGURE MARITAL STATUS AND SUICIDE PER 100,000 Highest suicide rates are found among the widowed and divorced. Does a stable marriage somehow tend to immunize people against killing themselves? What other reasons might explain these differences? Source: Luoma, Pearson, & Pearson (2002).

341

Correlates of Suicide 290a

80

192b

131a

Suicide rate per 100,000 (adult African American males)

Never married, single Married

70

Widowed Divorced 60

50

40

30

20

10

0

20–24

25–29

30–34

35–39

40–44

45–49

50–54

55–59

60–64

65–69

Years of age a Extrapolated b

census estimate using five years of available data Extrapolated census estimate using four years of available data

FIGURE

12.2 (continued)

RELIGION AND SUICIDE Many religions have strong taboos and sanctions against suicide. In countries in which Catholicism and Islam are strong, for example, the rates of suicide tend to be lower than in countries in which religious sanctions against suicide are not as deeply held.

70–74

> 75

–

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CHAPTER 12 • SUICIDE

NATIVE AMERICAN AND PROUD OF IT Suicide rates among American Indian youth are extremely high, due perhaps to a lack of validation of their cultural lifestyle. One effort to replenish native pride, shown here, is Camp Walakota, a “spiritual boot camp” for troubled teens from the Cheyenne River Sioux Tribe in South Dakota. Here teens are reacquainted with their cultural heritage as they bond with their elders, who offer many valuable life lessons.

Jails and Prisons As might be expected, suicide is the most frequent cause of death in U.S. jails. A suicide number that ranges from 90 to 230 per 100,000 means that the suicide rate in prisons is sixteen times higher than in the general population. The most frequent means in jails is hanging. Most victims were arrested for nonviolent crimes, and nearly half were intoxicated with drugs or alcohol at the time of death. Historical Period Suicide rates tend to decline during times of war and natural disasters, but they increase during periods of shifting norms and values or social unrest, when traditional expectations no longer apply. Sociologists speculate that during wars, people “pull together” and are less concerned with their own difficulties and conflicts. Communication of Intent More than two-thirds of the people who commit suicide communicate their intent to do so within three months of the fatal act. The belief that people who threaten suicide are not serious about it or will not actually make such an attempt is ill founded. It is estimated that 20 percent of persons who attempt suicide try again within one year and that 10 percent finally succeed. Most people who attempt suicide appear to have been ambivalent about death until the suicide. It has been estimated that fewer than 5 percent unequivocally wish to end their lives.

12.3 RATES OF

SUICIDE BY RACE/ETHNICITY Of all the groups, white men have the highest rates of suicide when men are separated from women. However, as a group (men and women combined), Native Americans have the highest overall group rates, with Asian Americans lowest. Source: Adapted from American Society of Suicidology (2008).

25,000

20,000

Suicide rates

FIGURE

15,000

10,000

5,000

0

White male (23,049)

White female (5,682)

Nonwhite Nonwhite male female (2,360) (564)

Black male (1,633)

Black female (306)

Specific groups

Hispanic Native Asian/Pacific (1,954) Americans Islanders (324) (661)

A Multipath Perspective of Suicide

343

Other Important Facts The time of year is correlated with suicides. Spring and summer months have the highest incidence. About one in six persons who complete the act leave suicide notes. Western mountain states seem to have higher rates, with Montana and Nevada being the highest. The average physician encounters six or more potentially suicidal persons in his or her practice per year.

A Multipath Perspective of Suicide As we have indicated throughout the text, the only viable explanation of mental disorders must come from an integrated and multidimensional analysis. This is truly exemplified in the study of suicide, in which so many different factors seem involved (Leong & Leach, 2008; Lester, 2008). Our biological, psychological, social, and sociocultural multipath model seems especially well suited for this purpose, as it acknowledges the multiple pathways to suicide.

Biological Dimension Most discussions of the correlates of suicide seem to stress psychological, social, and Did You Know? sociocultural factors. As we will shortly see, all three contribute, but biological facuicide rates in New Orleans tors and the interplay of all four seem to be operating in determining suicides (CDC have tripled since Hurricane Web-based Injury Statistics, 2005). Two sets of findings—from biochemistry and from Katrina devastated the city genetics—suggest that suicide may have a strong biological component. For example, (Saulny, 2006). Likewise, war you may recall that there is strong evidence that chemical neurotransmitters are assoveterans are twice as likely to ciated with depression and mania. Similar evidence shows that suicide is influenced by commit suicide as those in the low serotonin levels in the brain. general population (Dance, 2007). Evidence of this link began to accumulate in the mid-1970s, when researchers Both groups share commonalities: identified a chemical called 5-hydroxyindoleacetic acid (5HIAA; Boldrini et al., increased feelings of depression, 2005; Roy, 1994; Van Praag, 1983). This chemical is produced when serotonin, hopelessness, and alcohol abuse. a neurotransmitter that affects mood and emotions, is broken down in the body. Many also have posttraumatic stress Moreover, some evidence indicates that the serotonin receptors in the brainstem disorder. and frontal cortex may be impaired. And, as noted earlier, the spinal fluid of some depressed and suicidal patients has been found to contain abnormally low amounts of 5HIAA (Bongar, 1991). Statistics on patients with low levels of 5HIAA indicated that they are more likely than others to commit suicide, more likely to select violent methods of killing themselves, and more likely to have a history of violence, aggression, and impulsiveness (Edman et al., 1986; Roy, 1992). Researchers believe that the tendency toward suicide is not a simple link to depression. We already know that patients suffering from depression also exhibit low levels of 5HIAA. What is startling is that low levels of 5HIAA have been discovDid You Know? ered in suicidal people without a history of depression Top four states for suicides: Bottom four states for suicides: and in suicidal individuals suffering from other mental disorders (Brown et al., 1982; Volavka, 1995). • Alaska • New Jersey This discovery may lead to a chemical means of • Montana • Massachusetts detecting people who are at high risk for attempting • Nevada • New York suicide. However, researchers in this area caution that • New Mexico • District of Columbia social and psychological factors also play a role. If, in the future, cerebral serotonin can be detected easily in blood Source: CDC Web-based Injury Statistics (2007b). tests, it can be used as a biological marker (a warning sign) of suicide risk. Researchers believe that low 5HIAA content does not cause suicide but that it may make people more vulnerable to environmental stressors. And still another caution is in order: this evidence is correlational in nature; it does not indicate whether low levels of 5HIAA are a cause or a result of particular moods and emotions—or even whether the two are directly related. There is also evidence to implicate genetics in suicidal behavior, but the relationship is far from clear. There appears to be a higher rate of suicide and suicide attempts among parents and close relatives of people who attempt or commit suicide

S

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than among nonsuicidal people (Brent et al., 1996; Roy, 1992). As always, great care must be used in drawing conclusions because it can be argued that modeling by a close member of the family might make a family relative more prone to find suicide an acceptable alternative. Some researchers are hopeful that the Human Genome Project might provide a means of clarifying the genetic markers that may help identify those individuals at risk for suicide.

Psychological Dimension There are many psychological factors that have been found to be significantly related to suicide (Maris et al., 2000). Findings have consistently revealed that a number of individuals who commit suicide suffer from a DSM-IV-TR (Bryan & Rudd, 2006; Harris & Barraclough, 1997; Sanchez, 2001). Conversely, approximately 15 percent of individuals diagnosed with mood disorders, schizophrenia, and substance abuse attempt to kill themselves (Brent, Perper, & Allman, 1987; Rossow & Amundsen, 1995). Those suffering from schizophrenia are most likely to be experiencing an episode of depression, and their suicide methods are usually violent and bizarre; those with personality disorders are usually the emotionally immature with low frustration tolerance (borderline and antisocial personalities). A review of the literature on suicide also reveals a number of other contributing factors, including such experiences as separation and divorce (Garfinkel & Golumbek, 1983), academic pressures (Priester & Clum, 1992), shame (Shreve & Kunkel, 1991), serious illness (Mackenzie & Popkin, 1987), loss of a job, and other life stressors (Rosenfeld, 2004). Depression and Hopelessness Perhaps the psychological state of mind most correlated with suicide is depression and hopelessness (Berman, 2006; Bryan & Rudd, 2006). For example, interest in suicide usually develops gradually, as a result of pleasure loss and fatigue accompanying a serious depressed mood (Lester, 2008). Shneidman (1993) has described it as a “psychache,” an intolerable pain created from an absence of joy. Among both children and adolescents, depression seems to be highly correlated with suicidal behavior (CDC Web-based Injury Statistics, 2005; Eaton et al., 2006). Such data can lead to the conclusion that depression plays an important role in suicide. But the role depression plays in suicide is far from simple. For example, patients seldom commit suicide while severely depressed. Such patients generally show motor retardation and low energy, which keep them from reaching the level of activity required for suicide. The danger period often comes after some treatment, when the depression begins to lift. Energy and motivation increase, and patients are more likely to carry out the act. Most suicide attempts occur during weekend furloughs from hospitals or soon after discharge, a fact that supports this contention (Klerman, 1982). Although depression is undeniably correlated with suicidal thoughts and behavior, the relationship seems very complex. Why do some people with depression commit suicide, whereas others do not? The answer may be found in the characteristics of depression and in the factors that contribute to it (Jobes, 2006). For example, it has been found that an increase in sadness is a frequent mood indicator of suicide, but heightened feelings of anxiety, anger, and shame are also associated (Kienhorst et al., 1995). Some researchers believe that hopelessness, or negative expectations about the future, may be the major catalyst in suicide and, possibly, an even more important factor than depression and other moods (Lester, 2008; Weishaar & Beck, 1992). In a classic ten-year study, Beck, Emery, and Greenberg (1985) investigated 207 psychiatric patients who had suicidal thoughts but no recent history of suicide attempts. During the ten-year period, fourteen patients committed suicide, and the test scores of these people were compared with those of the others. The investigators found that the two groups did not differ in terms of depression and suicidal ideation, but they did differ in terms of hopelessness. Those who died were more pessimistic about the future than were those who survived. Although the overall results obtained by the scale did not predict suicide risk, the hopelessness item within the measure did. Some sample statements indica-

A Multipath Perspective of Suicide

tive of hopelessness are “My future seems dark for me”; “I might as well give up because there’s nothing I can do about making things better for myself”; “I never get anything I want, so it’s foolish to want anything.” These findings suggest that therapists should assess all depressed patients’ attitudes toward their futures to determine how hopeless they feel. Alcohol Consumption One of the most consistently reported correlates of suicidal behavior is alcohol consumption (Canapary et al., 2002; Schuckit, 1994; Shea, 2002). As many as 60 percent of suicide attempters drink alcohol before the act, and autopsies of suicide victims suggest that 25 percent are legally intoxicated (Flavin, Franklin, & Frances, 1990; Suokas & Lonnqvist, 1995). Indeed, a successful suicide unconnected to alcohol abuse is a rare event. Alcohol-implicated suicide rates may be as high as 270 per 100,000, which is an astounding 27 times higher than the rate found in the general population (Stillion, McDowell, & May, 1989). Heavy alcohol consumption, like binge drinking, also seems to deepen feelings of remorse during dry periods, and the person may be at risk even when sober (Beers & Berkow, 1999). Many theorists have traditionally argued that alcohol may lower inhibitions related to the fear of death and make it easier to carry out the fatal act. Recent formulations, however, suggest another explanation of the effects of alcohol: the strength of the relationship between alcohol and suicide is the result of alcohol-induced myopia (a constriction of cognitive and perceptual processes; Rogers, 1992). Alcohol use by an individual in psychological conflict may increase rather than decrease personal distress by focusing his or her thoughts on negative aspects of his or her personal situation. Steele and Josephs (1990) found that alcohol does constrict cognitive and perceptual processes. Although alcohol-induced myopia may relieve depression and anxiety by distracting the person from the problem, it is equally likely to intensify the conflict and distress by narrowing the person’s focus on the problem. Thus the link between alcohol and suicide may be the result of the myopic qualities of alcohol exaggerating a previously existing constrictive state. If this is true, alcohol is most likely to increase the probability of a suicide in an already suicidal person.

Social Dimension Case Study Bill, You have killed me. I hope you are happy in your heart, if you have one which I doubt. Please leave Rover with Mike. Also leave my baby alone. If you don’t I’ll haunt you the rest of your life and I mean it and I’ll do it. You have been mean and also cruel. God doesn’t forget those things and don’t forget that. And please no flowers; it won’t mean anything. Also keep your money. I want to be buried in Potter’s Field in the same casket with Betty. You can do that for me. That’s the way we want it (Shneidman, 1968, pp. 5–8).

The influence of social factors in suicides is clearly evident in this suicide note. There is great anger and resentment directed toward the recipient of the note, leading us to conclude that the suicide is filled with anger and retaliation. Indeed, psychodynamic theorists believe that suicides are hostilities turned inward. Whether or not we accept the Freudian interpretation, it is clear that many suicides are interpersonal in nature and are influenced primarily by unfulfilled wishes or needs involving a significant other (Jobes, 2006; Leenaars, 2008). Frustration, rage, manipulation, and attempts to elicit guilt or even to alleviate guilt are common. There were many reasons why Bruno Bettelheim chose to end his life, but one of the strongest was his desire not to burden his family and friends with his increasing dependency. And suicides and attempted suicides are often related to the quality and nature of our social relationships with people. It has been found that unhappiness over a broken or unhappy love affair, marital discord, disputes with parents, and recent bereavements are correlated with suicides (Rudd et al., 2004).

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Family instability and stress and a chaotic family atmosphere are correlated with suicide attempts by younger children as well. Tammy Jimenez, for example, took her own life because of feeling unloved and abused by her father. Suicidal children seem to have experienced unpredictable traumatic events and to have suffered the loss of a significant parenting figure before age twelve. Intensive family therapy, including the education of parents with regard to parenting roles, can help. Social factors that operate to separate people or to make them somehow less connected to other people or to their families, to religious institutions, or to their communities can increase susceptibility to suicide (Alcantara & Gone, 2008). Suicide prevention measures, therefore, should be vastly more effective when social support and connectedness are increased and when social isolation is decreased. Conversely, we would expect rates to be higher among the elderly, as their loved ones and friends die off and as they begin to disengage from their work and other activities through retirement. We would also expect that in the divorced, separated, or widowed population, suicide rates would be higher than among those who are married. As we have seen, the research literature supports all of these expectations.

Sociocultural Dimension As we saw earlier, rates of suicide vary with age, gender, marital status, occupation, socioeconomic level, religion, and ethnic group. Higher rates are associated with highand low-status (as opposed to middle-status) occupations, with urban living, with being a middle-aged man, with single or divorced status, and with upper and lower socioeconomic classes (CDC Web-based Injury Statistics, 2005; Jobes, 2006). In a pioneering work, the French sociologist Emile Durkheim related differences in suicide rates to the impact of sociocultural forces on the person (Durkheim, 1897/1951). From his detailed study of suicides in different countries and across different periods, he proposed one of the first sociocultural explanations of suicide. In Durkheim’s view, suicide can result from an inability to integrate oneself with society. Failing to maintain close ties with the community deprives the person of the support systems that are necessary for adaptive functioning. Without such support, and unable to function adaptively, the person becomes isolated and alienated from other people. Some suicidologists believe that modern, mobile, and highly technological society has deemphasized the importance of extended families and the sense of community. The result, even among young people, has been an increase in suicide rates. Suicides can also be motivated by the person’s desire to further group goals or to achieve some greater good. Someone may give up his or her life for a higher cause (in a religious sacrifice or the ultimate political protest, for example). Group pressures may make such an act highly acceptable and honored. During World War II, Japanese kamikaze pilots voluntarily dove their airplanes into enemy warships “for the Emperor and the glory of Japan.” The self-immolation of Buddhist monks during the Vietnam War are likewise in this category. Although likely to arouse considerable disagreement, a strong case can be made that the suicide bombings now so prevalent in the Middle East and in Iraq qualify for this category. From the perspective of those who condone such acts, the perpetrators do not perceive themselves as terrorists but as freedom fighters who willingly give their lives for a greater good. Sociocultural factors have been shown to account for the differential rates and manifestations of suicides among Asian/Pacific AN ALTRUISTIC SUICIDE During the Vietnam War, Americans (Leong & Leach, 2008), African Americans (Utsey, Stenard people were horrified by scenes of self-immolation & Hook, 2008), Latino/Hispanic Americans (Duarte-Velez & Bernal, by Buddhist monks as a form of protest against the 2008), Native Americans (Alcantara & Gone, 2008), and gays and government. This altruistic suicide in 1963 was witnessed lesbians (Leach, 2006). As mentioned previously, American Indians by passersby in the central market of Saigon.

Victims of Suicide

have much higher rates of suicide than are found among all other groups in American society, including European Americans (except white males). One in six American Indian teenagers has attempted suicide, a rate four times higher than that of the general teenage population (Resnick, Yehnuda, & Pitts, 1992). Among fifteen- to twenty-four-year-old American Indian youths, the suicide rate (completed, not attempted) is twice that for white youngsters. Asian American and Hispanic American rates are significantly lower than that of the white group (Duarte-Velez & Bernal, 2008; Leong & Leach, 2008). Although rates for African American youngsters have also been traditionally lower than for their white counterparts, recent reports reveal a dramatic increase over the past two decades (Utsey et al., 2008). Social change and disorganization, which leads to a breakup in integration with one’s community, often predisposes a group to suicide. Suicidologists point to the disorganization imposed on American Indians by Western society: deprived of their lands, forced to live on reservations, and trapped between the margins of two different cultural traditions, many American Indians become alienated and isolated from both their own communities and the larger society. Similarly, the increased suicide rate among African American youths may be due to movement to middle-class life, “accompanied by a splintering of community and family support networks, a weakening of bonds to religion and the pressure of trying to compete in historically white-dominated professions and social circles” (“Suicide Rate Climbing for Black Teens,” 1998, p. A17).

347

SUICIDE BOMBINGS These events have become an all too common sight in Iraq. In the aftermath of a suicide bombing in Baghdad on April 2007, two men try desperately to move a car away to clear the way for help. The incident was triggered by a suicide truck bomb in an attempt to destroy a satellite television station to take as many lives as possible.

Victims of Suicide In this section we briefly discuss two groups of people who are especially victimized by suicide: the very young and the elderly. It is important, however, to realize that those who are left behind may be considered victims as well. Indeed, it is estimated that for every suicide, six others are intimately affected as survivors (family members and friends; CDC Web-based Injury Statistics, 2005).

Children and Adolescents Suicide among the young is an unmentioned tragedy in our society. We have traditionally avoided the idea that some of our young people find life so painful that they consciously and deliberately take their own lives. As in the case of Tammy Jimenez, it may feel easier to call a suicide “an accident.” The suicide rate for children younger than fourteen is increasing at an alarming rate, and the rate for adolescents is rising even faster. Among fifteen- to twenty-four-year-olds, 73 percent of suicides are committed by white males, but the rise in suicides is most rapid among black males (CDC, 2007e; CDC Web-based Injury Statistics, 2005). Suicide is now second only to automobile accidents as the leading cause of death among teenagers, and some automobile “accidents” may also really be suicides (Rudd et al., 2004). In one Gallup poll of teenage respondents, 6 percent admitted to a suicide attempt, and another 15 percent said they had come close to trying (Freiberg, 1991). Experts on adolescent suicide, however, believe these to be gross underestimates (Berman, 2006). The Gallup Organization polled middle-class families (median family income of $41,500) and thus missed certain high-risk groups, such as school dropouts. The Gallup study suggested that between 8 and 9 percent of teenagers have engaged in self-harming behavior. Figures reveal that officially recorded suicides for young people between the ages of fifteen and twenty-four are more than triple the rate in 1957 (Freiberg, 1991; Maris et al., 2000).

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The clinical symptoms most often shown by both children and adolescents are changes in mood and aggressiveness, hostility, or both. Most suicide attempts (73 percent) occurred at home, 12 percent in public areas, 7 percent at school, and 5 percent at a friend’s house (Garfinkel, Froese, & Hood, 1982; United States Public Health Service, 1991). In 87 percent of the suicide attempts, someone else was nearby—generally parents. The fact that most suicide attempts occur at home implies that parents are in the best position to recognize and prevent suicidal behavior. Drug overdose was the primary means of attempted suicide, accounting for 88 percent of the attempts. Next, in order, were wrist laceration, hanging, and jumping from heights or in front of moving vehicles. Families of suicidal children are generally under greater economic stress and have twice the rate TEENS AND SUICIDE As more and more teens like those shown here find of paternal unemployment. Maybe parents who themselves attending the funerals of their peers, it is becoming clear that are preoccupied with economic concerns are less suicide among high school students is reaching epidemic proportions. To readily available to support their children in time prevent more suicides, schools sometimes initiate programs to help students of need. Furthermore, fewer than half the families and faculty cope with their feelings of loss and anger. of those who attempted suicide were two-parent families. The families of suicide attempters also had higher rates of medical problems, psychiatric illness, and suicide than did the control group families. The dominant psychiatric problem was alcohol or drug abuse (Cosand, Bourque, & Kraus, 1982). Copycat Suicides Considerable attention has been directed at multiple or so-called copycat suicides (suicide contagion), in which youngsters in a particular school or community seem to mimic a previous suicide (Alcantara & Gone, 2008; Phillips, Van Voorhees, & Ruth, 1992). For example, within a three-month period in 1985, nine youths ages fourteen to twenty-five killed themselves, all by hanging. All were members of the Shoshone tribe, and all lived in Wind River, Wyoming. In another incident in Omaha, Nebraska, seven high school students attempted suicide within a very short span of time; three were successful. Likewise, the Bergenfield, New Jersey, suicides grabbed headlines in 1987, when two male and two female students killed themselves by inhaling fumes from their car. Their deaths followed that of a friend who had also committed suicide. This event was unusual because the four signed a suicide pact on a brown paper bag. Tragically, their deaths were in turn followed by those of two other young women, who used the same method of death (“Suicide Belt,” 1986). More recently, New York University student Joanne Michelle Leavy leaped to her death from a twelve-story building on September 6, 2004. This would not have been noticed on a national level were it not that it represented the sixth fatal fall by students leaping to their deaths in the preceding year (Swindler, 2004). Although many events, beliefs, and feelings may have contributed to these tragic deaths, suggestion and imitation seem to have played an especially powerful role. Young people may be especially vulnerable, but studies indicate that highly publicized suicides—such as those of a celebrity, close friend, relative, coworker, or other well-known person—can increase the number of subsequent suicide attempts (Gould, 2007; Stack, 1987). As we noted earlier, in the months following Marilyn Monroe’s death, suicides increased by some 12 percent. When Nirvana’s Kurt Cobain committed suicide in 1994, many youth counselors warned about potential imitations by fans. Thus it appears that grief, depression, and mourning are not the culprits that induce copycat behaviors. Although imitative suicides may not be as common as the media suggest, research has indicated that publicizing the event may have the effect of glorifying and drawing

Victims of Suicide

349

attention to it. Thus depressed people may identify with a colorful portrayal, increasing the risk of even more suicides. This pattern appears to be especially true for youngsters who may already be thinking about killing themselves. The stable, welladjusted teenager does not seem to be at risk in these situations. Adolescence and young adulthood are often periods of confusing emotions, identity formation, and questioning. It is a difficult and turbulent time for most teenagers, and suicide may seem to be a logical response to the pain and stress of growing up. A suicide that occurs in school brings increased risk of other suicides because of its proximity to students’ daily lives. In such instances, a suicide prevention program should be implemented to let students vent their feelings in an environment equipped to respond appropriately—and perhaps even to save their lives. Encouragingly, approximately 41 percent of schools have programs aimed at suicide prevention (professional counseling services, peer counseling, and special seminars). It is no longer unusual to hear about school programs that are immediately implemented when a tragedy strikes (such as student suicide, violent death of a student or teacher, or natural disaster, for example; Freiberg, 1991).

Elderly People Aging inevitably results in generally unwelcome physical changes, such as wrinkling and thickening skin, graying hair, and diminishing physical strength. In addition, we all encounter a succession of stressful life changes as we grow older. Friends and relatives die, social isolation may increase, and the prospect of death becomes more real. Mandatory retirement rules may lead to the need for financial assistance and the difficulties of living on a fixed and inadequate income. Such conditions make depression one of the most common psychiatric complaints of elderly people. And their depression seems to be involved more with “feeling old” than with their actual age or poor physical health (Rosenfeld, 2004). Suicide seems to accompany depression for older people. Their suicide rates (especially rates for elderly white American men) are higher than those for the general population (McIntosh, 1992); indeed, suicide rates for elderly white men are the highest for any age group (CDC Web-based Injury Statistics, 2005). From 1980 through 1997, the largest relative increases in suicide rates occurred among those eighty to eighty-four years of age. Firearms were the most common method of suicide for both men and women sixty-five years or older. The elderly make fewer attempts per completed suicide, being among the most likely to succeed in taking their lives. In one study comparing rates of suicide among different ethnic groups, it was found that elderly white Americans committed almost 18 percent of all suicides, although they composed only about 11 percent of the population. Suicide rates for elderly Chinese Americans, Japanese Americans, and Filipino Americans are even higher than the rate for elderly white Americans. American Indians and African Americans show the lowest rates of suicide among older adults (although both groups are at high risk for suicide during young adulthood). Of the Asian American groups, first-generation immigrants were at greatest risk of suicide. One possible explanation for this finding is that newly arrived Asian immigrants intended to earn money and then return to their native countries. When they found they were unable to earn enough either to return home or to bring their families to the United States, they developed A MATTER OF RESPECT Suicide is less likely to occur among feelings of isolation that increased their risk of suicide. the elderly in cultures that revere, respect, and esteem people of This risk has decreased among subsequent generations increasing age. In Asian and African countries, increasing age is of Asian Americans (and, probably, among other immiequated with greater privilege and status, such as that shown for an grant groups as well) because of acculturation and the elderly Ghanian chief; in contrast, in the United States, growing old is creation of strong family ties. often associated with declining worth and social isolation.

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Preventing Suicide In almost every case of suicide, there are hints that the act is about to occur. Suicide is irreversible, of course, so preventing it depends very much on early detection and successful intervention (Comtois & Linehan, 2006; Klott & Jongsma, 2004). Mental health professionals involved in suicide prevention efforts operate under the assumption that potential victims are ambivalent about the act. That is, the wish to die is strong, but there is also a wish to live. Potential rescuers are trained to exert their efforts to preserve life. Part of their success in the prevention process is the ability to assess a client’s suicide lethality—the probability that a person will choose to end his or her life (Bryan & Rudd, 2006; Rudd et al., 2004).

TA B L E

12.3

RISK AND PROTECTIVE FACTORS IN SUICIDE ASSESSMENT AND INTERVENTION RISK FACTORS

• Previous suicide attempt • Mental disorders such as depression and bipolar disorder • Co-occurring mental and alcohol and substance abuse disorders • Family history of suicide • Hopelessness • Impulsive and/or aggressive tendencies • Barriers to accessing mental health treatment • Relational, social, work, or financial loss • Physical illness • Easy access to lethal methods, especially guns • Unwillingness to seek help because of social stigma • Family members, peers, or celebrities who have died from suicide • Cultural or religious beliefs that suicide is a noble resolution • Local epidemics of suicide that have a contagious influence • Isolation PROTECTIVE FACTORS

• Effective resources for clinical care for mental, physical, and substance abuse disorders • Easy access to a variety of clinical interventions and support for seeking help • Restricted access to lethal means of suicide • Family and community support • Good skills in problem solving, conflict resolution, and nonviolent means of handling disputes

the probability that a person will choose to end his or her life

lethality

• Cultural and religious beliefs that discourage suicide and support self-preservation instincts Source: Bryan & Rudd (2006); USPHS (1999).

Preventing Suicide

Working with a potentially suicidal individual is a three-step process that involves (1) knowing which factors are highly correlated with suicide; (2) determining whether there is high, moderate, or low probability that the person will act on the suicide wish; and (3) implementing appropriate actions (Canapary et al., 2002; see Table 12.3). People trained in working with suicidal clients often attempt to quantify the “seriousness” of each factor. For example, a person with a clear suicidal plan who has the means (e.g., a gun) to carry out a suicide threat is considered to be in a more lethal state than a recently divorced and depressed person.

Clues to Suicidal Intent The prevention of suicide depends very much on the therapist’s ability to recognize its signs. Clues to suicidal intent may be demographic or specific. We have already discussed a number of demographic factors, such as the fact that men are three times more likely to kill themselves than are women and that increased age is associated with an increased probability of suicide (Bryan & Rudd, 2006). And, although the popular notion is that frequent suicidal gestures are associated with less serious intent, most suicides do have a history of making suicide threats; to ignore them is extremely dangerous. Any suicidal threat or intent must be taken seriously (Berman, 2006). General characteristics often help detect potential suicides, but individual cases vary from statistical norms. What does one look for in specific instances? The amount of detail involved in a suicide threat can indicate its seriousness. A person who provides specific details, such as method, time, and place, is more at risk than one who describes these factors vaguely. Suicidal potential increases if the person has direct access to the means of suicide, such as a loaded pistol. Also, sometimes a suicide may be preceded by a precipitating event. The loss of a loved one, family discord, or chronic or terminal illness may contribute to a person’s decision to end his or her life. A person contemplating suicide may verbally communicate the intent. Some people make very direct statements: “I’m going to kill myself,” “I want to die,” or “If such and such happens, I’ll kill myself.” Others make indirect threats: “Goodbye,” “I’ve had it,” “You’d be better off without me,” and “It’s too much to put up with.” On the other hand, some cues are frequently very subtle. Behavioral clues can be communicated directly or indirectly. The most direct clue is a “practice run,” an actual suicide attempt. Even if the act is not completed, it should be taken seriously; it often communicates deep suicidal intent that may be carried out in the future. Indirect behavioral clues can include actions such as putting one’s affairs in order, taking a lengthy trip, giving away prized possessions, buying a casket, or making out a will, depending on the circumstances. In other words, the more unusual or peculiar the situation, the more likely it is that the action is a cue to suicide. Clinicians often divide up warning signs into two categories: (1) early signs, such as depression, statements or expressions of guilt feelings, tension or anxiety, nervousness, insomnia, loss of appetite, loss of weight, and impulsiveness; and (2) critical signs, such as sudden changes in behavior (calmness after a period of anxiety), giving away belongings or putting affairs in order, direct or indirect threats, and actual attempts.

Crisis Intervention Suicide prevention can occur at several levels, and the mental health profession has now begun to move in several coordinated directions to establish prevention efforts. At the clinical level, attempts are being made to educate staff at mental health institutions and even at schools to recognize conditions and symptoms that indicate potential suicides (Kaslow & Aronson, 2004). For example, a single man older than fifty years of age suffering from a sudden acute onset of depression and expressing hopelessness should be recognized by mental health professionals as being at high risk. When a psychiatric facility encounters someone who fits a particular risk profile for suicide, crisis intervention strategies will most likely be used to abort or ameliorate the processes that could lead to a suicide attempt. Crisis intervention is aimed at providing intensive short-term help to a patient in resolving an immediate life crisis. Unlike traditional psychotherapy, in which sessions are spaced out and treatment is provided on a more leisurely long-term basis, crisis intervention recognizes the immediacy of

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Preventing Suicides

Assess Risk Factors • • • • • • • • •

Suicide ideation or actual plan Giving away prized possessions Preoccupation with death Recent severe loss Depression or hopelessness Frequent use of alcohol or other drugs Previous suicide attempts Means and specificity of plan Other risk variables (age, gender, marital status, and so on)

Determine Lethality

High • Many risk factors present • Plan well thought out and method extremely lethal • Imminent danger

Possible actions • Obtain promise to continue therapy • Hospitalization (voluntary or involuntary) • Suicide watch

FIGURE

Moderate • Some risk factors present • Suicide ideation, but not specific • Less lethal method considered

Possible actions • Preventive counseling • Monitoring

Low • Minimal risk factors present • Vague reference to suicide, but no real intent verbalized

Possible actions • No immediate action called for • Referral for potential counseling

12.4

THE PROCESS OF PREVENTING SUICIDE Suicide prevention involves the careful assessment of risk factors to determine lethality—the probability that a person will choose to end his or her life. Working with a potentially suicidal individual is a three-step process that involves (1) knowing what factors are highly correlated with suicide; (2) determining whether there is high, moderate, or low probability that the person will act on the wish; and (3) implementing appropriate actions.

the patient’s state of mind. The patient may be immediately hospitalized, given medical treatment, and seen by a psychiatric team for two to four hours every day until the person is stabilized and the immediate crisis has passed. In these sessions, the team is very active not only in working with the patient but also in taking charge of the person’s personal, social, and professional life outside of the psychiatric facility. Many suicide intervention strategies have been developed through clinical work rather than research because the nature of suicide demands immediate action (Bryan & Rudd, 2006). Waiting for empirical studies is not a luxury the clinician can afford. Figure 12.4 summarizes the process of assessing risk and determining lethality. After patients return to a more stable emotional state and the immediate risk of suicide has passed, they are then given more traditional forms of treatment, either on an inpatient or outpatient basis. In addition to the intense therapy they receive from the psychiatric team, relatives and friends may be enlisted to help monitor patients when they leave the hospital. In these cases, the responsible relatives or friends are provided with specific guidelines about how to deal with the patient between treatment team contacts, whom to notify should problems arise outside of the hospital, and so forth.

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Suicide Prevention Centers Crisis intervention can be highly successful if a potentially suicidal patient is either already being treated by a therapist or has come to the attention of one through the efforts of concerned family or friends. Many people in acute distress, however, are not formally being treated. Although contact with a mental health agency may be highly desirable, many people are unaware of the services available to them. Recognizing that suicidal crises may occur at any time and that preventive assistance on a much larger scale may be needed, a number of communities have established suicide prevention centers. The first suicide prevention center was established in Los Angeles in 1958 by psychologists Norman L. Farberow and Edwin S. Shneidman. The center first sought patients from the wards of hospitals. Soon, however, its reputation grew, and in little more than a decade, 99 percent of its contacts were by phone (Farberow, 1970). In the past forty years, hundreds of suicide prevention centers patterned after the first one have sprung up throughout the United States. These centers are generally adapted to the particular needs of the communities they serve, but they all share certain operational procedures and goals. Telephone Crisis Intervention Suicide prevention centers typically operate twentyfour hours a day, seven days a week. Because most suicide contacts are by phone, a wellpublicized telephone number is made available throughout the community for calls at any time of the day or night. Furthermore, many centers provide inpatient or outpatient crisis treatment. Those that lack such resources develop cooperative programs with other community mental health facilities. Most telephone hot lines are staffed by paraprofessionals. All workers have been exposed to crisis situations under supervision and have been trained in crisis intervention techniques such as the following: 1. Maintain contact and establish a relationship. The skilled worker who establishes a good relationship with the suicidal caller not only increases the caller’s chances of working out an alternative solution but also can exert more influence. Thus it is important for the worker to show interest, concern, and self-assurance. 2. Obtain necessary information. The worker elicits demographic data and the caller’s name and address. This information is very valuable in case an urgent need arises to locate the caller. 3. Evaluate suicidal potential. The staff person taking the call must quickly determine the seriousness of the caller’s self-destructive intent. Most centers use lethality rating scales to help the worker determine suicide potential. These usually contain questions on age, gender, onset of symptoms, situational plight, prior suicidal behavior, and the communication qualities of the caller. Staffers also elicit other demographic and specific information that might provide clues to lethality, such as the information discussed in the section on clues to suicidal intent. 4. Clarify the nature of the stress and focal problem. The worker must help callers to clarify the exact nature of their stress, to recognize that they may be under so much duress that their thinking may be confused and impaired, and to realize that there are other solutions besides suicide. Callers are often disoriented, so the worker must be specific to help bring them back to reality. 5. Assess strengths and resources. In working out a therapeutic plan, the worker can often mobilize a caller’s strengths or available resources. INTERVENING BEFORE IT’S TOO LATE Suicide In their agitation, suicidal people tend to forget their own strengths. prevention centers (SPCs) operate twenty-four hours Their feelings of helplessness are so overwhelming that helping them a day, seven days a week, and have well-publicized recognize what they can do about a situation is important. The worker telephone numbers because most contacts are explores the caller’s personal resources (family, friends, coworkers), pro- made by phone. Even though there is controversy fessional resources (doctors, clergy, therapists, lawyers), and community about SPC effectiveness, the mental health resources (clinics, hospitals, social agencies). profession continues to support these centers.

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6. Recommend and initiate an action plan. Besides being supportive, the worker is highly directive in recommending a course of action. Whether the recommendation entails immediately seeing the person, calling the person’s family, or referring the person to a social agency the next day, the worker presents a plan of action and outlines it step by step. This list implies a rigid sequence, but in fact both the approach and the order of the steps are adjusted to fit the needs of the individual caller. The Effectiveness of Suicide Prevention Centers Today, approximately two hundred suicide prevention centers function in the United States, along with numerous “suicide hot lines” in mental health clinics. Little research has been done on their effectiveness, however, and many of their clients want to remain anonymous. Nevertheless, some data are available, although dated. One early study indicates that 95 percent of callers to suicide prevention centers never use the service again (Speer, 1971). This finding may indicate that the service was so helpful that no further treatment was needed or, just as possibly, that callers do not find the centers helpful and feel it is useless to call again. Worse yet, they may have killed themselves after the contact. Another study has shown that potential suicides do not perceive contact with a prevention center as more helpful than discussion with friends (Speer, 1972). And if the justification for such centers is based on their ability to offer services to a large number of clients, then the fact that only 2 percent of the people who kill themselves ever contact such a service is disturbing (Weiner, 1969). Furthermore, studies of cities with hot line services provide mixed findings (Lester, 1989, 1991). Some studies found that suicides decreased in a community with hot line services (Miller, Coombs, & Leeper, 1984), some found no change (Barraclough, Jennings, & Moss, 1977), and others found an increase (Weiner, 1969). However, in cities without prevention centers, the rates increased even more (Lester, 1991). Despite the conflicting evidence, there is always the possibility that suicide prevention centers do help. Because life is precious, the mental health profession continues to support them.

The Right to Suicide: Moral, Ethical, and Legal Issues The following letter captured worldwide attention when a twenty-one-year-old paraplegic, Vincent Humbert, wrote a special appeal to French President Jacques Chirac asking to end his own life:

Case Study Mr. Chirac, My respects to you, Mr. President. My name is Vincent Humbert, I am 21. I was in a traffic accident on 24 September 2000. I spent nine months in a coma. I am currently in Helio-Marins hospital in Berck, in the Pas-de-Calais region. All my vital organs were affected, except for my hearing and my brain, which allows me a little comfort. I can move my right hand very slightly, putting pressure with my thumb on each letter of the alphabet. These letters make up words and the words form sentences. This is my only method of communication. I currently have a nurse beside me, who spells me the alphabet separating vowels and consonants. This is how I have decided to write you. The doctors have decided to send me to a specialised clinic. You have the right of pardon and I am asking you for the right to die. I would like to do this clearly for myself but especially for my mother; she has left her old life to be by my side, here in Berck, working morning and evening after visiting me, seven days out of seven, without a day of rest. And all this to be able to pay the rent for her miserable studio flat. For the moment she is still young. But in a few years, she will not be able to keep up such a pace of work, that is to say she will not be able to pay her rent and so will be obliged to go back to her apartment in Normandy.

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But it is impossible to imagine my remaining here without her by my side, and I think that all patients who are sound of mind are responsible for their actions and have the right to want to continue to live or to die. I would like you to know that you are my last chance. You should also know that I was a fellow citizen without a history, without any judicial record, a sportsman and a volunteer fireman. I do not deserve a scenario as terrible as this and I hope that you will read this letter, which is specially addressed to you. Please accept, Mr. President, my warmest compliments.

In September 2003, after the release of his book I Ask the Right to Die, Vincent Humbert’s mother administered an overdose of sedatives into his intravenous line, causing his death (Smith, 2003). The case of Vincent Humbert set off a national debate about the morality and legality of euthanasia. Do people have the right to end their own lives if their continued existence would result in psychological and physical deterioration? Surveys of the American public indicate that a majority believe terminally ill individuals should be allowed to take their own lives; in a 1995 survey of physicians working with AIDS patients, over half indicated that they have prescribed lethal doses of narcotics to suicidal patients (Clay, 1997; Drane, 1995). Advocates contend that people should be allowed the choice of dying in a dignified manner, particularly if they suffer from a terminal or severely incapacitating illness that would cause misery for their families and friends (Rosenfeld, 2004). The act of suicide seems to violate much of what we have been taught regarding the sanctity of life. Many segments of the population consider it immoral and provide strong religious sanctions against it. Suicide is both a sin in the canonical law of the Catholic Church and an illegal act according to the secular laws of most countries. Within the United States, many states have laws against suicide, and some consider it illegal. Of course, such laws are difficult to enforce because the victims are not around to prosecute. Many are beginning to question the legitimacy of such sanctions, however, and are openly advocating a person’s right to suicide. In 1976, the California State Assembly became one of the first state legislatures to provide that right to people with terminal illnesses. Since then, many other states have passed “living will” laws that offer protection against dehumanized dying and confer immunity on physicians and hospital personnel who comply with a patient’s wishes. In November 1998, Oregon voters passed a physician-assisted suicide act granting physicians the legal right to help end the lives of terminally ill patients. In 2001, however, U.S. Attorney General John Ashcroft issued a directive intended to overturn the law. In May 2004, the United States Court of Appeals for the Ninth Circuit upheld Oregon’s law, ruling that the attorney general had overstepped his authority in trying to punish doctors who prescribed suicide drugs. Recent legislation has intensified the debate over whether it is morally, ethically, and legally permissible to allow relatives, friends, or physicians to provide support, means, and actions to carry out a suicide (Rosenfeld, 2004). Two highprofile individuals have fueled the debate by virtue of their actions. Derek Humphrey, former director of the Hemlock Society (an organization that advocates people’s right to end their lives), published a best-selling book, Final Exit (1991). It is a manual that provides practical information, such as drug dosages needed to end one’s life; when published, it created a national stir. Another individual who has become a household name is Dr. Jack Kevorkian, a physician who has helped nearly 130 people to end their own lives using a device he calls a “suicide machine.” Those who see Kevorkian as a courageous physician willing to help others in their search for a dignified death call him a savior; those who oppose his actions refer to him as “Dr. Death.” Ironically, the success of medical science has added fuel to the right-to-die movement. As a part of our remarkably successful efforts to prolong life, this society has also begun to prolong the process of dying. And this prolongation has caused

Did You Know?

T

homas Szasz (1986) is an outspoken critic of suicide prevention programs. He argues that suicide is an act of a moral agent who is ultimately responsible. Szasz opposes coercive methods (such as involuntary hospitalization) that mental health professionals use to prevent suicide. By taking such actions, Szasz claims practitioners have identified themselves as foes of individual liberty and responsibility.

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controversy

Do People Have a Right to Die?

O

n November 22, 1998, over 15 million viewers of 60 Minutes watched in either horror or sadness the death by lethal injection of fifty-two-year-old Thomas Youk. This was not, however, a death sentence carried out for a murder conviction but the enactment of a conscious desire and decision of a man suffering from the latter stages of Lou Gehrig’s disease. Youk’s wife stated she was “so grateful to know that someone would relieve him of his suffering. . . . I consider it the way things should be done.” The man who videotaped the event was Dr. Jack Kevorkian, a retired physician, who has carried on a ten-year battle with the U.S. legal system and society over the right to die. It is estimated that, since 1989, Kevorkian has assisted in the suicides of nearly 130 people (most of them women) with chronic debilitating diseases. The means of death was Kevorkian’s “suicide machine,” composed of bottles containing chemicals that could be fed intravenously into the arm of the person. The solution could bring instantaneous unconsciousness and quick painless death. His first client, Mrs. J. Adkins, suffered from Alzheimer’s disease. She did not want to put her family through the agony of the disease, believed that she had a right to choose death, stated that her act was that of a rational mind, and had the consent of her husband. Many others whom Kevorkian helped commit suicide did not have diseases that threatened to kill them in the immediate future. Before the CBS taping, charges of homicide had been brought against Kevorkian four previous times, and in each case either the charges were ultimately dropped or he was found innocent. Because of his actions, a Michigan law outlawing “physician-assisted suicides” was passed and used to charge him with manslaughter. Prosecutors contended that Kevorkian’s actions in the death of Youk went far beyond what many consider “assistance.” Because Thomas Youk

FIGHTING FOR THE RIGHT TO CHOOSE Dr. Jack Kevorkian, a Michigan physician, has been a lifelong advocate fighting for the repeal of laws against assisted suicide. Convicted of second-degree murder of Thomas Youk who suffered from Lou Gehrig’s disease, Kevorkian was released June 2007 after serving eight years of his sentence. was too weak to administer the dose himself, Kevorkian administered it for him. For that act, in 1999, the retired physician was charged with and convicted of second-degree murder, criminal assistance to a suicide, and delivery of a controlled substance. After serving eight years in prison, he was released in 2007 because of failing health after promising not to engage in assisted suicides. For Further Consideration 1. Did Thomas Youk have a right to end his own life? What reasons led you to your answer? Does a doctor—or, for that matter, anyone—have a right to help others terminate their lives? 2. What might motivate someone like Dr. Kevorkian to risk censure and imprisonment to help others to die? Would you be in favor of legislation that would legalize physician-assisted suicides? Why or why not?

many elderly or terminally ill people to fear the medical decision maker who is intent only on keeping them alive, giving no thought to their desires or dignity. They and many others find it abhorrent to impose on a dying patient a horrifying array of respirators, breathing tubes, feeding tubes, and repeated violent cardiopulmonary resuscitations—procedures that are often futile and against the wishes of the patient and his or her family. Humane and sensitive physicians, who believe that the resulting quality of life will not merit such heroic measures but whose training impels them to sustain life, are caught in the middle of this conflict. A civil or criminal lawsuit may be brought against the physician who agrees to allow a patient to die. Proponents of the right to suicide believe that it can be a rational act and that mental health and medical professionals should be allowed to help such patients without fear of legal or professional repercussions (Corey, 2001; Rosenfeld, 2004; Werth, 1996). Others argue, however, that suicide is not rational or that determining rationality is fraught with hazards. They cite studies indicating that suicide is a symptom of mental illness and that allowing this final act may result in “a duty to die” (Hendin, 1995; Seale & Addington-Hall, 1995). Some are voicing the fear that one result of legalizing suicide may be that patients will fall victim to coercion from

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relatives intent either on collecting inheritances or on convincing patients that they will overburden their loved ones and friends or become a financial drain on them. Other critics of assisted suicide fear that in this time of medical cost control, medical professionals might encourage the terminally ill to choose to die and that those who are poor and disadvantaged would receive the most encouragement (Werth, 1996). Major problems also exist in defining the subjective terms quality of life and quality of humanness as the criteria for deciding between life and death. At what point do we consider the quality of life sufficiently poor to justify terminating it? Should people who have been severely injured or scarred (through loss of limbs, paralysis, blindness, or brain injury) be allowed to end their own lives? What about mentally retarded or emotionally disturbed people? Could it be argued that their quality of life is equally poor? Moreover, who will decide whether a person is or is not terminally ill? There are many recorded cases of “incurable” patients who recovered when new medical techniques or treatments arrested, remitted, or cured their illnesses. Such questions deal with ethics and human values, and they cannot be answered easily. Yet the mental health practitioner cannot avoid these questions. Like their medical counterparts, clinicians are trained to save people’s lives. They have accepted the philosophical assumption that life is better than death and that no one has a right to take his or her own life. Strong social, religious, and legal sanctions support this belief. Therapists work not only with terminally ill clients who wish to take their own lives but also with disturbed clients who may have suicidal tendencies. These latter clients are not terminally ill but may be suffering severe emotional or physical pain; their deaths would bring immense pain and suffering to their loved ones. Moreover, as noted previously, most people who attempt suicide do not want to die, are ambivalent about the act, or find that their suicidal urges pass when their life situations improve (Bongar, 1991, 1992; Clay, 1997). Clearly, suicide and suicide prevention involve a number of important social and legal issues, as well as the personal value systems of clients and their families, mental health professionals, and those who devise and enforce our laws (Rosenfeld, 2004). And just as clearly, we need to know much more about the causes of suicide and the detection of people who are at high risk for suicide, as well as the most effective means of intervention (Rudd et al., 2004). Life is precious, and we need to do everything possible, within reason, to protect it.

There is a saying that goes like this: “We know much about suicide but we know very little about it.” Although this may sound contradictory, this chapter has been filled with an impressive array of facts, statistics, and information about many aspects of suicide. We are able to construct fairly accurate portraits of individuals most as risk, delineate protective factors, and even develop intervention strategies in working with suicidal individuals. We know that people commit suicide for many reasons. We know that biological, psychological, social, and sociocultural factors are related to suicides. Yet suicide continues to be a mystery. We are not sure that our explanations, formed from the many correlates of suicide, are accurate. Although we believe strongly in the multipath model, we know little about how the four major dimensions of suicide interact with one another nor whether one is more important than the other and under which conditions. For example, sociocultural explanations may be valid to an extent, but attributing suicide to a single sociological factor (race, culture, gender, economic class, place of residence, or occupation) is too simplistic and mechanistic. As we have noted throughout this text, correlations do not imply cause-and-effect relationships. Purely sociocultural explanations that take into account only one sociocultural factor—group cohesion, for example—omit the psychological dimension of the person’s inner struggles (psychological dimension) or his or her biological makeup (biological dimension). They fail to explain why only certain members of a group commit suicide and others do not. Hopefully, future research will begin to add clarity to our question: Why do people commit suicide?

I M P L I C AT I O N S

Summary 1. What do we know about suicide? ■

■

Suicide is the intentional, direct, and conscious taking of one’s own life. In the past, it has often been kept hidden, and relatives and friends of the victim did not speak of it. Mental health professionals now realize that understanding the causes of suicide is extremely important. Much is known about the facts of suicide, but little about the reasons is understood. Men are more likely to kill themselves than women, although the latter make more attempts; the elderly are at high risk for suicides; religious affiliation, marital status, and ethnicity all influence suicides; and firearms are the most frequent method used.

2. What are the major explanations of suicide? ■ In keeping with the multipath model, suicides appear to be an interaction of biological, psychological, social, and sociocultural factors. ■ More recent evidence has indicated that biological factors may be important: genetics and biochemical factors are implicated in suicides. ■ Psychological factors include mental disturbance, depression, hopelessness, and excessive alcohol consumption; all are highly correlated with suicide. ■ Lack of positive social relationships can lead to feelings of loneliness and disconnection. The elderly are prone to the loss of loved ones and friends, and divorce or lack of a life partner increases the chances of suicide. ■ Sociocultural factors such as race, culture, ethnicity, social class, gender, and other such demographic variables can either increase or decrease the risk of suicide. ■ The complex relationship between these four dimensions and suicide is not simply one of cause and effect but of an interaction among them.

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3. Who are the victims of suicide? ■

■

In recent years, childhood and adolescent suicides have increased at an alarming rate. A lack of research has limited our understanding of why children take their own lives. Many people tend to become depressed about “feeling old” as they age, and depressed elderly people often think about suicide.

4. How can we intervene or prevent suicides? ■ Perhaps the best way to prevent suicide is to recognize its signs and intervene before it occurs. People are more likely to commit suicide if they are older, male, have a history of attempts, describe in detail how the act will be accomplished, and give verbal hints that they are planning self-destruction. ■

■

Crisis intervention concepts and techniques have been used successfully to treat clients who contemplate suicide. Intensive short-term therapy is used to stabilize the immediate crisis. Suicide prevention centers operate twenty-four hours a day to provide intervention services to all potential suicides, especially people who are not undergoing treatment. Telephone hot lines are staffed by welltrained paraprofessionals who will work with anyone who is contemplating suicide. In addition, these centers provide preventive education to the public.

5. Are there times and situations in which suicide should be an option? ■ This question is difficult to answer, particularly when the person is terminally ill and wishes to end his or her suffering. Nevertheless, therapists, like physicians, have been trained to preserve life, and they have a legal obligation to do so.

c h a p t e r

13

Schizophrenia: Diagnosis, Etiology, and Treatment

A

t the age of eight, Elyn Saks had already begun to suffer from the hallucinations and the fears of being attacked that accompanied her throughout her life. Only through self-control could she hide the impact of delusional thoughts and hallucinations while maintaining top grades in college. Even with these disturbing thoughts, Elyn still vaguely understood the importance of not talking about what ran through her mind. When she entered graduate school, she had full-blown psychotic episodes (believing that someone had infiltrated her research; dancing on the roof of the law library) that resulted in her being hospitalized and diagnosed with schizophrenia. She believed her therapist was replaced by an evil person with an identical appearance. In her book The Center Cannot Hold: My Journey Through Madness, she recounts her lifelong struggle with mental illness, describing schizophrenia as a “slow fog” that becomes thicker over time (Saks, 2007). Elyn’s struggle with the disorder, as well as her experience of forced treatment, resulted in her interest in mental health and the law. Her doctors had painted a bleak picture of her future. They believed that she would not complete her degree nor be able to hold a job or get married. However, Elyn Saks did get married and is an associate dean and professor of law, psychology, and psychiatry at the University of Southern California.

Schizophrenia is a group of disorders characterized by severely impaired cognitive processes, personality disintegration, affective disturbances, and social withdrawal. Like Elyn Saks, people with schizophrenia may lose contact with reality, may see or hear things that are not actually present, or may develop false beliefs about themselves or others. According to the DSM-IV-TR criteria (American Psychiatric Association, 2000a), a diagnosis of schizophrenic disorder includes symptoms such as delusions, auditory hallucinations, or marked disturbances in thinking, affect, or speech (see Table 13.1). The patient must also have deteriorated from a previous level of functioning in areas such as work, interpersonal

chapter outline The Symptoms of Schizophrenia

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Types of Schizophrenia

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The Course of Schizophrenia

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Etiology of Schizophrenia 374 The Treatment of Schizophrenia

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IM PLICA TION S

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CONTROVERSY Should

We Challenge Delusions and Hallucinations?

364

CONTROVERSY Delusional

Parasitosis or Physical Disease?

373

CONTROVERSY Balancing

Prevention and Harm

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schizophrenia a group of disorders characterized by severely impaired cognitive processes, personality disintegration, affective disturbances, and social withdrawal

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FOCUSQUESTIONS

1 What are the symptoms of schizophrenia?

4 What causes schizophrenia?

2 How do the specific types of schizophrenia differ

5 What treatments are currently available for

from one another?

schizophrenia, and are they effective?

3 Is there much chance of recovery from schizophrenia?

relationships, or self-care. Diagnosis requires symptoms to have been present most of the time for at least one month, and some of the time for at least six months. Organic mental disorders and affective disorders must be ruled out as causes of the patient’s symptoms. Schizophrenia receives a great deal of attention for several reasons. For one, it can be a severely disabling disorder that has a profound impact on the individual and on family members and friends. The prognosis is often much different from the productive life experienced by Elyn Saks. In the following first-person account, Eric Sundstrom presents a personal perspective on the changes he witnessed in his older sister after she developed schizophrenia.

Case Study My family spent 3 years in Holland when my sister was in middle school. I think she was truly happy then, forming friendships and teaching me about the things she loved. It seems incredible she was once an ordinary girl, full of vibrant personality. I still remember how she taught me to read, using a now-ancient copy of The Cat in the Hat. When our family returned to America, all of her friends signed the clogs for her to remember them by. The clogs and a few memories are my only window into who she was then and who she should be now. (Sundstrom, 2004, p. 191)

TA B L E

13.1

DSM-IV-TR CRITERIA FOR SCHIZOPHRENIA A. A one-month period in which two or more of the following symptoms become prominent (if the symptoms involving hallucinations or delusions are particularly bizarre, only one is necessary to meet this first criterion): 1. Delusions 2. Hallucinations 3. Disorganized speech or incoherence 4. Grossly disorganized or catatonic behavior 5. Negative symptoms, such as flat affect, mental confusion, or apathy B. Functioning in one or more areas such as work, social relations, and self-care has deteriorated markedly. C. Some signs of the disorder have been present for at least six months. Source: American Psychiatric Association (2000a).

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Eric recalls how his sister developed delusions and violent behavior during her sophomore year in high school. Auditory hallucinations insulted her and commanded her to break things. One day, after a change of medication resulted in an intensification of symptoms, his sister destroyed items around the house and had to be hospitalized. After he and his brother cleaned up the broken glass, they ate dinner in silence and realized that their sister had baked quiche for them; one side filled with vegetables for his brother and the other side plain for him. For the relatives of individuals with schizophrenia, the psychotic symptoms shown by their loved ones can be confusing, frightening, and heart wrenching. At times, reality becomes so distorted that those affected by schizophrenia cannot trust their own perceptions and thoughts. Schizophrenia also receives considerable attention because the financial costs of hospitalization, treatment, and loss of productivity caused by schizophrenia are huge—estimated to be 62.7 billion dollars annually (Wu et al., 2005). And the lifetime prevalence rate of schizophrenia in the United States is about 1 percent, so it affects millions of people (McGrath, 2005; National Institute of Mental Health [NIMH], 2007e). In addition, the causes of schizophrenia are not well understood, and it has been difficult to find effective treatments. Although

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DSM-IV-TR tries to present schizophrenia as a distinct disorder, evidence suggests that it is a heterogeneous clinical syndrome with different etiologies and outcomes (Braff, 2007; Heinrichs, 1993; Roth et al., 2004). Although many individuals with schizophrenia do not recover from the illness, some do, as in the case of Elyn Saks. Indeed, there is currently a move away from the view that schizophrenia is a chronic disorder with an inevitably poor prognosis. In fact, there has been recent attention to a recovery model that strives for substantial return of function for many individuals with schizophrenia. The recovery model views schizophrenia as a chronic medical condition, such as diabetes or heart disease, in which there might be interference with optimal functioning but in which the condition does not define the individual. The recovery model is based on the following assumptions regarding schizophrenia (Bellack, 2006): 1. Recovery or improvement in functioning is possible. 2. Healing involves separating one’s identity from the illness and developing the ability to cope with the symptoms. 3. Empowerment of the individual helps correct the sense of powerlessness and dependence that results from traditional mental health care. 4. Establishing or strengthening social connections with others can facilitate healing. The recovery model has resulted in comprehensive action with respect to schizophrenia that includes fighting policies that neglect the rights of individuals with the disorder, identifying the impact of stigma and discrimination on mental health, and promoting healing, growth, and respect for patients (Glynn et al., 2006). In this chapter, we present findings regarding the diagnosis, etiology, and treatment of schizophrenia.

The Symptoms of Schizophrenia

FIRST-HAND EXPERIENCE Elyn Saks has written about the forced treatment of the mentally ill based, in part, on her experiences. She teaches mental health law, has academic appointments at the University of Southern California and the University of California, San Diego, and is the associate dean at USC. She is training to be a psychoanalyst.

The symptoms of schizophrenia fall into three categories: positive symptoms, negative symptoms, and cognitive symptoms.

Positive Symptoms Positive symptoms of schizophrenia involve unusual thoughts or perceptions such as delusions, hallucinations, thought disorder (shifting and unrelated ideas that produce incoherent communication), and bizarre behavior. These symptoms increase with stress and tend to disappear with treatment. They differ in intensity as a function of stressors and are also influenced by an individual’s mood state (Smith et al., 2006). Delusions Delusions are false personal beliefs that are firmly and consistently held despite disconfirming evidence or logic. Delusions reflect a loss of distinction between one’s private thoughts and external reality. In the following case of Erin, his therapists are trying to determine how a graduate student in neuroscience could not understand the illogic behind his belief that rats were inside his brain and consuming a section of his brain.

Case Study “Erin, you are a scientist,” they’d begin. “You are intelligent, rational. Tell me then, how can you believe that there are rats inside your brain? They’re just too big. Besides, how could they get in?” (Stefanidis, 2006, p. 422)

positive symptom a symptom of schizophrenia that involves unusual thoughts or perceptions such as delusions, hallucinations, thought disorder (shifting and unrelated ideas that produce incoherent communication), and bizarre behavior delusion a false belief that is firmly and consistently held despite disconfirming evidence or logic

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Erin did retain some rational ability. He reasoned that he would soon lose the function controlled by the area of the brain that the rats were consuming. To prevent this from happening, he banged his head so that the “activated” neurons would “electrocute” the rats. Because he was not losing his sight even though he believed that the rats were eating his visual cortex, he entertained two possible explanations. First, his brain had a capacity for rapid regeneration, or second, the remaining brain cells compensated for the loss. Whenever information became too discrepant, Erin depended on his enhanced thought processes or “Deep Meaning,” a system he believed transcended scientific logic. Although individuals with schizophrenia may struggle with the logical nature of their beliefs, most individuals are either unaware or only moderately aware of the illogical nature of their hallucinations or delusions or question their symptoms (Amador et al., 1994; see Figure 13.1). Poor insight is related to negative symptoms and disorganized thought processes (Mutsatsa et al., 2006). A variety of delusional themes are seen in those with schizophrenia: • Delusions of grandeur A person’s belief that he or she is a famous or powerful person (from the present or the past). Individuals with schizophrenia may assume the identities of these other people. • Delusions of control A person’s belief that other people, animals, or objects are trying to influence or take control of him or her. • Delusions of thought broadcasting A belief that others can hear the individual’s thoughts. • Delusions of persecution A person’s belief that others are plotting against, mistreating, or even trying to kill him or her. • Delusions of reference A person’s belief that he or she is always the center of attention or that all happenings revolve about himself or herself—for instance, that others are always whispering behind his or her back. • Thought withdrawal A person’s belief that his or her thoughts are being removed from his or her mind. A rare delusion is Capgras’s syndrome (named after the person who first reported it). It is the belief in the existence of identical “doubles” who may coexist with or replace significant others or the patient, such as Elyn Saks’s belief that her therapist had been replaced by an evil double. Similarly, one daughter would phone her mother and ask questions such as what she had worn as a Halloween costume at the age of twelve or who had attended one of her birthday parties. “She was testing me because she didn’t think I was her mother. … No matter what question I answered, she was just sobbing” (Stark, 2004, p. A1). The daughter believed that her mother had been replaced by an imposter in a body suit and that her real mother had been kidnapped. Delusions can produce strong emotional reactions such as fear, depression, or anger among those experiencing them. Those with persecutory delusions may respond to perceived threats by leaving “dangerous” situations, avoiding areas where they

The Symptoms of Schizophrenia

might be attacked, or becoming more vigilant. Paradoxically, these “safety” behaviors may prevent the processing of disconfirmatory evidence, as the lack of a catastrophe may be attributed to their cautionary behaviors (Freeman et al., 2007). Delusions may be unconnected or may involve a single theme. One woman had multiple delusions, including a belief that celebrities were talking to her through the television, that her deceased husband was still alive and cheating on her, and that her internal organs were getting infected (Mahgoub & Hossain, 2006b). Delusions may vary from those that are plausible, such as being followed or spied on, to those that are bizarre (removal of internal organs or thoughts being placed in their minds). In one study (Harrow et al., 2004), nearly half of individuals with delusions had some questions regarding their beliefs, and 21 percent were fully aware that others might view their beliefs as atypical. The strength of delusional beliefs and their effects on the person’s life vary. Delusions have less impact when the individual is able to suggest an alternate hypothesis regarding the delusion or acknowledge that his or her belief may be incorrect (Warman et al., 2007).

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A BEAUTIFUL MIND John Nash, a Princeton University professor whose battle with schizophrenia was portrayed in a film, struggled with his psychotic symptoms and learned to ignore hallucinations. Even today, he occasionally hears voices.

Myth vs Reality Myth: Individuals experiencing delusions or hallucinations steadfastly accept them as reality. Reality: The strength of hallucinations and delusions among individuals with schizophrenia varies during the course of the illness and among specific individuals. Some believe in them 100 percent, whereas others acknowledge being less certain. Even without treatment, many attempt to develop means of reestablishing contact with reality or testing out the reality of their thinking. Some individuals with schizophrenia, such as Elyn Saks and mathematician John Nash, who was portrayed in the movie A Beautiful Mind, are able to struggle with their illness through a combination of will power and medication. However, most need to supplement medications with specific cognitive training to develop the skills necessary to question their own hallucinations and delusions.

Individuals with schizophrenia sometimes reach conclusions based on limited information, which may lead to the development of unusual beliefs. Delusional individuals appear to make errors during the stages of hypothesis formation and evaluation. They develop unlikely hypotheses from limited information and then overestimate the probability that the hypotheses are true (Warman et al., 2007). In one study, delusional individuals demonstrated a reasoning bias by rating narratives of twenty-five actual delusions involving themes of grandiosity, persecution, thought broadcasting, or thought insertion as “more likely to be true” than nondelusional patients. Interestingly, they did not display this reasoning bias when presented with neutral narratives (themes that involved the probability that red or black balls could be picked blindly from a bag with differing proportions of colored balls). To account for these differences, the researchers hypothesized that delusional individuals may have an attentional bias for emotionally salient or threat-related information (McGuire et al., 2001). People with schizophrenia can be trained to challenge their delusions. One fiftyone-year-old patient believed—with almost 100 percent certainty—that she was younger than twenty and that she was the daughter of Princess Anne. Her therapist asked her to view her delusion as only one possible interpretation. Then they discussed evidence for her belief, and the therapist presented the inconsistencies and irrationality of the belief, as well as alternative explanations. After this procedure, the

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controversy

Should We Challenge Delusions and Hallucinations? The doctor asked of a patient who insisted that he was dead: “Look. Dead men don’t bleed, right?” When the man agreed, the doctor pricked the man’s finger, and showed him the blood. The patient said, “What do you know, dead men do bleed after all.” (Walkup, 1995, p. 323)

Clinicians have often been unsure about whether to challenge psychotic symptoms. Some contend that the delusions and hallucinations serve an adaptive function and that any attempt to change them would be useless or even dangerous. The example of the patient who believed he was dead illustrates the apparent futility of using logic in treating people with schizophrenia. However, Coltheart, Langdon, and McKay (2007) found that a “gentle and tactful offering of evidence” was successful in treating a man who believed his wife was not his wife but was, instead, his business partner. The man was asked to entertain the possibility that the woman was actually his wife. The therapist pointed out that the woman was wearing a wedding ring identical to the one he had bought for his wife. The man said that the woman probably bought the ring from the same shop. He was then shown the initials engraved in the ring as being those of his wife. Within one week, he accepted the fact that the woman was his wife. Other clinicians (Bak et al., 2003; Beck & Rector, 2000; Chadwick et al., 2000; Freeman et al., 2007) have also found that some clients respond well to challenges to their hallucinations and delusions. The approach has two phases. In the first, hypothetical contradictions are used to assess how open the patients are to conflicting information. During this phase, patients are introduced to information that might contradict their beliefs, and it is here that their delusions are often weakened.

• A woman, H.J., with auditory hallucinations was asked if her belief in the “voices” would change if it could be determined that they were coming from her. She agreed. She was given a set of industrial earmuffs, which she wore. She still reported hearing voices. • A woman believed that God was commanding her to kill. She was asked if her belief would be lessened if a priest informed her that God would not ask anyone to kill another person. In the second phase, the therapist issues a verbal challenge, asking clients to give evidence for their beliefs and to develop alternative interpretations. For example, one client claimed that voices were accurate in telling her when her spouse would return. The therapist asked how she might determine her husband’s return if the voices were unable to foretell the future. Another patient who claimed he would be killed if he did not comply with auditory commands was told that he could resist the voices and would not die. Alternative explanations are proposed for the hallucinations, including the possibility that the voices are thoughts or “self-talk.” After cognitive-behavioral treatment, most patients report a decreased belief in their psychotic symptoms. In H.J.’s case, her degree of certainty about her auditory hallucinations dropped from 100 percent to 20 percent. Although she still heard voices telling her she would die, she learned to disregard them and attributed them as “coming from her head.” For Further Consideration 1. Should we challenge psychotic symptoms? If so, what is the best way of doing so? 2. Could some psychotic symptoms have an adaptive function?

patient reported a large drop in the conviction of her beliefs, stating “I look 50 and I tire more quickly than I used to; I must be 50” (Lowe & Chadwick, 1990, p. 471). She agreed that she was probably older than Princess Anne and therefore could not be her daughter. Belief modification appears to be a helpful procedure for some individuals with schizophrenia, though there is some controversy surrounding this approach. Hallucinations The following patient is experiencing auditory hallucinations— voices asking her to injure herself. a sensory perception that is not directly attributable to environmental stimuli

hallucination

Case Study

loosening of associations

“Let’s get out the knife. This is what we want to do. Don’t worry, we are on your side. Think how it will feel. Think of the warm, red blood inside you, and how much we would like to see that. . . . Think about how much you want to cut yourself there. Think. Think”. (Fowler, 2007, p. 16)

in schizophrenia, continual shifting from topic to topic without any apparent logical or meaningful connection between thoughts

Hallucinations are sensory perceptions that are not directly attributable to environmental stimuli; they may involve a single sensory modality or a combination of modalities: hearing (auditory hallucinations), seeing (visual hallucinations),

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smelling (olfactory hallucinations), feeling (tactile hallucinations), and tasting (gustatory hallucinations). Auditory hallucinations are most common and can range from being malevolent to being benevolent or having both qualities (Copolov, Mackinnon, & Trauer, 2004). The greatest distress is expressed when the voices are dominant and insulting and the patient cannot communicate with the voices (Vaughan & Fowler, 2004). Auditory hallucinations appear to be “real” to the individual experiencing them. In one study, 61 percent reported that the voices had a distinct gender, 46 percent believed that the voice was that of a friend, family member, or acquaintance, and 80 percent reported having back-and-forth conversations with the voices. The voices, in some cases, introduced themselves to the patients and acted like real persons. As one individual responded, “They are not imaginary. They see what I do. They tell me that I’m baking a cake. They must be there. How would they know what I’m doing?” (Garrett & Silva, 2003, p. 447). Most believed the voices were independent entities, and some had conducted “research” to test the reality of the voices. One had said she initially thought that the voice might be her own but rejected it when her voice called her “mommy,” something she would not call herself. Disorganized Thought and Speech Disordered thinking is a primary characteristic of schizophrenia. During communication, the individual may jump from one topic to another, speak in an unintelligible manner, or reply tangentially to questions. Loosening of associations, also referred to as cognitive slippage, is the continual shifting from topic to topic without any apparent logical or meaningful connection between thoughts. It may be shown by incoherent speech or bizarre, idiosyncratic responses, as indicated in the following example.

DELUSIONS OF GRANDEUR Assuming the identity of another, powerful person can be a sign that an individual suffering from schizophrenia is experiencing delusions of grandeur.

Case Study INTERVIEWER: “You just must be an emotional person, that’s all.” PATIENT (1): “Well, not very much I mean, what if I were dead. It’s a funeral age. Well I um. Now I had my toenails operated on. They got infected and I wasn’t able to do it. But they wouldn’t let me at my tools.” (Thomas, 1995, p. 289)

The beginning phrase in the patient’s first sentence appears appropriate to the interviewer’s comment. However, the reference to death is not. Slippage appears in the comments referring to a funeral age, having toenails operated on, and getting tools. None of these thoughts are related to the interviewer’s observation, and they have no hierarchical structure or organization. People with schizophrenia may also respond to words or phrases in a very concrete manner and demonstrate difficulty with abstractions. A saying such as “a rolling stone gathers no moss” might be interpreted as “moss can’t grow on a rock that is rolling.” These communication difficulties may result from an inability to inhibit contextually irrelevant information (Titone, Levy, & Holzman, 2000). Disorganized Motor Disturbances The symptoms of schizophrenia that involve motor functions can be quite bizarre, as is evident in the following case:

Case Study At age 20, patient A … was found sitting at the edge of the bed for hours, displaying simple repetitive movements of the right hand, and simultaneously holding his left hand in a bizarre posture. This was accompanied by verbigerations (“I do, I do, I do . . . ”) (verbigerations are compulsive repetitions of meaningless words and phrases). (Stober, 2007, pp. 38–39)

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sychotic-like experiences are not uncommon among the general population. In a sample of 591 participants ages twenty and twenty-one, Rossler and colleagues (2007) found: • 38 percent endorsed the statement “someone else can control my thoughts” • 20 percent endorsed the statement “others are aware of my thoughts” • 18 percent endorsed the statement “I have thoughts that are not my own” • 3.2 percent reported “hearing voices other people don’t hear” In most cases, these beliefs were transient and not clinically relevant unless they become persistent, excessive, or associated with significant distress.

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Persons with schizophrenia may show extremes in activity level (either unusually high or unusually low), peculiar body movements or postures, strange gestures and grimaces, or a combination of these. Like hallucinations, a patient’s motoric behaviors may be related to his or her delusions. For example, during a clinical interview, one patient with schizophrenia kept lowering his chin to his chest and then raising his head again. Asked why he lowered his head in that way, the patient replied that the atmospheric pressure often became too great to bear, and it forced his head down. Some individuals may display extremely high levels of motor activity, moving about quickly, swinging their arms wildly, talking rapidly and unendingly, or pacing constantly. At the other extreme, others hardly move at all, staring out into space (or perhaps into themselves) for long periods of time. The inactive patients also tend to show little interest in others, respond only minimally, and have few friends. During periods of withdrawal, they are frequently preoccupied with personal fantasies and daydreams. The assumption and maintenance of an unusual (and often awkward) body position is characteristic of the catatonic type of schizophrenia (to be discussed shortly). A catatonic patient may stand for hours at a time, perhaps with one arm stretched out to the side, or may lie on the floor or sit awkwardly on a chair, staring, aware of what is going on around him or her but not responding or moving. If someone tries to change the patient’s position, the patient may either resist stubbornly or may simply assume and maintain the new position. Catatonic symptoms are not specific to schizophrenia and may also occur with mood disorders or medical conditions. See Figure 13.2 for the prevalence of specific symptoms in a group of individuals with catatonic schizophrenia.

Negative Symptoms Negative symptoms of schizophrenia are associated with an inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure. Such symptoms include avolition (an inability to take action or become goal-oriented), alogia (a lack of meaningful speech), and flat affect (little or no emotion in situations in which strong reactions are expected). A delusional patient, for instance, might explain in detail how parts of his or her body are rotting away but show absolutely no concern or worry through voice tone or facial expression. Clinicians are careful to distinguish between primary symptoms (symptoms that arise from the disease itself) and secondary symptoms (symptoms that may develop as a response to medication, institutionalization, or as a result of a mood PAINTING THE SYMPTOMS OF SCHIZOPHRENIA disorder such as depression). The inner turmoil and private fantasies of In clinical samples, approximately 20 to 25 percent of patients disschizophrenics are often revealed in their artwork. The play primarily negative symptoms (Kirkpatrick et al., 2006). Negative paintings you see here were created in the 1930s and 1940s by psychiatric patients in European hospitals. symptoms are associated with inferior premorbid (before the onset of illThey are part of the Prinzhorn Collection at the ness) social functioning and carry a poorer prognosis. Flat affect is more Psychiatric University Hospital in Heidelberg, Germany. common in men and is associated with a poor prognosis and outcome What do you think the paintings represent? (Gur et al., 2006). One group of individuals with schizophrenia with negative symptoms endorsed beliefs such as “Having friends is not as important as many say,” “I attach very little importance to having close friends,” “Taking negative symptom even a small risk is foolish because the loss is likely to be a disaster,” “If a person in schizophrenia, a symptom avoids problems, the problem tends to go away,” “If I show my feelings, others will associated with an inability or see my inadequacy,” and “Why bother, I’m just going to fail” (Rector, Beck, & Stolar, decreased ability to initiate actions 2005). These beliefs may contribute to a lack of motivation to interact with others. or speech, express emotions, or feel Individuals also vary regarding their degree of insight into their symptoms. Greater pleasure; includes avolition, alogia, awareness of their difficulties is related to more severe depression, whereas poorer and flat affect insight is associated with more severe negative symptoms (Mutsatsa et al., 2006).

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Cognitive Symptoms Cognitive symptoms of schizophrenia include problems with attention and memory and difficulty in developing a plan of action. As compared with healthy controls, those with schizophrenia have severe to moderately severe cognitive impairments, as evidenced by poor “executive functioning”—deficits in the ability to absorb and interpret information and make decisions based on that information; to sustain attention; and to retain recently learned information and use it right away (NIMH, 2007e). Cognitive symptoms are generally present even prior to the onset of the first psychotic episode (Pflueger et al., 2007), tend to persist even with treatment, and are found to a lesser degree among nonpsychotic relatives of patients with schizophrenia (Reichenberg & Harvey, 2007). Many researchers consider these cognitive impairments to be a core component of schizophrenia and should be added as a criterion for the diagnosis of schizophrenia in the next revision of the DSM (they are not currently part of the diagnostic criteria for schizophrenia) (Keefe & Fenton, 2007).

Cultural Issues Culture may affect how symptoms of schizophrenia are displayed or interpreted. In Japan, for example, schizophrenia is highly stigmatized. Part of the problem is that the condition is called seishin-bunretsu-byou, which roughly translates as a split in mind or spirit. The term conjures up an irreversible condition. Because of this connotation, the Japanese Society of Psychiatry and Neurology is considering finding a less negative term (Sugiura, Sakamoto, Tanaka, Tomada, & Kitamura, 2001). A negative reaction to the term schizophrenia is also part of the reason that many psychiatrists in Turkey will not mention the diagnosis to patients and family members (Ucok, 2007). In western countries, individuals with schizophrenia tend to show more depressive symptoms and to report thought broadcasting and insertion, whereas those in nonwestern countries tend to report more visual and directed auditory hallucinations (Jilek, 2001). The content of delusions also seems to be influenced by culture and society. In the 1960s, during the social and political upheaval of the period known as the Cultural Revolution in China, a number of different delusions appeared among Chinese patients with schizophrenia (Yu-Fen & Neng, 1981). These included the delusion of leadership lineage, in which patients insisted that their parents were people in authority; the delusion of being tested, in which patients believed that their superiors were assessing them to determine whether they were suitable for promotion; the delusion of impending arrest, in which patients assumed that they were about to be arrested by authorities; and the delusion of being married, in which a female patient insisted that she had a husband even though she was unmarried.

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an a mooing dog, an upsidedown house, and a red cloud identify individuals with schizophrenia? In one study, patients and healthy controls wore a head-mounted virtual reality display that gave them the sense of going through a neighborhood, a shopping center, and a market. Fifty incoherencies such as the preceding examples were presented during the journey. Eighty-eight percent of those with schizophrenia failed to detect these inconsistencies, whereas only one member of the control group did. Even if the patients identified the inconsistencies, about two-thirds had difficulty explaining them. Source: Sorkin, Weinshall, & Peled (2008).

cognitive symptom

in schizophrenia, a symptom that is associated with problems with attention, memory, and difficulty in developing a plan of action

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Ethnic group differences have also been found regarding the prevalence of schizophrenia. However, between-group differences are difficult to interpret. As DSM-IV-TR notes, “There is some evidence that clinicians may have a tendency to overdiagnose Schizophrenia in some ethnic groups. Studies conducted in the United Kingdom and the United States suggest that Schizophrenia may be diagnosed more often in individuals who are African American and Asian American than in other racial groups” (American Psychiatric Association, 2000a, p. 307). It is not clear whether these are actual differences in rates of the disorder or whether they represent clinician bias. Cultural differences between patient and clinician may produce diagnostic errors—the greater the difference, the greater the likelihood of error. Additionally, misdiagnosis can result from racial stereotyping or bias or from applying diagnostic systems based on white middle-class norms to other racial groups.

Types of Schizophrenia Five types of schizophrenic disorders are traditionally recognized: paranoid, disorganized, catatonic, undifferentiated, and residual (see Table 13.2).

TA B L E

13.2

DISORDERS CHART COGNITIVE DISORDER

Paranoid Schizophrenia

SCHIZOPHRENIA PREVALENCE

• Preoccupations with one or more systematized delusions or auditory hallucinations

Most common type, found equally in men and women

In the 30s; later in life than other types; later onset in women

Prognosis better than with other types; often little impairment in occupational functioning

Somewhat common type; more common in women

Mid to late teens; earlier in women than in men

Prognosis poor; continuous course without significant remission

Rare in United States, more prevalent in nonwestern countries

Late teens to early 20s

Course may be intermittent or insidious and chronic

• Does not meet criteria for other types

Relatively common type; found equally in men and women

Early 20s or somewhat earlier

Uncertain; depends on specific symptom patterns

Experienced at least one previous schizophrenic episode but now showing

Somewhat common type

Early 20s for both males and females

Course may be timelimited, representing a transition between psychotic episodes

• Absence of disorganized speech or behavior, or flat or inappropriate affect Disorganized Schizophrenia

• Grossly disorganized speech and behavior • Flat or grossly inappropriate affect

Catatonic Schizophrenia

AGE OF ONSET

SYMPTOMS

Marked psychomotor disturbances manifested in two or more of the following: • Motoric immobility or stupor • Excessive, purposeless motor activity • Extreme negativism or physical resistance

COURSE

• Peculiar voluntary movements • Echolalia or echopraxia Undifferentiated Schizophrenia

Residual Schizophrenia

The person’s behavior • Shows prominent psychotic symptoms

• Absence of prominent psychotic features • Continuing evidence of two or more symptoms

Source: From American Psychiatric Association (2000a); Beratis, Gabriel, & Hoidas (1994); Pfuhlmann & Stober (1997).

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Paranoid Schizophrenia The most common form of schizophrenia is the paranoid type. Paranoid schizophrenia is characterized by one or more systematized delusions or auditory hallucinations and by the absence of such symptoms as disorganized speech and behavior or flat affect. In this group, high levels of anxiety and worry over persecutory delusions are common (Startup, Freeman, & Garety, 2006), as are angry reactions to perceived persecution. Some delusions may function to protect the self-concept by turning personal problems into an accusation that “others are responsible for the bad things that are happening to me.” Several studies have found that individuals with paranoid delusions externalize their problems (Kinderman & Bentall, 1996, 1997). The deluded individuals believe that others are plotting against them, are talking about them, or are out to harm them in some way. They are constantly suspicious, and their interpretations of the behavior and motives of others are distorted. A friendly, smiling bus driver is seen as someone who is laughing at them derisively. A busy clerk who fails to offer help is part of a plot to mistreat them. A telephone call that was a wrong number is an act of harassment or an attempt to monitor their comings and goings. Interestingly, as compared with nonparanoid schizophrenic patients and control participants, patients with paranoid schizophrenia were more accurate in recognizing genuine nonverbal expressions of emotions (Davis & Gibson, 2000).

Case Study A 49-year-old woman, Janice, was convinced that she had been raped, even though her husband had been in bed with her and the dead bolt on the bedroom door was undisturbed. The woman was brought by the husband to the emergency room where she asked the medical staff to check her throat for signs of a sexual assault involving oral sex. None was found. Janice was convinced that furniture in the bedroom had been moved during the “break-in.” She also indicated a belief that her computer was controlled by unknown people and that programs had been deleted from the hard drive. She refused treatment, saying that “I came to the ER to see if this was due to something medical. If it’s psychological, I can deal with it myself.” (Muller, 2006, p. 43)

The prognosis for the paranoid type tends to be more positive than for other types of schizophrenia.

Disorganized Schizophrenia Disorganized schizophrenia (formerly called hebephrenic schizophrenia) is characterized by grossly disorganized behaviors manifested in disorganized speech and behavior and flat or grossly inappropriate affect. Behaviors may begin at an early age. People with this disorder act in an absurd, incoherent, or very odd manner that conforms to the stereotype of “crazy” behavior. Their emotional responses to reallife situations are typically flat, but a silly smile and childish giggle may appear at inappropriate times (Kumperscak et al., 2005). The hallucinations and delusions of patients with disorganized schizophrenia tend to shift from theme to theme rather than remaining centered on a single idea. Because of the severity of the disorder, many people affected with disorganized schizophrenia are unable to care for themselves and are institutionalized. People with this disorder usually exhibit extremely bizarre and seemingly childish behaviors, such as masturbating in public or fantasizing aloud.

Catatonic Schizophrenia Marked disturbance in motor activity—either extreme excitement or motoric immobility—is the prime characteristic of catatonic schizophrenia. Diagnostic criteria include two or more of the following symptoms: motoric immobility or stupor; excessive, purposeless motor activity; extreme negativism (resisting direction) or physical resistance; peculiar voluntary posturing or movements; or echolalia (repetition of other people’s speech) or echopraxia (repetition of other people’s movements; Stober, 2007). This disorder is quite rare but somewhat more prevalent in nonwestern countries.

paranoid schizophrenia

a schizophrenic subtype characterized by one or more systematized delusions or auditory hallucinations and by the absence of such symptoms as disorganized speech and behavior or flat affect disorganized schizophrenia

a schizophrenic subtype characterized by grossly disorganized behaviors manifested in disorganized speech and behavior and flat or grossly inappropriate affect catatonic schizophrenia

a schizophrenic subtype characterized by marked disturbance in motor activity—either extreme excitement or motoric immobility; symptoms may include motoric immobility or stupor; excessive purposeless motor activity; extreme negativism or physical resistance; peculiar voluntary movements; or echolalia or echopraxia

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CHARACTERISTICS OF DISORGANIZED SCHIZOPHRENIA Grossly disorganized behavior in which an individual dresses or behaves in an unusual manner is displayed in some people with schizophrenia. Here, a hospitalized patient showers in her clothes. Would the woman understand that this behavior is odd?

undifferentiated schizophrenia

a schizophrenic subtype in which the person’s behavior shows prominent psychotic symptoms that do not meet the criteria for paranoid, disorganized, or catatonic schizophrenia residual schizophrenia

a subtype of schizophrenic disorder reserved for people who have had at least one previous schizophrenic episode but are now showing an absence of prominent psychotic features; there is continuing evidence of two or more symptoms, such as marked social isolation, peculiar behaviors, blunted affect, odd beliefs, or unusual perceptual experiences

CHARACTERISTICS OF CATATONIC SCHIZOPHRENIA Individuals with catatonic schizophrenia experience a variety of disturbances in motor activity. Those who are excited exhibit great agitation and hyperactivity; those who are withdrawn may exhibit extreme unresponsiveness or adopt strange postures.

People with excited catatonia are agitated and hyperactive. They may talk and shout constantly, while moving or running until they drop from exhaustion. They sleep little and are continually “on the go.” Their behavior can become dangerous, and violent acts are not uncommon. People in withdrawn catatonia are extremely unresponsive with respect to motor activity. They show prolonged periods of stupor and mutism, despite their awareness of all that is going on around them. Some may adopt and maintain strange postures and refuse to move or change position. Others exhibit a waxy flexibility, allowing themselves to be “arranged” in almost any position and then remaining in that position for long periods of time. During periods of extreme withdrawal, people with catatonic schizophrenia may not eat or control their bladder or bowel functions. Alternating periods of excited motor activity and withdrawal may occur in this disorder (Caroff et al., 2007).

Undifferentiated and Residual Schizophrenia Undifferentiated schizophrenia is diagnosed when the person’s behavior shows prominent psychotic symptoms that do not meet the criteria for the paranoid, disorganized, or catatonic categories. These symptoms may include thought disturbances, delusions, hallucinations, incoherence, and severely impaired behavior. Sometimes undifferentiated schizophrenia turns out to be an early stage of another subtype. The diagnosis of residual schizophrenia is reserved for people who have had at least one previous schizophrenic episode but who are now showing an absence of prominent psychotic features. There is continuing evidence of two or more symptoms, such as marked social isolation, peculiar behaviors, blunted affect, odd beliefs, or unusual perceptual experiences. The disorder may be in remission. In any case, the person’s symptoms are neither strong enough nor prominent enough to warrant classification as one of the other types of schizophrenia.

Types of Schizophrenia

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13.3

COMPARISON OF BRIEF PSYCHOTIC DISORDER, SCHIZOPHRENIFORM DISORDERS, AND SCHIZOPHRENIA BRIEF PSYCHOTIC DISORDER

SCHIZOPHRENIFORM DISORDERS

SCHIZOPHRENIA

Duration

Less than one month

Less than six months

Six months or more

Psychosocial Stressor

Always present

Usually present

May or may not be present

Symptoms

Emotional turmoil; psychotic symptoms

Emotional turmoil; vivid psychotic symptoms

Emotional reactions variable; hallucinations

Outcome

Return to premorbid level of functioning

Possible return to earlier, higher level of functioning

Return to earlier, higher level of functioning is uncommon

Familial Pattern

No information; possible relationship to mood disorder

Possible increased risk of schizophrenia among family members

Higher prevalence of schizophrenia among family members

Psychotic Disorders That Were Once Considered Schizophrenia Exposure to psychological trauma such as combat can produce brief psychotic reactions. In a study of ninety-one men who had fought in Croatia, 20 percent reported hallucinations and delusions (Kastelan et al., 2007). Brief reactive psychosis has also been reported in cases of Guillain-Barré syndrome, during which the body and the muscles used for breathing can become paralyzed. Of forty-nine individuals who suffered severe forms of this syndrome, 25 percent developed a psychotic reaction (Weiss et al., 2002). Brief psychotic episodes were considered to represent acute forms of schizophrenia in DSM-II. With DSM-III-R and DSM-IV-TR, people who have “schizophrenic” episodes that last fewer than six months are now diagnosed as having either brief psychotic disorder (duration of at least one day but less than one month) or schizophreniform disorder (duration of at least one month but less than six months). In contrast to schizophrenia, a diagnosis of schizophreniform disorder does not require impairment in social or occupational functioning. Differences between these disorders and schizophrenia are shown in Table 13.3. Although they appear to be distinct, the disorders are often highly similar in characteristics. DSM-IV-TR recommends that the diagnoses of brief psychotic disorder and schizophreniform disorder be “provisional.” For example, an initial diagnosis of brief psychotic disorder may change to schizophreniform disorder if it lasts longer than one month and to schizophrenia if it lasts longer than six months. In a follow-up study of fifty-six individuals with schizophreniform disorders, 46 percent later received a diagnosis of schizophrenia, 35 percent a mood disorder, 18 percent a nonschizophrenic psychotic disorder, and 2 percent no disorder (Marchesi et al., 2007). Because duration is the only accurate means of distinguishing among the disorders, questions about the validity of categories have been raised.

Other Psychotic Disorders Other psychotic disorders include delusional disorder, shared psychotic disorder, and schizoaffective disorder.

brief psychotic disorder

psychotic disorder that lasts no longer than one month schizophreniform disorder

psychotic disorder that lasts more than one month but less than six months

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Delusional Disorder Delusional disorder is characterized by persistent, nonbizarre delusions that are not accompanied by other unusual or odd behaviors. It is not a form of schizophrenia, although it is often confused with paranoid schizophrenia. In both, thought processes are disturbed. Nevertheless, some differences do exist. Delusional disorder involves “nonbizarre beliefs” (situations that could actually occur) that have lasted for at least one month. Also, except for the delusion, the person’s behavior is not odd. In schizophrenia, additional disturbances in thoughts and perceptions are involved. People with delusional disorder behave normally when their delusional ideas are not being discussed. Common themes in delusional disorders involve: • Erotomania—the belief that someone is in love with the individual; usually the love is romanticized rather than sexual. • Grandiosity—the conviction that one has great, unrecognized talent or some special ability or relationship with an important individual. • Jealousy—the conviction that one’s spouse or partner is being unfaithful. • Persecution—the belief in being conspired or plotted against. • Somatic complaints—convictions of having body odor, being malformed, or being infested by insects or parasites. The following cases illustrate some features of delusional disorders: • A woman was convinced that people were watching her and following her because she saw the same people day after day in her neighborhood and the stores in which she shopped (Muller, 2006). • A fifty-two-year-old woman complained of insects that wandered in her body. Especially when she scratched her legs, she insisted she saw insects (Mecan et al., 2007). • A homeless man was arrested after lounging naked by a swimming pool he believed belonged to former tennis pro Anna Kournikova. He explained to the police that Anna loved him and had left the door unlocked and laid out clothing for him (“Man Accused,” 2005). A decreased ability to obtain corrective feedback, combined with a preexisting personality type that tends toward suspiciousness, may increase susceptibility to developing delusional beliefs. Delusional disorder can be treated with antipsychotic medications and/or cognitive behavior therapy (Mecan et al., 2007)

delusional disorder a disorder characterized by persistent, nonbizarre delusions that are not accompanied by other unusual or odd behaviors shared psychotic disorder

disorder in which a person who has a close relationship with an individual with delusional or psychotic beliefs comes to share those beliefs schizoaffective disorder

a disorder characterized by both a mood disorder (major depression or bipolar disorder) and the presence of psychotic symptoms “for at least two weeks in the absence of prominent mood symptoms”

Shared Psychotic Disorder Both a twenty-eight-year-old woman and her mother shared the delusion that the daughter had been given poisoned food and was hypnotized by a man so that he could rape her. They appeared at an emergency department together with the mother requesting that the daughter be “de-hypnotized” (Mahgoub & Hossain, 2006a). In shared psychotic disorder, a person who has a close relationship with an individual with delusional or psychotic beliefs comes to accept those beliefs (Wehmeier, Barth, & Remschmidt, 2003). Shared psychotic disorder is relatively rare and is more prevalent among those who are socially isolated. In the preceding case, the daughter never married, lived with and was submissive to her mother, and had no close relationships with others. The pattern generally involves a family member or partner acquiring the delusional belief from the dominant individual. In many cases, an individual who shares another person’s delusional or psychotic beliefs loses faith in those beliefs when the two individuals are separated. Schizoaffective Disorder Schizoaffective disorder includes both a mood disorder (major depression or bipolar disorder) and the presence of psychotic symptoms “for at least two weeks in the absence of prominent mood symptoms” (American Psychiatric Association, 2000a, p. 323). The disorder is more common in females and usually begins in early adulthood. The prognosis appears to be more positive for this disorder than for schizophrenia.

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controversy

Delusional Parasitosis or Physical Disease?

F

our years ago, “Mary Leitao plucked a fiber that looked like a dandelion fluff from a sore under her two-yearold son’s lips. . . . Sometimes the fibers were white, and sometimes they were black, red, or blue” (DeVitaRaeburn, 2007, p. 1). Leitao was frustrated by the inability of physicians to diagnose the problem in her son. In fact, many indicated that they could find no evidence of a disease or infection. Frustrated by the medical establishment, Mary put a description of the condition on a Web site in 2004 and called it Morgellons disease. More than eight thousand individuals responded to the Web site with reports of this condition either in themselves or in their children. Sufferers reported fiber-like threads emerging from the skin at the site of itching and sensations of crawling, stinging, or biting and nonhealing rashes and skin lesions (Paquette, 2007). What could cause this disorder? Many dermatologists and physicians believe that cases of Morgellons disease are actually a somatic type of delusional disorder or the result of self-inflicted wounds. In examining the bodies of patients with the disorder, physicians report being unable to find fibers at the sites of “infection” but often report

inflamed skin due to being scratched or picked at (DeVitaRaeburn, 2007). Stephen Stone, the current president of the American Academy of Dermatology, does not believe Morgellons disease is real and indicates that patients with this condition often respond well to treatment with antipsychotics. He warns that the Internet community may reinforce and help individuals with somatic delusions band together (Marris, 2006). Because of numerous complaints to the Centers for Disease Control (CDC) from those who believe they suffer from this condition, the CDC began conducting an investigation of this unexplained skin condition in 2007. For Further Consideration 1. Is the Morgellons disease Web site feeding into a population of vulnerable delusional individuals who can now receive reinforcement for their illness, or is it providing comfort for those with an actual disease? 2. If an actual physical condition is found, what will it mean in regard to the skepticism shown by the medical community?

The Course of Schizophrenia It is popularly believed that overwhelming stress can cause a well-adjusted and relatively normal person to experience a schizophrenic breakdown. There are, in fact, recorded instances of the sudden onset of psychotic behaviors in previously wellfunctioning people (Kastelan et al., 2007). In most cases, however, the person’s premorbid personality (personality before the onset of major symptoms) shows some impairment. Similarly, most people with schizophrenia recover gradually rather than suddenly. The typical course of schizophrenia consists of three phases: prodromal, active, and residual. The prodromal phase includes the onset and buildup of schizophrenic symptoms. Social withdrawal and isolation, peculiar behaviors, inappropriate affect, poor communication patterns, and neglect of personal grooming may become evident during this phase. Of eleven patients who were interviewed in one study (Campo et al., 1998), nine indicated that they had drastically changed their appearances (cutting or changing hairstyles, wearing multiples of the same type of clothing) just before the onset of the schizophrenic episode. They said the changes were an attempt to maintain their identities. Friends and relatives often considered such behavior odd or peculiar. Often, psychosocial stressors or excessive demands on an individual with schizophrenia in the prodromal phase result in the onset of prominent psychotic symptoms, or the active phase of schizophrenia. In this phase, the person shows the full-blown symptoms of schizophrenia, including severe disturbances in thinking, deterioration in social relationships, and flat or markedly inappropriate affect. At some later time, the person may enter the residual phase, in which the symptoms are no longer prominent. The severity of the symptoms declines, and the individual may show the milder impairment found in the prodromal phase. (At this point, the diagnosis would be residual schizophrenia.) Although long-term studies have shown that many people with schizophrenia can lead productive lives, complete recovery is rare (see Figure 13.3 for different courses of the disease).

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Long-Term Outcome Studies One episode only– no impairment

Course 1 (12.2 percent of patients)

Several episodes with no or minimal impairment

Course 2 (14.6 percent of patients) Impairment after the first episode with symptoms of anxiety and/or depression

Course 3 (17.1 percent of patients) Impairment increasing with each of several episodes followed by negative symptoms

What are the chances for recovery from or improvement in schizophrenia? According to DSM-IV-TR, “Complete remission (i.e., a return to full premorbid functioning) is probably not common in this disorder” (American Psychiatric Association, 2000a, p. 309). The chances for improvement or recovery are difficult to evaluate because of the changing definitions of schizophrenia over the years and recent improvements in both psychotherapy and medication. In a ten-year follow-up study of individuals hospitalized for schizophrenia, the majority of patients improved over time, while a minority appeared to deteriorate (Rabinowitz et al., 2007). Similarly, during a fifteenyear follow-up period of 274 patients with schizophrenia, the following were found (Harrow et al., 2005): • Over 40 percent showed one or more periods of recovery (defined as the absence of psychotic activity and negative symptoms, working half time or more, absence of very poor social activity levels, and no psychiatric hospitalization during the period of evaluation). • A sizable minority were not on any medication.

Course 4 (33 percent of patients)

An earlier follow-up study (Wiersma et al., 1998) also reported that about one-quarter of individuals diagnosed with schizophrenia showed complete remission of symptoms, although about half of Impairment with no this group had had more than one psychotic episode. About 50 perrecovery after first episode cent showed partial remission of symptoms that was accompanied Course 5 (11 percent of patients) by either anxiety and depression or negative symptoms, and 11 percent showed no recovery after the initial psychotic episode. Relapses FIGURE SOME DIFFERENT COURSES occurred in two-thirds of this sample, after which about one in six FOUND IN SCHIZOPHRENIA This figure shows five of showed no remission of symptoms. The long-term outcome for peothe many courses that schizophrenia may take. These ple with schizophrenia may be more positive than that portrayed by courses were observed in individuals during a fifteen-year DSM-IV-TR, especially if one focuses on the periods of recovery that follow-up study (Wiersma et al., 1998). have been found in individuals with schizophrenia. Factors associated with a positive outcome include gender (women have a better outcome), being married, and having a higher premorbid level of functioning and better educational background (Irani & Siegel, 2006).

13.3

Etiology of Schizophrenia Case Study A thirteen-year-old boy who was having behavioral and academic problems in school was taking part in a series of family therapy sessions. Family communication was negative in tone, with a great deal of blaming. Near the end of one session, the boy suddenly broke down and cried out, “I don’t want to be like her.” He was referring to his mother, who had been receiving treatment for schizophrenia and was taking antipsychotic medication. He had often been frightened by her bizarre behavior, and he was concerned that his friends would “find out” about her condition. But his greatest fear was that he would inherit the disorder. Sobbing, he turned to the therapist and asked, “Am I going to be crazy, too?”

If you were the therapist, how would you respond? At the end of this section on the etiology of schizophrenia, you should be able to reach your own conclusion about what to tell the thirteen-year-old boy. Schizophrenia and other psychotic conditions are best understood using a multipath model that integrates heredity (genetic influences on brain structure and neurotransmitters), personal vulnerability such as depression or other characteristics, cognitive appraisal (faulty psychological processes that maintain delusional ideas), and social adversities (such as low social or economic status; Van der Gaag, 2006). To develop an accurate etiological framework, all of these dimensions must be taken into consideration, as shown in Figure 13.4.

Etiology of Schizophrenia

13.4

FIGURE MULTIPATH MODEL FOR SCHIZOPHRENIA The dimensions interact with one another and combine in different ways to result in schizophrenia.

Biological Dimension • • • •

Genes and endophenotypes Neurotransmitter dysregulation Structural abnormalities in brain Physical insults (prenatal infections, obstetric complications, etc.)

Sociocultural Dimension

Psychological Dimension

• Gender • Low socioeconomic status, poverty • Social adversities • Migration

• Childhood traumas • Depression and low self-esteem • Aberrant cognitions • Use of drugs, especially cannabis

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375

Social Dimension • Exposure to abuse • Dysfunctional family interactions • Expressed emotions

In the following section, we discuss the biological, psychological, social, and sociocultural dimensions separately, remembering that each dimension interacts with the others. For example, emotional, psychological, or sexual abuse, cannabis use, and exposure to trauma (physical threat, serious accident) have all been hypothesized to affect dopamine levels or mechanisms in the brain. In one sample, the probability of persistent psychotic symptoms was influenced by each of these factors, especially among individuals who were exposed to all three influences (Cougnard et al., 2007).

Biological Dimension It is now recognized that single genes do not directly cause schizophrenia; rather more than a dozen “susceptibility” genes code for subtle molecular abnormalities that hypothetically provide a genetic “bias” toward inefficient information processing in brain circuits that mediate the symptoms of schizophrenia. … The coupling of sufficient genetic bias with stressful input from the environment is the modern formulation of how nature and nurture conspire to produce schizophrenia. (Stahl, 2007, p. 583)

Past research was focused on the attempt to identify the specific gene or genes that cause schizophrenia (Williamson, 2007). The disorder is now understood as the result of multiple genes and their interactions; specific genes appear to make only minor contributions toward the illness. That schizophrenia is a result of genetic influences is not disputed. Researchers have found the disorder more often among close relatives of people diagnosed with schizophrenia than among more distant relatives. Figure 13.5 demonstrates this relationship. The data are summarized from several major studies on the prevalence of schizophrenia (Gottesman, 1978, 1991). They show that closer blood relatives of people diagnosed with schizophrenia run a greater risk of developing the disorder. Thus the boy described earlier who was concerned about becoming schizophrenic like his mother has a 16 percent chance of being diagnosed with schizophrenia, but his mother’s nieces or nephews have only a 4 percent chance. (It should be noted that the risk for the general population is 1 percent.) However, even among monozygotic (identical) twins who share the same genetic material, if one twin receives the diagnosis of schizophrenia, the risk is less than 50 percent that the second twin will develop the disorder. Thus environmental influences also play a role in the expression of the disorder.

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MZ twins Child of two affected parents

Relationship to the person with schizophrenia

DZ twins Child of one affected parent Sibling Parents

Half-sibling Grandchild Niece and nephew Cousin Uncle and aunt Grandparent Spouse

13.5

FIGURE MORBIDITY RISK AMONG BLOOD RELATIVES OF PEOPLE WITH SCHIZOPHRENIA This figure reflects the estimate of the lifetime risk of developing schizophrenia—a risk that is strongly correlated with the degree of genetic influence. Source: Data from Gottesman (1978, 1991).

Endophenotypes Currently, the strategy in genetic research has moved from demonstrating that heredity is involved in schizophrenia to attempts to identify the genes that are responsible for specific characteristics or traits that are evident in this disorder. This approach involves the identification and study of endophenotypes—characteristics that are quantifiable, heritable, and trait-related (Braff, Freedman, Schork, & Gottesman, 2007). Endophenotypes, which are being studied with respect to an array of mental and physical disorders, are hypothesized to underlie the illness and exist in the individual before, during, and following remission of the disorder. It would be expected that these characteristics would be found with higher frequency, although in milder forms, among the “non-ill” relatives of individuals with schizophrenia (Gur et al., 2007). Researchers have identified several possible endophenotypes related to impairment in function in both the schizophrenic patient and unaffected biological relatives. The traits involved include working memory, executive functions, sustained attention, and verbal memory (Reichenberg & Harvey, 2007; Turetsky et al., 2007). Currently, researchers are attempting to identify the genes responsible for specific endophenotypes.

Neurostructures How do genes produce a vulnerability to schizophrenia? Clues to the ways that genes might increase susceptibility to developing No relationship schizophrenia have involved the identification of structural and neurochemical differences between those with schizophrenia and healthy controls. A 30 40 0 10 50 20 number of studies (Kim et al., 2007; Sim et al., 2006; Tregellas et al., 2007) Morbidity risk (percentage) have reported that individuals with schizophrenia have smaller cortical structures (hippocampal and medial temporal lobes, orbitofrontal cortices, and prefrontal lobes) and ventricle enlargement (enlarged spaces in the brain; Lawrie et al., 2008; Staal et al., 2001). Ventricular enlargement may indicate only an increased susceptibility to schizophrenia, because healthy siblings of patients with schizophrenia also show ventricle enlargement (Staal et al., 2001). In an interesting longitudinal study of brain changes among youths with and without schizophrenia, those with the disorder showed a striking loss of gray brain matter over a period of six years. The loss was so rapid that it was likened to a “forest fire” (Thompson et al., 2001). The regions of the brain in which the loss occurred are related to symptoms associated with the disorder. It is not clear how generalizable these findings are because the sample involved adolescents with early-onset schizophrenia. How might decreased volumes in cortical structures and enlarged ventricles predispose someone to the development of schizophrenia? These structural characteristics may result in aberrant or weak connectivity between the various brain regions, leading to reductions in the integrative function of the brain and impaired cognitive processing (Salgado-Pineda et al., 2007). RATE OF GRAY MATTER LOSS IN TEENAGERS WITH SCHIZOPHRENIA Thus the ineffectiveness of communication within the different Male and female adolescents with schizophrenia show brain systems may lead to the cognitive symptoms (impairment progressive loss of gray matter in the parietal, frontal, and in memory, decision making, and problem solving), negative temporal areas of the brain that is much greater than that found symptoms (lack of drive or initiative), and positive symptoms in “normal” adolescents. A similar pattern of gray matter loss in the different brain regions is found among both boys and girls (delusions and hallucinations) that are found in schizophrenia. with schizophrenia. How would you interpret this finding? However, the differences in brain structure between individuals

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CORONAL SECTIONS OF THE BRAIN IN A PATIENT WITH SCHIZOPHRENIA Structural brain abnormalities have been found in most individuals with schizophrenia. The degree and extent of the abnormalities appear to be related to outcome. Patients with poor outcome (represented by the left photo) show significantly greater loss of cerebral gray matter and greater enlargement of the ventricles than patients with a good outcome (represented by the photo on the right; Staal et al., 2001).

with and without schizophrenia are relatively small, and decreased cortical volumes have also been found in healthy individuals and individuals with other disorders. Neurotransmitters Abnormalities of neurotransmitters (chemicals that allow brain cells to communicate with one another) such as dopamine, serotonin, and glutamate have also been linked to schizophrenia (Tan et al., 2007). Considerable attention has been focused on the neurotransmitter dopamine and its involvement in schizophrenia (Borda & Sterin-Borda, 2006; Davis, Kahn, & Ko, 1991). According to the dopamine hypothesis, schizophrenia may result from excess dopamine activity at certain synaptic sites. Support for the dopamine hypothesis has come from research with three types of drugs: phenothiazines, L-dopa, and amphetamines. • Phenothiazines are conventional antipsychotic drugs that decrease the severity of thought disorders, alleviate withdrawal and hallucinations, and improve the mood of patients with schizophrenia. Evidence shows that the phenothiazines reduce dopamine activity in the brain by blocking dopamine receptor sites in postsynaptic neurons. • L-dopa is generally used to treat symptoms of Parkinson’s disease, such as muscle and limb rigidity and tremors. The body converts L-dopa to dopamine, and the drug sometimes produces schizophrenic-like symptoms. In contrast, the phenothiazines, which reduce dopamine activity, can produce side effects that resemble Parkinson’s disease. • Amphetamines are stimulants that increase the availability of dopamine and norepinephrine (another neurotransmitter) in the brain. When individuals not diagnosed with schizophrenia are given continual doses of amphetamines, they show symptoms very much like those of acute paranoid schizophrenia. Also, very small doses of amphetamine can increase the severity of symptoms in patients diagnosed with schizophrenia. Other stimulants, such as caffeine, do not produce these effects. Thus one group of drugs that is believed to block dopamine reception has the effect of reducing the severity of schizophrenic symptoms, whereas two drugs that increase dopamine availability either produce or worsen these symptoms. Such evidence suggests that excess dopamine may be responsible for schizophrenic symptoms. The evidence is not clear-cut, however. For example, the dopamine hypothesis might lead us to expect that treating schizophrenia with phenothiazines would be effective in almost all cases of schizophrenia, which is not the case. Additionally, whereas conventional antipsychotics influence dopamine levels by binding tightly to

dopamine hypothesis

the suggestion that schizophrenia may result from excess dopamine activity at certain synaptic sites

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Did You Know?

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or those at risk for schizophrenia, the five characteristics that most sharply increased the likelihood of actually developing the disorder were (1) having a genetic risk, (2) showing a recent deterioration in functioning, such as withdrawing socially or a drop in grades, (3) having a higher level of unusual thought content, (4) displaying high levels of suspiciousness and paranoia, and (5) having greater social impairment and a history of substance abuse. Source: Cannon et al. (2008).

the likelihood that both members of a twin pair will show the same characteristic

concordance rate

dopamine receptors, second-generation (newer) antipsychotics—most of which work on serotonin receptors, as well as increasing dopamine availability by loosely binding with dopamine receptors—are also effective in treating schizophrenia (Canas, 2005). This would indicate that researchers may be looking for an oversimplified explanation by focusing on dopamine alone without considering the interactive functioning of the brain and the biochemical system as a whole. As was indicated earlier, the neurotransmitter glutamate also plays a major role in schizophrenia (Tan et al., 2007). Because the concordance rate—the likelihood that both members of a twin pair will show the same characteristic—is less than 50 percent when one identical twin has the disorder, nonshared environmental influences (physical, psychological, social) between the twins must also play a role. Many of these may be physical in nature, such as damage to a susceptible fetus from prenatal infections, obstetric complications, or early trauma (Jablensky et al., 2005; Sanders & Gejman, 2001). Retroviruses have also been found in some cases of recent-onset schizophrenia (Karlsson et al., 2001). Although these findings may be coincidental, they illustrate the importance of attempting to identify early physical factors, such as injuries or infections during fetal development or during the birth process. Patients with schizophrenia often have histories of maternal complications during pregnancy and birth, factors that might have produced structural brain abnormalities (Compton, 2005; Ohman & Hultman, 1998). Several studies have reported that individuals whose mothers were exposed to the influenza virus during the second trimester of pregnancy have higher than expected rates of schizophrenia (Machon, Mednick, & Huttunen, 1997). These conditions may affect the neurodevelopment of the fetus by interfering with the normal development of neurons or connections in the brain (Stahl, 2007). Although genetic/biological and physical injuries or influences may increase one’s susceptibility to schizophrenia by changing or altering brain structures or neurotransmitters, so may the impact of specific psychological, social, and sociocultural variables. We now examine these as possible contributors to the disorder.

Psychological Dimension The psychological dimension includes behaviors, attitudes, and attributes that contribute to the symptoms of schizophrenia by increasing the vulnerability of predisposed individuals. For example, having depression or negative self-evaluations can trigger or worsen psychotic symptoms (Smith et al., 2006). Reports of childhood trauma have also been associated with the occurrence of psychotic symptoms (O’Brien et al., 2006; Whitfield, Dube, Felitti, & Anda, 2005). In addition, exposure to adverse psychological events may bias neuronal circuits toward schizophrenia. Certain cognitive patterns or unusual beliefs that precede the onset of the disorder have been reported in individuals with schizophrenia (Solano & DeChavez, 2000). Subclinical disordered thinking may transition into the development of a clinical disorder (Coltheart, Langdon, & McKay, 2007). For example, negative symptoms such as avolition, anhedonia, and flat affect may be due to individuals’ beliefs that they are “worthless” or “failures” and that their condition is “hopeless” (Rector, Beck, & Stolar, 2005). The combination of low expectancy for success, low expectancy due to their illness, and low expectancy for pleasure may maintain the negative symptoms. In fact, some researchers believe that it is the interpretation of events that causes the distress and disability rather than the experience itself (Garety et al., 2007). These pessimistic interpretations can produce and maintain negative symptoms. See Table 13.4 for patterns of thinking associated with negative symptoms. Other individual characteristics have also been associated with schizophrenia. The use of cocaine, amphetamines, alcohol, and especially cannabis seems to increase the chances of developing a psychotic disorder. Several interpretations are possible to explain this relationship. First, those who abuse substances may be at a higher risk for developing psychosis due to the substance abuse itself. Second, individuals with a predisposition for psychosis have a higher risk of abusing drugs (Thirthalli & Benegal, 2006). Additionally, individuals might self-medicate in an attempt to relieve symptoms. Use of substances may influence dopamine levels and increase the vulnerability of an individual to environmental stressors.

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Text not available due to copyright restrictions

Social Dimension Social relationships have long been considered to have etiological importance in the development of schizophrenia. Until the 1900s, biological factors were not considered to be of etiological importance (Walker & Tessner, 2008). Instead, it was believed that schizophrenia was the result of exposure to specific dysfunctional family patterns. However, as Lehman and Steinwachs (1998) note, “Research has failed to substantiate hypothesized causal links between family dysfunction and the etiology of schizophrenia. … The presumption that family interaction causes schizophrenia… has led to serious disruptions in clinician/family trust” (p. 8). These researchers believe that unless a person has a genetic predisposition toward schizophrenia, social factors have little impact on the development of the disorder. In this section, we consider social factors as either the cause of or a contributor to schizophrenia. Some researchers continue to believe that the family environment may be involved in the onset and course of the disorder. Several prospective studies—long-term studies of a group of people, beginning before the onset of a disorder, to allow investigators to see how the disorder develops—have found that high-risk children who develop schizophrenia are more likely to have negative family relationships than are high-risk children who do not develop the disorder. Among one high-risk group of children (offspring of a parent with schizophrenia), none who had received “good parenting” from a parent with schizophrenia developed schizophrenia (Burman et al., 1987; Marcus et al., 1987; Tienari et al., 1994). Similarly, among adolescents who were “at imminent risk” for the onset of psychosis, positive remarks and warmth expressed by caregivers were associated with improvement in negative and disorganized symptoms and social functioning (O’Brien et al., 2006). Children at higher biological risk for schizophrenia may be more sensitive to the effects of both adverse and healthy rearing patterns (Tienari et al., 2004). However, parenting style may also be a result of how “sick” the child is, a possibility we consider later in the chapter. Research has been directed to expressed emotion (EE), a negative communication pattern that is found among some relatives of individuals with schizophrenia and that is associated with higher relapse rates. The EE index is determined by the number of critical comments made by a relative (criticism); the number of statements of dislike or resentment directed toward the patient by family members (hostility); and the number of statements reflecting emotional overinvolvement, overconcern, or overprotectiveness made about the patient. For example, relatives high in EE are likely to make a greater number of statements such as “You are a lazy person” or “You’ve caused our family a lot of trouble” (Rosenfarb et al., 1995). Relatives high in EE may be more critical because they are more likely than relatives low in EE to believe that the psychotic symptoms are under the personal control of the patient (Weisman et al., 2000). The EE construct strongly predicts the course of

Did You Know?

I • • •

•

n a meta-analysis of thirty-five studies, the following conclusions were made: Risk of psychosis is increased by 40 percent in marijuana users. “Heavy pot users” increase risk of psychosis by 50 to 200 percent. Psychotic symptoms are not due to the transitory effects of intoxication. It is estimated that 14 percent of the cases of psychosis might not have occurred if marijuana had not been used

Source: Moore et al. (2007); Nordentoft & Hjorthoj (2007).

prospective study a long-term study of a group of people that begins before the onset of a disorder to allow investigators to see how the disorder develops expressed emotion (EE)

a negative communication pattern that is found among some relatives of individuals with schizophrenia and that is associated with higher relapse rates

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the disorder (Karno et al., 1987; Miklowitz, 1994; Mintz, Mintz, & Goldstein, 1987). A review of twenty-six studies Relapse 1. High EE in family members (Kavanagh, 1992) indicated that the median relapse rate for patients living with relatives high in EE was 48 percent, compared with 21 percent for those living with relatives Relapse low in EE. 2. Patient's odd behaviors However, the EE construct may have less meaning for different cultural groups. Family criticism scores were High EE in family members not associated with relapse for Mexican Americans with schizophrenia (Lopez et al, 2004; Rosenfarb, Bellack, & Aziz, 2006). In a sample of African American patients with Relapse 3. Patient's odd behaviors schizophrenia, high levels of critical and intrusive behavior by family members were associated with better outcome over a two-year period than were low levels of such behavior. Among African Americans, seemingly negative commuHigh EE in family members nication may, in fact, reflect caring and concern. The findings were in direct contrast with white American patients, in whom lower levels of EE were related to a better outFIGURE POSSIBLE RELATIONSHIPS BETWEEN come. Cultural factors determine the specific patient sympHIGH RATES OF EXPRESSED EMOTION AND RELAPSE RATES toms that are appraised as burdensome by relatives, as well IN PATIENTS WITH SCHIZOPHRENIA Although some researchers as the relationship among patients’ symptoms, burden of believe that high expressed emotions among family members are related to relapse rates in schizophrenic patients, the precise care, and relatives’ negative attitudes and behavior. White relationship has not been determined. This figure shows several ways relatives felt more burdened by and had more negative attiin which expressed emotions and relapse rates can be related. tudes toward their mentally ill family members than did African American relatives (Rosenfarb et al., 2006). Lopez and his associates (2004) concluded that family communication processes among ethnic minority members with schizophrenia must be examined according to a sociocultural perspective. Communication patterns such as emotional overprotection or overinvolvement may be interpreted differently by different cultural groups. In fact, therapists who focus on reducing critical and intrusive communication patterns in African American families may inadvertently increase family stress. Although these studies were better designed than some of the research discussed earlier, they are still correlational in nature and are therefore subject to different interpretations. Figure 13.6 indicates three possible interpretations: 1. A high-EE environment is stressful and may lead directly to relapse in the family member who has schizophrenia. Patients whose parents are rated high in EE are more likely to recount negative and stressful memories involving their parents than those whose parents are low on EE (Cutting & Docherty, 2000). 2. A more severely ill individual may cause more negative or high-EE communication patterns in relatives. The severity of the illness means that the chances of relapse are high. Schreiber, Breier, and Pickar (1995) found some support for this pattern. They examined the parental emotional response in families who had children both with and without schizophrenia. The parents reacted differently, with more EE communication being directed toward the child with schizophrenia. The researchers hypothesize that expressed emotions may be a response of parents to the “chronic disabling aspect of this illness, and a belief by the parents that increased involvement would facilitate increased functioning of the child” (p. 649). 3. In the bidirectional model, the patient’s odd behaviors or symptoms may cause family members to attempt to exert control and to react to the symptoms with frustration, which in turn produces more psychotic symptoms in the patient. An examination of communication patterns in families of patients with schizophrenia also shows some support for this view (Rosenfarb et al., 1995).

13.6

High-EE communication does not appear to be peculiar to schizophrenia. These patterns have also been found in the families of patients with depression, bipolar disorder, and eating disorders (Butzlaff & Hooley, 1998; Kavanagh, 1992). And although EE has been found to be related to relapse, little evidence supports the idea

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that deviant family communication patterns are, by themselves, sufficient to produce schizophrenia. Not all studies have supported the EE hypothesis, and some researchers are voicing concern that the EE hypothesis may be used to blame families for the disorder. Miklowitz (1994) points out that the use of terms such as “high expressed emotions” seem to imply that the relatives are excessively emotional or disturbed in some way. He recommends substituting a term such as “negative affective relationships” to indicate the bidirectional nature of interactions.

Sociocultural Dimension Although the prevalence of schizophrenia is roughly equal between men and women, gender differences in the age of onset of the disorder have been found. The age of onset of schizophrenia occurs earlier in males than in females. The gender ratio shifts by the mid-forties and fifties, when the percentage of women receiving this diagnosis exceeds that of men. This trend is especially pronounced in the mid-sixties and later (Howard et al., 2000; Thorup et al., 2007). Researchers have hypothesized that the later age of onset found in women is due to the protective effects of estrogen, which diminish after menopause (Grigoriadis & Seeman, 2002; Hafner et al., 1998). In a study of premenopausal women with schizophrenia, significant improvements in psychotic symptoms were observed during the luteal phase of their menstrual cycle (the period after ovulation) when estradiol (a type of estrogen) levels were higher (Bergemann et al., 2007). Estrogen may affect either dopamine levels or dopamine sensitivity, which have been associated with schizophrenia. Besides the possible protective function, higher estrogen levels are also associated with better cognitive functioning among women with schizophrenia (Hoff et al., 2001). A number of social factors have been identified as risk factors for schizophrenia, such as lower educational level of parents, lower occupational status of fathers, and living in poorer residential areas at birth (Werner, Malaspina, & Rabinowitz, 2007). These forms of social adversity, especially in children who are exposed to a larger number of adverse factors, appear to produce a threefold increase in the risk of developing schizophrenia as opposed to children who are exposed to none of these adversities (Wicks, Hjern, Gunnell, Lewis, & Dalman, 2005). Migration is also a risk factor in schizophrenia among first- and second-generation immigrants to the United Kingdom, especially for African Caribbean and African sections of the population (Selten, Cantor-Graae, & Kahn, 2007). Similarly, the incidence of schizophrenia has

AN ABANDONED BUILDING IN CAMDEN, NEW JERSEY Schizophrenia is much more prevalent in poorer neighborhoods. Some believe that the increased stress from living in poverty may be the cause; others believe that individuals with schizophrenia move into poor neighborhoods because of their decreased ability to function in society. How would you determine which view has the most support?

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been found to be very high among several ethnic groups in the Netherlands, particularly Moroccan immigrants (Veling et al., 2007). Experiences with social adversity may contribute to the increased incidence of the disorder. Among migrants, the evidence is not supportive of selective migration of individuals with a predisposition to schizophrenia (Selten et al., 2007), but migration may act as an additional stressor to predisposed individuals. How social stress might increase the risk for the disorder is not known, although there is a belief that stressors may cause dopamine deregulation or sensitization (Selten & Cantor-Graae, 2007). Culture also affects the way disorders are viewed, as evidenced in the case of a thirteen-year-old child of a Tongan mother and Caucasian father living in the United States. The girl appeared to have visual hallucinations, had become isolative, exhibited echolalia, could be observed conversing with herself, and reported hearing voices of a woman who sounded like her mother and a man who sounded like her dead grandfather. Although some improvement was observed with antipsychotic medication, the girl still reported being disturbed by ghosts and reported ideas of reference—that people were talking about her. The mother decided that her daughter suffered from “fakama-haki,” a culture-bound syndrome in which deceased relatives can inflict illness or possess the living when customs have been neglected. She took her daughter to Tonga to be treated. For five days, a traditional healer (“witch doctor”) treated the girl with herbal potions. Vomiting was induced to remove toxins from the body. She also visited her grandfather’s grave site to allow proper mourning. The girl returned to the United States and was reevaluated. No symptoms of psychosis could be found. Follow-up contact revealed that the girl was continuing to do well. This case is interesting because medication was only minimally successful, whereas traditional healing seemed to be effective. Again, it might have been just that the disorder was time-limited, but how can we account for the seemingly successful treatment of severe mental disorders through folk medicine (Takeuchi, 2000)? As noted throughout this book, the study of cross-cultural perspectives on psychopathology is important because indigenous belief systems influence views of etiology and treatment. In India, for example, the belief in supernatural causation of schizophrenia is very widespread, leading to consultation and treatment by indigenous healers (Banerjee & Roy, 1998). In a study of four ethnic groups of patients with schizophrenia (U.K. whites, African Caribbeans, Bangladeshi, and West Africans), distinct differences in explanatory models were found for the disorder (McCabe & Priebe, 2004; see Table 13.5). The different models included biological (physical illness/substance abuse); social (interpersonal problems/stress/negative childhood events/personality); supernatural (evil forces, evil magic); and nonspecific (do not know/other). The white group as compared to the other ethnic groups was the most likely to attribute biological causes for their condition. None identified supernatural causes as a potential causal factor—an explanation selected by a substantial minority of individuals from the other ethnic groups. The particular etiological model also influenced the response to treatment type. Those who cited biological causes believed they were receiving the right treatment (medications). Bangladeshis who supported TA B L E

13.5

EXPLANATORY MODELS OF ILLNESS IN SCHIZOPHRENIA AMONG FOUR ETHNIC GROUPS CAUSE OF ILLNESS

BIOLOGICAL

SOCIAL

SUPERNATURAL

NONSPECIFIC

African Caribbean

6.7%

60%

20%

23.3%

Bangladeshi

0.0%

42.3%

26.9%

30.8%

West African

10.7%

31%

28.6%

21.4%

U.K. White

34.5%

31%

0.0%

34.5%

From McCabe & Priebe (2004).

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a supernatural explanatory model wanted more alternative forms of treatment, such as religious activities. Thus views of etiology affect an individual’s ideas regarding the nature of his or her problem, its severity, prognosis, and appropriate treatment.

The Treatment of Schizophrenia Through the years, schizophrenia has been “treated” by a variety of means, including prefrontal lobotomy, a surgical procedure in which the frontal lobes are disconnected from the remainder of the patient’s brain, and “warehousing” severely disturbed patients in overcrowded asylums. Such radical procedures were generally abandoned in the 1950s, when the beneficial effects of antipsychotic drugs were discovered. Today schizophrenia is typically treated with antipsychotic medication, along with some type of psychosocial therapy. In recent years, the research and clinical perspective on people with schizophrenia has shifted from a focus on disease and deficit to one of recovery and promotion of health, competencies, independence, and self-determination (Bellack, 2006). This change of focus is affecting therapists’ roles, their views of clients and their families, and appropriate treatments (Glynn et al., 2006). We first discuss medication in the treatment of schizophrenia and then the psychological and social therapies.

Antipsychotic Medication Case Study Peter was a twenty-nine-year-old man with chronic paranoid schizophrenia. . . . When on medication, he heard voices talking about him and felt that his phone was bugged. When off medication, he had constant hallucinations and his behavior became unpredictable. . . . He was on 10 milligrams of haloperidol (Haldol) three times a day. . . . Peter complained that he had been quite restless, and did not want to take the medication. Over the next six months, Peter’s psychiatrist gradually reduced Peter’s medication to 4 milligrams per day. . . . At this dose, Peter continued to have bothersome symptoms, but they remained moderate. . . . He was no longer restless. (Liberman, Kopelowicz, & Young, 1994, p. 94)

The use of medication in Peter’s case illustrates several points. First, antipsychotic medications (also called neuroleptics) can reduce symptom levels; second, dosage levels should be carefully monitored; and third, side effects can occur as a result of medication. Most mental health professionals consider the 1955 introduction of Thorazine, the first antipsychotic drug, to be the beginning of a new era in treating schizophrenia. For the first time, a medication was available that sufficiently relaxed even violent patients with schizophrenia and helped organize their thoughts to the point that straitjackets were no longer needed for physical restraint. Although these medications have improved the lives of patients, they do not cure the disorder. Nearly five decades later, conventional antipsychotics (Thorazine and related medications called the phenothiazines) are still viewed as effective treatments for schizophrenia, although their use has been largely supplanted by newer, atypical antipsychotics. Conventional or older antipsychotic medications (chlorpromazine/Thorazine, haloperidol/Haldol, perphenazine/Trilafon, and fluphenazine/Prolixin) have dopaminergic receptor-blocking capabilities (they reduce dopamine levels), which led to the dopamine hypothesis of schizophrenia. The newer atypical antipsychotics (such as clozapine/Clozaril, risperidone/Risperdal, olanzapine/Zyprexa, quetiapine/Seroquel, and ziprasidone/Geodon) act on multiple receptor sites in the central nervous system and are less likely to produce side effects such as rigidity, persistent muscle spasms, tremors, and restlessness that are found with the older antipsychotic medications (Canas, 2005). Both types of antipsychotic medications can effectively reduce the severity of the positive symptoms of schizophrenia, such as hallucinations, delusions, bizarre speech, and thought disorders. Most, however, offer little relief from the negative symptoms of social withdrawal, apathy, and impaired personal hygiene (Carpenter,

antipsychotic drug that can help treat symptoms of schizophrenia but can also produce undesirable side effects, such as symptoms that mimic neurological disorders

neuroleptic

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Conley, Buchanan, Breier, & Tamminga, 1995; Strous et al., 2004). As Green (2007) noted, “Optimism that second-generation antipsychotics would yield cognitive improvements has progressively been tempered … the high hopes for beneficial cognitive effects from antipsychotic medications are now hanging by threads” (p. 992). Moreover, a “relatively large group” of people with schizophrenia do not benefit at all from antipsychotic medication (Wiesel, 1994; Silverman et al., 1987). Because of the side effects of the medications, treatment adherence is poor, especially among younger patients and African American patients (Valenstein et al., 2004). Newer antipsychotic medications cost ten times more than older antipsychotics. Are these newer antipsychotic medications more effective than first-generation antipsychotics? Are they less likely to produce side effects? Answers to these questions were sought in the largest, most comprehensive nationwide comparative drug study, known as CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness). The effectiveness of an older antipsychotic (perphenazine) was compared with several newer antipsychotic medications (olanzapine, quetiapine, risperidone, or ziprasidone) in the treatment of chronic schizophrenia (average length of illness in the participants was 14.4 years). The following conclusions were reached (Lieberman et al., 2005): • Surprisingly, the older, less expensive medication (perphenazine) used in the study generally performed as well as the four newer medications. Newer antipsychotics did not have an advantage over older antipsychotics in treating the symptoms of schizophrenia. • With all antipsychotics, there were high rates of discontinuation due to intolerable side effects or failure to control symptoms. (Nearly three-quarters of the patients discontinued their assigned drugs and switched to another.) • Olanzapine was slightly more effective but was associated with significant weight gain. • Contrary to expectations, extrapyramidal symptoms (movement side effects, rigidity, stiff movements, tremor, and muscle restlessness) were not seen more frequently with the older drug than with the newer drugs. These findings question the assumption that the newer antipsychotic medications are more effective and produce fewer side effects than older antipsychotic medications. (It should be noted that the older antipsychotic, perphenazine, was chosen for its more limited side effects.) Some of the earlier findings that showed second-generation antipsychotics to be superior in alleviating cognitive problems may be due to assessment practice effects. For example, healthy individuals showed the same “improvement” on cognitive tasks as individuals with schizophrenia when undergoing repeated testing (Goldberg et al., 2007), presumably because of practice effects. The findings from the CATIE study prompted one researcher, Green (2007), to suggest the need to identify new drugs that work through different neuropharmacological mechanisms. As was mentioned earlier, most individuals treated with antipsychotic medications will develop extrapyramidal symptoms, which include Parkinsonism (muscle tremors, shakiness, and immobility), dystonia (slow and continued contrasting movements of the limbs and tongue), akathesis (motor restlessness), and neuroleptic malignant syndrome (muscle rigidity and autonomic instability, which can be fatal if untreated). Other symptoms may involve the loss of facial expression, immobility, shuffling gait, tremors of the hand, rigidity of the body, and poor postural stability; these symptoms are usually reversible (Casey, 2006). A more chronic or permanent condition, tardive dyskinesia, may develop. This condition is characterized by involuntary and rhythmic movements of the tongue; chewing, lip smacking, and other facial movements; and jerking movements of the limbs. At risk for this disorder are people who have been treated with antipsychotic medications over a long period of time. The elderly appear to be especially vulnerable to neuroleptic side effects (Meltzer, 2000; Zayas & Grossberg, 1998). Women tend to have both more frequent and more severe tardive dyskinesia than do men (American Psychiatric Association, 1997; Yassa & Jeste, 1992).

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controversy

Balancing Prevention and Harm I am concerned that the article entitled “Randomized, double-blind trial of olanzapine versus placebo in patients prodomally symptomatic for psychosis” lacked discussion regarding the ethics of treating young (average age = 18.2 years) and nonpsychotic patients with the neuroleptic olanzapine for 1 year. (Block, 2006, p. 1838)

Block was responding to a study by McGlashan and colleagues (2006) in which the researchers identified a group of prodromal patients (individuals with early symptoms of schizophrenia that are associated with a heightened vulnerability to developing psychosis) and randomly assigned them to a medication or a placebo treatment. The study was controversial for several reasons. First, one group of prodromal individuals was given antipsychotic medications for one full year, while the other group of prodromal individuals received a placebo. Questions were raised regarding the use of an antipsychotic medication for an extended duration in individuals who had not yet developed the disorder and, conversely, the advisability of giving prodromal individuals only a placebo. In response to the criticism, McGlashan (2006) gave the following rationale for the study: • The individuals were prodromal and had a substantial risk of becoming psychotic within a year. • Medication might prevent the progression to psychosis. • It is probably more harmful to develop psychosis than to suffer the side effects of medication.

• Although false positives (mistakenly labeling an individual as ill) may occur, it is common in other medical interventions. What were the findings of the study? Of the two prodromal groups, 16.1 percent of the medication group and 37.9 percent of the placebo group developed psychosis during the one-year period. However, during an additional followup period, many more in the medication group developed psychosis. Medication seemed only to delay rather than to prevent the occurrence of psychosis. Additionally, the majority of the participants did not develop schizophrenia during the study nor within two follow-up periods. Another eight-month follow-up study (Niendam et al., 2007) of untreated prodromal individuals found that about 50 percent showed improvement in social and role functioning without treatment, whereas the other half showed either stability or decline in functioning. In other words, the emergence of psychosis is not inevitable among individuals during the prodromal period. For Further Consideration 1. In view of the fact that McGlashan and colleagues (2007) believe that the prodromal period should be a target for early identification and for treatment, what forms of intervention should be utilized, and how can you reduce the number of diagnostic false positives? 2. If early intervention is an important goal, does it make sense to expose prodromal individuals to a lengthy placebo condition?

Regulation and monitoring of antipsychotic drugs is especially important, as is using the minimum effective dose possible (Lehman et al., 2004). However, a study of 719 patients diagnosed with schizophrenia revealed that the dosage levels of their antipsychotic medications were often outside the recommended treatment ranges and that minority patients were more likely to be on higher levels than white patients (Lehman & Steinwachs, 1998). Equally disturbing, clinicians are often unaware of possible reactions to the drugs, which include tremors, motor restlessness, anxiety, agitation, extreme terror, and even impulsive suicide attempts (Drake & Ehrlich, 1985; Hirose, 2003; Lehman & Steinwachs, 1998). In one study (Weiden et al., 1987), clinicians did not identify motor symptoms such as restlessness, rigidity, and tremors produced by medications. Clinicians accurately identified only one of ten patients showing tardive dyskinesia (involuntary movement disorder). Therefore, although antipsychotic medications are still considered to be an effective treatment for schizophrenia, they must be carefully monitored in terms of dosage, effectiveness, and side effects.

Psychosocial Therapy Case Study Philip’s psychotic symptoms had been reduced with medication. However, he was unable to obtain employment because of cognitive and behavioral peculiarities. Philip did not seem to understand what was considered to be appropriate conversational topics and attire. The counselor suggested that his clothing (sweatshirt, exercise pants, head band, and worn sneakers) might be

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inappropriate for a job interview. In addition, his first-impression skills for interviews were lacking. Field trips allowed Philip to observe attire worn by individuals in different businesses. He was trained in conversational topics and practiced job interviews with his counselor. Philip decided to apply for landscape work, wore a work shirt, blue jeans, and construction boots, and was hired by a landscaping contractor. (Heinssen & Cuthbert, 2001)

Many individuals with schizophrenia behave “strangely,” do not have positive conversational skills, and display faulty thinking. Social communication is problematic because many exhibit consistent deficits in emotional perception and in understanding the beliefs and attitudes of others (Combs et al., 2007). Heinssen and Cuthbert (2001) found that eccentricities in appearance, attire, and communication patterns and lack of discretion in discussing their illness can impede employment or the establishment of social networks. Psychotherapeutic approaches have been tailored to address these issues, allowing many individuals with schizophrenia to acquire competitive employment. Most clinicians today agree that the most beneficial treatment for schizophrenia is some combination of antipsychotic medication and therapy. But even as scientists continue to introduce drugs that effectively reduce many symptoms of schizophrenia, one vital fact is clear: medicated and adequately functioning people with schizophrenia discharged from protective hospital environments often return to stressful home or work situations. The typical result is repeated rehospitalization; medication alone is often not enough to help those with schizophrenia function in their natural environments. Clinicians realize that antipsychotic medication must be supplemented with psychotherapy. Such therapy includes traditional institutional approaches, cognitive-behavioral therapies, and interventions based on family communication. Institutional Approaches Traditional institutional treatments providing custodial care and medication for patients with schizophrenia have yielded poor results, although milieu therapy and behavioral therapy have been found to be more effective. In milieu therapy, the hospital environment operates as a community, and patients exercise a wide range of responsibilities, helping to make decisions and to manage the wards. This type of therapy sharply contrasts with the passive role patients with schizophrenia have had in traditional settings. Social learning programs focus on increasing appropriate self-care behaviors, conversational skills, and role skills, such as job training and ward activities. Undesirable behaviors such as “crazy talk” or social isolation are decreased through reinforcement and modeling techniques. Both approaches have been shown to be effective in helping many people with schizophrenia achieve independent living (Falloon, Boyd, & McGill, 1984). Living in community homes also has produced positive results. In a study of nearly 100 patients with chronic schizophrenia placed in community facilities, almost all improved. They reported more friendships and fewer symptoms than those who remained institutionalized (Leff, 1994). Cognitive-Behavioral Therapy Major advances have been made in the use of cognitive and behavioral strategies in treating the symptoms of schizophrenia, especially among those who have not been fully helped through medications. The therapeutic interventions tend to share the same format. Positive and negative symptoms are targeted with the goal of reducing their frequency and severity and the associated distress. Coping skills are enhanced to allow the patient to manage both positive and negative symptoms and the cognitive deficits found in schizophrenia (Hansen, Kingdon, & Turkington, 2006; Zimmermann et al., 2005). The following is an example of the use of cognitive-behavioral treatment in an individual with schizophrenia. Note the strategies used to treat her symptoms: a therapy program in which the hospital environment operates as a community and patients exercise a wide range of responsibility, helping to make decisions and to manage wards

milieu therapy

Case Study A young African American woman with auditory hallucinations, paranoid delusions, delusions of reference, and a history of childhood verbal and physical abuse and adult sexual assault felt extremely hopeless about her prospects for developing social ties. She believed that her persecutors had informed others of her socially undesirable activities (for example, screaming for voices

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FAMILY COMMUNICATION AND EDUCATION Therapy that includes the family members of individuals with schizophrenia has reduced relapse rates. It is more effective than drug treatment alone.

to stop while in her apartment). . . . When she did leave her home, she often covered her head with a black kerchief and wore dark sunglasses, partly in an effort to disguise herself from her persecutors. . . . (Cather, 2005, p. 260)

In dealing with the symptoms of schizophrenia, the following steps are often utilized (Hansen et al., 2006). • Engagement The therapist explains the therapy and works to foster a safe and collaborative method of looking at causes of distress, drawing out the person’s own understanding of the situation and ways of coping with it. The relationship between stress, anxiety, and the worsening of symptoms in discussed. • Assessment Patients are encouraged to express their own thoughts about the fears and anxiety they experience; the therapist shares information about how symptoms are formed and maintained. In the preceding case, the case formulation, shared with the patient, was to help her make sense of her persecutory experiences. She was informed that victims of abuse often internalize beliefs that they are responsible for the abuse (such as a belief that only a bad person would be punished in such a manner). Her view that she was “bad” led to expectations of negative reactions from others and the need to disguise herself. • Identification of negative beliefs The therapist explains the linkage between the emotional distress the patient is experiencing and the beliefs he or she holds. The patient’s own beliefs, such as “Nobody will like me if I tell them about my voices” (p. 50), can be disputed and changed to “I can’t demand that everyone like me. Some people will and some won’t” (p. 50). This reinterpretation often leads to less sadness and isolation. • Normalization The therapist works with the patient to decatastrophize the psychotic experiences. Information that many people can have unusual experiences reduces the patient’s sense of isolation. • Collaborative analysis of symptoms Once a strong therapeutic alliance has been established, the therapist begins critical discussions of the patient’s symptoms, such as “If voices come from your head, why can’t others hear them?” Evidence for and against the maladaptive beliefs is discussed, combined with information about how beliefs are maintained through cognitive distortions or inferences. • Developing alternative explanations The therapist helps the patient develop alternatives to previous maladaptive assumptions, using the patient’s ideas whenever possible. If needed, the therapist helps collaboratively develop new explanations.

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A newer form of cognitive therapy, integrated psychological therapy (IPT), has also produced promising results. IPT specifically targets deficits found in individuals with schizophrenia, such as basic impairments in neurocognition (e.g., attention, verbal memory, cognitive flexibility, concept formation), deficits in social cognition (social and emotional perception, emotional expression), interpersonal communication (e.g., verbal fluency and executive functioning), and problem-solving skills. In a meta-analysis of IPT, Roder and colleagues (2007) concluded: “IPT is an effective rehabilitation approach for schizophrenia that is robust across a wide range of patients and treatment conditions” (p. 81).

Interventions Focusing on Family Communication and Education A serious mental illness such as schizophrenia can have a powerful effect on the patient’s family members, who may feel stigmatized or responsible for the disorder. As one woman stated:

ARTWORK TO DEMONSTRATE CREATIVE TALENTS A self portrait by artist William Scott is displayed at the Creative Growth Art Center in Oakland, California. The artist, diagnosed with schizophrenia and autism, has had his paintings and sculptures sold around the world in the trendiest galleries. The program hopes to decrease the stigma associated with mental illness by highlighting the creative talents of patients.

All family members are affected by a loved one’s mental illness. The entire family system needs to be addressed. To assure us that we are not to blame and the situation is not hopeless. To point us to the people and places that can help our loved one. The impact still lingers on (Marsh & Johnson, 1997).

Siblings without the disorder also display a variety of emotional reactions to their sick brother or sister—love (“She’s really kind and loves me so very much it’s never been a problem”), loss (“Somehow I’ve lost my sister the way she was before and I think I won’t get her back”) anger (“Yes, it’s hell. . . . She’s incredibly mean to our mother and she sure as hell doesn’t deserve that”), guilt and shame (“Yes, you can think about how he got ill and I didn’t”), and fear (“You worry a lot about getting it yourself”; Stalberg, Ekerwald, & Hultman, 2004, p. 450). More than 50 percent of recovering patients return to live with their families, and new psychological interventions address this fact. Family intervention programs have not only reduced relapse rates but have also lowered the cost of care. They have been beneficial for families with and without communication patterns such as EE. Most programs include the following components (Glynn et al., 2006; Mueser et al., 2001): 1. Normalizing the family experience 2. Demonstrating concern, empathy, and sympathy to all family members 3. Educating family members about schizophrenia 4. Avoiding blaming the family or pathologizing their coping efforts 5. Identifying the strengths and competencies of the patient and family members 6. Developing skills in problem solving and managing stress 7. Teaching family members to cope with the symptoms of mental illness and its repercussions on the family 8. Strengthening the communication and problem-solving skills of family members Family approaches and social skills training are much more effective in preventing relapse than is drug treatment alone. Combining cognitive-behavioral strategies, family counseling, and social skills training seems to produce the most positive result (Penn et al., 2004). The combination of medication and the new psychological interventions has provided hope for many patients with schizophrenia; continuing research points to an even more promising future for individuals with the disorder and their families.

The Treatment of Schizophrenia

Research and treatment on schizophrenia is undergoing a dramatic change. Genetic research has moved beyond attempting to identify the specific genes underlying the disorder to the recognition that schizophrenia is a result of dozens of genes and their interactions. Research has shifted to identifying the endophenotypes that underlie the characteristics of the disorder and the genes responsible. It is also increasingly acknowledged that environmental factors may alter neurodevelopment in a manner that increases the susceptibility to schizophrenia. New antipsychotic medications continued to be developed, although there is increasing pessimism about current medications because many cognitive characteristics are not improved with their use and because the majority of individuals on antipsychotics do not follow the treatment regimen. Psychosocial therapies are also evolving, with greater attention focused on treatments that address the specific deficits found in schizophrenia. The focus on “recovery” rather than cure offers a more optimistic philosophy in treatment.

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Summary 1. What are the symptoms of schizophrenia? ■ Positive symptoms of schizophrenia involve unusual thoughts or perceptions, such as delusions, hallucinations, thought disorder (shifting and unrelated ideas that produce incoherent communication), and bizarre behavior. ■

■

Negative symptoms of schizophrenia are associated with an inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure. Such symptoms include avolition (an inability to take action or become goal-oriented), alogia (a lack of meaningful speech), and flat affect (little or no emotion in situations in which strong reactions are expected). Cognitive symptoms of schizophrenia include problems with attention, memory, and difficulty in developing a plan of action.

2. How do the specific types of schizophrenia differ from one another? ■ Paranoid schizophrenia is characterized by one or more systematized delusions or auditory hallucinations and by the absence of such symptoms as disorganized speech and behavior or flat affect. ■ Disorganized schizophrenia is characterized by grossly disorganized behaviors manifested in disorganized speech and behavior and flat or grossly inappropriate affect. ■

Catatonic schizophrenia’s major feature is disturbance of motor activity. Patients show excessive excitement, agitation, and hyperactivity or withdrawn behavior patterns.

■

The undifferentiated type includes schizophrenic behavior that cannot be classified as one of the other types.

■

Residual schizophrenia is a category for people who have had at least one episode of schizophrenia but are

not now showing prominent symptoms. In addition, other severe disorders may include schizophrenic-like symptoms. 3. Is there much chance of recovery from schizophrenia? ■

Although most people assume that the prognosis for individuals with schizophrenia is not good, research is beginning to show that that may not be the case. Many of these individuals experience minimal or no lasting impairment. Most individuals with schizophrenia recover enough to lead relatively productive lives.

4. What causes schizophrenia? ■ The best conclusion is that genetics and environmental factors (physical, psychological, or social) combine to cause the disorder. Heredity is a major factor but not sufficient to cause schizophrenia; environmental factors are also involved. Certain negative family patterns involving parental characteristics or intrafamilial communication processes have been hypothesized to result in schizophrenia. There is little evidence that psychological factors in and of themselves can cause the condition. 5. What treatments are currently available for schizophrenia, and are they effective? ■ Schizophrenia seems to involve both biological and physiological factors, and treatment programs that combine drugs with psychotherapy appear to hold the most promise. ■ Drug therapy usually involves conventional antipsychotics (the phenothiazines) or the newer atypical antipsychotics. ■ The accompanying psychosocial therapy consists of either supportive counseling or behavior therapy, with an emphasis on social skills training and changing communication patterns among patients and family members.

c h a p t e r

14

Cognitive Disorders

A

lbert Harris is a sixty-seven-year-old man who suffered a stroke. In addition to physical therapy for his partially paralyzed right side, an effort was made to rehabilitate his speech. Mr. Harris was unable to communicate fully and expressed himself almost exclusively with the words “Mrs. Harris,” his wife’s name.

chapter outline The Assessment of Brain Damage

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Types of Cognitive Disorders

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Etiology of Cognitive Disorders

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Treatment/Prevention Considerations

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IMP LIC AT IONS

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CRITICAL THINKING

Moderators and Mediators: What Causes What?

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cognitive disorder a disorder that affects thinking processes, memory, consciousness, and perception and that is caused by brain dysfunction

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Psychologist: Hello, Mr. Harris. Mr. Harris (responding to psychologist): Hello, Mrs. Harris. Hello, Mrs. Harris. Psychologist: You look pretty cheerful today. Mr. Harris: Yes, Mrs. Harris. Ah … Ah … Ah (apparently trying to elaborate on his response) … Yes, Mrs. Harris. Ah … Ah (looking disappointed and frustrated). Psychologist: I know it’s hard to say what you want to say. Mr. Harris: Yes, Mrs. Harris, yes. Things will get better, Mrs. Harris. Psychologist: You’ve already shown improvement, don’t you think? Mr. Harris: Mrs. Harris a little bit better, yes. Slow but sure, Mrs. Harris. Albert Harris has a condition known as aphasia in which there is a loss of motor or sensory functions that are associated with language. He is currently undergoing speech therapy and skills training.

Like many other individuals, Mr. Harris suffers from a cognitive disorder—a behavioral disturbance that results from transient or permanent damage to the brain. DSMIV-TR (American Psychiatric Association, 2000a) characterizes cognitive disorders as disorders that affect thinking processes, memory, consciousness, perception, and so on and that are caused by brain dysfunction. Psychiatric conditions with associated cognitive symptoms (such as schizophrenia) are not considered in this category or in this chapter. Particular attention is paid to cognitive changes and disorders associated with aging because some cognitive disorders occur primarily in old age (Gatz, 2007).

FOCUSQUESTIONS

1 How can we determine whether someone has brain damage or a cognitive disorder?

2 What are the different types of cognitive disorders?

TA B L E

3 Why do people develop cognitive disorders? 4 What kinds of interventions can be used to treat people with cognitive disorders?

14.1

DISORDERS CHART

COGNITIVE DISORDERS

COGNITIVE DISORDER

SYMPTOMS

GENDER DIFFERENCES

AGE OF ONSET

COURSE

Dementias

Memory impairment and cognitive disturbances (aphasia, apraxia, agnosia, or disturbances in planning and abstracting)

Usually none; depends on type of dementia

Depends on type; usually highest rates found among elderly

Depends on type; onset frequently gradual; may be temporary or deteriorating

Delirium

Disturbances of consciousness and changes in cognition (memory deficit, disorientation, and language and perceptual disturbances)

Usually none; depends on type of delirium

Any age, but some variation, depending on type

Develops over hours to days; may persist for weeks

Amnestic Disorders

Memory impairment, inability to learn new information, inability to recall previously learned information

Usually none; depends on type of disorder

Variable

Variable; depends on type or etiology

Cognitive Disorders Not Otherwise Specified

Cognitive disorders that do not meet criteria for dementia, delirium, or amnestic disorders and that are presumed to be caused by a general medical or substance-induced condition

Variable

Variable

Variable

Note: Prevalence and characteristics of the disorders may be variable, largely depending on the ages of the individuals sampled; population of interest (e.g., delirium is common among hospitalized patients); methods of determining the presence, severity, and type of cognitive impairment; and the regions or countries studied. Source: Based on American Psychiatric Association (2000a).

DSM-IV-TR classifies cognitive disorders into four major categories: (1) dementia, (2) delirium, (3) amnestic disorders, and (4) cognitive disorders not otherwise specified (see Table 14.1). DSM-IV-TR also attempts to specify the etiological agent for each disorder (see Table 14.2).

TA B L E

14.2

COGNITIVE DISORDERS: ETIOLOGICAL FACTORS OR TYPES ETIOLOGICAL FACTORS OR TYPES

DESCRIPTION

General Medical Condition

Having a medical condition that is etiologically related to the disturbance

Substance-Induced Condition

Substance intoxication or withdrawal that is etiologically related to the disturbance

Multiple Etiologies

Having more than one etiological factor (e.g., more than one general medical condition or a general medical as well as a substance-induced condition) Note: In the case of amnestic disorders, the category of multiple etiologies is not used

Not Otherwise Specified

Not caused by conditions listed or inadequate evidence to specify cause

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To some extent, the diagnosis of a cognitive disorder is a process of elimination. For example, delirium is a syndrome in which someone shows a disturbance of consciousness, an inability to maintain attention, memory problems, disorientation, and so on. When the delirium cannot be attributed to another mental disorder (such as a mood disorder) and when evidence exists that a general medical condition (such as disease, health problems, cardiovascular or neurological problems, or brain trauma) is related to the disturbance, it is considered a cognitive disorder. The category of cognitive disorders is somewhat arbitrary, because other mental disorders may be associated with cognitive dysfunction and organic involvement. As you will see, it is often difficult to measure and assess, as well as to discern, the exact causes of the cognitive disorders. Possible causes of cognitive disorders include aging, trauma, infection, loss of blood supply, substance abuse, and various biochemical imbalances. These may result in cognitive, emotional, and behavioral symptoms that can resemble the symptoms of the mental disorders (Abeles & Victor, 2003). Although behavioral disturbance stems from brain pathology, it is influenced by social and psychological factors, as well as by the specific pathology. People with similar types of brain damage may behave quite differently, depending on their premorbid personalities, their coping skills, and the availability of such resources as family support systems. Furthermore, people with cognitive impairments often are treated with insensitivity by other people, so they experience a lot of stress. This stress may add STILL A CHAMPION BUT AT WHAT COST? Muhammad Ali, to or modify the symptoms that stem from the disorder. one of the greatest heavyweight champion boxers ever, Thus biological, psychological, social, and sociocultural factors suffers Parkinson-like symptoms, such as slurred speech, interact in complicated ways to produce the behaviors of people shuffling when walking, expressionless facial appearance, and who have cognitive disorders. Because many different factors can occasional memory lapses. These symptoms are believed to be caused by the repeated blows to the head suffered by cause cognitive disorders and because the factors interact with each Ali during his boxing career. What cognitive symptoms are other, the disorders clearly fall within a multipath model. Treatassociated with this disease? ment, too, often requires some combination of physical/biological, medicinal, and psychological therapy; it may include medication, behavior modification, and skills training. For some patients who have severe and irreversible brain damage, the only available options may be rehabilitation, modified skills training, and the creation of a supportive environment. We discussed the structure of the human brain in Chapter 2; here we focus primarily on the assessment, types, major causes, and treatment of cognitive disorders.

The Assessment of Brain Damage electroencephalograph (EEG)

a neurological test that assesses brain damage by measuring the electrical activity of brain cells computerized axial tomography (CT) a neurological test that

assesses brain damage by means of x-rays and computer technology cerebral blood flow measurement

a technique for assessing brain damage in which the patient inhales radioactive gas and a gamma ray camera tracks the gas—and thus the flow of blood—as it moves throughout the brain

Two types of techniques are used to assess brain damage, and both were discussed in Chapter 3. The first consists of psychological tests and inventories that require behavioral responses from the patient and that assess functions such as memory and manual dexterity. These tests have become quite sophisticated, in that theories from neuropsychological science and quantitative methods are being applied to find a means to assess brain pathology. The second type of assessment tool is neurological testing, which permits more direct monitoring of brain functioning and structure. This tool increases diagnostic accuracy by letting researchers and diagnosticians “look into” the living brain and see evidence of its structure and functions. For example, the electroencephalograph (EEG) measures electrical activity of brain cells. Computerized axial tomography (CT) scanning assesses brain damage by means of x-rays and computer technology. Two additional techniques monitor a radioactive substance as it moves through the brain. In cerebral blood flow measurement, the patient inhales a radioactive gas, and a gamma ray camera tracks the gas—and thus the flow of blood—as it moves throughout the brain. In a positron emission tomography (PET) scan, the patient is injected with radioactive glucose, and the metabolism of glucose in the patient’s

Types of Cognitive Disorders

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brain is monitored. This method provides a very accurate means of assessing brain function. A fifth technique produces snapshots of brain anatomy that have striking resolution, almost like a photograph with the skull removed—except that it is accomplished without surgery, exposure to x-rays (as in CT scans), or ingesting radioactive materials (as in PET scans). In magnetic resonance imaging (MRI), the patient is placed in a magnetic field, and radio waves are used to produce pictures of the brain. Continuing advances in neuroimaging, especially with MRI, have resulted in functional brain imaging approaches such as the dynamic functional MRI. Each of these techniques has strengths and weaknesses in terms of costs, benefits, and possible side effects. For example, compared with MRI, CT scanning is less expensive and faster to MRI SCANS A technician observing the MRI scan of operate, and it can be used with patients who have metal in their a patient. In MRI, radio waves produce pictures of the brain that are not obscured by bone. With striking resolution, heads (e.g., surgical clips, metal skull plates, etc.). On the other hand, MRI does not require use of x-rays and is better at detecting they can reveal detailed anatomical areas of the brain. However, the procedure is expensive and requires patients neoplasms, brain abnormalities related to seizures, and lesions in to remain perfectly still while the imaging is taking place. certain parts of the brain. In initial screening for cognitive disorders, clinicians may What advantages do you see in using the MRI over other procedures, such as PET or CT scans? evaluate cognitive functioning by using a mental status examination (see Chapter 3) or by simply asking a patient to give his or her name and place of birth and to repeat phrases or write sentences that the clinician says aloud. At that time, and equally important, the clinician assesses the patient’s general functioning, personality characteristics, and coping skills, as well as his or her behaviors and emotional reactions, particularly those that differ from reported premorbid functioning. Such an assessment can provide crucial information about brain dysfunction, and it is of utmost importance in planning treatment and rehabilitation.

Types of Cognitive Disorders Four major cognitive disorder categories are listed in DSM-IV-TR: dementia, delirium, amnestic disorders, and cognitive disorders not otherwise specified. In each, clinicians categorize the disorder according to its cause. In general, the causes are classified as due to a general medical condition, a substance-induced condition, multiple etiologies, or conditions not otherwise specified. For example, a client may be given the diagnosis of delirium. If the delirium is caused by the use of psychoactive substances, it is considered to be a case of substance-induced delirium. If the type of substance is identified, it is also specified (see Table 14.2). In some cases, individuals also have symptoms of other mental disorders (such as a mood, psychotic, or anxiety disorder) for which there is evidence that the disorder is due to a general medical condition (e.g., disease or brain trauma). In this case, DSMIV-TR lists the disorder within a category appropriate for the symptom pattern. For example, a mood disorder due to a general medical condition is classified under mood disorders, and an anxiety disorder due to a general medical condition is found under the category of anxiety disorders. Neither would be diagnosed as a cognitive disorder.

Dementia Dementia is characterized by memory impairment and cognitive disturbances, such as aphasia (language disturbance that was illustrated in the case of Albert Harris at the beginning of the chapter), apraxia (inability to carry out motor activities despite intact comprehension and motor function), agnosia (failure to recognize or identify objects despite intact sensory function), or disturbances in planning and abstracting in thought processes. The multiple cognitive deficits are severe enough to hinder social and occupational activities and represent a significant decline from a previous level of functioning. People with dementia may forget to finish tasks, the names of significant others, and past events. Some people who exhibit dementia also display impulse control problems. They may, for example, disrobe in public or make

positron emission tomography (PET) a technique for assessing

brain damage in which the patient is injected with radioactive glucose and the metabolism of the glucose in the brain is monitored magnetic resonance imaging (MRI) a technique to assess brain

functioning using a magnetic field and radio waves to produce pictures of the brain dementia a syndrome characterized by memory impairment and cognitive disturbances, such as aphasia, apraxia, agnosia, or disturbances in planning or abstraction in thought processes

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sexual advances to strangers. Dementia is characterized by gradual onset and continuing cognitive decline. It should be noted that memory decline in normal aging is distinct from that found in dementia. In age-associated memory PREVALENCE OF DEMENTIA impairment, patients experience a gradual loss of memory in daily life activiAGE PREVALENCE ties (e.g., remembering names, misplacing objects, or forgetting phone numbers) but retain intact global intellectual functioning. This normal-aging memory loss 65+ 5–8% does not mean that one has the early stages of Alzheimer’s disease (Wise, Gray, 75+ 15–20% & Seltzer, 1999). Dementia usually is caused by degeneration in the cerebral cortex, the part 85+ 25–50% of the brain responsible for thoughts, memories, actions, and personality. Death of brain cells in this region leads to the cognitive impairment that characterizes dementia (Boustani et al., 2003). As discussed in more detail later, dementia can occur for numerous reasons. DSM-IV-TR lists the major etiological categories Did You Know? for dementia as (1) general medical conditions (such as Alzheimer’s disease, cerebrohe brain neurons of liberals and vascular disease, Parkinson’s disease, brain trauma); (2) substance-induced persisting conservatives react differently, dementia, in which the symptoms are associated with substance use; (3) multiple suggesting that some political etiologies, in which more than one factor has caused the disorder (such as a general divides may be hard-wired. In an medical condition and substance use); and (4) dementia not otherwise specified, in experimental task, self-identified which there is insufficient evidence to establish a specific etiology. liberals showed significantly greater The prevalence of dementia increases with age, as shown in Table 14.3. The most conflict-related neural activity when common form of dementia, Alzheimer’s disease (AD), accounts for 50 to 75 percent the hypothetical situation called for of all cases of dementia. In fact, about 4.5 million Americans have AD (Hebert et al., an unscheduled break in routine. 2003), and that number is expected to grow to as many as 14 million by the middle Conservatives were less flexible, of the twenty-fi rst century as the population ages (Boustani et al., 2003). Another refusing to deviate from old habits. 20 to 30 percent of dementia is caused by reduced blood flow to the brain, most Whether that is good or bad, of commonly due to a series of small strokes (multi-infarct dementia). Other cerebrocourse, depends on one’s perspective. Although it is unclear which comes vascular causes include vasculitis from syphilis, Lyme disease, or other types of brain first, patterns in neuron activity or hemorrhage (Boustani et al., 2003). The remaining cases result from a variety of less political orientation, the findings common disorders. Gatz (2007) notes that among sixty-five-year-olds, lifetime risk indicate a relationship between of developing any dementia has been estimated to be 11 percent for men and 19 perpsychological and brain processes. cent for women. Prevalence rates appear to be higher for African Americans than for whites and for women than for men. Age is the best studied and the strongest risk Source: Amodio et al. (2007). factor for dementia. Dementia can also occur with delusions, hallucinations, disturbances in perception and communication, and delirium. If these features are predominant, they are Did You Know? noted in the DSM-IV-TR classification. TA B L E

14.3

T

T

he auto-driving competency of persons with dementia has been of major safety concern. One study has shown that in simulated driving situations, people with dementia had more speeding tickets, ran more stop signs, and were involved in more accidents than matched control persons with no dementia (de Simone et al., 2006). The vast majority of people with dementia are still driving.

Delirium Delirium is characterized by disturbance of consciousness and changes in cognition (memory deficit, disorientation, and language and perceptual disturbances). These impairments and changes are not attributable to dementia. The disorder develops rather rapidly over a course of hours or days. The patient often shows a reduced ability to focus, sustain, or shift attention and exhibits disorganized patterns of thinking, as manifested by rambling, irrelevant, or incoherent speech. At times patients show a reduced level of consciousness and disturbances in the cycle of sleep and waking. The condition is usually reversible. The following describes a case of a student who was treated for amphetamine-induced delirium:

Case Study

delirium a syndrome characterized by disturbance of consciousness and changes in cognition, such as memory deficit, disorientation, and language and perceptual disturbances

An eighteen-year-old high school senior was brought to the emergency room by police after being picked up wandering in traffic on the Triborough Bridge [in New York City]. He was angry, agitated, and aggressive and talked of various people who were deliberately trying to “confuse” him by giving him misleading directions. His story was rambling and disjointed, but he admitted to the police officer that he had been using “speed.” In the emergency room he had difficulty focusing his attention and had to ask that questions be repeated. He was disoriented as to time and place and was unable to repeat the names of three objects after five minutes. The family gave a history of the patient’s regular use of “pep pills” over the past two years, during which time he was frequently “high” and did very poorly in school. (Spitzer et al., 1994, p. 162)

Etiology of Cognitive Disorders

Certain groups of patients are at risk for developing delirium (Wise et al., 1999). They include the elderly, frail individuals who are recovering in a medical setting, patients with preexisting brain dysfunction (e.g., stroke), patients in the withdrawal phase of drug dependency, patients with AIDS, and those with high illness burden (e.g., burn patients and elderly patients; Edlund et al., 2007). Obviously, some patients have multiple risk factors, as found in those who are elderly, who have suffered a stroke, and who are recovering from surgery. When people grow older, they have less cerebral reserve and are more likely to develop delirium with medical illness, stress conditions, or surgical procedures (Wise, Hilty, & Cerda, 2001). As in the case of dementia, delirium is classified according to its cause: general medical condition, substance-induced condition, multiple etiologies, and not otherwise specified.

Delirium

Dementia Problems of attention or inability to shift mental sets

Slow development of symptoms; aphasia, apraxia, or agnosia

Problems in learning new information or recalling previously learned information

395

Rapid development of symptoms; disturbance of consciousness; impairment fluctuates during the day

Memory disturbance; impaired social and occupational functioning Confusion and disorientation

No other major cognitive symptoms

Amnestic Disorders

Amnestic disorders are characterized by memory impairAmnestic Disorders ment, such as an inability to learn new information or an inability to recall previously learned knowledge or past events. As a result, confusion and disorientation occur. The memory disturbance causes major problems FIGURE UNIQUE AND OVERLAPPING SYMPTOMS in social or occupational functioning and does not occur IN DEMENTIA, DELIRIUM, AND AMNESTIC DISORDERS Dementia, exclusively during the course of dementia or delirium. In delirium, and amnestic disorders share some symptoms. The three some cases, the condition is reversible. As in the case of overlapping circles show the unique and the overlapping areas. The dementia and delirium, the etiology is specified. The memsymptoms that occur in all three include memory disturbance and ory impairment is not the result of a developmental process impaired functioning. Where the circles do not overlap, symptoms but rather the result of some insult to the central nervous are largely unique. For example, aphasia and apraxia are exhibited in system (Burke & Bohac, 2001). The most common causes dementia but not in delirium or amnestic disorders. Confusion and of amnestic disorders include head trauma, stroke, and disorientation are more likely to occur in delirium and amnestic disorders Wernicke’s encephalopathy, which is an alcohol-induced than in dementia. organic mental disorder probably involving thiamine deficiency (Wise et al., 1999). All three conditions—dementia, delirium, and amnestic disorders—have overlapping symptoms, especially those involving memory deficits. Some important differences distinguish the three, however. Dementia involves not only memory impairment but also conditions such as aphasia, apraxia, or agnosia. In contrast, the memory dysfunctions that occur in delirium happen relatively quickly, unlike those of dementia, in which functioning gradually declines. Delirium also involves an impairment of consciousness. In amnestic disorders, the primary symptom involves memory. However, when other cognitive deficits are noted in individuals with amnestic disorders, the risk for the subsequent development of AD and dementia is increased (Tabert et al., 2006). Figure 14.1 shows the unique characteristics, as well as the overlap in cognitive symptoms, of the three conditions. Cognitive disorders that do not meet the criteria for dementia, delirium, or amnestic disorders would be classified as cognitive disorders not otherwise specified.

14.1

Etiology of Cognitive Disorders Cognitive disorders can be caused by many different factors, and the same factor can result in dementia, delirium, or amnestic disorder. Rather than dividing the etiological discussion into our multipath model that includes biological, psychological, social, and sociocultural factors, we focus on the sources of cognitive disorders. The reason is that the direct causes of cognitive disorders are usually specified, such as brain trauma; processes associated with aging, disease, and infection; tumors; epilepsy; and psychoactive substance-induced disorders. Table 14.4 lists the different kinds of causes for the different cognitive disorders.

a disorder characterized by memory impairment as manifested by the inability to learn new information and the inability to recall previously learned knowledge or past events

amnestic disorder

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Did You Know?

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aving limited interactions with others is related to an increased risk of dementia and mental decline. Wilson and colleagues (Wilson, Krueger, et al., 2007) have found that emotional isolation (feeling alone rather than being alone) increases risk for Alzheimer’s disease in late life. For some reason, loneliness appears to be a risk factor for Alzheimer’s disease, not an early sign of the disease. The findings reveal the importance of psychological factors in disease.

Heredity is important in some cognitive disorders, especially dementia. In twin studies, the concordance rate for all dementias in men was 44 percent for MZ (monozygotic) pairs and 25 percent for DZ (dizygotic) pairs, and in women it was 58 percent for MZ pairs and 45 percent for DZ pairs. However, the longer one lives, the greater the chances for dementia to develop, and women generally have a longer life expectancy than men. Thus, although rates were higher for women than for men, once the age of the women was taken into account, there was no significant difference in genetic influence by sex (Gatz, 2007).

Traumatic Brain Injury Case Study On September 13, 1848, at Cavendish, Vermont, Phineas Gage was working as foreman of a railroad excavation crew. A premature explosion of a blast sent a tamping iron—a three-foot rod about an inch in diameter–through the lower side of Gage’s face and out of the top of his head. Exhibiting some convulsions and bleeding profusely, Gage soon regained speech. He was taken to his hotel, where he walked up a flight of stairs to get to his room. Remarkably, Gage survived the trauma, even though there must have been extensive damage to his brain tissue. Later, he appeared to have completely recovered from the accident with no physical aftereffects. However, Gage began to complain that he had a strange feeling, which he could not describe. Soon, his employers and others noticed a marked personality change in him. Although he had been a very capable employee prior to the accident and was known for his affable disposition, Gage now became moody, irritable, profane, impatient, and obstinate. So radically changed was Gage that his friends said that he was “no longer Gage.” (Adapted from J. M. Harlow, 1868)

Traumatic brain injury (TBI) is a physical wound or injury to the brain, as in the case of Phineas Gage. Approximately 1.4 million people sustain a TBI each year in the United States. Of those, 50,000 die, 235,000 are hospitalized, and 1.1 million are treated and released from an emergency department (Centers for Disease Control and Prevention [CDC], 2007f). Figure 14.2 shows the sources of TBI. Falls, auto accidents, and striking or being struck by objects are the leading causes. TA B L E The severity, duration, and symptoms of TBI may SOME CAUSES OF COGNITIVE DISORDERS differ widely, depending on the person’s premorbid personality and on the extent and location of the neural COGNITIVE DISORDER POSSIBLE CAUSES damage. Symptoms include headaches, disorientation, Delirium General medical confusion, memory loss, deficits in attention, poor conSubstance-related centration, fatigue, and irritability. Generally, the greater Multifactor the tissue damage, the more impaired the functioning. In some cases, however, interactions among various parts Dementia Traumatic head injuries of the brain, coupled with brain redundancy, in which Alzheimer’s disease different parts of the brain can control a specific funcVascular origin tion, may compensate for some loss of tissue. Parkinson’s-related Head injuries are usually classified as concussions, HIV-related contusions, or lacerations. A concussion is a mild brain Neurosyphilis injury, typically caused by a blow to the head. Blood Huntington’s disease vessels in the brain are often ruptured, and circulatory General medical and other brain functions may be disrupted temporarily. Substance-related The person may become dazed or even lose consciousMultifactor ness. Symptoms are usually temporary, lasting no longer than a few weeks. In some cases, symptoms may persist Amnestic General medical for months or years, for unknown reasons, without neuSubstance-related rological signs of impairment. Multifactor In a contusion, the brain is forced to shift slightly and press against the side of the skull. The cortex of the brain may be bruised (that is, blood vessels may rupture) on impact with the skull. As in concussion, the person may lose consciousness for a few hours or even for days. Although the symptoms are similar to those of traumatic brain injury a physical concussion, they are generally more severe and last longer. wound or injury to the brain

14.4

Etiology of Cognitive Disorders

397

Case Study Thirteen-year-old Ron G was a catcher for his school baseball team. During a game, a player on the other team lost his grip on the bat as he swung at a pitch, and the bat hit Ron on the forehead. Although his catcher’s mask absorbed some of the force, the blow knocked Ron out. An hour elapsed before he regained consciousness at a nearby hospital, where he was diagnosed as having a cerebral contusion. Headaches, muscle weakness, and nausea continued for two weeks.

9% 7%

1% 2%

28%

3% 11%

20%

Lacerations are brain traumas in which brain tissue is torn, pierced, or ruptured, usually by an object that has penetrated the skull. When an object also penetrates the brain, death may result. If the person survives and regains consciousness, a variety of temporary or permanent effects may be observed. Symptoms may be quite serious, depending on the extent of damage to the brain tissue and on the amount of hemorrhaging. Cognitive processes are frequently impaired, and the personality may change. Closed-head injuries are the most common form of traumatic brain injury. They usually result from a blow that causes damage at the site of the impact and at the opposite side of the head. If the victim’s head was in motion before the impact (as is generally the case in car accidents), the blow produces a forward-and-back movement of the brain, accompanied by tearing and hemorrhaging of brain tissue. Damage to brain tissues in the left hemisphere often results in intellectual disorders, and affective problems more frequently result from damage to brain tissues in the right hemisphere. The cumulative impact of traumas to the head may also affect brain functioning. Severe brain trauma has long-term negative consequences. Many young adults who are comatose for at least twenty-four hours later experience residual cognitive deficits that interfere with employment and psychosocial adjustment. Recovery from the trauma often does not ensure a return to the victim’s premorbid level of functioning. Along with any physical or mental disabilities produced by the brain damage, motivational and emotional disturbances result from the frustration of coping with these physical or mental deficits.

19%

Falls Motor vehicle traffic Struck by/against Assault Pedal cycle (non MV) Other transport Suicide Other Unknown

14.2

FIGURE SOURCES OF TRAUMATIC BRAIN INJURIES Source: CDC (2007f ).

Did You Know?

D

ramatic changes can occur in patients who are comatose from brain injuries. Jesse Ramirez sustained head trauma and was comatose from an auto accident. Eighteen days after his wife instructed doctors to disconnect food and water tubes, Ramirez miraculously sat up in bed and communicated with visitors (Wagner, 2007). Shadlen and Kiani (2007) subjected a patient, comatose for six years from damage to his brain, to electrical brain stimulations from electrodes. He was able to awaken and name objects and use objects with his hands.

DANGER JUST A TUMBLE AWAY More than 8 million Americans suffer head injuries each year, such as concussions, contusions, and lacerations. In order to reduce the risk of head injuries, individuals are advised to wear helmets while skateboarding, rollerblading, and bicycling. If you engage in these activities, do you wear a helmet?

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Myth vs Reality Myth: Mild head injuries among children and adolescents are a “silent epidemic” in terms of seriousness of cognitive, psychosocial, and academic consequences. Reality: Although a great deal of concern has been raised over the frequency and consequence of mild head injuries among children, there is no compelling evidence that these injuries have the kinds of serious consequences as was initially believed. A thorough review of the research on children with mild head injuries revealed that most studies did not find major negative consequences (Satz, 2001). (A mild head injury is defined as one in which the period of unconsciousness is less than 20 minutes, which shows no evidence of hematoma, for which a patient is not hospitalized for more than two days, and in which the patient achieves nonserious scores on the Glasgow Coma Scale.) Of course, any head injury should be of concern. However, it is also important to place such injuries in proper perspective.

Did You Know?

C

oncern over traumatic brain injuries has been growing because of the number of soldiers in the Iraq war who may have suffered brain injuries from explosive devices or propelling objects. More than 150,000 troops may have head injuries from combat, and most have not been counted or identified. Source: Zoroya (2007).

Aging and Disorders Associated with Aging Before discussing the cognitive disorders often associated with aging, it seems appropriate to describe the nature of the older U.S. population (sixty-five years old or more), as noted by the Administration on Aging (2007). • About one in every eight people, or 12.4 percent of the population, is an older American. • The population age sixty-five and over will increase from 35 million in 2000 to 40 million in 2010 (a 15 percent increase) and then to 55 million in 2020 (a 36 percent increase for that decade). • Older women outnumber older men, at 21.4 million older women to 15.4 million older men. • In 2005, 18.5 percent of persons sixty-five and older were minorities; 8.3 percent were African Americans. Persons of Hispanic origin (who may be of any race) represented 6.2 percent of the older population. About 3.1 percent of the elderly were Asian or Pacific Islander, and less than 1 percent were American Indian or Native Alaskan. The cognitive disorders most common among the elderly are strokes, memory loss, and AD. These conditions are correlated with aging, but they also occur among younger people. Unfortunately, the elderly are less likely than younger individuals to seek help from mental health professionals (Clarkin & Levy, 2004).

RESULTS OF STROKE ON THE BRAIN Stroke is brain damage caused by the interruption of the brain’s blood supply, or by the leakage of blood through blood vessel walls. The two main causes are high blood pressure and narrowing of the arteries due to fat deposition. Here, a three-dimensional magnetic resonance angiogram scan shows a human brain after a stroke (cerebrovascular accident). Major arteries are shown in white, while the central region in yellow is an area of bleeding, or hemorrhage.

Cerebrovascular Accidents or Strokes A stroke (or cerebrovascular accident) is a sudden stoppage of blood flow to a portion of the brain, leading to a loss of brain function. The risk of a stroke is increased if one has hypertension, heart disease, a history of smoking and alcohol consumption, and diabetes. Strokes are the third major cause of death in the United States and the second leading cause of dementia, right behind AD (Wise et al., 1999). Stroke victims who survive often require long-term care while suffering from a variety of psychological

Etiology of Cognitive Disorders

distress and sensory-motor disabilities. Stroke victims are often frustrated and depressed by their handicaps, and they show greater depression and interpersonal sensitivity than other groups of patients. Their depression, pessimism, and anxiety about their disabilities occasionally leads to further disability (Burruss, Travella, & Robinson, 2001). The bursting of blood vessels (and the attendant intracranial hemorrhaging) causes 25 percent of all strokes and often occurs during exertion. Victims report feeling that something is wrong within the head, along with headaches and nausea. Confusion, paralysis, and loss of consciousness follow rapidly. Mortality rates for this type of stroke are extremely high. Strokes may also be caused by the narrowing of blood vessels owing to a buildup of fatty material on interior walls (atherosclerosis) or by the blockage of blood vessels. In either case, the result is cerebral infarction, the death of brain tissue from a decrease in the supply of blood. These strokes often occur during sleep, and the person is paralyzed when he or she awakens. The residual loss of function after a stroke usually involves only one side of the body, most often the left. Interestingly, one residual symptom of stroke is a “lack of acknowledgment” of various stimuli on one side of the body. For example, a patient who is asked to copy a pattern may draw half the pattern and may ignore the left side of his or her body. Some functional reorganization of the brain may occur after a stroke to compensate for the loss of function. Three months after suffering a stroke owing to cerebral infarction, one patient showed significantly reduced cerebral blood flow in one area. An examination performed one year later showed no abnormalities. The pattern of blood flow, however, suggested increased activation in brain areas surrounding the affected area. It is possible that the patient’s clinical improvement was due to brain reorganization, in which the function of the destroyed area was taken over by other areas. A series of infarctions may lead to a syndrome known as vascular dementia, which is characterized by the uneven deterioration of intellectual abilities (although some mental functions may remain intact). The specific symptoms of this disruption depend on the area and extent of the brain damage. Both physical and intellectual functioning are usually impaired. The patient may show gradual improvement in intellectual functioning, but repeated episodes of infarction can occur, producing additional disability. Memory Loss in Older People Fewer than one in five people over age sixtyfive experience moderate to severe memory impairment (see Figure 14.3). Among those eighty-five and older, about one-third suffer from moderate to severe memory impairment. As individuals age, their brains shrink. They gradually lose nerve cells that they had from birth, and information is processed more slowly. Consequently, memory begins to fail, and the learning of new concepts becomes more difficult. Some older adults may show pronounced deficits in perception, attention, and memory, although others perform at least as well as younger adults or experience less of a drop in cognitive function. Evidence suggests that the brain reorganizes itself, using different circuitry in older adults. It dynamically reacts to experience, showing both gains and losses with age (Population Reference Bureau, 2007). Memory loss occurs for a variety of reasons. It is one of the most obvious symptoms of AD, which we discuss in depth in the next section. Loss of memory may also be shown by elderly people suffering vascular dementia. Because memory loss is associated with so many disorders, as well as with normal aging, it is of concern to older adults and yet difficult for clinicians to assess. Occasional lapses of memory are not necessarily a sign of senility. One of the most common reasons for memory loss and confusion in older patients is therapeutic drug intoxication. People may take several medications that can interact with one another to produce negative side effects. Medication often has

399

EXPERIENCING A STROKE Neuroanatomist Jill Bolte Taylor is shown holding a human brain and spinal cord. One morning a congenital abnormality of the blood vessels in her brain burst. For several hours, she experienced her mind deteriorating. After becoming unconscious, she later awakened and could not talk, understand language, or remember her life. She felt completely disabled. After recovery, Taylor felt that the experience was in many ways delightful. It shifted her out of her left hemisphere, which thinks in language and focuses on the past and future, to the consciousness of her right hemisphere, which thinks in pictures and exists in the present moment. When her left hemisphere went off-line, her right hemisphere became dominant. Taylor became a different person. Shifting away from a typical type-A personality focused on academics, career, and achievement, she has become more compassionate and humane. Her values have shifted toward helping those in need such as people with mental disorders, the homeless, and those in jail.

stroke (cerebrovascular accident)

a sudden stoppage of blood flow to a portion of the brain, leading to a loss of brain function the death of brain tissue resulting from a decrease in the supply of blood serving that tissue

cerebral infarction

vascular dementia dementia characterized by uneven deterioration of intellectual abilities and resulting from a number of cerebral infarctions

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40 Men Women

Percent

30

20

10

0

65+

65–69

70–74

75–79

80–84

85+

Age

FIGURE

14.3

MEMORY LOSS IN OLDER PEOPLE Fewer than 1 in 5 adults over age 65 experience moderate to severe memory impairment. Source: Federal Interagency Forum on Aging-Related Statistics (2006).

a stronger effect on older people and takes longer to be cleared from their bodies, yet dosages are often determined by testing on young adults only. In addition, cardiac, metabolic, and endocrine disorders and nutritional deficiencies can produce symptoms resembling dementias. Age-related declines in cognitive functioning can be relatively large. The declines may not be noticed because cognitive ability is only one factor in the success of one’s functioning, because very few situations require maximum levels of performance, because people may adapt to age-related changes by somehow compensating for these changes, and because greater knowledge and experience may also make up for the changes (Salthouse, 2004). A decrease in cognitive functioning may also bring psychological problems. Mental decline has been associated with depression, and the decline seems to cause depression rather than depression causing decline (Ganguli et al., 2006).

Myth vs Reality Myth: As we become older, we experience negative or undesirable cognitive changes. Reality: With age, adults experience less negative emotion, attend less to negative than to positive emotional stimuli, and decrease their memory of negative versus positive emotional materials. They tend to show reduced reactivity to negative information while maintaining or even increasing reactivity to positive information. By using functional magnetic resonance imaging to assess amygdala activation, Mather and her colleagues (2004) found that for older adults, seeing positive pictures led to greater amygdala activation than seeing negative pictures, whereas this was not the case with younger adults. With age, the amygdala may show decreased reactivity to negative information while maintaining or increasing its reactivity to positive information. Perhaps this is one advantage that comes with age.

Alzheimer’s Disease Among Americans ages fifty-five and older, Alzheimer’s disease (AD), in which brain tissue atrophy results in marked deterioration of intellectual and emotional functioning, was the most feared on a list of diseases, exceeding cancer and strokes (Gatz, 2007). Many fear becoming a “mental vegetable.” AD is the most prevalent form of dementia, and it affects about five million Americans. The risk for the disease increases with age. However, it also can attack people in their forties or fifties. We have become increasingly aware of the disease because public figures such as former president Ronald Reagan and the late actor Charlton Heston have candidly discussed their condition.

Alzheimer’s disease (AD)

a dementia in which brain tissue atrophies, leading to marked deterioration of intellectual and emotional functioning

Characteristics of Alzheimer’s Disease The natural history of AD is one of progressive decline; cognitive, physical, and social functions gradually deteriorate. Thus “improvement” due to an intervention for AD means slowing the rate of decline (Boustani et al., 2003). Early symptoms—memory dysfunction, irritability, and cognitive impairment—gradually worsen, and other symptoms, such as social withdrawal, depression, apathy, delusions, impulsive behaviors, and neglect of personal hygiene may eventually appear. At present, no curative or disease-reversing interventions exist for AD (Rivas-Vazquez, 2001). From the time of diagnosis, people with AD survive about half as long as those of similar age without dementia (Larson et al., 2004).

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AGING WELL Members of laughter clubs participate in a laughter competition for the elderly to celebrate World Laughter Day in Mumbai, India. Laughter Yoga is a physically oriented technique that uses simple laughter exercises and is believed to improve health and increase well-being.

Case Study Elizabeth R, a forty-six-year-old woman diagnosed as suffering from AD, is trying to cope with her increasing problems with memory. She writes notes to herself and tries to compensate for her difficulties by rehearsing conversations with herself, anticipating what might be said. However, she is gradually losing the battle and has had to retire from her job. She quickly forgets what she has just read, and she loses the meaning of an article after reading only a few sentences. She sometimes has to ask where the bathroom is in her own house and is depressed by the realization that she is a burden to her family. (Clark et al., 1984, p. 60)

The deterioration of memory seems to be the most poignant and disturbing symptom for those who have AD. They may at first forget appointments, phone numbers, and addresses. As the disorder progresses, they may lose track of the time of day, have trouble remembering recent and past events, and forget who they are. But even when memory is almost gone, contact with loved ones is still important.

Case Study I believe the emotional memory of relationships is the last to go. You can see daughters or sons come to visit, for example, and the mother will respond. She doesn’t know who they are, but you can tell by her expression that she knows they’re persons to whom she is devoted. (Materka, 1984, p. 13)

AD can also create some unusual and bittersweet situations. Retired Supreme Court Justice Sandra Day O’Connor’s husband developed AD. While living at a facility for people with AD, he forgot his wife and fell in love with another woman at the facility. In a display of her love for her husband, Sandra Day O’Connor was relieved that her husband felt happy and was like “a teenager in love.” Prior to his new romance when he first came to the center, he basically spoke about suicide (Biskupic, 2007). Alzheimer’s Disease and the Brain Comparisons of the brains of persons with AD and those who are free of AD reveal a number of differences. First, the brain of a person with AD becomes clogged with two abnormal structures, called neurofibrillary tangles and senile plaques. Neurofibrillary tangles are twisted masses of protein fibers inside nerve cells or neurons. Senile plaques are composed of parts of neurons (for example, patches of degenerated nerve endings) surrounding a group of proteins called beta-amyloid deposits. Both conditions are believed to disrupt the transmission of impulses among brain cells, thereby producing the symptoms of the disorder. It is hypothesized that these plaques cause oxidative injury (damage due to release of free radicals during cellular metabolism), inflammation, and alterations in neurotransmitters, eventually resulting in the death of neurons and brain atrophy. AD is notable for its insidious or gradual onset (Gatz, 2007). Second, persons with this disease have an atrophy of brain tissue. In a prospective study using MRI scans, atrophy of the hippocampus and amygdala among cognitively intact elderly people was predictive of the subsequent development of AD and dementia

Did You Know?

O

ne of the agonizing questions that bother the elderly is whether mild cognitive impairments that they may experience are signs of Alzheimer’s disease. Some researchers have now developed a blood test that may be able to identify people who have mild cognitive impairment that progresses to Alzheimer’s disease two to six years later (Ray et al., 2007).

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critical thinking

Moderators and Mediators: What Causes What?

I

n our discussion of cognitive disorders, we have found that the disorders are often associated with brain anomalies. For example, in Alzheimer’s disease (AD), it was noted that senile plaques are found in the brain, as well as atrophy of the hippocampus. Senile plaques, hippocampus atrophy, and AD are then correlated, or related to each other. In introductory psychology courses, students learn that when we find that two or more factors are related or correlated with each other, it is not possible to come to cause-andeffect conclusions. How do we know which anomaly, if any, causes AD? For example, perhaps senile plaques cause AD. On the other hand, deterioration of the hippocampus may cause AD. Or perhaps an unidentified factor causes all three phenomena (AD, senile plaques, and hippocampus deterioration). The point is that when factors are correlated, it is not possible to determine cause and effect. Psychologists have made a distinction between moderator and mediator variables in correlational relationships (Baron & Kenny, 1986). A moderator is a variable that affects the direction and/or strength of the relation between an independent or predictor variable and a dependent or criterion variable. A mediator accounts for the relation between the predictor and the criterion. Whereas moderator variables specify when certain effects will hold, mediators speak to how or why such effects occur. The following example illustrates moderation and mediation. Suppose we find that in AD brain processing problems (a predictor) are related to AD (the criterion). Also suppose that we find that processing problems are more highly related to

Did You Know?

D

ifficulty identifying smells such as lemon, banana, and cinnamon may be the first sign of Alzheimer’s disease, according to a study that could lead to scratch-and-sniff tests to determine a person’s risk for the disorder (Wilson, Schneider, et al., 2007). The results support previous research showing that the lesions indicative of Alzheimer’s first appear in a brain region related to smell.

AD when there is brain atrophy than when there is no brain atrophy. In this case, brain atrophy is a moderator variable because it affects the strength of the relationship between brain processing and AD. In terms of mediation, we know that brain-processing anomalies are related to AD, that brain atrophy is related to AD, and that processing anomalies are related to brain atrophy. How can we try to determine what causes what? If we find that brain processing anomalies are related to AD only because brain atrophy has occurred, then we can infer that brain atrophy rather than brain processing is the more likely reason for AD. In this case, brain processing is the predictor, AD is the criterion, and brain atrophy is the mediator. In general, causal relations are difficult to prove, and the moderator-mediator analysis helps to decipher the nature of relationships. Psychologists often use the experimental method to try to determine causality. As we learned in Chapter 4, if one of two comparable groups is given an intervention, then resulting differences between the two groups may be caused by the intervention. Other tactics involve time analysis (e.g., if A causes B, then A must occur before B), theoretical-statistical fit (e.g., how empirical results fit one’s theory about causality or causal models; see Bentler, 2007), and the consistency and convergence of research findings that support a causal model. Can you give other examples of mediators and moderators? What are advantages and disadvantages of different methods to try to establish causality?

(den Heijer et al., 2006). Third, fundamental deficits in attention and perception have been found that are related to brain processing. Patients with AD and patients with mild cognitive impairment (MCI), defined as having memory complaints and functioning below the vast majority of others, have problems focusing their brain activity. On brain scans, they show less activity than normal people in the “correct” brain areas but also more activity in the “wrong” areas when processing information (Drzezga et al., 2005). Although these three factors—abnormal structures, brain atrophy, and different processing of information—may well cause AD, it is very difficult to decipher whether observed differences are a cause, an effect, or an accompanying condition of AD. Interestingly, depression may play a role in AD. Rapp and his colleagues (2006) found that: • People with depression had more plaques and tangles in a part of the brain called the hippocampus. As noted earlier, plaques and tangles are a key feature of AD. • People with AD with a history of depression and who were depressed at the time of diagnosis showed more marked, more pronounced neuropathological changes in the hippocampus. • People with a lifetime history of major depressive disorder were more likely to have a rapid decline into AD. Etiology of Alzheimer’s Disease The etiology of AD is unknown, although it is thought to be a product of hereditary and environmental factors (Hendrie, 2001). Many different explanations have been proposed. They include reduced levels of the

Etiology of Cognitive Disorders

403

ADVOCATE FOR ALZHEIMER’S Retired U.S. Supreme Court Justice Sandra Day O’Connor has become a strong advocate for treatment and prevention of Alzheimer’s disease. She is shown here with and her husband John Jay O’Connor who suffered from the disease.

neurotransmitter acetylcholine in the brain; repeated head injuries; inflammation of the brain; infections and viruses; decreased blood flow in the brain; toxic molecular fragments known as free radicals; diet and nutrition; and the effect of plaques and tangles in disrupting cellular metabolism or in reducing glucose absorption from the bloodstream. It may be that a number of factors can cause AD or that various factors interact with each other to put one at risk for the disease. We do know that several genes have been associated with higher incidences of AD, although the exact role of these genes still is unknown (Boustani et al., 2003). The risk of developing AD is 1.8 to 4.0 times higher for those with a family history of the disorder than for those without (Gatz, 2007). In a comparison of DZ and MZ twins for AD, several important findings emerged: (1) heritability for the disease is high, (2) gender NORMAL BRAIN AND ALZHEIMER’S BRAIN Computer graphic of a vertical slice through the brain of an Alzheimer patient (at left) compared with a normal brain (at right). The Alzheimer’s disease brain is considerably shrunken, due to the degeneration and death of nerve cells. The surface of the brain is often more deeply folded. Tangled protein filaments (neurofibrillary tangles) are found within nerve cells and patients also develop brain lesions of beta-amyloid protein. Alzheimer’s disease accounts for most cases of senile dementia. Symptoms include memory loss, disorientation, personality change, and delusion. It ultimately leads to death.

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PARKINSON’S DISEASE Actor Michael J. Fox, who has Parkinson’s disease, performs at a benefit for The Michael J. Fox Foundation for Parkinson’s Research in New York City.

differences do not appear to be significant, and (3) environmental influences are also important and should be the focus of interventions to reduce risk or delay onset of the disease (Gatz et al., 2006). There is some evidence that the genetic influence does not express itself during adulthood until late in life (over age sixty-five). That is, AD that is caused by heredity may not occur until late life (Jorm et al., 2007). Some researchers have found that genetic predisposition to AD, coupled with low levels of two B vitamins (B-12 and folate), may affect memory performance, suggesting that heredity and diet may be important (Bunce, Kivipelto, & Wahlin, 2004). What seems to be clear is that many factors may influence AD and that heredity is important at least for some cases of AD. Several protective factors have been identified that may delay the onset of AD. These include genetic endowment with the ApoE-e2 allele, which decreases the risk for the disease; higher education and occupational attainments; use of nonsteroidal anti-inflammatory drugs or estrogen replacement therapy; and taking vitamin E. The reasons that these factors may provide protection are unclear, but they may reduce the deleterious action of oxidative stress (via antioxidants such as vitamin E or estrogen) or the action of inflammatory mediators associated with plaque formation (U.S. Surgeon General, 1999). Cholinesterase inhibitors have been found to reduce the rate of cognitive decline among Alzheimer’s patients (Boustani et al., 2003). In the case of education and occupation, it may be that increased cognitive activity associated with education and occupational status helps to reduce the incidence of the disease (Wilson & Bennett, 2003), as discussed later.

Other Diseases and Infections of the Brain

A variety of diseases and infections result in brain damage that leads to behavioral, cognitive, and emotional changes, including the development of cognitive disorders.

Parkinson’s disease

a progressively worsening disorder characterized by four primary symptoms: tremor, or trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination

Parkinson’s Disease Parkinson’s disease is a progressively worsening disorder characterized by four primary symptoms: tremor, or trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination (National Institute of Neurological Disorders and Stroke, 2007b). It is associated with lesions in the motor area of the brainstem and with a loss of dopamine-producing brain cells. The disease is the second most common neurodegenerative disorder in the United States (Dobkin, Allen, & Menza, 2006). It affects about 500,000 persons in the United States. Parkinson’s disease strikes about 50 percent more men than women, but the reasons for this discrepancy are unclear. In some persons, the disorder may be caused by infections of the brain, toxins, cerebrovascular disorders, brain trauma, and poisoning with carbon monoxide; in other persons, no specific origin can be determined. Genetic predisposition may play a role in the disease (Kurth & Kurth, 1994). At present, there is no cure for Parkinson’s disease, but a variety of medications provide dramatic relief from the symptoms. Usually, patients are given L-dopa (levodopa) combined with carbidopa to enable nerve cells to make dopamine and replenish the brain’s dwindling supply. For some patients, high-technology surgical procedures on the brain or the implantation of electrodes to continuously stimulate areas of the brain have been helpful (Hartman-Stein, 2004). AIDS Dementia Complex The general public knows about the disastrous consequences of AIDS, or acquired immunodeficiency syndrome—the susceptibility to diseases, the physical deterioration, and death, often within several years of infection. Relatively few people, however, know that dementia may be the first sign of AIDS. The vast majority of AIDS patients have suffered from symptoms of dementia. The symptoms may involve an inability to concentrate and to perform complex sequential mental tasks. The person may be unable to follow television or movie plots, may miss appointments, and may have hand tremors. Other symptoms

Etiology of Cognitive Disorders

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TAMING POTENTIAL KILLERS THROUGH RESEARCH Shown at left is the syphilis spirochete Treponema pallidum, the bacterium responsible for the development of syphilis and, if untreated, general paresis; shown at right is the spherical bacterium Neisseria meningitidis, which causes bacterial meningitis in humans. Both can cause destruction of brain tissue, seizures, and ultimately death, but they can now be treated with antibiotics.

include forgetfulness, impaired judgment, and personality disturbances such as anxiety and depression. In more serious cases, a diagnosis of AIDS dementia complex (ADC) is made. Prevalence of ADC among persons with HIV infection is between 10 and 20 percent in western countries (Grant, Sacktor, & McArthur, 2005) and has been seen in only 1 to 2 percent of India-based infections (Wadia et al., 2001). Dietary differences, such as consumption of curcumin (in curry) and theaflavins (in teas) in India, may have protective effects. ADC can be attributed to at least three factors. First, the HIV virus itself reaches the brain at some phase of the infection. When it becomes active, the virus can affect mental, as well as physical, processes. Second, because AIDS affects the immune system, AIDS-related infections may cause infected cells to release toxic substances that cause changes in brain-controlled physiological processes. Some degree of cerebral atrophy is present in almost all HIV patients with dementia. Third, depression, anxiety, and confusion can arise from simply knowing that one has AIDS, and experiencing negative reactions from others increases stress for AIDS victims. Antiretroviral therapy has prevented or ameliorated ADC symptoms or delayed the onset of ADC, particularly in developed countries. Neurosyphilis (General Paresis) Syphilis is caused by the spirochete Treponema pallidum, which enters the body through contact with an infected person. This microorganism is most commonly transmitted from infected to uninfected people through intercourse or oral-genital contact. A pregnant woman can also transmit the disease to her fetus, and the spirochete can enter the body through direct contact with mucous membranes or breaks in the skin. Within a few weeks, the exposed person develops a chancre, a small sore at the point of infection, as well as a copper-colored rash. If untreated, the infection spreads throughout the body. There may be no noticeable symptoms for ten to fifteen years after the initial infection, but eventually the body’s organs are permanently damaged. In about 10 percent of persons with syphilis who are untreated, the spirochete directly damages the brain or nervous system, causing general paresis (muscular weakness, mental deterioration, and speech problems). Encephalitis Encephalitis is a brain inflammation that is caused by a viral or bacterial infection and that produces symptoms of lethargy, drowsiness, fever, delirium, vomiting, and headaches. The infections can come from a variety of sources, including herpes viruses and bites from mosquitoes, ticks, and animals. One form, epidemic encephalitis, was widespread during World War I, but the disease is now very rare in the United States. It is still a problem, however, in certain areas of Africa and Asia. Most cases follow a rapidly developing course that begins with headache, prostration (having to lie down), and diminished consciousness. Epileptic seizures are common in children with encephalitis, and these seizures may be the most obvious symptom.

brain inflammation that is caused by a viral or bacterial infection and that produces symptoms of lethargy, drowsiness, fever, delirium, vomiting, and headaches

encephalitis

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Acute symptoms, as noted earlier, include lethargy, fever, delirium, and long periods of sleep and stupor. When wakeful, the victim may show markedly different symptoms: hyperactivity, irritability, agitation, and seizures. A coma, if there is one, may end abruptly. Rest, having a healthy diet, and antiviral medications can be helpful. Meningitis Meningitis is an inflammation of the meninges, the membrane that surrounds the brain and spinal cord, and it can result in the localized destruction of brain tissue and seizures. Research on meningitis is complicated, because the disorder can be caused by three different kinds of germs: bacterial, viral, and fungal. The symptoms of meningitis vary with the age of the patient. In neonates and young infants, the symptoms are nonspecific (fever, lethargy, poor eating, and irritability), which makes diagnosis difficult. In patients older than one year, symptoms may include stiffness of the neck, headache, and cognitive and sensory impairment. All three forms can result in the localized destruction of brain tissue and in seizures, but their incidence is much greater in the bacterial form than in the others. The outcome is most serious when meningitis is contracted during the neonatal period. Residual effects of the disorder may include partial or complete hearing loss as a result of tissue destruction, mental retardation, and seizures. Meningitis also seems to attack the abstract thinking ability of some of its victims. MAJOR DISCOVERY Dr. Nancy Wexler helped to develop the first test to determine who was carrying the gene for Huntington’s disease. Her mother died of the disease.

Huntington’s Disease Huntington’s disease is a rare, genetically transmitted degenerative disease characterized by involuntary twitching movements and eventual dementia. Because the disorder is transmitted from parent to child through an abnormal gene, approximately 50 percent of the offspring of an affected person develop it. Scientists have identified the gene that causes the disease, so they are able to better detect whether a person has inherited the disorder. At this time, Huntington’s disease cannot be treated, so genetic counseling is extremely important in preventing transmission of the disease. The symptoms can be reduced through the use of medication and physical fitness. The first physical symptoms are generally twitches in the fingers or facial grimaces. As the disorder progresses, these symptoms become more widespread and abrupt, involving jerky, rapid, and repetitive movements. Changes in personality and emotional stability also occur. For example, individuals with Huntington’s disease may become moody and quarrelsome. They may develop a peculiar manner of walking and find it difficult to speak normally. Huntington’s disease always ends in death, on the average from thirteen to sixteen years after the onset of symptoms. Early misdiagnoses are given in many of the cases; schizophrenia is a common misdiagnosis.

meningitis inflammation of the meninges, the membrane that surrounds the brain and spinal cord; can result in the localized destruction of brain tissue and seizures

Cerebral Tumors

a rare, genetically transmitted degenerative disease characterized by involuntary twitching movements and eventual dementia

Huntington’s disease

a mass of abnormal tissue growing within the brain

cerebral tumor

any disorder characterized by intermittent and brief periods of altered consciousness, often accompanied by seizures, and excessive electrical discharge from brain cells

epilepsy

A cerebral tumor is a mass of abnormal tissue growing within the brain. The symptoms depend on the area affected and on the amount of intracranial pressure exerted by the tumor. Fast-growing tumors generally produce severe mental symptoms, whereas slow growth may result in few symptoms. Unfortunately, in the latter case, the tumor is often not discovered until death has occurred in a psychiatric hospital. The most common symptoms of cerebral tumors are disturbances of consciousness, which can range from diminished attention and drowsiness to coma. People with tumors may also show mild dementia and other problems of thinking. Mood changes may also result from either the direct physical impact of the tumor or the patient’s reaction to the problem. Presence of neuropsychiatric symptoms is influenced by many factors, including the extent of tumor involvement, the rapidity of its growth, its propensity to cause increased intracranial pressure, and the patient’s premorbid psychiatric history, level of functioning, and characteristic psychological coping mechanisms (Price, Goetz, & Lovell, 2002). Removing a cerebral tumor can produce dramatic results.

Epilepsy Epilepsy is a general term that refers to a set of symptoms rather than to a specific etiology. In particular, epilepsy includes any disorder characterized by intermittent and brief periods of altered consciousness—often accompanied by seizures—and

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A CEREBRAL TUMOR Symptoms of cerebral tumor, an abnormal tissue growing within the brain, depend on the size and location of the tumor. Some are fairly large, such as the one shown in this CT scan. The most common effects of tumors involve disturbances in consciousness.

by excessive electrical discharge from brain cells. It is the most common of the neurological disorders; 1 to 2 percent of the population has epileptic seizures at some time during their lives. Epilepsy affects an estimated 2.7 million people in the United States and costs about $15.5 billion in medical expenses and lost or reduced earnings and productivity each year. Epilepsy is most frequently diagnosed during childhood. It can be symptomatic of some primary disorder of the brain without apparent etiology, or it can arise from such causes as hereditary factors, brain tumors, injury, degenerative diseases, and drugs. Epileptic seizures and unconsciousness may last from a few seconds to several hours; they may occur only a few times during the patient’s entire life or many times in one day. And they may produce only a momentary disturbance of consciousness or a complete loss of consciousness—in which case they can be accompanied by violent convulsions and a coma lasting for hours. Alcohol, lack of sleep, infections, stroke, fever, a low blood-sugar level, hyperventilation, a brain lesion or injury, or general fatigue can all induce an epileptic seizure. Particular musical notes, flickering lights, and emotionally charged situations have also been known to provoke epileptic attacks. Often, the cause is unknown. Epilepsy can often be controlled, but it cannot be cured. Although people with epilepsy usually behave and function quite normally between attacks, their chronic, long-term illness is still regarded with suspicion and repugnance by much of society. An attack can be frightening to the afflicted person and observers alike. Many people with epilepsy have accompanying psychological problems (CDC, 2007a). As we have noted, epilepsy has been attributed to a wide range of factors, including brain tumors, head injuries, biochemical THE MOST COMMON NEUROLOGICAL DISORDER Epilepsy imbalances, physical illness, and stress. These somehow result in refers to any disorder that is characterized by intermittent and excessive neuronal discharge within the brain. Sometimes the disbrief periods of altered consciousness, often accompanied by charge appears to be quite localized, producing focal seizures or seizures. It also seems to be one of the earliest recognized twitching in isolated parts of the body. Generalized seizures are organic brain syndromes. Among those who suffered from the presumably caused by general cortical discharge, and the effects disease was Vincent van Gogh, shown here in a self-portrait painted sometime after he had cut off his ear. involve the whole body.

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Some researchers have investigated the hypothesis that genetic or personality factors predispose people to epilepsy. The concordance rate for epilepsy is greater among identical than among fraternal twins, and seizures are much more frequent among family members of a person with epilepsy than among unrelated people (Devinsky, 1994). However, heredity may not be a necessary or sufficient condition for the onset of epilepsy.

Use of Psychoactive Substances Using psychoactive substances (see Chapter 9) can result in cognitive disorders (dementia, delirium, or amnestic disorder). The substances have effects on the nervous system. Most people diagnosed as having cognitive disorders involving psychoactive substances also have problems concerning substance use. The most common psychoactive substances that can lead to cognitive disorders are alcohol, amphetamines, caffeine, marijuana, cocaine, hallucinogens, inhalants, nicotine, opioids, PCP, and sedatives.

Treatment/Prevention Considerations Because cognitive disorders can be caused by many different factors and are associated with different symptoms and dysfunctions, treatment approaches have varied widely. In general, the major interventions for cognitive disorders have been surgical, medical, psychological, and environmental. Surgical procedures may be used to remove cerebral tumors, relieve the pressure caused by tumors, or restore ruptured blood vessels. Psychotherapy may help patients deal with the emotional aspects of these disorders. And some patients who have lost motor skills can be retrained to compensate for their deficiencies or can be retaught these skills. Sometimes, patients with cognitive disorders need complete hospital care. Most treatment programs are comprehensive in nature, providing patients with medication, rehabilitation, therapy, and environmental modifications. Although some potentially reversible conditions exist, few cases of mild to moderate dementia are fully reversible (Boustani et al., 2003). For those disorders that are reversible or treatable, the underlying cause of the dementia may be the focus of the intervention, and rehabilitation may be required for residual deficits. Vascular dementias may not be reversible, but their progress can be halted in some cases. Nonreversible dementias are usually managed by placing the patient in a supportive environment and by using medications targeted at associated symptoms. Treatment for stroke-related dementia begins by minimizing the risk of further strokes—through smoking cessation, aspirin therapy, and treatment of hypertension, for instance.

Medication Drugs can prevent, control, or reduce the symptoms of brain disorders, as in the use of L-dopa in Parkinson’s disease. Medication is of the most benefit in controlling some symptoms of cognitive disorders. Tacrine, an acetylcholinesterase inhibitor, has been helpful in treating memory loss in AD. It increases the availability of acetylcholine in the synaptic clefts of the brain (DHHS, 1999). Antiepileptic drugs are the most common form of treatment for epilepsy (CDC, 2007s). More than 50 percent of people with epilepsy can control their seizures with medication such as Dilantin; another 30 percent can reduce the frequency of seizures. However, side effects can occur, such as a decrease in the speed of motor responding, tremors, weight gain, and swollen gums. Sometimes medication is used to control emotional problems that may accompany cognitive impairment. Antidepressant drugs, for example, can alleviate the depression found in many patients with AD, and low doses of antipsychotic medication may be used to reduce patient symptoms involving paranoia, hallucinations, and irritability. Interestingly, the regular use of some anti-inflammatory medications,

Treatment/Prevention Considerations

409

such as ibuprofen, may cut the risk of developing the disease by as much as one-half (Nash, 1997). The goals of current treatment approaches have been to delay the onset of symptoms, slow the progression of the disease, improve symptoms and reduce disease morbidity, modify risk factors, and prevent the disease (Masterman & Cummings, 2001).

Cognitive and Behavioral Approaches The cognitive therapeutic approaches also appear to be particularly promising. They are used to reduce the frequency or severity of problem behaviors, such as aggression or socially inappropriate conduct; to decrease anxiety or depression; and to improve functional skills. Strategies may include reducing complex tasks, such as dressing, eating, or personal hygiene, HELP FOR PEOPLE WHO EXPERIENCE MEMORY PROBLEMS Memory loss can be extremely frustrating. Affected individuals may require constant attention into simpler steps or reducing the amount of activity in the environment to avoid confusion. and aid from others in locating items. With labels like the ones shown on the cupboards here, those with memory problems are able to function more A cognitive-behavioral treatment package for independently. depression in people with Parkinson’s disease was created by Dobkin and colleagues (2006). The treatment involved training in stress management, behavioral modification, getting sound sleep, relaxation techniques, and cognitive restructuring. Treatment began by identifying life stressors that appeared to be contributing to depressed mood. Afterward, both long- and short-term plans to minimize stress and maximize quality of life were formulated. The investigator found that the intervention was feasible and effective.

Lifestyle Changes In preventing or reducing the effects of cognitive disorders, research suggests that lifestyle changes are important. For vascular dementia, health habits related to preventing stroke—for example, avoiding smoking, obesity, and hypertension—are relevant to prevention (Gatz, 2007). In a population-based study of elderly persons in Taiwan, researchers found that participating in social activities seems to help preserve cognitive function over a seven-year follow-up period (Glei et al., 2005). Respondents who engaged in one or two social activities had 13 percent fewer failures on cognitive tasks than those with no social activities. Respondents who engaged in three or more social activities failed one-third fewer tasks. The nine social activities measured included playing games; volunteering; and participating in a religious group, clan association, or organizations for the elderly. Mental stimulation has been found to be important. A large-scale, randomized trial showed that mental exercises can improve memory, reasoning ability, and the information-processing speed for older adults (Willis et al., 2006). Participants who received training that targeted specific cognitive abilities—memory, reasoning, or speed of processing—reported less difficulty with daily living activities five years after the training compared with those in the control group (Population Reference Bureau, 2007). Mental activity also seems to be important in preventing Alzheimer’s disease and in improving cognitive functioning among those who already have the disorder or who have other forms of dementia. The activities ranged from playing computer games (Tárraga et al., 2006) to reading a newspaper, playing games such as chess or checkers, visiting a library, or attending a play (Wilson, Scherr, et al., 2007). The beneficial effects of mental activity in preventing Alzheimer’s disease exist independently of patient’s income, education, and social or physical activity.

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Environmental Interventions and Caregiver Support The effects of many cognitive disorders are largely irreversible. This raises the issue of how family and friends can assist those with cognitive disorders. There are a variety of means by which people with these disorders may be helped to live comfortably and with dignity while making use of those abilities that remain. Modifying the environment can increase safety and comfort while decreasing confusion and agitation. Home modifications for safety include removing or locking up such hazards as sharp knives, gas appliances, and dangerous household chemicals. Long-term institutional care may be needed for the person with dementia, as profound cognitive losses often precede death by a number of years. The family and friends who provide care may themselves need support. They often feel overwhelmed, helpless, frustrated, anxious, or even angry at having to take care of someone with a cognitive impairment. They may worry about how to take proper care of a loved one who has a cognitive disorder or feel guilty if the loved one is injured or deteriorates under their care. Sometimes, agonizing decisions must be made about whether to have persons with cognitive disorders live at home or with relatives versus nursing homes or assisted care facilities. In all of these circumstances, caregivers should learn as much as possible about the disorder and the means of taking care of loved ones, realize that the role of a caregiver is stressful, and seek out personal support (such as through self-help groups composed of other caregivers; Dobkin et al., 2006).

I M P L I C AT I O N S

In this chapter, we have not directly focused on the multipath model simply because cognitive disorders are usually classified by etiology. Because most cognitive disorders are characterized by underlying damage, deterioration, or abnormalities to the brain or its processes, biological factors are apparent. However, we have also noted the importance of psychological, social, and sociocultural factors in the disorders. For example, persons with memory problems often experience depression, which also affects their well-being. Increasing cognitive activities and mental stimulation, such as memory and reasoning exercises—psychological activities—has been found to improve memory or reduce the likelihood of developing AD. The importance of social and sociocultural factors is revealed by findings that engaging in social activities reduces decrements in cognitive functioning and by the fact that the prevalence of AIDS dementia complex among persons with HIV infection is much higher in western countries than in India, perhaps because of cultural and dietary habits. Finally, treatment and preventive interventions involve biological, psychological, social, and sociocultural factors.

Summary 1. How can we determine whether someone has brain damage or a cognitive disorder? ■

■

■

Cognitive disorders are behavioral disturbances that result from transient or permanent damage to the brain. The effects of brain damage vary greatly. The most common symptoms include impaired consciousness and memory, impaired judgment, orientation difficulties, and attentional deficits. The assessment of brain damage is performed using interviews, psychological tests, brain scans and imaging, and other observational or biological measures.

2. What are the different types of cognitive disorders? ■ DSM-IV-TR lists four major types of cognitive disorders: dementia, delirium, amnestic disorders, and other cognitive disorders. ■ In dementia, memory is impaired and cognitive functioning declines, as revealed by aphasia (language disturbance), apraxia (inability to carry out motor activities despite intact comprehension and motor function), agnosia (failure to recognize or identify objects despite intact sensory function), or disturbances in planning, organizing, and abstracting in thought processes. ■ Delirium is characterized by disturbance of consciousness and changes in cognition (memory deficit, disorientation, and language and perceptual disturbances). These impairments and changes are not attributable to dementia. ■ Amnestic disorders are characterized by memory impairment, as manifested by the inability to learn

■

new information and the inability to recall previously learned knowledge or past events. Cognitive impairments that do not meet the criteria for the other three are classified as cognitive disorders not otherwise specified.

3. Why do people develop cognitive disorders? ■

■

■

Many different agents can cause cognitive disorders; among these are physical wounds or injuries to the brain, processes of aging, diseases that destroy brain tissue (such as neurosyphilis and encephalitis), and brain tumors. As we age, the proportions of persons with memory problems and cognitive disorders increase. In fact, one of the best predictors of Alzheimer’s disease is being elderly. However, many elderly people do not suffer from any major cognitive decline. Epilepsy is characterized by intermittent and brief periods of altered consciousness, frequently accompanied by seizures, and excessive electrical discharge by neurons. Psychoactive substances can also cause cognitive disorders.

4. What kinds of interventions can be used to treat people with cognitive disorders? ■ Treatment strategies include corrective surgery and cognitive and behavioral training. Medication is often used, either alone or with other therapies, to decrease or control the symptoms of the various cognitive disorders. Caregivers can learn to provide assistance to loved ones with cognitive disorders.

411

c h a p t e r

15

Disorders of Childhood and Adolescence

L

eave Me Alone”

chapter outline Pervasive Developmental Disorders 414 Attention Deficit/ Hyperactivity Disorders and Disruptive Behavior Disorders

422

Elimination Disorders

431

Learning Disorders

434

Mental Retardation

435

IMPLICA TION S

442

CONTROVERSY Are We

Overmedicating Children? 414 CRITICAL THINKING

School Violence: A Sign of the Times?

429

CRITICAL THINKING

Child Abuse

412

432

The five-and-a-half-year-old preschooler sat apart from the other children. In his hand, Ahmed held a toy truck, and he was spinning its wheels and humming aloud as if to mimic the sound. He then stood and placed the truck in the corner of the room before moving to the window. Peering out, he ran his right forefinger along the sill exactly five times. He then returned to the corner, picked up the truck, and repeated the entire sequence again, as he had been doing all morning. If by chance one of the other children accidentally moved or handled the truck, Ahmed seemed panic stricken and filled with rage. Caretakers’ attempts to comfort him were unsuccessful. He showed no response when they talked to him, and he seldom looked in their eyes. Ahmed seemed to live in a world of his own, and he treated people as if they were inanimate objects that stood in his way. Diagnosis: autistic disorder “Sit Still and Pay Attention” The mother sat in the psychiatrist’s office, watching apprehensively as her ten-year-old son fidgeted in his seat and played with the ornaments hanging from the nearby Christmas tree. The mother explained to the psychiatrist that Adam had been expelled from school twice for disruptive classroom behavior. He had difficulty concentrating in class, and he was failing. The school psychologist had said Adam was “hyperactive” and recommended that they seek professional help. Throughout the interview, the mother admonished the child, saying, “Sit still,” “Don’t play with those,” and “Pay attention.” Each time, the child appeared remorseful and his behavior abated briefly. But remaining still seemed impossible for Adam, and he was soon fidgeting again. By the end of the session, he had been in and out of his seat some half dozen times and had accidentally broken two ornaments. Diagnosis: attention deficit/hyperactivity disorder

FOCUSQUESTIONS

1 Which disorders fall under the category of pervasive developmental disorders?

2 What are some of the characteristics of attention deficit/hyperactivity disorder, and what is the difference between conduct disorder and oppositional defiant disorder?

3 What are elimination disorders, and what is their prognosis?

4 How common are learning disorders? 5 What is mental retardation, and what are some of its causes and treatments?

“No, I Won’t” The father had never struck Kim before, but he was on the verge of doing so now. He was enraged and incensed at his fourteen-year-old son’s defiance and argumentative nature. Standing before his father with a scowl on his face and both hands clenched in fists, Kim refused to come out of his room to meet friends and relatives attending his mother’s surprise birthday party. Just hours before, he and his father had had a heated encounter over picking up his room and helping with chores around the house. Kim had steadfastly refused. Even when he was threatened with being “grounded,” Kim only stated, “You can’t make me do anything.” Diagnosis: oppositional defiant disorder

In this chapter, we discuss problems that arise primarily during childhood and adolescence. Much of the public continues to cling to the popular notion that childhood is a period relatively free of stress and that it represents a carefree and happy existence. Because children are less able to express unhappiness or fears verbally, their problems often go unnoticed unless they become glaringly extreme, as in the preceding cases. Although it is easy for us to dismiss such childhood disorders as rare and unusual, about one in five children suffers from a serious emotional or behavioral problem (Koppelman, 2004). Children and adolescents are subject not only to childhood disorders but also to many of the “adult” disorders discussed in previous chapters. Unless effective intervention takes place early in the child’s life, an untreated disorder may develop into a lifelong pattern that creates problems in future years.

Myth vs Reality Myth: Childhood psychiatric disorders are easy to diagnose because symptoms in childhood and adolescence parallel characteristics of adult disorders. Reality: It is generally more complex to diagnose psychiatric disorders in children and adolescents: first, because of variations in the presentation of symptoms of disorders between childhood and adulthood; second, because characteristics that signify mental illness in adults may occur in normally developing children; and third, because children may have a more difficult time articulating their thoughts and feelings. Accurate diagnosis and treatment of psychiatric disorders requires a thorough understanding of normal child development and issues of child temperament, as well as an understanding of risk factors for and the symptoms of psychiatric disorders in children and adolescents.

The disorders of childhood and adolescence encompass a wide variety of behavioral problems, ranging from severe disturbances affecting many aspects of behavior to those that are less severe. One of the most disturbing is a cluster of impairments

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controversy

Are We Overmedicating Children?

A

large number of medications are being prescribed to treat childhood disorders. They include tranquilizers, stimulants, and antipsychotic medications. As with adults, the use of medications with children and adolescents has been increasing dramatically. Drug companies are now advertising directly to the public via television and magazines. They point out that many children suffer from some mental illness (Kluger, 2003) and that medication is often needed. Controversy continues over the “quick fix” nature of medication, the large number of children for whom medications are prescribed, and the need to carefully determine whether medication, therapy, or intervention that focuses on other factors affecting the child (such as bullying at school or domestic violence within the home) is the best course of action for children experiencing difficulties (Marsa, 2000). Concerns about the overprescription of psychoactive drugs for children, especially stimulant medication, have resulted in legislative efforts to prohibit schools from recommending, requiring, or, in some cases, even discussing the idea of a child being evaluated for possible ADHD. ADHD is now diagnosed at earlier ages, and subsequently medication therapy begins earlier, resulting in more prescriptions being given (Zito et al., 2000). Furthermore, a physician may prescribe to young children a medication that has been approved by the FDA for use with adults or older children rather than with young children. (This use is called

Did You Know?

C

hildhood behaviors and emotional problems differ from culture to culture. For example, in Thailand, where parenting may foster more prolonged dependence and slower psychological maturation, certain problems involving dependence or immaturity can be found that are not found in the United States. Thus sociocultural factors play a role in the kinds of problems exhibited and in how they are defined. Source: Weisz et al. (2006).

“off-label.”) Yet young children’s bodies handle medications differently than those of older individuals. The brains of young children are in a state of very rapid development, and the developing neurotransmitter systems can be very sensitive to medications. Several questions are raised. Are the medications being used with children safe and effective in treating the specific disorders? Are medications being prescribed too freely? Is adequate assessment or evaluation being done to determine whether medication is appropriate? Are the effects of the drug being adequately monitored and possible side effects identified? Does adequate information exist on the use of the specific medication with children? For example, clinicians recommend that medication for children be prescribed only after a comprehensive diagnostic and evaluation procedure. The particular symptom or symptoms to be treated should be identified and the dosage modified if necessary. Prescribing any medication also necessitates the communication of possible side effects and contraindications to the child and parent. For Further Consideration 1. What criteria would you use to determine whether medications are prescribed too freely? 2. Do you think the benefits of prescribing medication to children outweigh the risks?

called pervasive developmental disorders. Autistic disorder, such as in the case of Ahmed at the beginning of the chapter, is a particularly baffling and debilitating condition that all too often dooms a child to constant dependent care. We also discuss disorders that involve attention deficits and/or hyperactivity that become especially pronounced during the school years, such as in the case of Adam at the beginning of the chapter. Attention deficit/hyperactivity disorder (ADHD) has become a controversial diagnosis because of the criticisms leveled at the frequent use of the medication Ritalin to control the problem. The case of Kim at the beginning of the chapter is a typical example of the class of problems called disruptive behavior disorders. In this case, the son can be described as suffering from an oppositional defiant disorder. Children also experience emotional disorders such as depression (including bipolar disorders) and anxiety (such as fears over separation from parents and school phobia). Indeed, the numbers of childhood and adolescent disorders are plentiful. We have chosen to concentrate on representative disorders that fall under the following classifications: pervasive developmental disorders (especially autism), attention deficit/hyperactivity disorders (ADHD), disruptive behavior disorders (oppositional defiant disorder and conduct disorder), elimination disorders, learning disorders, and mental retardation.

Pervasive Developmental Disorders The pervasive developmental disorders, also known as autism spectrum disorders, involve severe childhood impairment in areas such as social interaction and communication skills and the display of stereotyped interests and behaviors

(Ozonoff & Rogers, 2003). They range from a severe form, called autistic disorder, to a milder form, called Asperger’s syndrome. If a child has symptoms of either of these disorders but does not meet the specific criteria for either, the diagnosis is called pervasive developmental disorder not otherwise specified (PDD-NOS). Other rare, very severe disorders that are included in the autism spectrum disorders are Rett syndrome and childhood disintegrative disorder. Estimates of the prevalence of these disorders, as high as 6.7 per 1,000 children, have been increasing as new diagnostic procedures have been improved (Centers for Disease Control and Prevention [CDC], 2007d). The impairments shown in the pervasive developmental disorders are not simply delays in development but are distortions that would not be normal at any developmental stage (Kabot, Masi, & Segal, 2003). The pervasive developmental disorders differ distinctly from the psychotic conditions observed in adolescents and adults; they do not include symptoms such as hallucinations, delusions, loosening of associations, or incoherence. A child showing these symptoms probably would be diagnosed with schizophrenia. We begin our discussion with autistic disorder.

Autistic Disorder

Percentage of individuals with trait

Pervasive Developmental Disorders

415

80 70 60 50 40 30 20 10 0

Occurrence of seizures

Minimal or no speech Trait

IQ score lower than 70

Males

15.1

FIGURE SOME CHARACTERISTICS OF INDIVIDUALS WITH AUTISM/AUTISM SPECTRUM DISORDERS Biological factors appear to be implicated in the unique characteristics shown in autism. For seizures, rates have varied from 3 percent to over 30 percent. Source: Based on Dawson & Castelloe (1992); Ozonoff & Rogers (2003); Tharp (2003).

Case Study Chicken and potatoes. Chicken and potatoes. Danny Boronat wants chicken and potatoes. He asks for it once, twice . . . ten times. In the kitchen of the family’s suburban New Jersey home, Danny’s mother, Loretta, chops garlic for spaghetti sauce. No chicken and potatoes, she tells Danny. We’re having spaghetti. But Danny wants chicken and potatoes. Chicken and potatoes. His twelve-year-old sister, Rosalinda, wanders in to remind her mother about upcoming basketball tryouts. His brother Alex, twenty-two, grabs some tortilla chips and then leaves to check scores on ESPN. His other brother Matthew, seventeen, talks about an upcoming gig with his band. Danny seems not to notice any of this. “Mom,” he asks in a monotone, “why can’t we have chicken and potatoes?” If Danny were a toddler, his behavior would be nothing unusual. But Danny Boronat is twenty years old. “That’s really what life with autism is like,” says Loretta. “I have to keep laughing. Otherwise, I would cry.” (Kantrowitz & Scelfo, 2006, p. 47)

At the beginning of this chapter, we introduced a child with autistic disorder. In Danny Boronat’s case, we see a young adult who grew up with the disorder. But what is autism? In 1943, Leo Kanner, a child psychiatrist, identified a triad of behaviors that have come to define the essential features of autism: an extreme isolation and inability to relate to people; a psychological need for sameness; and significant difficulties with communication. Kanner called the syndrome infantile autism, from the Greek autos (“self”), to reflect the profound aloneness and detachment of these children. A typical characteristic of autistic children is their extreme lack of responsiveness to adults. Kanner and Lesser (1958) felt that the child who had the disorder is aware of people but considers them not differently from the way he (or she) considers the desk, bookshelf, or filing cabinet. The puzzling symptoms displayed by the children Kanner described fit the diagnostic criteria for autistic disorder in DSM-IV-TR (American Psychiatric Association, 2000a)— qualitative impairment in social interaction and/or communication; restricted, stereotyped interests and activities; and delays or abnormal functioning in a major area before the age of three. Figure 15.1 illustrates some characteristics of children with autism. Autistic disorder occurs in about 2 in every 1,000 children (Newschaffer et al., 2007). The prevalence of autism has not been found to vary across socioeconomic classes (Bristol et al., 1996). Autistic disorder occurs four to five times more frequently in boys than in girls (American Psychiatric Association, 2000a). Unfortunately, only one-third

pervasive developmental disorder a disorder involving

severe childhood impairment in areas such as social interaction and communication skills and the display of stereotyped interests and behaviors; includes autistic disorder, Rett syndrome, childhood disintegrative disorder, Asperger’s syndrome, and pervasive developmental disorders not otherwise specified a severe childhood disorder characterized by qualitative impairment in social interaction and/or communication; restricted, stereotyped interest and activities; and delays or abnormal functioning in a major area before the age of three

autistic disorder

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CHAPTER 15 • DISORDERS OF CHILDHOOD AND ADOLESCENCE

of children with autism are able to lead even partially independent lives as adults (American Psychiatric Association, 2000a). Impairments The impairments found with this disorder occur in three major areas: social interactions, verbal and nonverbal communication, and activities and interests (National Institute of Mental Health [NIMH], 2007c). • Social Interactions Unusual lack of interest in others is a primary aspect of autistic disorder. Individuals with autism interact as though other people are unimportant objects, and they show little interest in establishing friendships, imitating behaviors, or playing games. As a result, children with autistic disorder often fail to develop peer relationships. Disturbances may be displayed in body postures, gestures, facial expressions, and eye contact. Autistic children appear to be unaware of other people’s identity and emotions. They appear not to need physical contact with or emotional responses from their caretakers. For example, although children with autistic disorder are as likely as other children to smile when they successfully complete a task, they are much less likely to look at an adult to convey this feeling. The social interactive component is missing. Infants with autism are usually content to be left alone and do not show an anticipatory response to being picked up. AUTISTIC GIRL WEARING HELMET Besides having problems with social interactions and communication, autistic • Verbal and Nonverbal Communication About 50 percent of autischildren can show a variety of symptoms, such as impulsivity, tic children do not develop meaningful speech. Those who do gentemper tantrums, and self-injurious behavior. Here a child erally show oddities such as echolalia (echoing what has previis wearing a helmet to prevent damage from head banging. ously been said). One child constantly repeated the words “How How do self-injurious behaviors arise? do you spell relief?” without any apparent reason. In addition, the child may reverse pronouns. For example, “you” might be used for “I,” and “I” for “me.” Even when they can speak, such children may be unable or unwilling to initiate conversations. • Activities and Interests Children with autistic disorder engage in few activities. They often have unusual repetitive habits, such as spinning objects, whirling themselves, or fluttering or flapping their arms. They may show intense interest in self-induced sounds or in staring at their hands and fingers. They may stare into space and be totally self-absorbed. Minor changes in the environment may produce rages and tantrums. Children with this disorder also show a lack of imaginary activities. As many as three-fourths of children with autistic disorder have IQ scores lower than 70. However, some of them display splinter skills—that is, they often do well on one or more isolated tasks such as drawing, puzzle construction, and rote memory but perform poorly on verbal tasks and tasks requiring language skills and symbolic thinking. These children are referred to as “autistic savants.” One Chinese boy with autism could identify the day of the week for different dates, knew the lottery numbers and their drawing dates for the previous three months, and could cite the titles of songs in the popular charts for the previous ten years and their dates of release (Ho, Tsang, & Ho, 1991). Diagnosis Autism, which almost always occurs before age three, might seem to be easy to diagnose, given its unique characteristics (Ozonoff & Rogers, 2003). Yet diagnosis is often complicated by several problems: 1. There are no medical tests that can pinpoint autism. Typical evaluation procedures might include clinical observations, parent interviews, developmental histories, psychological testing, speech and language assessments, and possibly the use of one or more autism diagnostic tests. 2. Different medical conditions or other disorders can produce the behavioral characteristics of autism.

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417

3. The autistic symptom profile has been found in children with and without signs of neurological impairments. 4. Symptoms can vary widely from child to child. In terms of age, the disorder can often be reliably detected by the age of three, and in some cases as early as eighteen months. Some studies suggest that many children may be accurately identified by the age of one or even younger. Parents are usually the first to notice unusual behaviors in their child. In some cases, the baby seemed “different” from birth (Volkmar, Charwarska, & Klin, 2005), unresponsive to people, or focusing intently on one item for long periods of time. Children with autism are often diagnosed as having mental retardation, and the two disorders often coexist. Still, there are ways to distinguish children with THERAPIST SIGNS TO AUTISTIC BOY Autistic individuals both autism and mental retardation from children with mental retardation alone. For example, children with autistic disorder often benefit from the use of sign language to enhance their exhibit splinter skills much more often than children with men- receptive and expressive communication skills. Can you think tal retardation. Also, children with mental retardation are more of additional means of communication that might be useful in working with autistic individuals? likely to relate to others and to be more socially aware than are children with both autism and mental retardation. Although we are learning more about the symptoms of autism, many questions remain. What causes the bizarre and puzzling abnormalities that are seen in children with autism? Why do they lack social responsiveness? After a brief discussion of other pervasive developmental disorders, we discuss the causes, prognosis, and treatment of autism.

Other Pervasive Developmental Disorders Some children show some but not all of the characteristics of autistic disorder, and they also show severe social impairment. These children would receive a diagnosis from one of the other categories of the pervasive developmental disorders. The diagnosis may be Rett syndrome, childhood disintegrative disorder, Asperger’s syndrome, or pervasive developmental disorder not otherwise specified. Characteristics of these disorders often overlap with those of autistic disorder (see Table 15.1) to such a degree that some psychologists question whether they should be considered distinctive disorders. Some researchers believe that the various disorders are actually variations and partial expressions of a more primary disorder. They categorize all of the disorders as autism spectrum disorder (Jensen, 2003). Others have argued that not all of the disorders should be listed as a pervasive developmental disorder. Little research exists on children with these diagnoses. To see the difficult diagnostic issues involved, consider the following case of a girl who was videotaped by her parents several times from birth to two years and seven months (Eriksson & de Chateau, 1992).

Case Study During the first year of her life the girl showed normal development (smiled, laughed, babbled, waved bye-bye to parents, and played peek-a-boo). During the second year she spoke few words. She sat on the floor and played with a book in a stereotyped manner and showed little response to her parents. After two years of age, she was withdrawn, spoke no words except meaningless phrases from songs. She was preoccupied with rocking or spinning her mother’s hair. Computerized axial tomography scans, magnetic resonance imaging, and electroencephalogram readings were normal. No physical disorder was found to be associated with her condition.

Would you diagnose this child as suffering from autistic disorder or one of the following pervasive developmental disorders? 1. Asperger’s syndrome Children with this disorder differ from those with autistic disorder in that they do not experience significant language delays and

Did You Know? The early signs of autism spectrum disorders: • A lack of warm, joyful expressions while gazing at parent/caregiver • No back-and-forth babbling between infant and parent • Disregarding others’ vocalizations (for example, lack of response to one’s name) yet showing keen awareness of environmental sounds • Failure to make eye contact • Delayed onset of babbling past nine months of age • No or few prespeech gestures, such as waving or pointing

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15.1

DISORDERS CHART

PERVASIVE DEVELOPMENTAL DISORDERS

PERVASIVE DEVELOPMENTAL DISORDER

SYMPTOMS

PREVALENCE

AGE OF ONSET

COURSE

• Qualitative impairment in social interaction and communication

About 0.2% of children; affects more boys than girls

Early childhood

As many as 75% have low IQ; lack of speech and/or social withdrawal common; prognosis poor

0.3% of children

Varies in childhood

Varies depending on uniqueness of the disorder

About .01% of children; diagnosed almost exclusively in females; often classified as form of autism

6 to 18 months

Generally lifelong, with marked delay in cognitive, language, and social skills

About .002%; often classified as form of autism

Normal development for at least two years; loss occurs between 2 and 10 years

Normal development during first two years of life followed by disintegration of social, verbal, and motor skills

0.1%; affects many more boys than girls

Early childhood

Impairment in social skills and emotional reciprocity; does not seem to affect language and cognitive development

Autistic Disorder

• Restricted, stereotyped interest and activities • Delays or abnormal functioning in one of the above major areas before the age of three Pervasive Developmental Disorder Not Otherwise Specified

• Severe and pervasive impairment in reciprocal social interaction or restricted, stereotyped interests

Rett Syndrome

• Normal development for at least five months/onset between 5 and 48 months

• Does not fully meet onset age, specific behavior pattern, or other criteria for any specific pervasive developmental disorder

• Deceleration of head growth • Loss of previously acquired movements and development of stereotyped hand movements • Loss of social engagement • Appearance of poorly coordinated movements • Marked delay and impairment in language Childhood Disintegrative Disorder

• Normal development for at least two years • Loss of previously acquired skills in two or more areas: language, social skills, bowel or bladder control, play, or motor skills • Qualitative impairment in social interaction and communication • Restricted, stereotyped interest and activities

Asperger’s Syndrome

• Qualitative impairment in social interaction • Repetitive, stereotyped interest and activities • No significant delay in language • No delay in cognitive development (appropriate self-help skills, adaptive behaviors, and curiosity)

Source: Data from American Psychiatric Association (2000a); Fombonne (2003); Johnson et al. (2007); Newschaffer et al. (2007); NIMH (2007c).

Pervasive Developmental Disorders

consistently have average to above-average cognitive skills (Newschaffer et al., 2007). However, they exhibit significant impairment in social interaction skills, limited and repetitive interests and activities, and lack of emotional reciprocity. An individual may not be diagnosed with Asperger’s syndrome if, at any time, they have met the diagnostic criteria for autistic disorder. Asperger’s syndrome is diagnosed five times more frequently in males than females (American Psychiatric Association, 2000a). Individuals with Asperger’s syndrome exhibit an “eccentric and one-sided social approach to others rather than the social or emotional indifference seen in autistic disorder” and may even be seen as intellectually precocious in their early years due to an adult-like vocabulary, particularly in an area in which they have obsessive interest (American Psychiatric Association, 2000a). In view of the symptoms of social isolation, interpersonal relationship difficulties, communication abnormalities, desire for sameness, and narrow interests that are so similar to autistic disorder, there is continuing controversy as to whether Asperger’s syndrome is, in fact, a separate disorder or simply a description of high-functioning individuals with autistic disorder. The neuropsychological profiles of the two groups are quite similar, and many of the symptoms overlap (Ghaziuddin & Mountain-Kimchi, 2004; Miller & Ozonoff, 2000). 2. Childhood Disintegrative Disorder This disorder is characterized by at least two years of normal development in social relationships, verbal and nonverbal communication, motor skills, play, and bowel or bladder control, with subsequent severe impairment and deterioration in two or more of these skills beginning between two and ten years of age. The child also develops autistic-like symptoms, including impairment in social interaction, communication, and repetitive or stereotyped behaviors and interests. 3. Rett Syndrome This disorder is characterized by normal development for at least five months and an onset of symptoms between six and eighteen months, including deceleration of head growth, a loss of purposeful hand skills replaced by stereotyped hand movements, severely impaired language development, and a loss of social interaction skills. This condition is almost exclusively diagnosed in females. A mutation in the sequence of a single gene can cause Rett syndrome. This discovery may help doctors slow or stop the progress of the syndrome. It may also lead to methods of screening for Rett syndrome, thus enabling doctors to start treating these children much sooner and improving the quality of life these children experience (NIMH, 2007c). 4. Pervasive Developmental Disorder Not Otherwise Specified This category is for cases that are not typical in terms of age of onset or specific behavior pattern. Pervasive and severe impairment in reciprocal social interactions occurs, as do communication abnormalities and limited interests and activities. These children do not, however, meet the full criteria for autistic disorder. Did you have trouble choosing a diagnosis? Based on the information given (approximately one year of normal development, severe isolation and communication difficulties, repetitive behaviors, no mention of deceleration of head growth), you may have correctly concluded that autistic disorder would be the most likely diagnosis. However, diagnosis involving the specific pervasive developmental disorders is difficult, and the appropriate criteria for each are still evolving.

Etiology Etiological research has focused primarily on autism rather than other types of pervasive developmental disorders. Although psychological, social, and sociocultural factors play a role in the disorders, biological factors seem to be critical. Biological Dimension Evidence points to genetic factors playing a prominent role in the causes of autism spectrum disorders. Concordance rates for autism are

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COMMUNICATING THROUGH ART 20-year-old Tito Mukhopadhyay is severely autistic but can communicate his thoughts and feelings through prose and poetry. He is pictured here with his mother Soma, who gave up a career in chemistry to devote her life to teaching her son.

Did You Know?

F

or years, some have claimed that chemicals in vaccines can cause autism. Despite their concerns, vaccines for influenza and mumps-measles-rubella are safe for children. The U.S. Food and Drug Administration has found that small amounts of the mercury-based preservative thimerosal found in some vaccines do not cause autistic disorders.

much higher for MZ (monozygotic) than DZ (dizygotic) twins. Furthermore, the prevalence of autistic disorder among siblings of individuals with autistic disorder ranges from 2 to 14 percent. These rates are many times higher than for the general population. Taken together, twin studies and family studies clearly establish that a genetic susceptibility to autism exists. However, because MZ concordance is less than 100 percent and the degree of impairment and range of symptoms vary markedly among concordant pairs, environmental factors are most likely etiologically significant as well (Newschaffer et al., 2007). The particular genes and mechanism involved in the disorder are unclear at this time, although preliminary research has implicated chromosome 13, 15, 16, or 17 in some cases of autistic spectrum disorders. Genetic problems or defects may be inherited or may be acquired by random genetic accidents (for example, defects in the formation of the egg or sperm). How genetic defects translate into impaired brain mechanisms or brain processing is unclear. Neuroimaging studies have shown that a contributing cause of autism may be abnormal brain development beginning in the infant’s first months (NIMH, 2007c). This “growth dysregulation hypothesis” holds that the anatomical abnormalities seen in autism are caused by genetic defects in brain growth factors. Postmortem and MRI studies have shown that many major brain structures may be implicated in autism. This includes the cerebellum, cerebral cortex, limbic system, corpus callosum, basal ganglia, and brainstem. Other research is focusing on the role of neurotransmitters such as serotonin, dopamine, and epinephrine. Some biological hypotheses about autistic disorder have included immune reactions, endocrine abnormalities, in utero experiences, and environmental toxins. There is a real possibility that autism is a heterogeneous brain disorder that can have many different causes. Psychological Dimension Some research suggests that autism may be a disorder involving cognitive impairments that affect perception, particularly in the recognition and response to others. For example, normal infants can distinguish between male and female and between child and adult, an ability that suggests responsiveness and attention to social cues. In contrast, children with autistic disorder have been described as treating human beings as inanimate objects. Autistic infants fail to socially gaze at parents or others, and they do not engage in pretend play, even when prompted (Charman et al., 1997). Children with autism often do not appear to seek connectedness; they are content being alone, ignore their parents’ bids for attention,

Pervasive Developmental Disorders

and seldom make eye contact or bid for others’ attention with gestures or vocalizations (Johnson et al., 2007). They do a better job of discriminating between pictures of buildings than between faces (Boucher & Lewis, 1992). They also have difficulty responding to people according to qualities, such as age or gender. Individuals with autistic disorder seem unable to understand that others think and have beliefs. This inability to appreciate other people’s mental states appears to be long lasting. Children who showed this deficit displayed unchanged performance seven years later, even though their experience had increased (Holroyd & BaronCohen, 1993). Social Dimension Early psychodynamic theories that involve social relationships of autism stressed the importance of deviant parent-child interactions in producing this condition. Kanner (1943), who named the syndrome, concluded that cold and unresponsive parenting is responsible for the development of autism. He described the parents as successfully autistic and as cold, humorless perfectionists who preferred reading, writing, playing music, or thinking. Kanner has since changed his position and now believes the disorder is “innate.” Although psychological and social factors such as child-rearing practices, parentchild interactions, and reactions from peers play a role in the child’s behaviors, autism is largely influenced by biological factors. Concern over blaming parents and inflicting guilt on parents who already bear the burden of raising a child with this disorder has also led to a deemphasis on psychological and social factors in the disorder. Sociocultural Dimension Autism appears to vary according to sociocultural and demographic characteristics (Newschaffer et al., 2007). Studies have found higher or equal prevalence of the disorder among African American mothers and lower prevalence among Mexican-born mothers than among white, Asian, and U.S.-born Hispanic mothers. Paternal age (that is, having older fathers) is associated with high prevalence of autism. What these findings mean is unclear. Perhaps factors such as ethnicity or age are mediated by some other factors. (Recall that in Chapter 14 we discussed mediators. In a situation in which age of parents is related to autism, it may be that autism is caused by genetic damage and that age is related to autism simply because older parents may be more likely to pass on damaged genes.) In any event, the evidence suggests that although psychological, social, and sociocultural factors may play a role in the disorder, biological conditions are most important.

Prognosis The prognosis for children with pervasive developmental disorders is mixed. Most children diagnosed with autism retain their diagnosis at nine years of age. However, many, especially those with initial higher levels of functioning (for example, those with Asperger’s syndrome), improve. A minority have good outcomes. They have normal intelligence and function reasonably well in mainstream classrooms but still may exhibit residual clinical signs of social awkwardness, restrictive interests, or mild, infrequent stereotyped behaviors (Johnson et al., 2007). The same is true for adult outcomes. Those with higher levels of cognitiveadaptive functioning fare better than those with intellectual disability and severe autistic symptoms. Many individuals with the disorder are self-sufficient and successfully employed. There are reports of significant intellectual success for some with Asperger’s syndrome; in fact, it is reported that compelling evidence exists that Albert Einstein exhibited symptoms consistent with Asperger’s syndrome or highfunctioning autism (Perner, 2001).

Treatment Because patients with these disorders have communication or social impairments, pervasive developmental disorders are very difficult to treat. Therapy with the parents, family therapy, drug therapy, and behavior modification techniques are

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all currently being used, with some success (Ozonoff & Rogers, 2003). Intensive behavior modification programs seem the most promising treatment. Comprehensive Programs Immersing the child in a comprehensive program with the following characteristics is beneficial: • Provision of intensive intervention in systematically planned, developmentally appropriate educational activities designed to address identified objectives • Inclusion of a family component (including parent training as indicated) • Promotion of opportunities for interaction with typically developing peers • Incorporation of a high degree of structure through elements such as predictable routine, visual activity schedules, and clear physical boundaries to minimize distractions • Implementation of strategies for applying learned skills to new environments and situations (generalization) and for maintaining functional use of these skills • Use of assessment-based curricula that address communication, social skills, functional adaptive skills, disruptive or maladaptive behavior, and cognitive and academic skills, such as perspective taking • Use of drug therapy, including the antipsychotic medication haloperidol, which has been found to produce modest reductions in withdrawal, stereotypical movements, and fidgetiness; other medications, such as selective serotonin reuptake inhibitors, antipsychotic agents, and stimulants (Myers et al., 2007), are sometimes used to decrease anxiety, repetitive behaviors, and impulsivity • Maintenance of behavior modification procedures to eliminate echolalia, self-mutilation, and self-stimulation and to increase attending behaviors, verbalizations, and social play through social interaction training (Lovaas, 2003; Myers et al., 2007) Autism spectrum disorders cause major disruption in families and unfulfilled lives for many children. However, comprehensive treatment programs have enabled some children with these disorders to develop more functional skills.

Attention Deficit/Hyperactivity Disorders and Disruptive Behavior Disorders Attention deficit/hyperactivity disorders and disruptive behavior disorders involve symptoms that are often socially disruptive and distressing to others (see Table 15.2). They include attention deficit/hyperactivity disorders (ADHD), conduct disorder, and oppositional defiant disorder. These disorders often occur together and have overlapping symptoms. Without intervention, these disorders tend to persist beyond childhood (Farmer, 1995; Fergusson, Horwood, & Lynskey, 1995; Root & Resnick, 2003). Early identification and intervention are necessary to interrupt the negative course of these disorders. Raising a child with a disruptive behavior disorder is difficult. Parents report more negative feelings about parenting, higher stress levels, and a more negative impact on their social lives than do parents of normally developing children (Donenberg & Baker, 1993).

Attention Deficit/Hyperactivity Disorders Case Study Ron, an only child, was always on the go as a toddler and preschooler. He had many accidents because of his continual climbing and risk taking. Temper outbursts were frequent. In kindergarten Ron had much difficulty staying seated for group work and in completing projects. The quality of his work was poor. In the first grade, Ron was referred to the school psychologist for evaluation. Although his high activity level and lack of concentration were not so pronounced in this oneon-one situation, his impulsive approach to tasks and short attention span were evident throughout the interview. Ron was referred to a local pediatrician who specializes in attention deficit disorders. The pediatrician prescribed Ritalin, which helped reduce Ron’s activity level.

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15.2

DISORDERS CHART

ATTENTION DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS

DISORDER

SYMPTOMS

PREVALENCE

AGE OF ONSET

COURSE

Attention Deficit/ Hyperactivity Disorder

• Symptoms are present before age 7

3–9% of the school population; males and poor children more likely to have this diagnosis

Usually diagnosed in elementary school but probably begins earlier

Improvement usually noticeable at 18–24 years of age; in some cases, continues to affect the person as an adult

1–3%; found more often in males; difficult to estimate since determining normal and pathological defiance is a relative judgment

Generally before age 8

May be lifelong or situational

1–10% of children; mostly males; more common in urban settings

May be childhoodonset type or adolescent-onset type

Prognosis poor; often leads to criminal behaviors, antisocial acts, and problems in adult adjustment to relationships and occupational responsibilities

• Disruptive behavior in either one or both of the following: • Attentional problems • Hyperactivity • Symptoms are present in two or more settings • Clear evidence of interference with social or academic functioning

Oppositional Defiant Disorder

• Pattern of negativistic, hostile, and defiant behavior • Often loses temper, argues with adults, and defies or refuses adult requests • Does not take responsibility for actions • Angry and resentful • Often blames others • Often spiteful and vindictive

Conduct Disorder

• Often bullies or threatens others • Lying and cheating common • Deliberately destroys property • Steals • Often truant from school • May be physically cruel to people and animals • Often initiates physical fights • Serious violations of rules

Source: Data from American Psychiatric Association (2000a); Froehlich et al. (2007); Gaub & Carlson (1997).

Attention deficit/hyperactivity disorder (ADHD) is characterized by socially disruptive behaviors—either attentional problems or hyperactivity—that are present before age seven and persist for at least six months. Hyperactivity is a confusing term because it refers to both a diagnostic category and behavioral characteristics. Children who are “overactive” or who have “short attention spans” are often referred to as “hyperactive,” even though they may not meet the diagnostic criteria for this disorder. Whether a child is merely overactive or has ADHD is often difficult to determine. Three types of attention deficit/hyperactivity disorders are recognized: • ADHD, predominantly hyperactive-impulsive type, is characterized by behaviors such as heightened motoric activity (fidgeting and squirming), short attention span, distractibility, impulsiveness, and lack of self-control. Children with this type of ADHD tend to have a pattern of being rejected by peers and more accidental injuries (American Psychiatric Association, 2000a). • ADHD, predominantly inattentive type, is characterized by problems such as distractibility, difficulty with sustained attention, inattention to detail, and difficulty completing tasks. Children with attentional deficits tend to have less severe conduct problems and impulsivity than children with the hyperactive form of ADHD. Instead, they are more likely to be described as sluggish, daydreamers,

attention deficit/hyperactivity disorder (ADHD) disorders

of childhood and adolescence characterized by socially disruptive behaviors—either attentional problems or hyperactivity—that are present before age seven and persist for at least six months

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anxious, and shy; they respond to lower doses of stimulants than do children with hyperactivity (Frick & Lahey, 1991). This type of ADHD affects approximately the same number of boys as girls and tends to have the greatest impact on academic performance (American Psychiatric Association, 2000a). • ADHD, combined type, is probably the most common form of the disorder. In this case, the criteria for both the hyperactive and inattentive types are met. A confusing aspect of attention deficit/hyperactivity disorder is the apparent inconsistency. Attentional deficit and excessive motor activity are not necessarily observed in all settings. Boys with ADHD, for example, may show greater motor activity during academic tasks but may not differ from normally functioning children during lunch, recess, and physical education activities. Thus a child might be identified as hyperactive in one situation but not in others. To receive a diagnosis of ADHD, the individual must display these characteristics in two or more situations (American Psychiatric Association, 2000a). ADHD is the most common cognitive and behavioral disorder diagnosed among schoolchildren (Banerjee, Middleton, & Faraone, 2007). In a national sample of eight-to fifteen-year-old children, the prevalence was 8.7 percent. Boys and poor children were much more likely to receive this diagnosis than girls and wealthy children, respectively (Froehlich et al., 2007). ADHD is particularly difficult to diagnose in preschool-age children because there is such variability in their attentional skills and activity levels, in addition to the fact that preschoolers have fewer demands for sustained attention. ADHD is a persistent disorder. Children with ADHD continue to show problems with impulsivity, family conflicts, and attention during adolescence (Gaub & Carlson, 1997) and even into adulthood (Fischer et al., 2005). In fact, follow-up studies suggest that between 30 and 50 percent of children diagnosed with ADHD continue to experience symptoms such as inattention, fidgeting, difficulty sitting still, and impulsive actions throughout adulthood (Jackson & Farrugia, 1997). These difficulties may affect social relationships and occupational functioning. ADHD is associated with many behavioral and academic problems. Children with this disorder are more likely to have poor grades, poor reading and math test scores, and increased grade retention. ADHD is also associated with increased use of school-based services, increased rates of detention and expulsion, and with relatively low rates of high school graduation and postsecondary education (Loe & Feldman, 2007). Boys with ADHD have more difficulty in less structured situations or in activities demanding sustained attention. Based on parent reports, boys with ADHD show more sadness, anger, and guilt than those without ADHD (Braaten & Rosen, 2000).

INTERVENTIONS FOR ADHD A mother is shown at her home with her six-year-old son. He is enrolled in a study called Project Achieve in which his parents and daycare/preschool teachers are taught strategies to control his problem behaviors. New research shows that giving more structure to a preschooler’s day can offer a non-drug alternative to help children with attention deficit/hyperactivity disorder.

Etiology Attention deficit/hyperactivity disorder is an early-onset, highly prevalent neurobehavioral disorder, with genetic, biological, and environmental etiologies, that persists into adolescence and adulthood in a sizable majority of afflicted children of both sexes (Spencer, Biederman, & Mick, 2007). Early studies supported the hypothesis of genetic transmission because higher prevalence rates for the disorder were found in the first- and second-degree relatives of children with ADHD and because higher concordance rates for this disorder existed among identical rather than fraternal twins (Gillis, Gilger, Pennington, & DeFries, 1992; Knopf, 1984). Twin and sibling pair studies in Australia also provided evidence for the hypothesis that ADHD symptoms are highly heritable in both boys and girls (Rhee et al., 1999). In addition to genetic involvement, many researchers believe that the symptoms of overactivity, short attention span, and impulsiveness suggest central nervous system involvement. Different hypotheses

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have arisen as to the kind of mechanisms that may be operating in the brain of persons with ADHD (Spencer et al., 2007): 1. There may be impaired functioning in the dorsolateral prefrontal cortex, which may affect organizational, planning, working memory, and attentional processes. 2. Neuroimaging studies have found that persons with ADHD have smaller volumes in the frontal cortex, cerebellum, and subcortical structures, perhaps affecting frontosubcortical pathways in the brain. In fact, children with ADHD compared with children without ADHD have marked developmental delays in attaining peak thickness throughout most of the cerebrum (Shaw et al., 2007). The delay was most prominent in prefrontal regions important for control of cognitive processes, including attention and motor planning. This may mean that, over time, many children with ADHD outgrow the disorder as their brains mature. 3. The frontosubcortical system pathways associated with ADHD are rich in catecholamines such as dopamine, and ADHD may be caused by inadequate dopamine in the central nervous system. Although heredity may affect these brain conditions, so might lead poisoning, cigarette and alcohol exposure, maternal smoking during pregnancy, low birth weight, oxygen deprivation during birth, and fetal alcohol syndrome. They have all been associated with ADHD (U.S. Surgeon General, 1999; NIMH, 2007b). Some researchers believe that certain foods, food coloring, or food additives produce physiological changes in the brain or other parts of the body, resulting in hyperactive behaviors. This view was promoted by Feingold (1977), who developed a diet excluding these substances. Sugar has also been suspected as a causal factor in ADHD (Chollar, 1988). Many parents have tried the recommended diets for their children, and many claim that their children’s behavior improved. But parental expectations or treating the children differently (for example, going shopping with them to buy only certain foods) might result in behavioral changes. To determine whether certain chemicals or sugars are implicated in hyperactivity, carefully controlled double-blind studies have also been conducted. In the study, the diets of the children were alternated so that some of the time they ate food with the additive and other times without. The parents were not aware of the type of food they were giving their children. Past results of such studies led some to believe that eliminating food additives or certain chemicals from the diets of hyperactive children had little effect on their behavior (NIMH, 2007b; Wolraich, Wilson, & White, 1995). However, one recent study involving three hundred British children provides some support for the influence of food additives (McCann et al., 2007). Over three one-week periods, the children were randomly assigned to consume one of three fruit drinks daily: one contained the amount of dye and sodium benzoate typically found in a child’s diet, a second drink had a lower concentration of the additives, and a third was additive-free. Parents and teachers, who did not know which drink the kids were getting, evaluated the kids as to general hyperactivity, restlessness, inability to concentrate, fidgeting, and talking or interrupting too much. McCann and colleagues (2007) found that children were significantly more hyperactive when consuming drinks with the additives. However, not all children given drinks with additives became more hyperactive, and the reason for this is unclear. In any event, results from McCann et al.’s (2007) rigorously controlled study have rekindled the debate over the effects of food additives in ADHD. Although we have primarily been discussing biological perspectives on ADHD, many psychological, social, and sociocultural factors are related to the disorder. For example, the aggregate of adversity factors (such as severe marital discord, low social class, large family size, family conflicts, maternal psychopathology, paternal criminality, maternal mental disorder, and foster care placement) seems to contribute to ADHD (Spencer et al., 2007). We also know that hyperactive kids often encounter negative reactions from others. These negative reactions may result in stress, low self-esteem, and rebelliousness, causing even more hyperactivity.

Did You Know?

S

ome parents claim that certain foods lead to hyperactivity in their kids. Now, based on the study by McCann et al. (2007), Britain’s Food Standards Agency issued an immediate advisory to parents to limit their children’s intake of additives if they notice an effect on behavior. Some foods that contain such additives are baked goods, candy, cheeses, gum, jam, soft drinks, and soup (Wallis, 2007).

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INTERVENTIONS FOR OLDER KIDS WITH ADHD Students eat while camping out at the Center for Attention and Related Disorders camp in Connecticut. The four-week camp matches one instructor for every two campers and provides the structure, discipline, and social order that are helpful for children who suffer from ADHD and similar disorders.

Treatment For decades, medications have been used to treat the symptoms of ADHD. The medications that seem to be the most effective are stimulants such as Ritalin. Approximately 75 to 90 percent of children with ADHD respond positively to stimulant medication (DHHS, 1999). Nevertheless, clinicians have suggested that both physicians and therapists should pay more attention to family dynamics and child management problems rather than relying solely on pharmacological intervention. Comprehensive psychosocial and behavioral forms of treatment, such as parent training, modeling, role playing, and classroom, academic, and peer interventions, have also been successfully employed. Results indicate that school-age children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option (Daly et al., 2007). Simply providing recesses to schoolchildren with ADHD has been found to be beneficial in reducing inappropriate behaviors (Ridgway et al., 2003).

Oppositional Defiant Disorder

oppositional defiant disorder (ODD) a childhood disorder

characterized by a pattern of negativistic, argumentative, and hostile behavior in which the child often loses his or her temper, argues with adults, and defies or refuses adult requests; refusal to take responsibility for actions, anger, resentment, blaming others, and spiteful and vindictive behavior are common, but serious violations of other’s rights are not

Oppositional defiant disorder (ODD) is characterized by a negativistic, argumentative, and hostile behavior pattern. Children with this disorder often lose their temper, argue with adults, and defy or refuse adult requests. They may refuse to do chores and refuse to take responsibility for their actions. The defiant behavior is directed primarily toward parents, teachers, and other people in authority. Anger, resentment, blaming others, and spiteful and vindictive behaviors are common. Although confrontation often occurs, it does not involve the more serious violations of the rights of others that are involved in conduct disorders. Before puberty more males than females meet the criterion for this disorder, with closer to equal numbers after puberty (American Psychiatric Association, 2000a). ODD is one of the more controversial childhood disorders. It is often difficult to separate this disorder from milder forms of conduct disorder and from normal developmental difficulties in children and adolescents. Most children and adolescents go through a period or several periods of defiant behaviors. In DSM-IV-TR, a criterion indicating that the problem causes “significant impairment in social or academic functioning” was added to try to discriminate between “normal” and “pathological” defiance. ODD tends to be associated with depression, parent-child conflict, the espousing of unreasonable beliefs, and negative family interactions (Barkley et al., 1992; Costello et al., 2003).

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A TROUBLED TEEN Conduct disorders involves a persistent pattern of antisocial behaviors. Here a teenager wearing a red plaid shirt watches for security as he shoplifts CDs in a music store.

Conduct Disorders Case Study Charles was well known to school officials for his many fights with peers. After a stabbing incident at school, he was put on probation and then transferred to another junior high school. Two months later, at age fourteen, Charles was charged with armed robbery and placed in a juvenile detention facility. He had few positive peer contacts at the juvenile facility and seemed unwilling or unable to form close relationships. Some progress was achieved with a behavioral contract program that involved positive reinforcement from adults and praise for refraining from aggression in handling conflicts. He was transferred to a maximum-security juvenile facility when he seriously injured two of his peers, whose teasing had angered him. Charles completed a vocational training program in this second facility, but he couldn’t hold a regular job. He was sent to prison following a conviction for armed robbery.

Conduct disorders are characterized by a persistent pattern of antisocial behaviors that violate the rights of others. Many children and adolescents display isolated instances of antisocial behavior, but this diagnosis is given only when the behavior is repetitive and persistent. Conduct disorders may include behaviors such as bullying, lying, cheating, fighting, destroying property, stealing, setting fires, cruelty to people and animals, assaults, rape, and truant behavior. The pattern of misconduct must last for at least twelve months to warrant this diagnosis (American Psychiatric Association, 2000a). The diagnosis of conduct disorder applies only when the behaviors reflect dysfunction in the individual rather than a reaction to the individual’s social and economic environment. Males with this disorder tend to display confrontational aggressiveness such as fighting, stealing, and vandalism, whereas females are more likely to display truancy, running away, substance abuse, prostitution, or chronic lying. Approximately 6 to 16 percent of boys and 2 to 9 percent of girls meet the diagnostic criteria for conduct disorder. The incidence of conduct disorder increases from childhood to adolescence (Searight, Rottnek, & Abby, 2001). Two types of conduct disorder are recognized: (1) childhood-onset type (at least one conduct problem occurs before age ten) and (2) adolescent-onset type (conduct problem occurs after age ten). Early onset for both boys and girls is related to more chronic and more serious offenses. In about 40 percent of cases, childhood-onset conduct disorder develops into adult antisocial personality disorder (Searight et al., 2001). Although oppositional defiant disorder frequently precedes childhood-onset conduct disorder, it is important to note that many children with oppositional defiant disorder do not later exhibit a conduct disorder. Although many childhood disorders remit over

disorder of childhood and adolescence characterized by a persistent pattern of antisocial behaviors that violate the rights of others; repetitive and persistent behaviors include bullying, lying, cheating, fighting, throwing temper tantrums, destroying property, stealing, setting fires, cruelty to people and animals, assaults, rape, and truant behavior

conduct disorder

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Did You Know?

B

oys are more likely to show direct forms of bullying— intimidating, controlling, or beating up other children—whereas girls demonstrate more relational bullying, such as using threats of social exclusion (Demaray & Malecki, 2003). Many adolescents engage in cyberbullying, which includes sending e-mail that involves ridicule, threats, slurs, and name-calling and that contains personal contact information for their victims at Web sites.

FIGURE

time, children are less likely to outgrow conduct disorders. Not only do children with this disorder have the externalizing aggressive behaviors that define the disorder, but many also display internalizing symptoms, such as withdrawal and major depression, perhaps due to the social alienation created by their behaviors (Lambert et al., 2001; Substance Abuse and Mental Health Services Administration [SAMHSA], 2003). As noted, prognosis for conduct disorders is poor; they often lead to criminal behavior, antisocial personality, and problems in marital and occupational adjustment during adulthood. Many people with these disorders show early involvement with alcohol and illegal drugs, and many delinquent adolescents later become adult criminals. The prognosis is poorer for male children whose conduct disorder is accompanied by serious aggression, especially sexual aggression, and who have low IQ scores or parents who are antisocial. Etiology Many cases of conduct disorder begin in early childhood. Some infants who are especially “fussy” seem to be at risk for developing conduct disorder. The etiology of conduct disorder probably involves an interaction of genetic/constitutional, psychological, social-familial, and sociocultural factors. Searight et al. (2001) propose that children who have conduct disorder may inherit decreased baseline autonomic nervous system activity, requiring greater stimulation to achieve optimal arousal. This hereditary factor may account for the high level of sensation-seeking activity (increased risk taking) associated with conduct disorder (van Goozen et al., 2007). As indicated in Figure 15.2, a number of factors are associated with the development of conduct disorders. We have categorized the factors into our multipath dimensions, although some factors may belong in more than one dimension. For example, having antisocial parents can be a genetic factor (when genes are passed to children) or a social factor (for example, when children imitate their parents’ behavior). In any event, research has found that many different conditions involve biological, psychological, social, and sociocultural factors. For example, increased risk of conduct disorders is associated with having antisocial parents (in the case of boys), coming from large and poverty-stricken families, being abused, and experiencing parental discord (SAMHSA, 2003). It may be that genetic predisposition toward aggressive or antisocial behavior may be expressed in adverse rearing environments, especially those in which the child receives harsh or inconsistent discipline or is exposed to high levels of interparental conflict or marital breakdown (van Goozen et al., 2007). The child may then not experience a consistent relationship between his or her behavior and its consequences (Searight et al., 2001).

15.2 MULTIPATH

Biological Dimension • Antisocial parents for boys (heredity)

MODEL FOR CONDUCT DISORDERS The dimensions interact with one another and combine in different ways to result in a conduct disorder.

Psychological Dimension Sociocultural Dimension • • • •

Large family size Crowding Gender differences Poverty

CONDUCT DISORDERS

Social Dimension • Early institutionalization • Family neglect • Parental marital discord

• Early maternal rejection • Separation from parents, without an adequate alternative caregiver • Abuse or violence • Parental mental disorder • Ineffective behavioral control of antisocial behaviors

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critical thinking

School Violence: A Sign of the Times?

V

iolence, theft, drugs, and firearms are prevalent in our schools (DeVoe et al., 2004). The National Center for Children Exposed to Violence (2006) reported that:

• One study has found that over 17 percent of high school students had carried a weapon to school during the preceding 30 days. • Another study found that 71 percent of public elementary and secondary schools experienced at least one violent incident during the school year. • 12 percent of 12- through 18-year-old students reported experiencing some form of victimization at school. • 12- through 18-year-old students living in urban and suburban locales were equally vulnerable to serious violent crime at school. • In one study, one in six teachers report having been the victim of violence in or around school. • Nationwide, 15 percent of high school students were found to have participated in a physical fight.

Schools need to play a critical role in the mental health of children (Adelman & Taylor, 2004). What can we do to enhance emotional well-being and keep students from violence? Some remedies have been proposed. How would you evaluate the effectiveness of the following proposed actions in trying to reduce violence? 1. Society should enact tougher gun control laws. 2. We should find better means of identifying potentially violent students and then have them undergo some sort of counseling. 3. Make all students go through metal detectors so that weapons can be confiscated. 4. Increase penalties for students who engage in violence. Some proposals may make sense but are difficult to implement. For example, to identify potentially violent students, schools are encouraging students to report to school officials when they become aware that a student has made threatening comments or has developed plans for attacking others. Although it is recognized that potential reasons for not reporting might include a belief that the person is “only joking,” concerns about retaliation or getting a friend in trouble, or concern about being labeled a “narc” or a “squealer,” there is a need for systematic research to explore why students are not reporting threats of violence and to understand the characteristics of schools in which students do report potential problems (Lazarus, 2001). Understanding how to create a school environment in which students are willing to report potential danger is particularly important in view of reports that in over 75 percent of the cases of school violence studied by the U.S. Secret Service, the attacker had

talked to at least one person about the plan prior to the attack. In addition, in about 70 percent of the attacks, the violent actions were actually encouraged by peers who knew about the plan (Vossekuil et al., 2000). Although implementation of preventive strategies has been difficult, measures have been taken and plans have been developed to deal with school violence. The United States Department of Education has sponsored the Safe and Comprehensive Schools Project, an effort to examine actions that can be taken both to prevent violence and to recognize and intervene when there may be the potential of violence. Schools involved in the project have focused on three levels of intervention: (1) comprehensive planning to create a positive climate within the school—students are taught social skills and ways of peacefully solving conflicts; (2) developing procedures for early identification and intervention for students who may be undergoing emotional difficulties or who appear to have violent tendencies or preoccupation with violent themes; and (3) developing effective responses to violence, with a philosophy not only of zero tolerance for any level of harassment or aggression but also of creating procedures for responding to these behaviors and providing support to students about whom chronic or acute concerns exist. Some signs of the times: students as young as kindergarten age practice lockdown procedures and are trained in safety procedures in the event of violence in the schools in the same manner that earthquake and fire drills have been practiced for years. Professional mental health associations have also gotten involved. The American Psychological Association has developed a partnership with MTV to provide a public outreach campaign to help end school violence. The National Association of Social Workers (NASW, 2007) issued the following policy statement concerning school violence: NASW believes that all schools must develop comprehensive violence prevention plans that address both risk factors for school violence and protective factors that reduce that risk. Since violence prevention starts in families and communities, any approach to school violence must include parents, community resources, school staff, and the students themselves, in order to be effective. Among the specific actions schools can take are building an effective schoolwide behavior management system and developing a clear code of conduct, with appropriate consequences for infractions. Further, children can be taught tolerance and civility as well as conflict resolution skills; they can be engaged in character-building activities; and schools can recognize students who contribute positively to a school’s climate and culture.

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Patterson (1986) formulated a psychological-behavioral model of antisocial conduct that involves parents’ failure to effectively punish misbehavior. In his work with families of children with conduct disorders, he noticed that these children counterattacked when a parent requested something from them or criticized them. In the face of this response, the parent withdrew from the conflict. The child then fails to learn to respect authority, and this failure generalizes to the school setting, resulting in academic failure and poor peer relations. Patterson concluded that the specific factors that contribute to the development of antisocial behaviors include (1) a lack of parental monitoring (increases in unsupervised street time were associated with increased rates of antisocial behaviors), (2) inconsistent disciplinary practices, (3) failure to use positive management techniques or to teach social process skills, and (4) failure to teach the skills necessary for academic success (listening, compliance, following directions, and so on). Although Patterson focused primarily on the learning aspects in the etiology of conduct disorders, he also supported the view that predisposing factors such as difficult child temperament may increase the need for parents to learn and consistently apply appropriate management skills. Treatment Although conduct disorders have resisted traditional forms of psychotherapy, training in social and cognitive skills appears promising. In a review of treatment programs for children, several types of interventions were found to be well established or probably efficacious with children exhibiting conduct problems (Herschell, McNeil, & McNeil, 2004). One program (Kolko, Loar, & Sturnick, 1990), for example, focused on helping aggressive boys develop verbal skills to enter groups, play cooperatively, and provide reinforcement for peers. The cognitive element included using problem-solving skills to identify behavior problems, generate solutions to them, and select alternative behaviors. In addition, the children learned positive social skills through viewing videotapes and role-playing with therapists and peers. Dishion, McCord, and Poulin (1999) caution that group interventions involving the aggregation of young high-risk adolescents need to be considered carefully for use with delinquent youths because of possible “deviancy training effects” that may occur, resulting in increases in substance abuse and in antisocial and violent behavior. They propose mobilizing adult mentors or interventions targeting the parents of delinquent youths as powerful alternatives. Particularly important is for the mentors or parents to develop a therapeutic relationship with the child involving empathy, warmth, and acceptance. Kazdin, Whitley, and Marciano (2006) found that it was the most important factor for a positive outcome in children with oppositional, aggressive, or antisocial behavior. Parent management training has also been successful (SAMHSA, 2003). These programs, which have evolved over a period of more than twenty years of work with problem children, teach specific skills so that parents learn how to establish appropriate rules for the child, implement consequences, and reward positive behaviors. The parents first practice their newly learned skills on simple problems and gradually work on more difficult problems as they become more proficient in management techniques. A combination of building children’s cognitive and social skills and training parents in management techniques appears to produce the most marked and RESISTING BULLYING In this photo, a student at an elementary school is a victim durable changes in children with conduct disof bullying by fellow sixth-graders in a skit. The skit is part of an anti-bullying and prevention program sponsored by the Delaware State Attorney General’s office. orders. A curricular intervention for aggressive

Elimination Disorders

431

behavior on the playground showed clear reductions in aggressive actions, especially for those children who were initially the most aggressive (Stoolmiller, Eddy, & Reid, 2000). It has been suggested that early intervention targeting young children with high aggression, in addition to other risk factors such as low levels of parent education and early childbearing, is particularly important (Nagin & Tremblay, 2001).

Elimination Disorders Case Study Eight-year-old Billy did not want to go to school anymore. He was embarrassed about his inability to control his bladder, he frequently wet his pants while in class, and he had to put up with merciless teasing by classmates. Billy had been continent by age five, but he started wetting the bed again around the age of seven. His father was especially irate about his son’s problem. He constantly berated Billy for being “a baby” and said he “should wear diapers again.” The problem had become so severe that it disrupted the family’s travel plans. On long outings by automobile, Billy—fearful that he would wet his pants—requested restroom stops every thirty minutes. For the first time, the family canceled their annual visit to their families on the East Coast. The trip would require traveling by plane, and both parents felt that the number of times Billy would visit the restroom on the plane and his tendency to wet his pants at the most inopportune times would ruin their pleasure in the vacation.

Most psychologists would agree with Freud that toilet training represents a major source of potential conflict for the child. It is one of the first times that demands for control of normal biological urges (urinating and defecating) are placed on the child. Most children handle this developmental milestone well, with no resulting problems. A small percentage of children like Billy experience elimination disorders—problems of bladder or bowel control.

Enuresis According to DSM-IV-TR, enuresis is the habitual voiding of urine during the day or night into one’s clothes, bed, or floor. The behavior is generally involuntary, but in rare situations it may be intentional. Enuresis is most likely to occur during sleep, but it is not uncommon during the daytime. To be diagnosed with enuresis, the child must be at least five years old and must void inappropriately at least twice per week for at least three months. Enuresis is also associated with clinically significant distress and with impairment in social, academic, or other areas of functioning. It is a fairly common disorder. In epidemiological studies, 4.9 to 8.0 percent of seven- to seventeen-year-olds were found to be enuretic (Klages et al., 2005). Most children outgrow the disorder by adolescence, although 1 percent of individuals with enuresis continue to have symptoms in adulthood (American Psychiatric Association, 2000a). Many children with enuresis experience significant distress or impairment in their social, academic, or everyday lives, and the disorder can also drastically affect their families. A large epidemiologic sample of more than eight thousand children found a higher rate of parent-reported psychological problems in children age seven and a half years with daytime wetting compared with those with no daytime wetting. The largest differences were found for externalizing problems, such as attention and activity problems, oppositional behavior, and conduct problems (Joinson, Heron, & von Gontard, 2006). Children tend to be fearful and apprehensive about not being able to control their bladders, sensitive to imagined or real parental disappointment and disapproval, and frightened of peer ridicule. They may withdraw from peer relationships or may be ostracized by other children. Unsympathetic or impatient parents can exacerbate the problem by putting greater pressures on the child, producing further anxiety and a sense of failure. A vicious cycle may ensue: the child wets the bed, which leads to condemnation by one or both parents, which causes the child to feel intense guilt and anxiety about

an elimination disorder in which a child who is at least five years old voids urine during the day or night into his or her clothes or bed or on the floor, at least twice weekly for at least three months

enuresis

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CHAPTER 15 • DISORDERS OF CHILDHOOD AND ADOLESCENCE

critical thinking

Child Abuse

B

ecause the three-and-a-half-year-old boy Neglect only had defecated in his pants once too often, the mother forced him to sit for two whole Multiple maltreatment types days on the toilet. She told her son that he would not be allowed to get up or eat unless he evacuated Physical abuse only his stools. When the son became constipated and did not respond appropriately, the mother pulled Psychological maltreatment only, other only, or unknown only him from the toilet seat and lashed his buttocks. She did this every hour on the hour, until they were Sexual abuse only raw and bleeding. Despite the son’s pleading, the 0 5 10 15 20 25 30 35 40 mother became so enraged that she gave him an Percentage enema with scalding water. The youngster lost consciousness and had to be hospitalized. FIGURE CHILD ABUSE AND NEGLECT FATALITIES BY “Children are our most precious resource.” “The MALTREATMENT TYPE, 2004 future of society depends upon the youths of today.” Source: Child Welfare Information Gateway (2006). “Caring and nurturance of children are important responsibilities of a civilized society.” These that last into adulthood. They are more prone to exhibit statements are repeated often by parents, teachers, significant direct and indirect physical and psychological social scientists, and politicians. Yet the maltreatment of problems. The physical consequences of abuse range children remains a significant national problem. What is child from mild bruises and lacerations to quite severe longabuse and neglect? In general, abuse or neglect is any act or term damage, including brain damage, mental retardation, failure to act on the part of a parent or caretaker that results and cerebral palsy. Orthopedic injuries such as broken in death, serious physical or emotional harm, sexual abuse, bones are not uncommon. X-rays of children who have or exploitation. States vary in their precise definitions of been abused frequently reveal evidence of multiple old abuse and neglect. At least four types of maltreatment have fractures and breaks that have healed. Psychological been recognized: neglect, effects of abuse include impaired memory, depression, physical abuse, emotional 3.4% self-destructive behavior, low self-esteem, and aggressive abuse, and sexual abuse. 4.1% impulsivity. Abused children may show excessive anxiety, In the United States, which can lead to bedwetting, nightmares, eating and about 900,000 cases of sleeping disorders, and—in the teenage years—conduct child abuse were found 11.5% 45% disorders (Margolin & Gordis, 2004). Although physical in 2005 (U.S. Department and mental abuse can by itself be devastating, the impact of Health and Human of abuse is even more complex when it involves sexual Services, 2007). Nearly molestation, incest, or rape (Kendall-Tackett, Williams, 36% 1,500 deaths from child & Finkelhor, 1993). Adults who have been seriously abused abuse occurred. Figure 15.3 as children reported long-term difficulties with substance and Figure 15.4 show the abuse, self-injury, suicide, depression, rage, strained gender statistics for age and cause relationships, self-concept and identity issues, and a of fatalities (Child Welfare Younger than 1 year discomfort with sex (Denov, 2004). Teicher and colleagues Information Gateway, 1–3 years (2006) have found that psychological effects or adult 2006). Fatalities occur psychopathology are present even when the childhood usually among the very 4–7 years abuse is emotional (for example, verbal abuse or witnessing young (one- to three-year8–11 years domestic violence) rather than physical. olds and four- to seven12–17 years year-olds), with neglect The Abuser being the most frequent FIGURE CHILD Why would parents abuse their own children? This is a very kind of abuse and the kind ABUSE AND NEGLECT difficult question to answer. As noted by the Child Welfare most frequently involved FATALITIES VICTIMS BY AGE, Information Gateway (2006), one or both parents were in death. 2004 The youngest are the involved in 78.9 percent of child abuse or neglect fatalities Children subjected most vulnerable. in 2004. Of the other 21.1 percent of fatalities, 10.7 percent to abuse may suffer Source: Child Welfare Information were the result of maltreatment by nonparent caretakers, psychological effects Gateway (2006).

15.4

15.3

Elimination Disorders

and 10.4 percent represent unknown or missing information. Most fatalities from physical abuse are caused by fathers and other male caretakers. Mothers are most often responsible for deaths resulting from child neglect. We also know that most people who abuse were themselves abused as children. Most are under the age of thirty and lack high school diplomas, are rarely psychotic, may show personality disorders, experience serious stress, have low levels of tolerance for frustration, and often abuse alcohol and drugs (Child Welfare Information Gateway, 2005; Petersen & Brown, 1994). It is clear that many factors contribute to abuse. Some, such as poverty, are situational; others, such as immaturity and lack of parenting skills, are more related to individual temperament. Prevention and Public Policy Federal and state laws require all mental health professionals, teachers, and doctors to report child abuse

433

or neglect if they suspect such a situation exists. Despite the fact that all fifty states have enacted such legislation, child abuse persists. There have been efforts to increase public awareness of the problem of child abuse through educational campaigns on television and other media concerning the prevalence and impact of child abuse. A continual debate in the field of child protection is the balance between child safety and maintaining the family (Dogden, 2000). Many communities now run parent education and support groups, especially for families identified as “at risk.” Try to think through some answers to some important questions. We hear a great deal about parental child abuse or sexual abuse of teenagers by some priests. What are the consequences of child abuse on its victims? Do adults who were abused as children show psychological effects of abuse? Why would those who are abused as children become abusers?

causing the problem, which fosters the child’s belief in being unable to control the urge to urinate, which only reinforces the child’s continued enuresis. Studies evaluating self-esteem in enuretic children show lowered self-esteem prior to treatment but increased self-esteem following treatment, even when the treatment was not successful (Longstaffe, Moffatt, & Whalen, 2000). Both psychological and biological explanations have been associated with enuresis. Psychological stressors—unrealistic toilet training demands placed on the child, delayed or lax toilet training, a stressful life situation (such as death of a parent or birth of a new sibling), disturbed family patterns, or the presence of other emotional problems—may be predisposing factors (Haug Schnabel, 1992; Joinson et al., 2006). Biological determinants may include delayed maturation of the urinary tract, delays in the development of normal rhythms of urine production, decreased production of hormones that control urination, or a hypersensitive or small bladder. Thiedke (2003) has noted that studies have found that when both parents were enuretic as children, their offspring had a 77 percent risk of having nocturnal enuresis. The risk declined to 43 percent when only one parent was enuretic as a child, and to 15 percent when neither parent was enuretic. The vast majority of children with nocturnal enuresis have a family history of the disorder. Interventions often involve using medications that decrease the depth of sleep (allowing the child to recognize the bladder urges) or that decrease urine volume (thereby decreasing enuretic events; Saldano et al., 2007). The most successful psychological procedures involve behavioral methods (Herschell et al., 2004), such as parents giving constant reinforcement to the child, awakening the child to use the toilet, and giving the child responsibility for making up his or her own bed should an accident occur. A bedtime urine alarm treatment is particularly effective (Schulman et al., 2000), especially when used with medication (Saldano et al., 2007).

Encopresis Although less common than enuresis, encopresis may be more disturbing because it involves repeated defecating onto one’s clothes, the floor, or other inappropriate places. To be diagnosed with this disorder, the child must be at least four years old and must have defecated inappropriately at least once a month for at least three months. The incidents must not be due to the use of laxatives. Epidemiological

encopresis an elimination disorder in which a child who is at least four years old defecates in his or her clothes, on the floor, or other inappropriate places, at least once a month for three months

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studies found that 0.7 to 3.5 percent of seven- to seventeen-year-olds were encopretic (Klages et al., 2005), and the disorder is much more common in males than in females (Ingersoll & Previts, 2001). Intermittent episodes of encopresis can persist for years. Encopresis is most commonly seen with functional constipation. The typical pattern for children with encopresis is a history of constipation, resulting in painful defecation and subsequent withholding of bowel movements, leading to additional constipation and involuntary soiling (Issenman, Filmer, & Gorski, 1999). In rare situations in which encopresis is deliberate, other features of oppositional defiant disorder or conduct disorder may be present. In cases of encopresis in which constipation is not a primary factor, it is important to identify the reason for the resistance to using the toilet and to assess possible medical, developmental, or behavioral contributors to the problem, to understand the toilet refusal behavior, to ensure appropriate stools through diet and medication, and to develop a schedule for toileting (Kuhn, Marcus, & Pitner, 1999; LoeningBaucke, 2000). According to DSM-IV-TR, the amount of psychological impairment associated with encopresis is in direct proportion to its effects on the child’s self-esteem. Intense social problems can arise through shame, embarrassment, and attempts to conceal the disorder. Ostracism by peers, anger on the part of significant caregivers, and overall rejection can compound the problem. The most common means of treatment include proper medical evaluation (especially when constipation is present) and the use of behavioral and family forms of therapy. Parent and child education about toileting regimens and a well-organized bowel management program can produce dramatic results (Loening-Baucke, 2000).

Learning Disorders Disorders of childhood and adolescence also include cognitive and academic functioning. Learning disorders are characterized by academic functioning that is substantially below that expected in terms of the person’s chronological age, measured intelligence, and age-appropriate education. The disturbance significantly interferes with academic achievement or with activities of daily living. Substantially below is usually defined statistically as a severe discrepancy between achievement and IQ. If a sensory deficit is present, the learning difficulties must be in excess of those usually associated with the deficit. Care should be taken to ensure that intelligence testing procedures reflect adequate attention to the individual’s ethnic or cultural background, which may affect performance. Individualized testing is always required to make the diagnosis of a learning disorder. The prevalence of learning disorders ranges from 2 to 10 percent, depending on the nature of ascertainment and the definitions applied. Approximately 5 percent of students in public schools in the United States are identified as having a learning disorder. The school dropout rate for children or adolescents with learning disorders is reported at nearly 40 percent (or approximately 1.5 times the average). Children with learning disorders may try to hide their problem and feel stupid, inferior, or embarrassed by poor school performance. Learning disorders may persist into adulthood. Adults with learning disorders may have significant problems in employment or social adjustment. Table 15.3 provides a brief overview of learning disorders.

Etiology a disorder characterized by academic functioning that is substantially below that expected in terms of the person’s chronological age, measured intelligence, and age-appropriate education learning disorder

Little is currently known about the precise causes of learning disabilities. However, some etiological possibilities are: • Some children mature and develop at a slower rate than others in the same age group. Consequently, they may not be able to perform at the expected level in school. There is a “maturational lag.” • Some children with normal vision and hearing may misinterpret everyday sights and sounds because of some kind of nervous system disorder.

Mental Retardation

TA B L E

435

15.3

DISORDERS CHART

LEARNING DISORDERS

TYPE OF DISORDER

SYMPTOMS

PREVALENCE

Reading disorder (dyslexia)

Difficulty with reading and reading comprehension

4% of school-age children; more males than females

Mathematics disorder (dyscalculia)

Difficulty with computation, remembering math facts, concepts of time and money

1% of school-age children

Disorder of written expression (dysgraphia)

Difficulty with handwriting, spelling, composition, grammar, punctuation

Difficult to establish

Other learning disorder

Vary

Not established

Source for prevalence: American Psychiatric Association (2000a).

• Injuries, illnesses, or physical traumas before birth or in early childhood probably account for some later learning problems. • Children born prematurely and children who had medical problems soon after birth sometimes develop learning disabilities. • Learning disabilities tend to run in families, so some learning disabilities may be inherited. • Learning disabilities are more common in boys than girls, possibly because boys are slower to mature. • Some learning disabilities appear to be linked to the irregular spelling, pronunciation, and structure of the English language, because the incidence of learning disabilities is lower in Spanish- and Italian-speaking countries.

Treatment Learning disabilities are lifelong and cannot simply go away with treatment. However, persons with learning disabilities can adjust and adapt in order to function effectively in society. Severity of the disorder varies, and appropriate action involves the accurate assessment of the limitations of the disorder and individualized interventions. What has been helpful is to teach children with learning disabilities skills that capitalize on their abilities and strengths while correcting and compensating for disabilities and limitations.

Mental Retardation A teenager with mental retardation told his fellow students, during a high school assembly, how he felt about his handicap:

Case Study My name is Tim Frederick. . . . I would like to tell you what it is like to be retarded. . . . I am doing this so that you might be able to understand people like me. I do chores at home. I have to take care of all the animals—twelve chickens, three cats, a dog, three goldfish, and a horse. That’s a lot of mouths to feed. . . . After I graduate from school, I hope to live in an apartment. . . . The hardest thing is when people make fun of me. I went to a dance a few weeks ago, and no girl would dance with me. Can you guys imagine how you would feel if that happened to you? Well, I feel the same way. (K. Smith, 1988, pp. 118–119)

The perception of mental retardation, formerly considered a hopeless condition that required institutionalization, is undergoing a fundamental change. Tim Frederick’s mother was told that her son’s development would be delayed and that he might never

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15.4

DISORDERS CHART

MENTAL RETARDATION

DISORDER

PREVALENCE

Mental retardation

1–3%

GENDER DIFFERENCES

1.5:1 (male to female)

AGE OF ONSET

COURSE

Before age eighteen; precise age of onset depends on etiology and severity

Depends on severity; with appropriate training, many individuals learn good adaptive skills

Source: Based on American Psychiatric Association (2000a).

be able to walk or talk. We now know that the effects of mental retardation are variable and that with training even people with severe retardation can make intellectual and social gains (see Table 15.4).

Diagnosing Mental Retardation

Did You Know?

M

any people have advocated replacing the term mental retardation with the term intellectual and developmental disabilities (American Association on Intellectual and Developmental Disabilities, 2007). The latter is simply less stigmatizing than mental retardation, mental deficiency, feeble-mindedness, idiocy, imbecility, and other terminology that has been cast aside over the years. The larger issue is one of promoting inclusion and acceptance of people with intellectual and developmental disabilities in society.

mental retardation (MR)

a disability characterized by significant limitations both in intellectual functioning and in adaptive behaviors as expressed in conceptual, social, and practical adaptive skills

Mental retardation (MR) is a disability characterized by significant limitations both in intellectual functioning and in adaptive behaviors as expressed in conceptual, social, and practical adaptive skills (American Association on Intellectual and Developmental Disabilities, 2007). Prevalence figures for the United States are 1 to 3 percent, depending primarily on the definition of adaptive functioning (Popper & West, 1999). As mentioned earlier, mental retardation is categorized by DSM-IV-TR as one of the disorders usually first diagnosed in infancy, childhood, or adolescence. Mental retardation is not considered a cognitive disorder, although it may have characteristics that are similar to those found in some cognitive disorders. To render a diagnosis of mental retardation in DSM-IV-TR, the following criteria are used: 1. Significant subaverage general intellectual functioning (ordinarily interpreted as an IQ score of 70 or less on an individually administered IQ test) 2. Concurrent deficiencies in adaptive behavior (social and daily living skills, degree of independence lower than would be expected by age or cultural group) 3. Onset before age eighteen (subaverage intellectual functioning arising after age eighteen is typically categorized as dementia) Common characteristics that accompany mental retardation are dependency, passivity, low self-esteem, low tolerance of frustration, depression, and self-injurious behavior (American Psychiatric Association, 2000a). Relative to the general population, persons with mental retardation are much more likely to suffer from psychiatric problems. The problems include a higher incidence of aggression, self-injurious behavior, tantrums, and stereotyped behaviors (Phelps, Brown, & Power, 2002). The more severe levels of mental retardation are associated with speech difficulties, neurological disorders, cerebral palsy, and vision and hearing problems. Individuals with autism may also exhibit cognitive deficits, but mental retardation has been distinguished from autism on various mental and perceptual tasks (Shulman, Yirmiya, & Greenbaum, 1995). Levels of Retardation DSM-IV-TR specifies four different levels of mental retardation, which are based on IQ score ranges, as measured on the revised Wechsler scales (WISC-R and WAIS-R): (1) mild (IQ score 50–55 to 70), (2) moderate (IQ score 35–40 to 50–55), (3) severe (IQ score 20–25 to 35–40), and (4) profound (IQ score below 20 or 25). Social and vocational skills and degree of adaptability may vary greatly within each category. Table 15.5 contains estimates of the number of people within each level in the United States. It should be noted that the American Association on Intellectual and Developmental Disabilities (AAIDD, 2007) does not use a classification of mental retardation

Mental Retardation

TA B L E

15.5

ESTIMATED NUMBER OF MENTALLY RETARDED PEOPLE BY LEVEL OF RETARDATION RANGE WECHSLER IQ

PERCENTAGE OF ALL MENTALLY RETARDED

NUMBER

Mild

50–70

85

7,926,000

Moderate

35–49

10

933,000

Severe

20–34

3–4

326,700

Profound

0–19

1–2

140,000

LEVEL

Note: Estimates based on percentages from the American Psychiatric Association (2000a) and applied to the normal probability distribution of intelligence based on a U.S. population of 274 million.

based on levels of intellectual functioning as revealed in IQ scores. Instead, AAIDD considers concurrent limitations in both the intellectual and adaptive skills of the individual (Kanaya, Scullin, & Ceci, 2003). It makes five assumptions: 1. Limitations in present functioning must be considered within the context of community environments typical of the individual’s age peers and culture. 2. Valid assessment considers cultural and linguistic diversity, as well as differences in communication, sensory, motor, and behavioral factors. 3. Within an individual, limitations often coexist with strengths. 4. An important purpose of describing limitations is to develop a profile of needed supports. 5. With appropriate personalized supports over a sustained period, the life functioning of the person with mental retardation generally will improve. Adaptive skills include those required in communication, self-care, social interactions, health and safety, work, and leisure. Furthermore, the skills are placed in the context of one’s culture and community. Mental retardation is diagnosed only if low intelligence is accompanied by impaired adaptive functioning. Low intelligence alone, or deficits in adaptive behaviors alone, do not result in a diagnosis of mental retardation according to AAIDD (Popper & West, 1999). Although DSM-IV-TR and AAIDD use intellectual and adaptive functioning as criteria in the diagnosis of mental retardation, AAIDD focuses more on adaptive functioning and specifies the type and nature of psychosocial supports needed in adaptive functioning (Harris, 2001). Finally, AAIDD considers mental retardation to be a disability and not a mental or medical disorder (AAIDD, 2007).

Etiology of Mental Retardation Mental retardation is thought to be produced by biological, psychological, social, and sociocultural factors. These factors are largely grouped into environmental conditions (such as poor living conditions), biological conditions, or some combination of the two (see Table 15.6). It can be caused by injury, disease, or a brain abnormality. The etiology is dependent to some extent on the level of mental retardation. Mild retardation is generally idiopathic (having no known cause) and familial, whereas severe retardation is typically related to genetic factors or to brain damage (Popper & West, 1999). Environmental Factors Certain features of the environment may contribute to retardation. Among these are the absence of stimulating factors or situations, a lack of attention and reinforcement from parents or significant others, and chronic stress and frustration. In addition, poverty, lack of adequate health care, poor nutrition, and inadequate education place children at a disadvantage. For example, iodine deficiency in a baby can cause mental retardation (Angermayr & Clar, 2004).

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15.6

PREDISPOSING FACTORS ASSOCIATED WITH MENTAL RETARDATION FACTOR

PERCENTAGE OF CASES

EXAMPLES

Heredity

5

Errors of metabolism (Tay-Sachs), single gene abnormalities (tuberous sclerosis), chromosome aberrations (translocation Down syndrome, fragile X syndrome)

Alteration of embryonic development

30

Chromosomal changes (Down syndrome, trisomy 21), prenatal damage due to toxins (fetal alcohol syndrome), infections

Pregnancy and perinatal complications

10

Malnutrition, prematurity, hypoxia, traumas, infections

Infancy or childhood medical conditions

5

Traumas, infections, lead ingestion

Environmental influences and other mental conditions

15–20

Social, linguistic, and nurturance deprivation; severe mental disorders (autistic disorder)

Etiology unknown

30–40

Etiological factors cannot be identified

Source: Based on American Psychiatric Association (2000a).

Down syndrome a condition produced by the presence of an extra chromosome (trisomy 21) and resulting in mental retardation and distinctive physical characteristics

Genetic Factors Genetic factors in mental retardation include genetic variations and genetic abnormalities. Mental retardation caused by normal genetic variation simply reflects the fact that in a normal distribution of traits, some individuals will fall in the upper range and some in the lower. Researchers have suggested that the normal range of intelligence lies between the IQ scores of 50 and 150, and that some individuals simply lie on the lower end of this normal range (Zigler, 1967). No organic or physiological anomaly associated with mental retardation is usually found in this type of retardation. Most people classified with mild retardation have normal health, appearance, and physical abilities. One of the most common inherited forms of mental retardation is called the fragile X syndrome because an abnormal gene is present on the bottom end of the X chromosome (Kornman et al., 2002). It occurs in one of every two thousand to five thousand live births (Hessl et al., 2001). Affected by the abnormal gene are the higher control processes of attention, such as executive functioning. The executive cognitive functions include cognitive flexibility, planning, initiation, behavioral and attentional regulation, feedback utilization, and self-perception (Loesch et al., 2003). Although impairment in functioning varies among those with inherited forms of mental retardation, many affected persons have severe deficits (Raymond et al., 2007). Those with profound retardation (about 1 to 2 percent of those with the disorder) may be so intellectually deficient that they require constant and total care and supervision. Many also have significant sensorimotor impairment and are confined to beds or wheelchairs by the congenital defects that produced the retardation. Even with teaching, there is minimal, if any, acquisition of self-help skills among these individuals. Their mortality rate during childhood is extremely high. Associated physical problems, such as neuromuscular disorders, impairment of vision or hearing, and seizures, may coexist. Down syndrome is a condition produced by the presence of an extra chromosome (trisomy 21, an autosomal, or nonsex, chromosome) and resulting in mental retardation and distinctive physical characteristics. Most cases of Down syndrome are not inherited but occur as random events that affect the genes during the formation of reproductive cells (eggs and sperm). The condition may occur as often as once in every eight hundred to one thousand live births (“Down Syndrome,” 2007). About 10 percent of children with severe or moderate retardation show

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this genetic anomaly. As Table 15.7 shows, the prevaTA B L E lence rate increases dramatically with the age at which the mother gives birth, and the rate for Hispanics is RATE OF DOWN SYNDROME BIRTHS TO higher than for other racial/ethnic groups(California MOTHERS IN CALIFORNIA Birth Defects Monitoring Program, 2007). The well-known physical characteristics of Down MOTHER’S AGE RATE PER 1,000 BIRTHS syndrome are short incurving fingers, short broad under 17 years 1.06 hands, slanted eyes, furrowed protruding tongue, flat and broad face, harsh voice, and incomplete or delayed 17–19 years .99 sexual development. Some children with Down syn20–24 years .78 drome receive cosmetic surgery (consisting mostly of modifying tongue size) to make their physical appear25–29 years .79 ance more nearly normal and to allow them to speak 30–34 years 1.23 more clearly and to eat more normally. The procedure is intended to enable people with Down syndrome to 35–39 years 2.90 fit in as much as possible with their peers to enhance their social interactions and communication abilities. over 39 years 9.99 People with Down syndrome who live past age forty MOTHER’S RACE/ETHNICITY RATE PER 1,000 BIRTHS are at high risk for developing early-onset dementia of the Alzheimer type (Bush & Beail, 2004), discussed White 1.15 earlier in this chapter. The gene responsible for the African American 1.12 amyloid plaques and neurofibrillary tangles found in AD is located on chromosome 21, indicating a possible Asian 0.98 relationship between Down syndrome and AD. Congenital heart abnormalities are also common in people Latina/Hispanic 1.53 with Down syndrome, causing a high mortality rate. Other 1.16 Surgical procedures have improved the probability of surviving these heart defects and have resulted in both Source: Adapted from California Birth Defects Monitoring Program (2007). longer life expectancies and healthier lives. Prenatal detection of Down syndrome is possible through different techniques, including amniocentesis, a screening procedure in which a hollow needle is inserted through the pregnant woman’s abdominal wall and the amniotic fluid is withdrawn from the fetal sac. This procedure is performed during the fourteenth or fifteenth week of pregnancy. The fetal cells from the fluid are cultivated and, within three weeks, can be tested to determine whether Down syndrome is present. This procedure involves some risk for both mother and fetus, so it is employed only when the chance of finding Down syndrome is high—as, for example, with women older than age thirty-five. Other, less common genetic anomalies—such as Turner’s syndrome, Klinefelter’s amniocentesis a screening syndrome, phenylketonuria (PKU), Tay-Sachs disease, and cretinism—can also proprocedure in which a hollow duce mental retardation.

15.7

Nongenetic Biological Factors Mental retardation may be caused by a variety of environmental mishaps during the prenatal (from conception to birth), perinatal (during the birth process), or postnatal (after birth) period. During the prenatal period, the developing organism is susceptible to viruses and infections (such as German measles), drugs, radiation, poor nutrition, and other nongenetic influences. Increasing attention is being focused on the problem of mental deficits related to alcohol consumption during pregnancy, especially because the problem is preventable. Some children born to mothers who drink during pregnancy have fetal alcohol syndrome (FAS). FAS occurs in 0.2 to 1.5 per 1,000 live births (CDC, 2007d). It is a group of congenital physical and mental defects including small body size and microcephaly, an anomaly whose most distinguishing feature is an unusually small brain. Such children are generally mildly retarded, but many are either moderately retarded or of average intelligence. Those with normal intelligence seem to have significant academic and attentional difficulties, however, as

needle is inserted through the pregnant woman’s abdominal wall and amniotic fluid is withdrawn from the fetal sac; used during the fourteenth or fifteenth week of pregnancy to determine the presence of Down syndrome and other fetal abnormalities

fetal alcohol syndrome (FAS)

a group of congenital physical and mental defects found in some children born to alcoholic mothers; symptoms include small body size and microcephaly, in which the brain is unusually small and mild retardation may occur

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THE TRISOMY OF DOWN SYNDROME Three chromosomes in the number 21 chromosome set (trisomy 21) can be seen in this photograph. The extra chromosome is responsible for Down syndrome.

well as a history of hyperactivity and behavioral deficits (Streissguth, 1994). Smoking and poor nutrition may increase the likelihood that an alcoholic mother will have offspring with FAS. Among the different ethnic groups in the United States, the rate of FAS is especially high among American Indians (U.S. Department of Health and Human Services, 1995). During the perinatal period, mental retardation can result from birth trauma, prematurity, or asphyxiation. After birth or during the postnatal period, head injuries, infections, tumors, malnutrition, and ingesting toxic substances such as lead can cause brain damage and consequent mental retardation. Compared with prenatal factors, however, these hazards account for only a small proportion of organically caused mental retardation.` The most common birth condition associated with mental retardation is prematurity and low birth weight. Although most premature infants develop normally, approximately 20 percent show signs of neurological problems reflected in learning disabilities and mental retardation (Pound, 1987). Low birth weight is also a risk factor for mental retardation. The IQ scores of adolescents who had low birth weights have been found to be in the normal range but significantly lower than those of adolescents with normal birth weights (Whitaker et al., 2006). Although incidence rates are decreasing for most types of mental retardation, retardation owing to postnatal causes is on the increase. For example, direct trauma to the head produces hemorrhaging and tearing of the brain tissue, often as the result of an injury sustained in an automobile accident or from child abuse. Other postnatal causes include brain infections, neurological disease, toxic exposure, and even extreme malnutrition (Popper & West, 1999).

Programs for People with Mental Retardation Because mental retardation is a disability rather than a disease that can be “cured,” the goal of intervention is to develop the person’s potential to the fullest extent possible. Early Intervention Programs such as Head Start have not produced dramatic increases in intellectual ability among at-risk children (those from low-income families). But long-term follow-up studies have found that they do produce positive results (U.S. Surgeon General, 1999). Children who participated in early intervention programs were found to perform better in school than nonparticipants. In addition, a greater proportion of the participants in early intervention finished high school,

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which no doubt helped them obtain and hold better jobs. The families of participants were also positively influenced by the programs. They rated the programs as personally helpful, spent more time working with their children on school tasks, and perceived their children as becoming happier and healthier. School Services Services received by children diagnosed with mental retardation can vary greatly between school districts, as noted by Kanaya, Scullin, and Ceci (2003). Some of the more common services offered to these students include modified regular classroom assignments (for example, making the assignments shorter and/or easier) and direct instructions that explicitly teach the skills necessary to complete assignments (for example, organizing materials for the student or showing the student exactly where the necessary information is in the text). Special education services may include removal from regular classrooms for all or part of the day to receive instruction from special education specialists, paid aides, and volunteers. In general, the trend is to individualize school services to meet the needs of the child and his or her family (National Dissemination Center for Children with Disabilities, 2007).

PERSON WITH DOWN SYNDROME IN WORK ENVIRONMENT Many people with Down Syndrome can function well in various jobs. Here, a baker is carrying fresh bread.

Employment Programs People with mental retardation can achieve more than was previously thought. The parents of one teenage boy, for example, were told that he would always be childlike and that the only job he would ever be fit for was stringing beads. Another person with moderate retardation, who spent most of his time staring at his hands and rubbing his face, also appeared to have a dismal future. Both of these men now have paying jobs, one as a janitor and the other as a dishwasher. Programs that enable people with mental retardation to learn specific job skills, to interact with coworkers and supervisors, and to complete work-related tasks with speed and quality are helpful (AAIDD, 2007). Gains made in social and vocational skills appear to be maintained or increased in follow-up studies. Living Arrangements Institutionalization of people with mental retardation is declining, as more individuals are placed in group homes or in situations in which they can live independently or semi-independently within the community. The idea is to provide the “least restrictive environment” that is consistent with their condition and that will give them the opportunity to develop more fully. Although the implication seems to be that institutions are bad places, they do not have uniformly negative effects. Nor do group homes always provide positive experiences. What seems to be most important are program goals; programs that promote social interaction and the development of competence have positive effects on the residents of either institutions or group homes. Nontraditional group arrangements, in which a small number of people live together in a home, sharing meals and chores, provide increased opportunity for social interactions. Although group arrangements vary considerably from setting to setting (Perry & Felce, 2005), “normalized” living arrangements were found to produce benefits such as increased adaptive functioning, improved language development, and socialization. It should be noted that living arrangements, environmental supports, and interventions should be tailored to the type of retardation and severity of limitations found among the individuals (Dykens & Hodapp, 1997). As mentioned earlier, parents and family members often serve as caregivers for a significant period of time. When this occurs, the family members may need education and training in dealing with someone who has mental retardation. Overcoming myths

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about the disorder, finding out how to deal with the affected family member, identifying supports and resources, and handling emotional problems (such as anxiety, guilt, and anger) within the family are important tasks for caregivers (Harris, 2001).

I M P L I C AT I O N S

In this chapter, we have discussed the symptoms, causes, and treatment and prevention of childhood disorders. Because we are dealing with a population (children and adolescents) and not a disorder (such as depression), many kinds of disorders are included. Thus some, such as autism spectrum disorders and mental retardation, have a strong biological etiology. Heredity, conditions during pregnancy, and early infancy factors are likely to play a strong role in these disorders. Nevertheless, even in these and other childhood disorders, we see that psychological, social, and sociocultural factors are implicated. For example, in conduct disorders, we see that the prevalence is higher among boys than girls and among children who are abused or neglected, poor, or subjected to parental discord. Disorders that occur in childhood are a product of many factors.

Summary 1. Which disorders fall under the category of pervasive developmental disorders?

the child, both elimination disorders usually abate with increasing age.

Pervasive developmental disorders include autistic disorder, Rett syndrome, childhood disintegrative disorder, Asperger’s syndrome, and pervasive developmental disorder not otherwise specified.

4. How common are learning disorders? ■ Approximately 5 percent of students in public schools in the United States have learning disorders in which their academic functioning is substantially below that expected in terms of the person’s chronological age, measured intelligence, and age-appropriate education.

■

2. What are some of the characteristics of attention deficit/ hyperactivity disorder, and what is the difference between conduct disorder and oppositional defiant disorder? ■ Attention deficit/hyperactivity disorder, or ADHD, is characterized by overactivity, restlessness, distractibility, short attention span, and impulsiveness. Three types of ADHD are recognized: predominantly hyperactiveimpulsive, predominantly inattentive, and combined. ■ Oppositional defiant disorder (ODD) is characterized by a pattern of hostile, defiant behavior toward authority figures. Children with ODD do not display the more serious violations of others’ rights that are symptomatic of conduct disorders. Conduct disorders, especially those that have an early onset, show a clear continuity with adult problems. 3. What are elimination disorders, and what is their prognosis? ■ Enuresis and encopresis are elimination disorders that are diagnosed when children pass an age in which bladder or bowel control should normally exist. Enuresis is the usually involuntary voiding of urine into one’s own clothes or bed. Encopresis is the usually involuntary expulsion of feces into one’s own clothes or bed. Although they cause considerable distress to

5. What is mental retardation, and what are some of its causes and treatments? ■ DSM-IV-TR identifies four different levels of mental retardation, which are based only on IQ scores: mild (IQ score 50–70), moderate (IQ score 35–49), severe (IQ score 20–34), and profound (IQ score below 20). ■ Causes of retardation include environmental factors (psychological, social, and sociocultural factors), normal genetic processes, genetic anomalies, and other biological abnormalities, such as physiological or anatomical defects. Most mental retardation does not have an identifiable organic cause and is associated with only mild intellectual impairment. ■

The vast majority of those with mental retardation can become completely self-supporting with appropriate education and training. Public schools provide special programs for children and adolescents; even people with severe retardation are given instruction and training in practical self-help skills. Various approaches— behavioral therapy in particular—are used successfully to help people with mental retardation acquire needed “living” skills.

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Eating Disorders

I

’m not anorexic, I do eat. 3 meals a day, almost every day. Breakfast, lunch, dinner. So I tell myself, my friends, my parents, my boyfriend, I’m OK. “How can you accuse me? You see me eat, I’m not starving myself.” It’s amazing how much lettuce you can eat and keep below 100 calories, the soups you can make at 50–100 calories per serving. The meals you can make and show people you eat to calm them down. I’m a master at these meals. “I’m not anorexic, I do eat.” I’m 5’6 and 99 pounds, I know I’m skinny. I look at myself in the mirror, find the fat, find the places where more pounds can be shed, tell myself that I’m not unhealthy, I’m still safe, there is no reason to stop yet. . . . (Anonymous 5, 2008) I would eat crazy amounts of food. . . . I’d eat ten pieces of bread and butter, a box of crackers, two bowls of cereal, and anything else that was sitting around in the kitchen. It was like I was in an alcoholic trance and I couldn’t stop myself. In the morning I’d wake up thinking, I am so stupid. How can I be so stupid? (Jacobson & Alex, 2001, p. 1)

chapter outline Eating Disorders

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Etiology of Eating Disorders

454

Treatment of Eating Disorders

464

Obesity

467

Etiology of Obesity

469

Treatments for Obesity

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IM PLICA TION S

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CRITICAL THINKING

Anorexia’s Web Disturbed eating patterns, including bingeing, purging, and excessive dieting, and eating disorders, such as anorexia nervosa, bulimia nervosa, and binge-eating disorder, appear to be increasing in frequency. In this chapter we attempt to determine the reasons for the increase and consider the characteristics, associated features, etiology, and treatment of anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders NOS (not otherwise specified). We also cover obesity because it has important health implications and has been proposed as a category for DSM-V (Volkow & O’Brien, 2007).

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CRITICAL THINKING Is Our Society Creating Eating Disorders? 462 CONTROVERSY Are the

BMI Index Standards Appropriate?

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FOCUSQUESTIONS

1 What kinds of eating disorders exist?

4 What is obesity, and should it be included in DSM-V?

2 What are some causes of eating disorders?

5 What are some causes of obesity?

3 What are some treatment options for eating

6 What are some treatment options for obesity? 1

disorders?

Eating Disorders Eating disorders and disordered eating patterns are becoming more prevalent in the United States, even among children and adolescents (Marcus & Kalarchian, 2003). These behaviors appear to stem from dissatisfaction with body weight or shape. In a sample of 4,745 middle and high school students, many were unhappy with their bodies (41.5 percent of females; 24.9 percent of males) and had self-esteem issues due to body shape or weight (36.4 percent of female; 23.9 percent of males; Ackard, Fulkerson, & Neumark-Sztainer, 2007). Data from national surveys indicate that nearly 50 percent of adolescent females and 20 percent of adolescent males diet to control their weight. Weight concerns are so great that a reported 13.4 percent of girls and 7.1 percent of boys have engaged in disordered eating patterns (see Table 16.1). Factors associated with disordered eating patterns include excess weight, body dissatisfaction, low self-esteem, depression, substance use, and suicidal ideation (Neumark-Sztainer, Hannan, & Stat, 2000; T. D. Wade, 2007). It is unclear whether these factors are the result or the cause of disordered eating. Eating problems may be a result of the availability of many attractive high-calorie foods, of mass media, family, and peer influences, and of the American pursuit of thinness (Pelletier & Dion, 2007; Tiggemann & Kuring, 2004). Paradoxically, the increasing emphasis on thinness, especially for women, is occurring as the population of the United States is becoming heavier. Currently two-thirds of adults and 16 percent of children are overweight or obese (Wang & Beydoun, 2007). Studies indicate that from 30 to 67 percent of normal-weight adolescent girls and college females believe that they are overweight. Weight and body shape concerns exist not only among young white females but also among older women and minorities (Andersen, 2001; Gilbert, 2003). Rates of eating disorders are high among Hispanic American and Native American females and are increasing among immigrant and Asian American females (Gilbert, 2003; Lee & Lock, 2007; Sherwood, Harnack, & Story, 2000; Story et al., 1998; Wax, 2000). Although African American women are less likely than white women to have eating disorders, there is some indication that prevalence rates are increasing (Talleyrand, 2006). Although overeating and being overweight are more acceptable for men than for women, there is evidence of increasing body dissatisfaction in males. Weight dissatisfaction in adolescent boys and college males revolves around a desire to be heavier and more muscular (Farquhar & Wasylkiw, 2007; Ricciardelli & McCabe, 2004). Similar findings about weight were reported in a cross-cultural study involving college men in Germany, France, and the Text not available due to copyright restrictions United States. In the study (Pope et al., 2000), images of men with different degrees of fatness and muscularity were shown to a group of research participants. The males were asked to choose images that represented their own bodies, the bodies they would like to have, the body of an average man their age, and the male body they thought women preferred. In all three countries, the men picked an ideal body that was about twenty-eight pounds more muscular than their own. The participants also believed

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that women preferred a male body thirty pounds more muscular than their current bodies. In actuality, women indicated a preference for an ordinary male body without added muscle. The body dissatisfaction displayed by both men and women may be due to social comparison processes involving media images that few can achieve. In a study of advertisements in Sports Illustrated magazine from 1975 to 2005, male bodies portrayed were increasingly muscular and lean. When male adolescents were exposed to these types of images, they made more negative self-evaluations of themselves (Farquhar & Wasylkiw, 2007). Women’s magazines have also shown a dramatic increase in the number of ads displaying the male body. In contrast to the 1970s, when photos exposing men’s bodies generally involved men on beaches advertising bathing suits, ads today show undressed fit male bodies advertising electronics, telephones, furniture, and beverage products (Pope, Olivardia, Borowiecki, & Cohane, 2001). Perhaps the emphasis on the male body is responsible for the finding that between 6 and 7 percent of boys between the ages of fifteen and eighteen have taken anabolic steroids to gain more muscle mass (Kanayama, Pope, & Hudson, 2001). Disordered eating patterns because of preoccupation with weight and body dimensions sometimes become extreme and lead to an eating disorder—anorexia nervosa, bulimia nervosa, or binge-eating disorder (see Table 16.2). The lifetime

TA B L E

16.2

DISORDERS CHART

EATING DISORDERS

EATING DISORDER

SYMPTOMS

Anorexia Nervosa • Restricting

• Refusal to maintain body weight above the minimum normal weight for one’s age and height (is more than 15% below expected weight)

• Binge Eating/ Purging

• Intense fear of becoming obese, which does not diminish even with weight loss

Types:

PREVALENCE AND GENDER DIFFERENCES

AGE OF ONSET

Over 90% are white females; 0.5% to 0.9% prevalence rate

Usually after puberty or late adolescence

Over 90% are white females; 1–2% prevalence rate

Late adolescence or early adulthood

1.5 times more prevalent in females than males; about 30% in weight control clinics have this disorder; 0.7–4% prevalence rate

Late adolescence or early 20s

• Body image distortion (not recognizing one’s thinness) • In females, absence of at least three consecutive menstrual cycles otherwise expected to occur Bulimia Nervosa

• Recurrent episodes of binge eating

Types:

• Loss of control of eating behavior when bingeing

• Purging

• Use of vomiting, exercise, laxatives, or dieting to control weight

• Nonpurging

• Two or more eating binges a week, occurring for three or more months • Overconcern with body weight and shape Binge-Eating Disorder

• Recurrent episodes of binge eating

Proposed Category

• No regular use of inappropriate compensatory activities to control weight

• Loss of control of eating when bingeing

• Binge eating occurs two or more times a week for six months • Concern about the effect of bingeing on body shape and weight • Marked distress over binge eating

Source: Data from American Psychiatric Association (2000a); Hudson, Hiripi, Pope, & Kessler (2007); Walsh & Devlin (1998).

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prevalence rates for anorexia nervosa, bulimia nervosa, and binge-eating disorder are .9 percent, 1.5 percent, and 3.5 percent, respectively, for women and .3 percent, .5 percent, and 2.0 percent, respectively, for men (Hudson, Hiripi, Pope, & Kessler, 2007). In addition, up to 60 percent of individuals treated in eating disorder programs suffer from eating disorder NOS, another eating disturbance (Fairburn et al., 2007; Dalle Grave & Calugi, 2007). Unfortunately, disordered eating attitudes and behaviors are becoming more common and are occurring even in young children (Eddy et al., 2007; Jones et al., 2001).

Myth vs Reality Myth: Females and males can accurately judge the body shape preferred by members of the opposite sex. Reality: Female heterosexuals desire a body shape that is thinner than the body type preferred by heterosexual males. Male heterosexuals desire to have a more muscular body than that preferred by heterosexual females. Lesbian females appear to have fewer body image problems than heterosexual females, whereas gay males have greater body image concerns than heterosexual males.

Anorexia Nervosa Case Study Marya Hornbacher is an award-winning writer who fights a continuing battle with anorexia nervosa. She has written a book, Wasted, that chronicles the influences of sociocultural factors in the development of her eating disorder. At the age of eighteen, she weighed only fifty-two pounds and was so thin that she got bruises from lying in bed. As a fourth grader, Marya had become concerned about being “chubby,” and she experimented with vomiting to control her weight. She ate highly colored foods so that she could identify them after throwing up. Marya is healthier now but still underweight—and she continues to struggle with eating. Her anorexia has left her with a variety of physical ailments: her heart muscle has been weakened, her stomach and esophagus are lacerated, her bones are brittle, and her immune system has been weakened. The disease has probably shortened her lifespan. Although fighting anorexia is difficult, Marya still believes that “it’s your choice. . . . We are not just victims of external disease—we have choices.” (Marshall, 1998, p. D2)

an eating disorder characterized by low body weight, an intense fear of becoming obese, and body image distortion

anorexia nervosa

Anorexia nervosa is characterized by a refusal to maintain a body weight above the minimum normal weight for one’s age and height; an intense fear of becoming obese that does not diminish with weight loss; body image distortion; and, in females, the absence of at least three consecutive menstrual cycles otherwise expected to occur. Individuals with this bizarre and puzzling disorder literally engage in selfstarvation. Those with anorexia nervosa weigh themselves repeatedly and eat only small quantities of certain low-calorie foods (National Institute of Mental Health [NIMH], 2007d). Although anorexia nervosa has been recognized for more than one hundred years, it is receiving increased attention owing to greater public knowledge of the disorder and the apparent increase in its incidence. The disorder occurs primarily in adolescent girls and young women, with most cases occurring between the ages of fifteen and seventeen (American Psychiatric Association, 2000a; Walsh & Devlin, 1998). Although a minority of men also develop this disorder, they are more likely to display “reverse anorexia”—a belief that they are “too small.” A major concern with anorexia nervosa is that it is associated with serious medical complications. The mortality rate of up to 19 percent is the highest for any major psychiatric disorder, with many deaths occurring suddenly, usually from ventricular arrhythmias (Andersen, 2007; Panagiotopoulos, McCrindle, Hick, & Katzman, 2000). In fact, Sao Paulo, Brazil, received recent attention when, within a period of two months,

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four young women (two students, a manicurist, and a model) all died of complications from anorexia nervosa (Rohter, 2006). A very frightening characteristic of anorexia nervosa is that most people with this disorder, even when clearly emaciated, continue to insist they are overweight. Others will acknowledge that they are thin but claim that some parts of their bodies are “too fat.” They may measure or estimate their body size frequently and believe that weight loss is a sign of achievement and that gaining weight is a failure of selfcontrol (American Psychiatric Association, 2000a). One eighteen-year-old woman with anorexia nervosa vomited up to ten times daily, took laxatives, and exercised four hours each day. Yet when her friends said, “You look sick,” or “You need to eat,” she viewed their comments as a sign of jealousy (Tarkan, 1998). Other times, peers will inadvertently provide reinforcement by expressing admiration for thinness. One woman, Rachel, hid her thin starving body under layers of bulky clothing. Some of her friends commented positively on her figure, which increased her determination to starve (Holahan, 2001). In most cases, the body image disturbance is profound. As one researcher (Bruch, 1978, p. 209) noted more than thirty years ago, people with this disorder “vigorously defend their often gruesome emaciation as not being too thin. . . . They identify with the skeleton-like appearance, actively maintain it, and deny its abnormality.” Some patients incorporate characteristics of disordered eating into their identities and are reluctant to give up the drive for thinness. At times, competition develops in treatment settings, with patients competing in terms of who is the thinnest, who ate the least, or who exercised the most (Bulik & Kendler, 2000). During the early part of the disorder, individuals with anorexia nervosa generally have only limited recognition of their disorder and may consider their symptoms as ego-syntonic—that is, their symptoms seem normal to them (American Psychiatric Association, 2000a). Subtypes of Anorexia Nervosa There are two subgroups of patients with anorexia nervosa: the restricting type and the binge-eating/purging type. The restricting type accomplishes weight loss through dieting or exercising. The binge-eating/purging type loses weight through the use of self-induced vomiting, laxatives, or diuretics, often after binge eating. In one study of 105 patients hospitalized with this disorder, 53 percent had lost weight through constant fasting (restricting type); the remainder had periodically resorted to binge eating followed by purging or vomiting (binge-eating/purging type). Although both groups vigorously pursued thinness, they differed in some aspects. Those with restricting anorexia were more introverted and tended to deny that they suffered hunger and psychological distress. Those with the binge-eating/purging type were more extroverted. They reported more anxiety, depression, and guilt; admitted more frequently to having a strong appetite; and tended to be older (Halmi et al., 2000). Physical Complications Self-starvation produces a variety of physical complications along with weight loss. Patients with anorexia often exhibit cardiac arrhythmias because of electrolyte imbalance; most have low blood pressure and slow heart rates. They may be lethargic, have dry skin and brittle hair, show hypertrophy of the parotid glands (from purging) that results in a chipmunk-like face, and exhibit hypothermia (NIMH, 2007d). For example, one woman had to wear heavy clothing even when the temperature was over ninety degrees (Bryant, 2001). Irreversible osteoporosis, vertebra contraction, and stress fractures are also significant complications of the disorder. Males with the bulimic type of anorexia are also prone to osteoporosis and are more likely than women to have comorbid substance use disorder and antisocial personality (American Psychiatric Association, 2000a). In addition, the heart muscle is often damaged and weakened because the body may use muscles as a source of protein during starvation.

ANOREXIA CLAIMS A VICTIM Ana Carolina Reston died with a body mass index of 13.4; an index of 18.5 is considered underweight. She was one of four young women from Sao Paulo, Brazil, who died within a two-month period due to anorexia. How can those with severe anorexia nervosa not realize they are starving themselves to death?

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critical thinking

Anorexia’s Web Drink ice-cold water (“Your body has to burn calories to keep your temperature up”) and hot water with bullion cubes (“only 5 calories a cube, and they taste wonderful”; Springen, 2006, p. 1). “Starvation is fulfilling. Colors become brighter, sounds sharper, odors so much more savory and penetrating. . . . The greatest enjoyment of food is actually found when never a morsel passes the lips” (Irizarry, 2004). “I will be thin, at all costs, it is the most important thing, nothing else matters” (Ana Creed; Bardone-Cone & Cass, 2007).

These tips to reduce caloric intake, testimonials on the satisfaction of not eating, and creeds or rules to remain thin are part of the numerous pro-ana (anorexia) and pro-mia (bulimia) Web sites. Many of them describe eating disorders as an acceptable lifestyle. Some of the names used in online discussion groups include “thinspiration,” “puking pals,” “disappearing acts,” “anorexiangel,” and “chunkeee monkeee.” Web anorexia support group members contend that celebrities such as Mary-Kate Olsen, Nicole Richie, and Kate Moss are fine at their weight and do not need to be treated for eating disorders. The Web sites include pictures of ultra-thin models, tips for dieting, and ways to conceal thinness from family members and friends. They provide a circle of friends and encouragement. In one study, 43 percent of those who visited the Web sites indicated that they received emotional support. “I kind of lost all of my friends at school and in my neighborhood but I still have my pro-ana and pro-mia friends” (Csipke & Horne, 2007, p. 202). In response to before and after (thinner) pictures on the Web, one person wrote: “You’re my thinspiration! How did you do it?” Another responded, “Your collarbones are beautiful—nice job” (Hayley, 2004, p. 1). Participants on the Anorexic Nation Web site talk about how it is important to have friends who are like them and argue that anorexia is a lifestyle choice and not an illness. A woman on one site writes, “I am very much for anorexia and this webpage is a reflection of that. If you are recovered or recovering from an eating disorder, please, please, PLEASE do not visit my site. I can almost guarantee it will trigger you! But if you are like me and your eating disorder is your best friend and you aren’t ready to give it up, please continue” (Hellmich, 2001, p. 3).

Such Web sites are visited by thousands of people each day and used frequently by adolescents with eating disorders, who reported learning new weight loss and purging methods (Wilson et al., 2006). Medical experts are deeply concerned that the sites will produce a surge in eating-disorder cases, especially among susceptible individuals. Judy Sargent, who is recovering from the disorder, says, “These sites don’t tell you that you’re going to die if you don’t get treatment” (“Anorexia’s Web,” 2001, p. 2). Eating disorder organizations have been alarmed by these sites and have petitioned Yahoo! and other hosts to remove the forums; however, many sites simply switched to other servers. Although individuals with eating disorders generally gain a feeling of support when visiting these Web sites, how much danger do they pose to people with and without eating disorders? Should eating disorders be considered a lifestyle choice? Course and Outcome Anorexia nervosa tends to develop during adolescence, and the course is highly variable. Individuals with the bingeing/purging type may have a better outcome. However, the course and outcome of anorexia nervosa may also be influenced by the reason for the behavior. People with anorexia may form a heterogeneous group, with some developing the disorder because they fear their impulses and want to attempt to prove they can regulate them; others as an act of competitiveness or out of a sense of achievement; others as a form of self-punishment or a means of demonstrating control over one aspect of their lives. A difficulty in attempting to determine outcome by anorexia nervosa type is that many patients who have the restricting type later develop the binge-eating/purging subtype. The course of anorexia nervosa is highly variable, with some recovering after one episode, others showing a fluctuating pattern of weight gain and relapse, and others having a chronic and deteriorating course (American Psychiatric Association, 2006). In a five-year follow-up study of ninety-five female patients age fifteen and older with anorexia, 59 percent of the patients initially had the restricting type and 41 percent the binge-eating/purging type. At follow-up, over 50 percent no longer had a diagnosable eating disorder, although most still showed disturbed eating patterns, poor body image, and psychosocial difficulties (Ben-Tovim et al., 2001). A study of the five-year clinical recovery rate (clinical recovery within five years as evidenced by absence of bingeing and purging, restoration of weight, and menstruation for at least one year) in Finnish women with anorexia nervosa was even more promising. Two-thirds had reached either complete or nearly complete recovery, resembling healthy women in weight and on psychological measures (Keski-Rahkonen et al., 2007).

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Unfortunately, even with the severe health and emotional damage associated with the disorder, support groups advocating anorexia as a lifestyle choice have appeared on the Internet (Wilson et al., 2006). Associated Characteristics A number of mental disorders (depression, anxiety, and obsessive-compulsive disorders) are comorbid with anorexia nervosa. Some investigators believe that women with anorexia nervosa strive for perfection and control over some aspect of their lives: “I’m not eating now and it’s kind of a control thing . . . at least I have control over what I’m eating” (Budd, 2007, p. 100). Another individual noted, “Nothing could prevent my will from controlling my body” (Segall, 2001, p. 22). Obsessive-compulsive behaviors and thoughts that may or may not involve food or exercise are often reported (Rogers & Petrie, 2001). One woman developed obsessive thoughts and behaviors about food. She feared that touching or even breathing around food would cause her to gain weight (Bulik & Kendler, 2000). The manner in which these symptoms are related to anorexia nervosa is unclear because of the possibility that malnutrition or starvation may cause or exacerbate obsessive symptoms. Some researchers believe that anorexia nervosa is a variant of obsessive-compulsive disorder. In one study, a somewhat higher frequency of obsessive-compulsive disorder was found among first-degree relatives of anorexia probands than in a group of comparison participants (Bellodi et al., 2001). Personality disorders and other characteristics have also been linked to anorexia nervosa, although the restricting and binge-eating/purging types may differ in the characteristics with which they are linked. As noted earlier, the restricting type is more likely to be linked to traits of introversion, conformity, perfectionism, and rigidity, whereas the bingeing/purging type is more likely to be associated with extroverted, histrionic, emotionally volatile personalities, impulse control problems, and substance abuse. Interpreting these relationships has been difficult, as they could (1) represent the misfortune of having two or more disorders by chance, (2) indicate that anorexia is an expression of a personality disorder, or (3) be the result of common environmental or genetic factors that underlie both anorexia and the personality disorder (Westen & Harnden-Fischer, 2001).

Bulimia Nervosa Case Study “At first, after eating too much, I would just go to the toilet and make myself sick. I hadn’t heard of bulimia. … I started eating based on how I was feeling about myself. If my hair looked bad, I’d stuff down loads of candy. After a while, I started exercising excessively because I felt so guilty about eating. I’d run for miles and miles and go to the gym for three hours.” (Dirmann, 2003, p. 60)

Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating (the rapid consumption of large quantities of food) at least twice a week for three months, during which the person loses control over eating. Two subtypes exist: the purging type, in which the individual regularly vomits or uses laxatives, diuretics, or enemas; and the nonpurging type, in which excessive exercise or fasting are used in an attempt to compensate for binges. A persistent overconcern with body image and weight also characterizes this disorder. Eating episodes may be stopped when abdominal pain develops or when vomiting is induced (American Psychiatric Association, 2000a). Individuals with bulimia nervosa judge themselves almost exclusively on their eating and in terms of body shape and weight. They have maladaptive beliefs such as “I am a failure because I am fat” (Jones, Leung, & Harris, 2007). Compared with women at similar weight levels but without the disorder, women with bulimia exhibited more psychopathology, a greater external locus of control, lower self-esteem, and a lower sense of personal effectiveness (Shisslak, Pazda, & Crago, 1990; Williams, Taylor, & Ricciardelli, 2000).

an eating disorder characterized by recurrent episodes of the rapid consumption of large quantities of food, a sense of loss of control over eating combined with purging (vomiting, use of laxatives, diuretics, or enemas), and/ or excessive exercise or fasting in an attempt to compensate for binges

bulimia nervosa

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Did You Know?

M

illions of Americans underwent cosmetic procedures in 2007 to enhance their appearance. How many of these procedures may be an attempt to achieve standards of beauty portrayed in mass media? • Liposuction: 458,828 • Breast augmentation: 399,440 • Blepharoplasty (cosmetic eye surgery): 240,763 • Abdominoplasty (tummy tuck): 185,335 • In addition, 2,775,176 Americans had botox injections Source: American Society for Aesthetic Plastic Surgery (2008).

Those with bulimia realize that their eating patterns are not normal and are frustrated by that knowledge. They become disgusted and ashamed of their eating and hide it from others. The binges, characterized by rapid consumption of food, typically occur in private. Some eat nothing during the day but lose control and binge in the late afternoon or evening. A loss of self-control when eating is characteristic of this disorder, and it is difficult to stop eating once a binge has begun. Consequences of binge eating are controlled through vomiting or the use of laxatives, which produce feelings of relief from physical discomfort and the fear of gaining weight, often followed by feelings of shame and despair. Those with the nonpurging type of bulimia often follow overeating episodes with a commitment to a severely restrictive diet, fasting, or engaging in excessive exercising or physical activity (NIMH, 2007d). Bulimia is much more prevalent than anorexia. The lifetime prevalence rate for bulimia nervosa, which often begins in adolescence, is up to 2 percent in women (Hudson, Hiripi, Pope, & Kessler, 2007; Van Hoeken, Seidell, & Hoek, 2003). An additional 10 percent of women report some symptoms but do not meet all the criteria for the diagnosis. The incidence of bulimia appears to be increasing in women and is especially prevalent in urban areas. Fewer males exhibit the disorder, presumably because there is less cultural pressure for them to remain thin, although it is estimated that about 10 percent of those affected by this disorder are males (American Psychiatric Association, 2000a). A person’s weight seems to have little to do with whether the individual develops bulimia. Most are within the normal weight range (Mehler, 2003). Of a sample of forty women with the disorder, twenty-five were of normal weight, two were overweight, one was obese, and twelve were underweight. These women averaged about twelve binges per week, and the estimated calories consumed in a binge could be as high as 11,500. Typical binge foods were ice cream, candy, bread or toast, and donuts (Gordon, 2001). Physical Complications As noted earlier, people with bulimia use a variety of measures—fasting, self-induced vomiting, diet pills, laxatives, and exercise—to control the weight gain that accompanies binge eating. More than 75 percent of patients with this disorder practice self-induced vomiting (McGilley & Pryor, 1998). Side effects and complications may result from this practice or from the excessive use of laxatives. The effects of vomiting include erosion of tooth enamel from vomited stomach acid; dehydration; swollen parotid glands, which produces a puffy facial appearance; and lowered potassium, which can weaken the heart and cause arrhythmia and cardiac arrest (American Dietetic Association, 2001; Mehler, 2003). In rare cases, binge eating can cause the stomach to rupture. Other possible gastrointestinal disturbances include inflammation of the esophagus and gastric and rectal irritation. Associated Features Individuals with bulimia eat not only out of hunger but also as an emotionally soothing response to distressing thoughts or external stressors. As noted earlier, women with this disorder tend to be more likely to perceive events as stressful. There appears to be a close relationship between emotional states and disturbed eating patterns. As one woman stated, “Purging was the biggest part of my day. . . . It was my release from the stress and monotony of my life” (Erdely, 2004, p. 117). Weight preoccupation is also related to the type of coping response an individual shows to life stressors. In a nonclinical sample of university women, those who responded emotionally when facing stressful situations (e.g., “Get angry,” “Wish I could change what happened”) were more preoccupied with weight than women who responded in a task-oriented style (e.g., “Outline my priorities,” “Think about how I solved problems”; Denisoff & Endler, 2000). A task-oriented approach may diminish stress and, therefore, reduce the need to use food to control one’s emotional state. A number of mental disorders and features are comorbid with bulimia nervosa. Mood disorders are common, and rates of seasonal affective disorder, a syndrome

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characterized by depression during the dark winter months followed by remission during the spring and summer months, are higher among those with bulimia nervosa than in the general population (Lam et al., 2001). Characteristics of borderline personality, such as impulsivity, substance abuse, and affective instability, are also found in individuals with bulimia nervosa, although many with this disorder show little evidence of personality disturbances. There may be several subtypes of bulimia nervosa with different etiologies (Wonderlich et al., 2007). Interpreting the meaning of coexisting conditions is difficult because characteristics such as depression and borderline personality may precede the eating disorder or they may be the consequence of the eating disorder. Course and Outcome Bulimia nervosa has a somewhat later onset than anorexia nervosa, beginning in late adolescence or early adult life. Outcome studies have shown a mixed course, although the prognosis is more positive than for anorexia nervosa. In a five-year community study of 102 participants with bulimia nervosa, only a minority still met the criteria for the disorder at the end of the study period. However, each year about one-third would remit, and another one-third would relapse. Most continued to show disturbed eating patterns and low self-esteem, and 40 percent met the criteria for a major depressive disorder (Fairburn et al., 2000). Another five-year study of individuals with bulimia nervosa reported a more positive outcome. Almost three-fourths had no diagnosable eating disorder at the end of the study (Ben-Tovim et al., 2001). The findings of a longer follow-up study (ten years) also revealed generally positive outcomes. About 70 percent were in either partial or full remission; 11 percent met the full criteria for bulimia nervosa, 0.6 percent for anorexia nervosa, and 18.5 percent for eating disorder not otherwise specified. A history of substance use and a longer duration before treatment were associated with a poorer outcome (Keel, Mitchell, Miller, Davis, & Crow, 1999).

Binge-Eating Disorder Case Study Ms. A was a thirty-eight-year-old African American woman who was single, lived alone, and was employed as a personnel manager … she weighed 292 lb. … Her chief reason for coming to the clinic was that she felt her eating was out of control and, as a result, she had gained approximately 80 lb over the previous year. … A typical binge episode consisted of the ingestion of two pieces of chicken, one small bowl of salad, two servings of mashed potatoes, one hamburger, one large serving of french fries, one large chocolate shake, one large bag of potato chips, and 15 to 20 small cookies—all within a 2-hour period … she was embarrassed by how much she was eating, and felt disgusted with herself and very guilty after eating. (Goldfein, Devlin, & Spitzer, 2000, p. 1052)

Binge-eating disorder (BED) is a diagnostic category that has been “provided for further study” in DSM-IV-TR (American Psychiatric Association, 2000a). Further research will be conducted to determine whether BED should be adopted as a distinct diagnostic category in DSM-V. The disorder is similar to bulimia nervosa in that it involves the consumption of large amounts of food over a short period of time, an accompanying feeling of loss of control, and “marked distress” over eating during the episodes. However, in BED, the episodes are not generally followed by “the regular use of compensatory behaviors” such as vomiting, excessive exercise, or fasting. As in the case of bulimia nervosa, the individual with this disordered eating pattern eats large amounts of food, is secretive about this activity, and may eat large amounts even when not hungry. To be diagnosed with BED, an individual must have a history of binge-eating episodes at least two days a week for six months. Females are one and a half times more likely to have this disorder than males; its lifetime prevalence rate is 3.5 percent in women and 2.0 percent in men (Hudson, Hiripi, Pope, & Kessler, 2007). White women make up the vast majority of clinical cases, whereas in community samples,

binge-eating disorder (BED)

an eating disorder that involves the consumption of large amounts of food over a short period of time, an accompanying feeling of loss of control, and distress over the excess eating without regular inappropriate compensatory behavior.

FIGURE

C H A P T E R 1 6 • EATING DISORDERS 5

16.1 BINGE-EATING

DISORDER Scores on subscales of the Eating Disorder Questionnaire by African American and white women with or without binge-eating disorder. Source: Pike et al. (2001).

4 Mean subscale score

452

3

2

1

0

Eating concern

Dietary restraint

Shape concern

Weight concern

Eating disorder examination questionnaire subscale African American women with bingeeating disorder

White American women with bingeeating disorder

African American comparison subjects

White American comparison subjects

the percentages of African American and white women with BED are roughly equal (Wilfley et al., 2001). Differences have been found between African American and white women with BED. The former are less likely to have been treated for eating problems, are more likely to be obese, and show lower levels of eating, weight concerns, and psychiatric distress (Pike et al., 2001) (see Figure 16.1). American Indian women also appear to be at higher risk for BED, with a 10 percent prevalence rate reported in one study (Sherwood et al., 2000). Associated Characteristics In contrast to those with bulimia nervosa, individuals suffering from binge-eating disorder are likely to be overweight (Bull, 2004). It is believed that BED is a contributor to the development of obesity in vulnerable individuals (Yanovski, 2003). It is estimated that from 20 to 40 percent of individuals in weight-control programs have BED. The risk factors associated with this disorder include adverse childhood experiences, parental depression, vulnerability to obesity, and repeated exposure to negative comments from family members about body shape, weight, or eating (Fairburn et al., 1998; Wilfley, Wilson, & Agras, 2003). The binges are often preceded by poor mood, low alertness, feelings of poor eating control, and cravings for sweets (Greeno, Wing, & Shiffman, 2000; Hilbert & Tuschen-Caffier, 2007). The complications from this disorder are due to medical conditions associated with obesity, such as high blood pressure, high cholesterol level, and Type 2 diabetes. People with BED are also likely to suffer from depression (Hoffman, 1998; T. D. Wade, 2007). As with the other eating disorders, comorbid features and mental disorders are associated with BED. In one study comparing 162 individuals with BED with other psychiatric samples, the lifetime rate for major depressive disorder, obsessive-compulsive personality disorder, and avoidant personality disorder was higher among those with BED. The presence of personality disorders was related to more severe binge eating, and those with avoidant or obsessive-compulsive personality disorders reported higher rates of binge eating one year after treatment (Wilfley et al., 2000). (See Table 16.3 for questions you might ask to assess for an eating disorder.) Course and Outcome The onset of binge-eating disorder is similar to that of bulimia nervosa in that it typically begins in late adolescence or early adulthood. The findings are mixed regarding the natural course of BED in women. In one

Eating Disorders

sample, the average duration of the disorder was 14.4 years (Pope et al., 2006). However, in another study, most individuals with BED made a full recovery over a five-year period, even without treatment, with only 18 percent demonstrating an eating disorder of clinical severity versus 51 percent of the bulimia nervosa cohort. They also showed improved self-esteem and higher social functioning. However, their weight remained high, and 39 percent eventually met the criteria for obesity (Fairburn et al., 2000).

Eating Disorder Not Otherwise Specified According to DSM-IV-TR (American Psychiatric Association, 2000a), the category eating disorder not otherwise specified (NOS) is for seriously disturbed eating patterns that do not meet all the criteria for anorexia or bulimia nervosa. It currently includes the proposed category of binge-eating disorder. Examples of disordered eating that would fit in this category are (American Psychiatric Association, 2000a): 1. A female who meets all the criteria for anorexia nervosa but has regular menses. 2. An individual who meets all the criteria for anorexia nervosa and has lost a significant amount of weight but is in the normal weight range. 3. An individual who engages in binge eating and compensatory activities less than twice a week or who has engaged in these behaviors for less than three months. 4. An individual of normal weight who uses compensatory behaviors even after ingesting small amounts of food (vomiting after eating a candy bar). 5. A person who chews or spits out large amounts of food without ingesting the food. 6. A person with binge-eating disorder (proposed category discussed earlier).

TA B L E

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16.3

DO YOU HAVE AN EATING DISORDER? QUESTIONS FOR POSSIBLE ANOREXIA NERVOSA

1. Are you considered to be underweight by others? (What is your weight?) (Screening question. If yes, continue to next questions.) 2. Are you intensely fearful of gaining weight or becoming fat even though you are underweight? 3. Do you feel that your body or a part of your body is too fat? 4. If you had periods previously, have they stopped? QUESTIONS FOR POSSIBLE BULIMIA NERVOSA

1. Do you have binges in which you eat a lot of food? (Screening question. If yes, continue to next questions.) 2. When you binge, do you feel a lack of control over eating? 3. Do you make yourself vomit, take laxatives, or exercise excessively because of overeating? 4. Are you very dissatisfied with your body shape or weight? QUESTIONS FOR POSSIBLE BINGE-EATING DISORDER

1. Do you have binges in which you eat a lot of food? 2. When you binge, do you feel a lack of control over eating? 3. When you binge, do three or more of the following apply? a. b. c. d. e.

You eat more rapidly than usual. You eat until uncomfortably full. You eat large amounts even when not hungry. You eat alone because of embarrassment from overeating. You feel disgusted, depressed, or guilty about binge eating.

4. Do you feel great distress regarding your binge eating? Note: These questions are derived from the diagnostic criteria for DSM-IV-TR (American Psychiatric Association, 2000a). For anorexia nervosa, the individual’s weight is less than 85 percent of the expected weight for age and height; for bulimia nervosa the binges must occur, on average, about twice a week for three months; and for binge eating the binges must occur, on average, at least two days a week for six months. If the full criteria for these disorders are not met and disturbed eating patterns exist, they may represent subclinical forms of the eating disorders or may be diagnosed as eating disorder not otherwise specified (NOS).

Eating disorder NOS, the diagnosis received by up to 60 percent of individuals in eating disorders treatment programs (Andersen, Bowers, & Watson, 2001; Dalle Grave & Calugi, 2007), is a problematic diagnostic category. The category includes such a heterogeneous grouping of symptoms that managed care companies often refuse to cover the diagnosis. There have been proposals to include binge-eating disorder as a separate diagnosis and to eliminate some of the restrictive criteria for anorexia nervosa and bulimia nervosa. Women with eating disorders NOS have more weight and shape concerns, dietary restraints, and depressive feelings than controls but less so than women with bulimia nervosa (T. D. Wade, 2007).

eating disorder not otherwise specified (NOS) a category for

individuals with problematic eating patterns who do not fully meet the criteria for one of the eating disorders; currently includes bingeeating disorder

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Etiology of Eating Disorders The etiology of eating disorders is believed to be determined by biological, psychological, social, and sociocultural factors (Becker, 2004; Tylka & Subich, 2004). Figure 16.2 presents the multipath model delineating some of the risk factors for eating disorders. Usually, it is a combination of variables rather than a single factor that produces an eating disorder, and this combination may differ for specific individuals. In this section we present some of the etiological factors involved.

Biological Dimension Genetic influences may contribute to eating disorders, as disordered eating appears to run in families, especially among female relatives (Hoffman, 1998; Steiger & Bruce, 2007). Strober and colleagues (2000) examined the lifetime rates of full or partial anorexia nervosa and bulimia nervosa among first-degree relatives of patients with these eating disorders. The rate was compared with that of relatives of matched, never-ill comparison participants. Support was found for a genetic contribution to the disorders. Whereas anorexia nervosa and bulimia nervosa were relatively rare among the relatives of the never-ill group, these disorders occurred at significantly high levels among the first-degree relatives of those with eating disorders. Kendler, MacLean, and their associates (1991) examined identical and fraternal twins to estimate the role of genetics in bulimia nervosa. They reported concordance rates of 22.9 percent and 8.7 percent, respectively, which suggested a modest genetic influence. Wade, Bulik, Sullivan, Neale, and Kendler (2000) also believe that some common genetic factors exist for binge eating and bulimia among female twins. However, the genetic influences may be triggered by physical changes such as puberty. In a sample of twins, heritability appeared to be low among preadolescent teens but was substantial after reaching puberty. This suggests that puberty may influence the expression of genes for disordered eating (Klump et al., 2007). The genetic influence may involve neurotransmitters or brain structures, such as the hypothalamus, which are involved in eating behaviors. Current research has focused on dopamine, which is thought to be the primary neurotransmitter

FIGURE

16.2 MULTIPATH

MODEL FOR EATING DISORDERS The dimensions interact with one another and combine in different ways to result in an eating disorder.

Biological Dimension • Genetic factors • Neurological or neurotransmitter vulnerabilities • Obesity/overweight/pubertal weight gain

Sociocultural Dimension

Psychological Dimension

• Social comparison • Media: TV, magazines presenting distorted images • Cultural definitions of beauty • Objectification: female and male bodies evaluated through appearance

• Body image/dissatisfaction/ distortions • Low self-esteem; lack of control • Perfectionism or other personality characteristics • Childhood sexual or physical abuse

EATING DISORDER

Social Dimension Parental attitudes and behaviors Parental comments regarding appearance Weight-concerned mothers History of being teased about size or weight • Peer pressure regarding weight/eating • • • •

Etiology of Eating Disorders

involved in the reinforcing effects of food. Low levels of dopamine are responsible for the desire to consume more food, whereas increased dopamine concentrations can result in a decrease in appetite. Some studies have reported differences in the dopamine transporter gene between individuals with eating disorders and healthy controls, with the short allele of the gene being more prevalent among individuals with eating disorders. The researchers (Shinohara et al., 2004) concluded that there is an association between individuals with short or long alleles in this gene and dopamine levels. People with lower levels of dopamine may need greater quantities of food or other rewarding substances, such as drugs, to obtain pleasure. The possible influence of dopamine in eating disorders is being further investigated by examining drugs that affect dopamine levels. For example, some stimulant medications such as methylphenidate inhibit dopamine reuptake and appear to decrease appetite (Epstein et al., 2007). Although dopamine seems like a promising lead in explaining eating disorders, other neurotransmitters and brain regions appear to be involved. Individuals with anorexia nervosa presented with highly palpable foods showed different activation pattern of the prefrontal region of the brain compared with controls (Treasure, 2007). The participants with anorexia nervosa also showed less salivation to food cues and reported a lower preference for fat and sweet substances than did control participants. Indeed, in the Epstein et al. (2007) study, some individuals with the short allele of the dopamine gene tended to be ambivalent about eating, whereas others without this genetic variation responded very strongly to food. It is also possible that changes in eating patterns can alter the amount of specific neurotransmitters in the brain. Although these studies indicate the involvement of genetic and biological factors, more research is needed to determine the precise relationship between genetic factors, brain centers, neurotransmitters, and environmental influences.

Psychological Dimension Individuals with eating disorders often display excess concern regarding body image, fragile or low self-esteem, moderate levels of depression, and feelings of helplessness; they appear to use food or weight control as a means of handling stress or anxieties (Schwitzer et al., 2001; Walsh & Devlin, 1998). One anorexic woman stated, “90 percent of you is miserable, and 90 percent of you is depressed, but then there is 10 percent that has this satisfaction in knowing that you weigh such a low weight and that you are getting thinner” (Budd, 2007, p. 102). The element of control appears to provide some satisfaction in dealing with stress. Alternately, binge eating as a source of comfort can be used to counteract depression and other negative emotions (Bergstrom & Neighbors, 2006). Dysfunctional beliefs such as “I am a failure because I am fat” also accompany and help maintain eating disorders (Waller et al., 2003; Jones et al., 2007). Women with bulimia nervosa show more weight and shape concerns, dietary restraint, lifetime major depression, and suicidality as compared with those with eating disorders NOS (T. D. Wade, 2007). Individuals with anorexia have been described as perfectionistic, obedient, good students, excellent athletes, and model children. It is hypothesized that people with eating disorders evaluate themselves according to selfimposed personally demanding standards such as grades and performance. Dieting and weight standards may be similarly imposed (Bardone-Cone & Cass, 2007). Among African American women, body mass, body dissatisfaction, and low selfesteem are related to bulimic symptoms such as binge eating (Lester & Petrie, 1998; Talleyrand, 2006). For both men and women, higher scores on characteristics such as passivity, low self-esteem, dependence, and nonassertiveness are associated with higher scores on disordered eating. Dieting may be used to demonstrate self-control and improve self-esteem and body image (Budd, 2007; Lakkis, Ricciardelli, & Williams, 1999). Another line of inquiry has interested some researchers. Rates of affective disorders such as depression are higher in the relatives of individuals with eating

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BODY CONSCIOUSNESS Females are socialized to be conscious of their bodies. While most of the attention has been directed to concerns over appearance among young white females, rates of disordered eating and body dissatisfaction are also high among Hispanic American and American Indian girls.

disorders compared with controls, and some investigators believe that eating disorders represent an expression of an affective disorder (Rutter, MacDonald, et al., 1990). Mood disorders often accompany eating disorders. One interesting finding is that binge eating, purging, and mood have been found to vary seasonally among patients with bulimia nervosa (Blouin et al., 1992). The researchers hypothesize that, as noted earlier, for some people, a relationship between bulimia and seasonal affective disorder may exist. The cycle of bingeing and purging may be associated with light availability. At this point, we still do not know the precise relationship between affective disorders and eating disorders. Some therapists believe that depression is the result, not the cause, of anorexia or bulimia (Vanderlinden, Norre, & Vandereycken, 1992). Although it is widely believed that sexual abuse is a major causal factor in eating disorders, several studies have failed to find such a connection (Conners & Morse, 1993; Pope & Hudson, 1992; Pope et al., 1994). Sexual abuse may be indirectly related to eating disorders in that it produces body disparagement or bodily shame, which affects body image (Tripp & Petrie, 2001). Individuals with eating disorders judge themselves exclusively on their eating, shape, weight, or ability to control these elements (Jones et al., 2007).

Social Dimension

IDEAL MALE BODIES? Most males prefer to be heavier and more muscular. Will the exposure in the media of physically powerful men produce body image distortion and dissatisfaction among men?

Interpersonal interaction patterns with parents and peers have also been put forth as explanations for eating disorders. The early psychodynamic formulation, which was based primarily on anorexia nervosa, hypothesized the following family characteristics. The girl with the disorder has problems with maturation. She is afraid of having to grow up, which would lead to having to separate from her family and develop her own identity. By staying thin and not menstruating, she fulfills the unconscious desire to remain a child (Bruch, 1978; Halmi et al., 2000; Sands, 2003). Unfortunately, the reported findings regarding psychodynamic formulations are difficult to interpret. Most are based on case studies or family systems theory or depend on the perception of family members regarding their

Etiology of Eating Disorders

relationships—family patterns may be the result of dealing with an eating disorder rather than the cause. Parents may become more “controlling” in an attempt to force the person with the eating disorder to gain weight or to establish a healthier eating pattern. Interestingly, in one form of family therapy, the adolescent with anorexia nervosa is seen as no longer capable of making sound choices regarding his or her health; the therapist encourages this responsibility to be temporarily taken over by the parents (Sim et al., 2004). Few empirical studies involving the observation of families with a member who has an eating disorder exist. We need to test the different theories or observations to determine whether any of the actual or perceived characteristics related to eating disorders are accurate. At this point we do not know whether the described “family characteristics should be considered cause, consequence, or means of coping with an eating disorder” (Herzog et al., 2000, p. 360). Socialization agents such as peers or family members can produce pressure to be thin by engaging in criticism of weight, encouragement to diet, and the glorification of ultra-slim models (Annus et al., 2007; Stice & Bearman, 2001). Perceived pressure from family, friends, dating partners, or the media to have a slender figure has been associated with the internalization of a thin ideal and feelings of depression. One woman remembered her mother telling her to “suck in your gut” (Budd, 2007). These messages result in body dissatisfaction and the view that “one should be able to diet or exercise to lose weight”—in other words, that obtaining a slim figure is under voluntary control. Later, eating “too much,” unsuccessful dieting, and guilt from purging or loss of control contributes to depressive feelings. Being teased about weight is also reported by women with eating disorders. A woman relayed that her childhood nickname was “Checker.” It was not until she was a teenager that her mother told her the name came from Chubby Checker (Goldfein et al., 2000). This revelation increased the young woman’s sensitivity about her weight. Teasing and criticism about body weight or shape by family members has been found to predict ideal-body internalization, body dissatisfaction, dieting, and eating problems (Vincent & McCabe, 2000). Other family and peer relationships are associated with eating disorders. Peer relationships can either serve as a buffer against eating disorders or produce pressure to lose weight. Girls exist in a subculture in which thinness is emphasized and weight issues are frequently discussed. Nearly 50 percent of adolescent girls in one study reported being encouraged to lose weight by their mothers, friends, or sisters (Mukai, 1996). Mothers who diet also indirectly transmit the message of the importance of slimness and the thin ideal to their daughters. Class differences have also been found. Adolescent girls from higher socioeconomic status families had a greater awareness and acceptance of societal ideals of slimness (Wardle et al., 2004). For boys, peer and father encouragement to lose weight was related to more severe disordered eating patterns. In general, it was the direct influences of family and peers rather than the quality of these relationships that predicted body dissatisfaction and disordered eating in both adolescent boys and girls (Vincent & McCabe, 2000).

Sociocultural Dimension By far, the greatest amount of research has been directed to sociocultural factors in the etiology of eating disorders and the influence of unrealistic standards of beauty that are derived from mass media portrayals. In the United States and most western cultures, physical appearance is a very important attribute, especially for females. The average American woman is five feet four inches tall and weighs 162 pounds, but teenage girls describe their ideal body as five feet seven inches, weighing 110 pounds, and fitting into a size five dress. Although this ideal is far from the actual statistics for body size among American women, it is consistent with the image portrayed in mass media. It is estimated that only about 5 percent of American women can achieve the size required for fashion models (Irving, 2001; see the height and weight table in Table 16.4).

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Women are socialized to be conscious of their body shape and weight. As a result, many researchers believe that eating disorders result from the socioculHEIGHT AND WEIGHT TABLE FOR WOMEN tural demand for thinness in females, which produces AND MEN (20 TO 74 YEARS) FOR 1980–2002 a preoccupation with body image (Pelletier & Dion, 1980 1994 2000 2006; Stice, Shaw, & Nemeroff, 1998). The APA Task Force on the Sexualization of Girls (2007) points out Women that women are sexualized through television, music Height (inches) 63.7 63.9 64.0 videos, lyrics, magazines, and advertising. Females are dressed in revealing clothing and objectified. A Weight (pounds) 145.4 153.0 162.9 narrow standard of physical beauty is emphasized, Men which affects girls in particular. Following exposure to these messages, girls begin to: (1) believe that their Height (inches) 69.1 69.2 69.4 primary value comes from being attractive; (2) define themselves according to the bodily standards shown Weight (pounds) 173.8 181.3 189.8 on media; and (3) become objectified rather than havAverage weight by ethnicity and gender ing the capacity for independent action and decision making. As girls and women adopt these unrealistic White women 151.4 161.7 standards, many develop a thin-ideal internalization, African American women 169.7 182.4 which is indicated by strong agreement with statements such as “slender women are more attractive” Mexican American women 152.6 157.1 and “I would like to look like the women that appear in TV shows and movies” (Thompson & Stice, 2004, White men 183.7 193.1 p. 99). In a random sample of one hundred teenage African American men 181.2 189.2 girls, over 60 percent reported trying to change their appearance to resemble that of celebrities or actors Mexican American men 172.3 177.3 (Seitz, 2007). Source: Ogden et al. (2004). What kind of predisposition or characteristic leads some people to interpret images of thinness in the media as evidence of their own inadequacy? Are people who develop eating disorders chronically self-conscious to begin with, or do they develop eating disorders because agents in their social environment make them chronically self-conscious? How does exposure to mass media portrayals of thinness influence the values and norms of young people? The development of disordered eating and preoccupation with body image may involve multiple processes (Harrison, 2001; Tylka & Subich, 2004; see Figure 16.3). A process of social comparison occurs in which women and girls begin to evaluate themselves according to external standards. Because these standards are unattainable for the vast majority of women, body dissatisfaction occurs. This leads to a form of self-consciousness from habitual monitoring of one’s external appearance that leads to an increase in anxiety or shame about the body. Dissatisfaction with one’s body leads to disturbed eating patterns and depression (Tiggemann & Kuring, 2004). TA B L E

16.4

Pressure to be thin

Body dissatisfaction

Social comparison

FIGURE

Dieting

Eating disorders

Thin-ideal internalization

Negative affect

16.3 ROUTE TO EATING DISORDERS

The route to the development of eating disorders.

Source: Adapted from Stice (2001).

Etiology of Eating Disorders

Social comparison has been found to trigger negative reactions in women. In one study, female restrained eaters and nonrestrained eaters (classified based on degree of dietary restriction) read descriptions of a peer described either as “thin,” “average,” or “overweight” and then completed measures of self-evaluation. The restrained eaters showed more negative self-perceptions in response to the description of a thin peer, suggesting they may be more vulnerable to social comparison processes that lead to body dissatisfaction and lower self-esteem (Trottier, Polivy, & Herman, 2007). Although societal emphasis on thinness is related to an increase in disordered eating, it is not a sufficient explanation. Only a relatively small percentage of individuals in our media-conscious society develop eating disorders. Protective variables against the impact of media on body image include strong social bonds and social support, personality variables such as self-determination and autonomy, and viewing attractiveness as only one of many qualities that are deemed important (Pelletier & Dion, 2006). Adolescent girls gave the following reasons for dieting and concern over their bodies: mass media (magazines, television, advertising, fashions), peer influences (wanting to fit in), and criticisms by family members about their weight (Wertheim et al., 1997). The beginning of dating and mixed-gender social activities is also related to dieting and disordered eating, especially for young women who have recently experienced menarche (Cauffman & Steinberg, 1996). Unfortunately, high school and college females may not be aware of the psychologically harmful effect of the superslim standard for women. When asked to examine forty magazine ads and indicate which ads featured potentially harmful female stereotypes, they picked out ones that portray women as helpless or dumb, as sex objects, or as using alcohol or cigarettes. They appeared to overlook the ultra-thin models, possibly because they were accustomed to seeing this or have accepted it as a social-cultural norm (Gustafson, Popovich, & Thomsen, 2001).

Did You Know? Do most women want to be ultra-thin? • Among overweight and obese women, the amount of weight they would “ideally” like to lose would still place them in the overweight category. • Women in the normal weight range want to lose only a few pounds, not the amount needed to be extremely thin. • Underweight women believe they are at the ideal weight. This group may be most responsive to messages regarding thinness. Source: Neighbors & Sobal (2007).

PLUS SIZE MODELS These women are wearing outfits made by Elena Miro for larger sized women. More and more fashion designers are developing attractive clothing lines for ordinary and plus size figures.

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Body dissatisfaction was studied by Forbes, Adams-Curtis, Rade, and Jaberg (2001). Both male and female college students were asked to choose from drawings the figure that was closest to their own, the one that they would most like to have, the one that their gender would like, and the one that the opposite sex would like best 1 2 3 4 5 6 7 8 9 (see Figure 16.4). From the drawings of male figures, males perceived the one “closest to their 3 4 2 1 1 own” as smaller than the one that most men or most women would prefer. Female participants For Female Participants Mean Rating believed the figure “closest to their own” was much larger than the one they would like to or 3.85 1 Which body type closely matches your own? that other women or men would prefer. 2.99 2 Which body type would you most like to have? Although society’s emphasis on body types 2.69 3 Which body type would most women like to have? for males and especially for females may lead 2.85 4 Which body type do you believe men like best? to general body dissatisfaction, it is important to identify individuals who are most influenced by the standard. The researchers found For Male Participants Mean Rating that among both males and females, those of either gender with low self-esteem displayed 3.52 1 Which body type do you find most attractive? the greatest degree of body dissatisfaction. Heterosexual women especially are likely to be inaccurate about the female body preferences PREFERENCES FOR FEMALE BODY TYPES BY FEMALE FIGURE AND MALE COLLEGE STUDENTS of males. In a study that asked “Do men find ‘bony’ women attractive?” males indicated a Source: Forbes et al. (2001). preference for a heavier female body type than women thought men preferred (Bergstrom, Neighbors, & Lewis, 2004). As noted in the beginning of the chapter, mass media portrayals of lean, muscular male bodies are also increasing. For example, male centerfolds displayed in Playgirl have become more muscular in recent times (Bergstrom & Neighbors, 2006). There appears to be a gradual shift away from traditional measures of masculinity that include wealth and power to physical appearance. If this is true, there may be dramatic increases in eating disorders among men in the near future. In fact, as noted earlier, more cases of muscle dysphoria (dissatisfaction with one’s degree of muscularity) have been reported in men (Cafri et al., 2005; Pope et al., 2001). The gay male subculture places a great deal of value on physical attractiveness, resulting in more concern over body size and appearance and a greater prevalence of disturbed eating patterns than found among heterosexual males (Strong et al., 2000). Some studies estimate that gay males constitute 30 percent of males with eating disorders (Carlat, Camargo, & Herzog, 1997; Heffernan, 1994). Subcultural influences on attractiveness are also apparent in the fact that lesbians appear to be less concerned about physical appearance and to have a better body image than other females (Boehmer, Bowen, & Bauer, 2007).

16.4

Ethnic Minorities and Eating Disorders Research has also been directed to the influence of cultural standards and values on body dissatisfaction and eating disorders among ethnic minorities. In a meta-analysis of the impact of ethnicity and body dissatisfaction among women in the United States, Grabe and Hyde (2006) came to the following conclusions. First, body dissatisfaction is not just a problem among white women; it also exists among ethnic minority women. Second, Hispanic and Asian American women had levels of body dissatisfaction equivalent to those of white women. Third, black women show body dissatisfaction but at a lower level than all other comparison groups. African American girls and women are more satisfied with their body size, weight, and appearance than are white females, even though they tend to be

Etiology of Eating Disorders

heavier than their white counterparts. They also have a lower level of negative attitudes toward body size and weight and less motivation for thinness (Gilbert, 2003; Lovejoy, 2001), and they are less distressed by their weight gain and change in shape during pregnancy (Cameron et al., 1996). Although some show dissatisfaction with their bodies and weight, more African American college students report satisfaction with their appearance, body size, and shape compared with their white peers (Harris, 2006; Powell & Kahn, 1995). Similarly, findings from a national survey of adolescents on dieting and disordered eating supports the view that African American adolescent females appear to be less concerned about their body size and shape than white adolescents (Neumark-Sztainer et al., 2000). Ethnic comparisons suggest that dieting is lowest among African American girls (37.6 percent) and highest among white girls (51.3 percent). Disordered eating patterns (bingeing and purging) were highest among Hispanic American girls (19.1 percent) and lowest among African American girls (11.4 percent). Although the results may indicate that African American girls appear to experience lower levels of body dissatisfaction than girls from other ethnic groups, a substantial percentage of them also diet and binge or purge (Story et al., 1998). Table 16.5 compares some differences in body image and weight concerns between African American and white women. Why is it that African American women appear to be somewhat insulated from unrealistic standards of thinness? It is possible that African American girls and women are protected by several cultural factors. First, because they do not identify with white women, media messages of thinness may have less impact. Second, their definition of attractiveness is broad, encompassing dress, personality, and confidence, and does not focus solely on external characteristics such as body shape and weight. Additionally, African American men are more willing than white men to date heavier women (Powell & Kahn, 1995). Third, African American women have characteristics such as being assertive and egalitarian in relationships that allow them to have important roles in the community. In this way, they are less influenced by gender-restrictive messages. However, not all African American women are immune to majorityculture messages. The prevalence of eating disorder NOS among African TA B L E

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HEALTHY OR OVERWEIGHT? In high school, Jamie-Lynn Sigler, who played Meadow on The Sopranos, would get up at 4 A.M. to exercise for two hours. Her dinner consisted merely of fat-free yogurt. She was so thin that size 0 clothing was too large for her. Now recovered, she has received criticisms from some fans that she is overweight and fat!

16.5

DIFFERENCES IN BODY IMAGE AND WEIGHT CONCERNS AMONG AFRICAN AMERICAN AND WHITE FEMALES CONCERN

AFRICAN AMERICAN FEMALES

WHITE AMERICAN FEMALES

Satisfied with current weight or body shape

70%

11%

Body image

Perceive selves to be thinner than they actually are.

Perceive selves to be heavier than they actually are.

Attitude toward dieting

Better to be a little overweight than underweight (65% of respondents in a survey).

Need to diet to produce a slender body. Fear of being overweight.

Definition of beauty

Well groomed, “style,” and overall attractiveness. Beauty is the right “attitude and personality.”

Slim; 5’7’’; 100 to 110 pounds. Perfect body can lead to success and the good life.

Being overweight

Of those who were overweight, 40 percent considered their figures attractive or very attractive.

Those who considered selves as not having a weight problem were 6 to 14 pounds under the lower limit of the “ideal” weight range.

Age and beauty

Believed they would get more beautiful with age (65% chose this response).

Beauty is fleeting and decreases with age.

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critical thinking

Is Our Society Creating Eating Disorders?

T

here appears to have been a dramatic increase in eating disorders over the past twenty-five years, which is correlated with our society’s emphasis on thinness and attractiveness. As many as 64 percent of women exhibit symptoms of eating disorders, and even more are dissatisfied with their body shapes (National Association of Anorexia Nervosa and Associated Disorders, 2004). What role has society played in eating disorders, and why do they appear primarily in western societies? Eating disorders are rare in China, Singapore, Malaysia, and Hong Kong (Marsh et al., 2007; Tsai & Gray, 2000) and in other nonwestern cultures (Bhadrinath, 1990; Miller & Pumariega, 2001). Other societies do not place such emphasis on thinness. Some observers believe that eating disorders are a culture-bound syndrome found only in western cultures. Far fewer reports of eating disorders are found in Latin America, South America, and Asia, whereas they appear to be high or increasing in European countries, Israel, and Australia (Miller & Pumariega, 2001). Countries or groups that have been exposed to western values show an increasing concern over eating and body size (Becker, 2004; Steiger & Bruce, 2007). Although the standard of beauty among women in

Did You Know?

T

hroughout history, the specific body weight of women has been less important to males than a relatively curvy body. Men may be “hard wired” to find the hourglass figure in women attractive because of evolutionary reasons—to have an intellectually superior child. Lassek and Gaulin (2008) found that women with larger hip to waist ratio had offspring with higher cognitive abilities. It is possible that fat stores in the lower body may meet the special nutritional needs of the developing brain of the fetus, especially during the third trimester (Lassek & Gaulin, 2006).

South Africa is based on fuller figures, black teenage girls in this region are drawn to western standards of thinness, resulting in a dramatic increase in eating disorders among this group (Simmons, 2002). Asian female adolescents born in Britain also have concerns over body shape and eating (Hill & Bhatti, 1995). Among Pakistani adolescent girls, those who were the most exposed to western culture had the highest rates of abnormal eating attitudes (Mumford, Whitehouse, & Choudry, 1992). As psychologists, we are interested in the etiology of problems. Is the “pursuit of thinness” a culture-bound phenomenon? Do contemporary women gain status or identity through their physical appearance? Why have western cultures been so susceptible to eating disorders? The women’s movement stressed the importance of ability over appearance. With the greater freedom and power that women have gained, why is there an increase in the importance of appearance? If society continues to equate desirable characteristics with thinness, how can we change this message? In the mass media, we are beginning to see more focus on physical attractiveness in males. Will this result in a dramatic increase in eating disorders among men?

American women appears to be equivalent to that found in white American women (Mulholland & Mintz, 2001). And although fewer African American women appear to have either anorexia nervosa or bulimia nervosa, they are as likely as other groups of women to have binge-eating disorder (Lovejoy, 2001; Striegel-Moore et al., 2003). As with white American women, self-esteem and body dissatisfaction among African American women is related to bulimic symptoms. This relationship is greatest among those who have internalized U.S. societal values concerning attractiveness (Grabe & Hyde, 2006; Lester & Petrie, 1998). In a study of African American and white women with or without binge-eating disorder, certain differences were found (Pike et al., 2001). African American women had higher body weight than white women and had fewer weight and shape concerns, regardless of whether they had the disorder. Among those with binge-eating disorder, African Americans had significantly lower scores on eating concerns, dietary restraints, and shape and weight concerns. Thus African American women with binge-eating disorder differed in certain eating disorder characteristics from their white counterparts. The drive for thinness may be less an etiological factor for African Americans than it is for white Americans. Among Hispanic American female college students, weight and adherence to mainstream values were positively related to bulimic symptoms (Lester & Petrie, 1998). Some studies show that American Indian, Asian American, and Hispanic American girls show greater body image dissatisfaction than white females, possibly due to attempts to fit into the societal definition of beauty (Gilbert, 2003). Thus it appears that ethnic minorities are becoming increasingly vulnerable to societal messages regarding attractiveness and may be at especially high risk for developing eating disorders, as a greater percentage of ethnic minority children and adults, especially females, are overweight (Ogden et al., 2004). Cross-Cultural Studies on Eating Disorders Cultural values and norms also affect views on body shape and size. Eating often plays a role in family gatherings

Etiology of Eating Disorders

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and socialization. Weight normalcy is influenced by cultural beliefs and practices. For example, Micronesians view thinness as a sign of illness. As one parent responded, “The culture on Saipan, the fat one is the healthy one . . . but when they are skinny, ‘Oh, my goodness, nobody is feeding that child’” (Bruss, Morris, & Dannison, 2003). Historically, eating disorders in Chinese populations have been rare because plumpness in females has been considered desirable and attractive. Feeding is an extension of love and care of parents toward their children. However, the obesity rate is low and may also result from the cultural value of moderation. Interestingly, in a recent study in Hong Kong, adolescent girls picked an ideal female body size that was somewhat larger than that preferred by boys (Marsh et al., 2007). This finding is in contrast to studies cited earlier in which American girls and women choose ideal body sizes that were thinner than those preferred by males. What happens when other cultures are exposed to western standards of beauty? Becker (2004) reported on the impact of television on adolescent girls living in a rural community in Western Fiji. Traditional cultural norms support robust appetites and body sizes. Food and feasts are considered to be important contributors to social exchange, and plump bodies are considered to be aesthetically pleasing. In interviews of girls after three years of exposure to western television programs, comments revealed admiration for western standards: “The actresses and all those girls, especially those European girls, I just like, I just admire them and want to be like them. I want their body, I want their size” (p. 546). The girls also paid attention to TV commercials advertising exercise equipment, which portrayed the ease in which weight could be lost. “When they show exercising on TV . . . I feel I should . . . lose my weight” (p. 542). Becker attributes the strong impact of television on the values of the girls to the rapid social and economic changes in Fiji, a country that went from subsistence to a cash economy with a related rise in consumerism. Although eating disorder increases in developing countries have been associated with rapid transitions in global market economies and heavy media exposure, Anderson-Fye (2004) found that in San Andres, Belize, body size and shape preferences have not changed because of exposure to western media. In Belize, there is high level of contact with U.S. citizens via tourism. There is also a long history of beauty pageants in Belize. However, girls and women appear to eat freely and show minimum concern with their bodies. They have a broad definition regarding BEAUTY STANDARDS African American females have a greater acceptance of heavier body sizes than white women. In addition, they adopt a broader definition of beauty that includes attitude, personality, and “style.”

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beauty that involves dress, hairstyle, makeup, and personality. It is believed that adorning oneself “properly” can make nearly any female “beautiful.” Girls from different socioeconomic classes, ethnicity, and body shapes have participated in and won pageants. Among the girls, the shapes preferred by boys are the “Coca-Cola” (hourglass) or “Fanta” (smaller on top and bigger on the bottom). The least preferred shape is the “straight shape.” Eating disorders are rare in Belize. It remains to be seen whether the cultural norms and values will continue to protect against eating disorders.

Treatment of Eating Disorders Prevention programs have been developed in schools to reduce the incidence of eating disorders and disordered eating patterns. A school-based group intervention program was developed for adolescent girls who were showing some problems with eating, body image, and self-esteem (Daigneault, 2000). The goals for the girls involved (1) learning to develop a more positive attitude toward their bodies, (2) becoming aware of societal messages of “what it means to be female,” (3) developing healthier eating and exercise habits, (4) increasing their comfort in expressing their feelings to peers, family members, and significant others, (5) developing healthy strategies to deal with stress and pressures, and (6) increasing assertiveness skills. These points were addressed through group discussions and the use of videos, magazines, and examples from mass media. Similarly, Sands (1998) believes that the social context of eating disorders needs to be acknowledged in any type of treatment. She recommends including a gender analysis by identifying sex role messages such as “girls must be thin, pretty, and sexy,” identifying the consequences of the gender-related messages (“I’m going to starve myself to be thin”), choosing a statement of change and implementing it (“Being healthy is important to me so I will eat and exercise sensibly”), and developing assertiveness skills to combat patterns of helplessness and submissiveness. Both of these approaches focus on teaching girls and women to reexamine the consequences of gender messages and on the necessity of institutional awareness of the problem. These elements have been included in most of the treatments for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Programs that are the most effective are those that involve an interactive rather than a lecturing format, are designed specifically for women, and that include multiple sessions (Stice & Shaw, 2004).

Treating Anorexia Nervosa Case Study A female undergoing treatment for anorexia nervosa—who was 5 feet, 3 inches tall and weighed 81 pounds and still felt fat—reported, “I did gain 25 pounds, the target weight of my therapist and nutritionist. But every day was really difficult. I would go and cry. A big part of anorexia is fear. Fear of fat, fear of eating. But (my therapist) taught me about societal pressures to be ultra-thin comes from the media, TV, advertising. . . . She talked me through what I was thinking and how I had completely dissociated my mind from my body. . . . I’m slowly reintroducing foods one thing at a time. I’d like to think I am completely better, but I’m not. I’m still extremely self-conscious about my appearance. But I now know I have a problem and my family and I are finding ways to cope with it.” (Bryant, 2001, p. B4)

As you have seen, eating disorders, especially anorexia nervosa, can be life threatening. Treatment for anorexia nervosa can be delivered on either an outpatient or an inpatient basis, depending on the weight and health of the individual. Developing a therapeutic alliance through the use of empathy, positive regard, and support is vital because readiness for change is an important predictor of successful treatment (McHugh, 2007). Because it is a complex disorder, there is a need for teamwork

Treatment of Eating Disorders

between physicians, psychiatrists, and psychotherapists. The order of treatment is as follows (American Psychiatric Association, 2006): 1. Restoration of a healthy weight. For females, this involves the return of menses and ovulation; for males, the return of normal sexual drive and hormone levels. 2. Treatment of physical complications. These include symptoms related to starvation and also physiological reactions during refeeding. 3. Enhancement of motivation to participate in the treatment program. 4. Psychoeducation about healthy eating patterns and nutrition. 5. Identification of attitudes, dysfunctional thoughts and beliefs, conflicts, and feelings that underlie the eating disorder. 6. Provision of psychotherapy to deal with emotional disturbances related to eating. 7. Mobilization of family support and use of family therapy, when appropriate. 8. Relapse prevention. Because the individual is starving, the initial goal is to restore weight, a process carefully coordinated with psychological support. During the refeeding process, the patient’s feelings of apathy may begin to fade. Typically, the individual with anorexia nervosa will become terrified of gaining weight and need the opportunity to discuss her or his reactions. During the weight restoration period, new foods are introduced, because the individual’s choices are often not sufficiently high in calories. The physical condition of the person has to be carefully monitored because sudden and severe physiological reactions can occur during refeeding. A dental exam is often conducted to assess for damage from purging. Psychological interventions are used to help the patient (1) understand and cooperate with nutritional and physical rehabilitation, (2) identify and understand the dysfunctional attitudes related to the eating disorder, (3) improve interpersonal and social functioning, and (4) address comorbid psychopathology and psychological conflicts that reinforce eating-disorder behavior (American Dietetic Association, 2001; American Psychiatric Association, 2006; Walsh & Devlin, 1998). The behavioral approach is designed to correct irrational preoccupation with weight and to encourage weight gain through the use of such positive reinforcers as telephone privileges, visits from family and friends, mail, and access to street clothes. The particular reinforcers used to reward weight gain depend, of course, on the likes and dislikes of the patient. Weight-gain plans are generally aimed at increases of about two pounds per week (Wilson & Shafran, 2005). Once the patient has gained sufficient weight to become an outpatient, family therapy sessions may be implemented. Experience has shown that this approach helps maintain the treatment gains achieved in the hospital. Although antidepressants may be helpful in treating the depressive feelings in anorexia nervosa, they were not any more useful than a placebo in preventing relapse in patients who had achieved a healthy weight during therapy (Walsh et al., 2006). Family therapy is often an important component of the treatment plan. The family of an eighteen-year-old girl who was unsuccessfully treated by inpatient treatment, dietary training, and cognitive-behavioral therapy was enlisted to participate in a new form of family therapy. The therapy involved (1) having the parents help refeed the adolescent through the planning of meals, (2) reducing parental criticism by understanding anorexia nervosa as a serious disease, (3) negotiating a new pattern of family relationships, and (4) assisting the family with the developmental process of separation and individuation. Parents were encouraged to understand and help their daughter develop the skills, attitudes, and activities appropriate to her developmental stage. This form of family therapy resulted in the girl’s gaining over twenty-two pounds (Sim et al., 2004). Overall, family therapy has been found to be modestly successful in treating anorexia nervosa (Halvorsen & Heyerdahl, 2007).

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Treating Bulimia Nervosa In bulimia nervosa, treatment goals include (1) reducing or eliminating binge eating and purging; (2) treating any physical complications; (3) motivating the client to participate in the restoration of healthy eating patterns; (4) providing psychoeducation regarding nutrition and eating; (5) identifying dysfunctional thoughts, moods, and conflicts that are associated with eating; (6) providing psychotherapy to deal with these issues; (7) obtaining family support and conducting family therapy, if needed; and (8) preventing relapse (American Psychiatric Association, 2006). During the initial assessment of patients with bulimia nervosa, conditions that might contribute to purging, such as esophageal reflux disease, should be identified. Physical conditions resulting from purging include muscle weakness, cardiac arrhythmias, dehydration, and electrolyte imbalance, as well as gastrointestinal problems involving the stomach or esophagus. In many patients, dental erosion can be quite serious. As with anorexia nervosa, bulimia nervosa should involve an interdisciplinary team that includes a physician and psychotherapist. One important goal in treatment is to normalize the eating pattern and to eliminate the binge/purge cycle. A routine of eating three meals a day with one to three snacks a day is used to break up the disordered eating pattern. Cognitive-behavioral therapy and the use of antidepressant medication such as selective serotonin reuptake inhibitors (SSRIs) have been helpful in treating this condition (American Psychiatric Association, 2000b, 2006; Wilson & Shafran, 2005). Cognitive-behavioral approaches have also been effective in helping individuals with bulimia and binge-eating disorder develop a sense of self-control (Parrott, 1998). Common components of cognitive-behavioral treatment plans involve encouraging the consumption of three or more balanced meals a day, reducing rigid food rules and body image concerns, and developing coping strategies. This approach was as successful as antidepressant medication in treating bulimia nervosa, although combined treatment was the most effective (Agras et al., 1992). Even with these approaches, only about 50 percent of those with the disorder fully recover. Characteristics associated with treatment failure include poorer social adjustment and a reduction in purging of less than 70 percent by the sixth treatment session. For these individuals, different treatment strategies may be required (Agras et al., 2000). Other approaches have demonstrated some promise. Twenty-two adolescent patients with bulimia nervosa who did not respond to cognitive-behavioral treatment were given twelve sessions of cue exposure. This approach is based on the classical conditioning model in which the craving response was extinguished in the presence of food. During each of the sessions, patients were exposed to attractive food and allowed to touch it, raise it to their mouths, and smell it but not actually eat it. This routine was to be performed even if the patient developed a great deal of anxiety. The program resulted in significant reduction in bingeing and purging behaviors (Martinez-Mallen et al., 2007). One family-based treatment that has been moderately successful empowers parents to disrupt binge eating, purging, and pathological weight control measures until their adolescent can successfully assume responsibility for healthy eating (Levine & Mishna, 2007).

Treating Binge-Eating Disorder Treatments for binge-eating disorder are similar to those for bulimia nervosa, although binge-eating disorder presents fewer physical complications because of the lack of purging. Individuals with binge-eating disorder do differ in some ways from those with bulimia nervosa. Most are overweight and have to deal with prejudices toward overweight individuals. Due to the health consequences of excess weight, some therapy programs also focus on healthy approaches to weight loss. In general, treatment follows two phases (Ricca et al., 2000; Shelley-Ummenhofer & MacMillan, 2007). First, cognitive factors underlying the eating disorder are determined. The clients also are taught to use strategies that reduce eating binges. One patient, Mrs. A, had very rigid rules concerning eating that, when violated,

Obesity

467

would result in her “going the whole nine yards.” Two types of triggers were identified for binges—emotional distress (anger, anxiety, sadness, or frustration) and work stress (long hours, deadlines). Interventions were applied to help her develop more flexible rules regarding eating and to deal with her stressors. In many of these programs, body weight is recorded weekly, and a healthy pattern of three meals and two snacks a day is implemented. Food diaries may be utilized to determine type and amount of the food consumed and the psychological states preceding eating. Information about obesity, proper nutrition, and physical exercise is provided. These steps make up the first part of the program. Second, cognitive strategies are employed to change distorted beliefs about eating. The client is asked to prepare a list of “forbidden” foods and to rank them in order of “dangerousness.” Gradually, the foods are introduced into normal eating, first beginning with those perceived as being less dangerous. The clients are asked to observe their own bodies in a mirror CHILDHOOD OBESITY Childhood obesity has reached epidemic proportions in to help reduce or eliminate cognitive distordeveloped countries due to a lack of physical activity and the presence of attractive tions associated with their bodies. The preju- high calorie foods. At the Children’s Medical Center in Texas, children play kickball dices of society about body size are discussed, and other games to help them achieve a healthier weight. and realistic expectations about the amount of change are addressed. Participants are asked to observe attractive individuals with a larger body size to help them consider positive qualities other than focusing on the body. After performing this “homework,” Mrs. A discovered that overweight women can look attractive, and she began to buy more fashionable clothes for herself. She was astonished at the positive reactions and comments from friends and coworkers. Although she had lost twelve pounds, she attributed the attention to her confidence and improved body image (Goldfein et al., 2000). Cognitive-behavioral therapy can produce significant reductions in binge eating but is less successful in reducing weight (Shelley-Ummenhofer & MacMillan, 2007; Wonderlich et al., 2003). Few treatment programs have been developed specifically for eating disorder NOS because of the heterogeneous disorders it encompasses.

Obesity Case Study When I’m uptight, I often overeat. I know that I often use food to calm me when I’m upset and even find myself feeling that when things don’t go my way, I’ll just have my way by eating anything and all I want. Like an alcoholic who can’t stop drinking once he or she starts, I don’t seem to be able to stop myself from eating once I start. (LeCrone, 2007, p. 1)

Obesity is defined as a body mass index (BMI)—an estimate of body fat calculated on the basis of a person’s height and weight—greater than 30. DSM-IV-TR acknowledges eating disorders such as anorexia and bulimia as mental disorders with serious adverse outcomes but does not recognize obesity despite its devastating medical and psychological consequences (Volkow & O’Brien, 2007). Whether obesity will eventually be included in DSM-V is still a matter of conjecture.

obesity a body mass index of greater than 30 body mass index (BMI)

an estimate of body fat calculated on the basis of a person’s height and weight

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1995

2000

2005

10–14 15–19 20–24 25–29 > 30 –

Obesity stems from many causes, including genetic and biological factors, our sedentary modern-day lifestyle, easy access to attractive, high-calorie foods, and the disturbed eating patterns seen in eating disorders. In one study, the majority of obese women surveyed had engaged in binge eating (Bulik & ReichbornKjennerud, 2003). Obesity is a condition that is often accompanied by depression and anxiety disorders, low self-esteem, poor body image, and unhealthy eating patterns (Eddy et al., 2007). Obesity is second only to tobacco use in terms of being a preventable cause of disease and death. Being overweight or obese increases the risk of high cholesterol or triglyceride levels, Type 2 diabetes, cancer, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and respiratory problems (Centers for Disease Control and Prevention [CDC], 2007c). Obesity also results in annual health care costs of up to $100 billion dollars a year (Finkelstein, Fiebelkorn, & Wang, 2004) and a reduction of life expectancy of between five and twenty years (Fontaine et al., 2003). Being overweight or obese in childhood is related to an increased risk of coronary heart disease in adulthood (Baker, Olsen, & Sorenson, 2007). Some researchers believe that forms of obesity that are characterized by an excessive drive for food should be recognized in DSM-V as a “food addiction” (Volkow & O’Brien, 2007). Some of the characteristics that they believe are similar to substance dependence include: • Development of tolerance—the need to increase the amount consumed to maintain satiety • Withdrawal symptoms such as distress or dysphoria when dieting • Larger amount of food ingested than intended • Great deal of time spent thinking about or consuming food • Overeating despite attempts to curtail the amount consumed • Overeating despite adverse physical and psychological consequences

According to BMI standards, 66.3 percent of American adults are either overweight or obese (32.2 percent are obese), and 16 percent of children and adolescents are either overweight or obese. (See Figure 16.5 on increase in obesity from 1995 to 2005.) The prevalence of overweight and obesity in the United States INCREASE IN OBESITY FROM 1995 TO 2005 FIGURE has doubled since the 1970s, and it is estimated that by Percentage of adults age 18 years and over who were obese, by state. 2015, 75 percent of adults and 24 percent of children Source: Behavior Risk Factor Surveillance System, United States, 1995, 2000, and and adolescents will be overweight or obese. Statistics 2005 (Centers for Disease Control, 2007c). for African Americans, Mexican Americans, American Indians, and women show even higher rates of obesity (Wang & Beydoun, 2007). Childhood and adolescent obesity has reached epidemic proportions in developed nations and is a strong risk factor for adult obesity (Singhal, Schwenk, & Kumar, 2007).

16.5

Etiology of Obesity

469

Etiology of Obesity Obesity is a product of biological/genetic, psychological, social, and sociocultural influences, as shown in Figure 16.6. How these dimensions interact is still being investigated. For example, one theory, termed the “thrifty genotype” hypothesis, includes the roles of both genetics and the environment in accounting for the rapid rise in obesity. According to this perspective, humans inherited genes that helped our ancestors survive famines by storing fat. The same gene, however, may be dysfunctional in an environment in which high-fat foods are now plentiful (CDC, 2007c). Although “thrifty” genes and access to foods can account for some cases of obesity, other factors must be involved, because rates of obesity also vary according to variables such as class, gender, and race/ethnicity.

Biological Dimension Estimates regarding genetic contributions to obesity generally are derived by determining the frequency of obesity among family members and twins. Others have investigated specific genetic variations among the obese. Genes can influence eating behaviors through brain structures and neurochemistry. The hypothalamus and hormones such as leptin regulate food consumption and appetite and have been implicated in obesity. Other brain regions, such as the cortex, amygdala, and dopamine-sensitive nuclei, are involved in both the inhibitory and motivational processes involved in food consumption (Volkow & O’Brien, 2007). Scientists have begun to focus specifically on the influence of dopamine as it affects food palatability. Epstein and colleagues (2007) found that about 50 percent of people carry a gene variation affecting dopaminergic activity—a gene that appears to increase pleasure in eating. This gene is also associated with addictions such as gambling and the abuse of alcohol and other substances. In their study, obese individuals with this genotype worked harder to be able to get food as a reward. It is hypothesized that individuals with this genetic variation may have to take in more of a substance to achieve the same level of satisfaction or reward as those without this variation. The importance of dopamine has been found in several other studies. Obese individuals were found to have fewer dopamine receptors than those of normal weight, and this decrease was proportional to their BMI (Wang et al., 2001). Similar findings

16.6

Biological Dimension • Genetic influence on appetite • “Thrifty genotype” • Dopamine receptors and pleasure in eating

Sociocultural Dimension

Psychological Dimension

• Cultural influences on body preference • Poorer neighborhoods, less access to healthy foods • Advertising of high-calorie foods

OBESITY

Social Dimension • Teasing from family members or peers • Overweight friends • Parental attitudes regarding eating

• Negative mood states • Binge-eating • Poor self-esteem due to harassment

FIGURE MULTIPATH MODEL FOR OBESITY The dimensions interact with one another and combine in different ways to result in obesity.

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controversy

Are the BMI Index Standards Appropriate? Brent Hagen, 26, is overweight—according to the body mass past standards had more weight divisions and separate tables index, or BMI, way of calculating. That is not what he thought. for men and women. Following are the past and present BMI “I don’t think of myself as overweight, and I don’t think anyone standards. Does the change seem to make sense? I know has ever thought of me as overweight either.” (Mask, 2007, p. 1) 1997 ADULT BMI An obesity researcher, Steve Blair, believes that people STANDARDS CURRENT BMI STANDARDS can be fit and “fat” and that Americans “have been whipped into ‘near hysteria’ by hype over the ‘obesity epidemic.’ ” (BOTH MEN He suggests that people concentrate on healthy eating and WOMEN MEN AND WOMEN) exercise rather than obsessing about gaining a few extra pounds. (Associated Press, 2007) Underweight <19.1 <20.7 <18.5

In the year 1998, changes were made in the BMI’s diagnostic thresholds. The BMI scores were lowered for all weight classes. A consequence of the lowering of the diagnostic thresholds was to raise the prevalence of individuals considered “overweight” or “obese.” For example the cutoff score for the category of “overweight” was lowered from 27 to 25. This resulted in 29 million Americans being added to the overweight category, a 42 percent increase. Although it was hoped that this move would allow for early treatment and disease prevention, will such a move take away limited resources from those with severe weight issues? In addition, what are the implications for those who now bear the stigma of being “overweight” or “obese” (Schwartz & Woloshin, 1999)? Is the change in BMI standards justified? One study of 2.3 million American adults found that although both obesity and being underweight were related to increased mortality, such an association did not exist for being up to twenty-five pounds overweight. In fact, the death rate for those who were “overweight” was lower than that for other weight groups (Flegal et al., 2007). As we mentioned earlier, the BMI standards have changed. Present BMI standards are the same for men and women, whereas

Normal weight range

19.1–25.8

20.7–26.4

Marginally overweight

25.8–27.3

26.4–27.8

Overweight

27.3–32.3

27.8–31.1

Obese

>32.3

18.5–24.9

25–29.9 >30

Using the newer standards, a man who is 5’10” and weighs 175 pounds has a body mass index of 25.14 and is classified as overweight. A woman who is 5’3” and weighs 141 pounds has a body mass index of 25.01 and is also classified as overweight. For Further Consideration 1. Are the current standards better than those of the past? Do they provide better information regarding health risks? Should the current BMI standards consider gender, race, ethnicity, and body type? 2. Calculate your BMI using an online calculator. Which BMI standard (past or current) do you believe most accurately describes your weight?

regarding dopamine receptors were found among genetically lean and obese rats (Thanos et al., 2008). It is not clear, however, whether reduced dopamine receptor levels are the cause or effect of obesity. It is possible that overeating may produce lower receptor levels or that those with genetically low receptor levels may be predisposed to overeat. In the Thanos et al. study (2008), restricting food intake in rats caused an increase in dopamine receptors. Also, in the Epstein and colleagues (2007) study, many individuals with the genetic variation associated with obesity did not become overweight, and some without the genetic variation became obese. Clearly, additional factors are involved in the etiology of obesity.

Psychological Dimension Individuals who are obese report negative mood states and poor self-esteem. These responses are likely affected by the weight stigma that exists in society with the resultant harassment, teasing, and discrimination in school, work, and hiring practices (Obesity Action Coalition, 2007). The stigmatization faced by obese children from peers, parents, and teachers is pervasive and often unrelenting (Puhl & Latner, 2007). Among a

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sample of 122 overweight youths, many reported being teased about their weight, as well as suffering from mood and anxiety disorder, and having a thin-ideal internalization; more than one-third had engaged in recent binge eating (Eddy et al., 2007). It is not clear whether negative mood states are the cause of being overweight, but it is easy to imagine how they can be the result of societal responses to excess weight.

Social Dimension Family environments have also been associated with overweight and obese children and adolescents, including reports of teasing by family members about weight issues (Eddy et al., 2007). Parental eating patterns and attitudes influence food intake in children (Bruss et al., 2003). In families in which a positive mealtime atmosphere was reported, adolescents were less likely to engage in disordered eating (Neumark-Sztainer et al., 2004), although parental encouragement to diet affected mealtime atmosphere in a negative manner (Fulkerson et al., 2007). In an interesting study, Christakis and Fowler (2007) followed the social networks of 12,067 adults over a period of thirty-two years to determine social factors associated with obesity. They wanted to see whether friends, siblings, spouses, or neighbors had an impact on weight gain. Some of the findings were quite surprising. If someone a person considers to be a friend becomes obese, a person’s chances of also becoming obese increased by 57 percent. (In the case in which two individuals considered each other as friends, the chances increased by 171 percent.) Geographic distance between friends was not a factor, so the effect involves more than just proximity. The chances for obesity in an individual also increased when one of the following individuals became obese: adult sibling: 40 percent; spouse: 37 percent; neighbors: 0 percent (unless they were also friends). The researchers hypothesize that weight gains in others in the social network changed the norms or acceptability of being overweight for these individuals.

Sociocultural Dimension Attitudes regarding food and weight normalcy are developed in the home and community. Rates of obesity tend to be highest among ethnic minorities. In many ethnic groups, there is less pressure to remain thin, and being overweight is not a big concern unless it is extreme. As noted earlier, among African Americans, there is greater acceptance of fuller figures, and a larger derriere in women is seen as desirable (Foster-Scott, 2007). Rates of obesity also tend to be higher among lower social class individuals and may be a product of limited availability of fruits, vegetables, low-fat food, and opportunities for exercise in poorer neighborhoods (Peralta, 2003). Advertising of high-calorie foods is also seen by some to be a contributor to obesity. Food advertising to children in both Sweden and Quebec was banned more than ten years ago. However, neither region showed any benefit from this action; the childhood obesity rate increased in a manner similar to that of other areas (Adamson & Zywicki, 2007).

Treatments for Obesity Treatments for obesity have included dieting, lifestyle changes, medications, and surgery. In general, dieting in and of itself may produce short-term weight loss but tends to be ineffective long term; some individuals gain back more weight than was lost. Mann and colleagues (2007) concluded that most would be better off not dieting because of the stress on the body as a result of weight cycling. Indeed, the “yo-yo” effect in dieting (cycles of weight gain and loss) has been found to be related to an increased risk of cardiovascular disease, stroke, and altered immune functioning. Comprehensive programs appear to be somewhat more promising. In a metaanalysis of studies incorporating “rigorous randomized trials” of obesity treatments that have included a minimum of two years of follow-up, Powell, Calvin, and Calvin (2007) reported the following conclusions: 1. Lifestyle interventions (low-calorie diets and exercise) were successful in producing moderate and sustained reductions in weight. This modest weight loss was associated with a reduction in Type 2 diabetes, blood pressure, and overall mortality rate.

Did You Know?

I

n a twelve-year study of American adults sixty years and older: • Obese individuals who were fit had lower mortality rates than unfit normal-weight or lean individuals. • Among fit individuals, survival rates were similar for normal weight, overweight, or obese individuals. • Being overweight and obese was not an independent predictor of death. Staying fit may be more important than losing weight. Source: Sui et al. (2007).

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2. Drug treatments such as the use of Orlistat, which blocks the gastrointestinal uptake of about 30 percent of ingested fat, resulted in a sustainable weigh loss of about seven pounds. 3. Gastric bypass surgery for individuals who are morbidly obese (BMI greater or equal to 35) or obese with serious comorbid disease resulted in a weight loss of about fifty to eighty pounds for about 70 percent of the patients. In one trial, over a period of five years, 45 percent had sustained only a twenty-two-pound loss. It appears that following surgical intervention, it is not unusual for weight gain to occur after the initial period of rapid weight loss. Thus comprehensive interventions that combine lifestyle changes with drugs and/or surgery appear to be most beneficial in sustaining weight loss.

I M P L I C AT I O N S

Eating disorders and obesity are a heterogeneous group of disorders. Scientists are only recently focusing on how genetics influences neurochemistry. Most of the research has been done with anorexia nervosa and obesity on dopaminergic activity that affects both a lack of appetite and overeating. However, we must be aware that, in some cases, the behavior of overeating or not eating may, in fact, result in changes in the level of dopamine in certain areas of the brain. Also, some individuals may have an eating disorder or problem even without evidence of biological predisposition. Thus it is important to consider psychological, social, and sociocultural dimensions that may also be involved. Eating disorders have become more prevalent as media provides thin models as the standard of beauty for women. Among men, body dissatisfaction is also increasing due to portrayals of muscular men in advertising, television, and movies. Because of a broader definition of beauty and the greater cultural acceptance of increased weight among African Americans, there is somewhat less body dissatisfaction within this group. Thus the topic of eating disorders and obesity is complex and is best understood using the multipath model and rejecting any single dimensional explanation.

Summary 1. What kinds of eating disorders exist? ■ Individuals with anorexia nervosa suffer from body image distortion. They weigh less than 85 percent of their expected weight and suffer from effects of starvation but are still deathly afraid of getting fat. ■ An individual with bulimia nervosa is generally of normal weight, engages in binge eating, feels a loss of control over eating during these periods, and uses vomiting, exercise, or laxatives to attempt to control weight. Some people with anorexia nervosa also engage in binge/purge eating but weigh less than 85 percent of their expected weight. ■

■

Although many people have engaged in binge eating, the diagnosis for the disorder is given only when the individual has regularly recurrent episodes in which she or he feels a loss of control over eating and shows marked distress about the activity. Individuals who show atypical patterns of severely disordered eating that do not fully meet the criteria for anorexia nervosa, bulimia nervosa, or binge-eating disorder are given the diagnosis of eating disorder not otherwise specified. Currently, binge-eating disorders are subsumed under this category.

2. What are some causes of eating disorders? ■

Genetics and neurotransmitter abnormalities are implicated in eating disorders. Research currently is focusing on the role of dopamine in eating disorders.

■

It is believed that the societal emphasis on thinness as being attractive may contribute to the increasing incidence of eating disorder. This is believed to lead to an internalized thin ideal that girls and women aspire to achieve.

■

Parental attitudes regarding the importance of thinness are implicated in eating disorders, as is teasing regarding weight, especially among children with low self-esteem or with childhood trauma.

■

Countries that are influenced by western standards also report an increased incidence of eating disorders in women.

3. What are some treatment options for eating disorders? ■ Many of the therapies attempt to teach clients to identify the impact of societal messages regarding thinness and encourage them to develop healthier goals and values.

Summary ■

For individuals with anorexia nervosa, medical, as well as psychological, treatment is necessary because the body is in starvation mode. The goal is to help clients gain weight, normalize their eating patterns, understand and alter their thoughts related to body image, and develop more healthy methods of dealing with stress.

■

With bulimia nervosa, medical assistance may also be required because of the physiological changes associated with purging.

■

Because many people with binge-eating disorder are overweight or obese, weight reduction strategies are also included in treatment. With both bulimia nervosa and binge-eating disorder, the therapy involves normalizing eating patterns, developing a more positive body image, and dealing with stress in a healthier fashion.

■

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4. What is obesity, and should it be included in DSM-V? ■ Obesity is defined as having a body mass index greater than 30. Some researchers believe that obesity should be included because it has characteristics of addictive behavior similar to that seen in substance abuse. 5. What are some causes of obesity? ■

The causes of obesity vary from individual to individual and are often combinations of biological predispositions and psychological, social, and sociocultural influences.

6. What are some treatment options for obesity? ■ In general, dieting alone has been ineffective over the long term. Lifestyle changes that include reduced intake of high-calorie foods combined with exercise have proven more effective. In the case of severely obese individuals, surgery has produced some promising longterm results.

c h a p t e r

17

Legal and Ethical Issues in Abnormal Psychology

O

chapter outline Criminal Commitment

478

Civil Commitment

482

Rights of Mental Patients

485

Deinstitutionalization

490

The Therapist-Client Relationship

492

Cultural Competence and the Mental Health Profession

494

IMP LIC AT IONS

495

CRITICAL THINKING Predicting Dangerousness: The Case of Serial Killers and Mass Murderers 486 CONTROVERSY Court-Ordered

Assisted Treatment: Coercion or Caring? 489

n June 30, 2001, Andrea Yates waited until her husband left for work, filled the bathtub to the very top, and proceeded to kill her five children, whose ages ranged from seven months to seven years. She systematically drowned each child in the bathtub, carried them to a bedroom, laid them out next to one another, and covered them with a sheet. The fifth child to be killed was left floating in the water. Yates then called 911 and asked for the police. She called her husband next and stated “You need to come home. . . . It’s time. I did it.” When asked what she meant, Yates responded “It’s the children . . . all of them.” When the police arrived and discovered the bodies, Yates was drenched in water, offered no resistance, and in a calm manner explained how she had killed her five young children. Police report that the children had struggled vigorously as the mother held each under the water until they drowned. The case of Andrea Yates shocked the nation. How could a mother possibly commit such an unthinkable deed? Although filicides (killing one’s own child or children) are often reported in the news media, this one was especially heinous because it involved five children and was carried out in such a methodical manner. During Yates’s trial in 2002, the prosecution asked for the death penalty, but the defense contended that she was psychotic, suffering from postpartum depression, insane, and should not be held accountable for her actions. The jury, however, found her guilty. The verdict was subsequently overturned by an appeals court, and on July 26, 2006, another Texas jury found her not guilty by reason of insanity. Questions: What criteria are used to determine sanity and insanity? Is being mentally ill the same as being insane? On July 24, 1998, Russell Weston, Jr., carried a concealed gun into the nation’s Capitol building as literally hundreds of tourists crowded through the security machines. Setting off an alarm as he passed through, Weston was confronted by Capitol guards

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FOCUSQUESTIONS

1 What are the criteria used to judge insanity, and what is the difference between being insane and being incompetent to stand trial?

2 Under what conditions can a person be involuntarily committed to a mental institution?

4 What is deinstitutionalization? 5 What legal and ethical issues govern the therapistclient relationship?

6 What is cultural competence in the mental health profession?

3 What rights do mental patients have with respect to treatment and care?

and exchanged volleys of gunfire with them. Tourists ran panic stricken throughout the hallways as Weston killed two police officers and wounded a tourist. Weston was subsequently captured, arrested, and charged with murder. Prosecutors offered no motive for the killings, but family members testified that Weston had a twenty-year history of mental illness, suffered from paranoid schizophrenia, and believed government agents were out to get him. A government psychiatrist concluded that Weston “suffers from a mental disease or defect rendering him mentally incapable of assisting in his defense” and that he should be hospitalized indefinitely until he was capable of understanding the proceedings. To improve his condition and render him competent, psychiatrists attempted to administer antipsychotic drugs. When consent forms for the medication were presented to Weston, he refused to sign. His attorneys successfully fought for his right to refuse treatment until January 2002, when a judge allowed forced medication of Weston. However, as of 2007, Weston still has not been tried for the murders of two Capitol police officers. Questions: Is being insane at the commission of a crime different from being mentally incapable to stand trial? If medication will improve people’s mental state, can they be forced to take it? Don’t people have a right to refuse treatment? Known as the “Wild Man of West 96th Street,” Larry Hogue is a homeless Vietnam veteran who lives in the alleyways and doorways of Manhattan. He sleeps on park benches or in cardboard boxes, constantly forages for food from garbage cans, urinates and defecates on public streets, and wanders through the neighborhood talking to himself. But Hogue’s notoriety and visibility go beyond these dimensions. He has been reported to harass passersby, threaten and stalk people in the area, and smoke crack. When Hogue’s behavior has been perceived as a threat to others, he has been committed and treated. With psychiatric help and medication, Hogue usually improves and is discharged. Without family or friends, financial resources, or a place to live, however, he returns to his former haunts, where his behavior once again deteriorates. Although Hogue is generally not violent when on prescribed medications, he is noted to be unreliable in taking them. Questions: How do we determine whether people are dangerous to others? Can we commit them even if they have not committed a crime? Under what conditions can they be confined (committed) against their will? In 1968, Prosenjit Poddar, a graduate student from India studying at the University of California at Berkeley, sought therapy from the student health services for depression. Poddar was apparently upset over what he perceived to be a rebuff from a female student, Tatiana Tarasoff, whom he claimed to love. During the course of

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treatment, Poddar informed his therapist that he intended to purchase a gun and kill the woman. Judging Poddar to be dangerous, the psychologist breached the confidentiality of the professional relationship by informing the campus police. The police detained Poddar briefly but freed him because he agreed to stay away from Tarasoff. On October 27, Poddar went to Tarasoff’s home and killed her, first wounding her with a gun and then stabbing her repeatedly with a knife. Because of this case, the California Supreme Court made a landmark 1976 ruling popularly known as “the Duty to Warn”; the therapist should have warned not only the police but the intended victim as well. Questions: What are the limits of therapeutic confidentiality? What legal obligations do therapists have in reporting whether clients pose a threat to themselves or to others? If confidentiality cannot be absolutely guaranteed, how will it affect client self-disclosures?

THE INSANITY DEFENSE Naveed Haq, a Pakistani American, invaded the downtown office of the Jewish Federation of Greater Seattle railing against Israel and the Iraq war. He fired at workers, killing one woman and wounding five. He appears here on April 14, 2008, the first day of his trial. Haq is pleading innocent by reason of insanity. His family and a psychiatrist testified that he has a long history of mental illness and that Haq was in a manic state on the morning of the rampage. In June 2008, the jury became hopelessly deadlocked, and a mistrial was declared. Prosecutors assert they will try Haq again.

Psychologists and mental health professionals are increasingly becoming involved in the legal system and must deal with the multiple questions posed here. They are playing important roles in determining the state of mind of individuals and are participating in decisions and actions of the legal system that affect human relationships (Simon & Gold, 2004; Tolman & Mullendore, 2003). In the past, psychologists dealt primarily with evaluation of competency and issues related to criminal cases such as those of Andrea Yates and Russell Weston. Now, however, their expanded roles include giving expert opinions on child custody, organic brain functioning, traumatic injury, suicide, and even deprogramming activities (see Table 17.1). And just as psychologists have influenced decisions in the legal system, they have also been influenced by mental health laws passed at local, state, and federal levels (Shuman, Cunningham, Connell, & Reid, 2003). All four of the preceding examples fit the definition of abnormal behavior, and we can clearly see many of their clinical implications. What is less clear to many is that clinical or mental health issues can often become legal and ethical ones as well. This is evident in the Capitol Hill shooting of two police officers, for which the court psychiatrist ruled that Russell Weston is not competent to stand trial. Yet how do we determine whether a person is competent to stand trial or whether someone like Yates is insane or sane? What criteria do we use? If we call on experts, we find that professionals often disagree with one another (Shuman & Greenberg, 2003; Tolman & Mullendore, 2003). Further, might defendants in criminal trials attempt to fake mental disturbances to escape guilty verdicts? The task of determining sanity is even more difficult because many lawyers are using clients’ claims of child abuse, domestic violence, and other psychological traumas to explain the criminal actions of their clients. The example of Larry Hogue leads us into the area of civil and criminal commitments, and legal rulings that force mental health practitioners to go beyond clinical concepts defined in DSM-IV-TR (American Psychiatric Association, 2000a). Some of Hogue’s behaviors are extreme, but should a person who has committed no crime be institutionalized because he appears severely disturbed? Certainly, defecating and urinating in public are disgusting to most people and are truly unusual behaviors, but are they enough to deprive someone of his civil liberties? Does being a nuisance or a “potential danger” to oneself or others constitute grounds for commitment? What are the procedures for civil commitment? What happens to people once they are committed? In the first three case examples, the focus of legal and ethical issues tends to be on the individual or defendant. Mental health issues become legal ones (1) when competence to stand trial is in doubt, (2) when an accused person bases his or her criminal defense on insanity or diminished mental capacity, (3) when decisions must

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17.1

THE INTERSECTION OF PSYCHOLOGY AND THE LAW Psychologists are finding that their expertise is either being sought in the legal system or being influenced by the law. Only a few of these roles and activities are described here: Assessing dangerousness The psychologist engaged in assessing dangerousness—suicide and homicide potential, child endangerment, civil commitment, and so on—must be knowledgeable about the clinical and research findings affecting such determinations. Child custody evaluations in divorce proceedings Psychologists provide expertise to help courts and social service agencies to determine the “best interests of the child” in custody cases involving parenting arrangements, termination of parental rights, and issues of neglect and abuse. Psychological evaluations in child protection matters While being mindful of the parents’ civil and constitutional rights, the psychologist may attempt to determine whether abuse or neglect has occurred, whether the child is at risk for harm, and what, if any, corrective action should be recommended. Repressed/recovered or false memory determinations Psychologists may be asked to determine the accuracy and validity of repressed memories—claims by adults that they have recovered memories of childhood abuse. Although psychologists are usually called as expert witnesses by the lawyers defending or prosecuting the alleged abuser, they sometimes play another role: suits have also been filed against mental health professionals for promoting the recall of false memories. Civil commitment determination Psychologists may become involved in the civil commitment of an individual or the discharge of a person who has been so confined. They must determine whether the person is at risk of harm to him- or herself or others, is too mentally disturbed to take care of him- or herself, or lacks the appropriate resources for care if left alone.

Determination of sanity or insanity Mental health experts are often asked by the court, prosecution, or defense to determine the sanity or insanity of someone accused of a crime. Results are usually presented via a private hearing to the judge or expert testimony in front of a jury. Determination of competency to stand trial Psychologists may determine whether an individual is competent to stand trial. Is the accused sufficiently rational to aid in his or her own defense? Jury selection Jury specialists help attorneys determine whether prospective jurors might favor one side or the other. They use clinical knowledge in an attempt to screen out individuals who might be biased against their clients. Profiling of serial killers, mass murderers, or specific criminals Law enforcement officers now work hand in hand with psychologists and psychiatrists in developing profiles of criminals. The Unabomber Theodore Kaczynski, for example, was profiled with amazing accuracy. Testifying in malpractice suits A psychologist may testify in a civil suit on whether another practicing clinician failed to follow the “standards of the profession” and is thus guilty of negligence or malpractice and/or on whether the client bringing the suit suffered psychological harm or damage as a result of the clinician’s actions. Protection of patient rights Psychologists may become involved in seeing that patients are not grievously wronged by the loss of their civil liberties on the grounds of mental health treatment. Some of these valued liberties are the right to receive treatment, to refuse treatment, and to live in the least restrictive environment.

be made about involuntary commitment to mental hospitals, and (4) when the rights of mental patients are legally tested. In the Tarasoff case, the focus of legal and ethical concern shifts to the therapist. When is a therapist legally and ethically obligated to breach patient-therapist confidentiality? In this case, had the therapist done enough to prevent a potentially dangerous situation from occurring? According to all previous codes of conduct issued by professional organizations such as the American Psychological Association, and according to accepted practice in the field, many would answer yes. Yet in 1976 the California Supreme Court ruled that the therapist should have warned not only the police but also the likely victim. The ruling has major implications for therapists in the conduct of therapy. One implication is also related to the earlier cases. How does a therapist predict that

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another person is dangerous (to him- or herself, to others, or to society)? To protect themselves from being sued, do therapists report all threats of homicide or suicide? Should psychologists warn clients that not everything they say is privileged or confidential? How will this affect the clinical relationship? We cover these and other topics in this chapter, and we begin by examining some of the issues of criminal and civil commitment. Then we look at patients’ rights and deinstitutionalization. We end by exploring the legal and ethical parameters of the therapist-client relationship, taking a final look at ethical issues related to cultural competence in mental health.

Myth vs Reality Myth: Because psychologists are specialists in understanding the human condition, they can predict the dangerousness of their clients well. We should rely on them to determine whether clients, inmates, and others are in danger of violence to others or of harm to themselves. Reality: It would be wonderful if psychologists could predict dangerousness well. They appear to be no better than other citizens in predicting dangerousness, and some believe they are poorer; most mental health professionals overpredict dangerousness, thus lowering their accuracy. This seems to make sense, as they may be inclined to “play it safe.” Some believe that police officers do a better job of ascertaining potential violence in people.

Criminal Commitment A basic premise of criminal law is that all of us are responsible beings who exercise free will and are capable of choices. If we do something wrong, we are responsible for our actions and should suffer the consequences. Criminal commitment is the incarceration of an individual for having committed a crime. Abnormal psychology accepts different perspectives on free will; criminal law does not. Yet criminal law does recognize that some people lack the ability to discern the ramifications of their actions because they are mentally disturbed. Although they may be technically guilty of a crime, their mental state at the time of the offense exempts them from legal responsibility. Let us explore the landmark cases that have influenced this concept’s evolution and application. Standards arising from these cases and some other important guidelines are summarized in Figure 17.1.

The Insanity Defense

SHOULD THIS MAN BE COMMITTED? Between 1986 and 1993, Larry Hogue, known to some as the “Wild Man of West 96th Street” in New York City, frightened and intimidated residents in the neighborhood. Living in alleys and doorways of Manhattan, he would talk to himself, walk barefoot in winter, threaten to eat pets, and generally behave in bizarre ways. He has been arrested numerous times for threatening people and damaging property, but he has never been permanently confined.

The concept of “innocent by reason of insanity” has provoked much controversy among legal scholars, mental health practitioners, and the general public. The insanity defense is a legal argument used by defendants who admit they have committed a crime but plead not guilty because they were mentally disturbed at the time the crime was committed. The insanity plea recognizes that under specific circumstances people may not be held accountable for their behavior. The fear that such a plea might be used by a guilty individual to escape criminal responsibility was portrayed in a popular film, Primal Fear, in which actor Richard Gere, playing a high-powered attorney, was duped into believing that his client suffered from a dissociative identity disorder (formerly known as multiple-personality disorder). The client was found not guilty by reason of insanity at the trial, only to have Gere’s character discover the ghastly truth. Unfortunately, the rare but highly publicized cases—such as those of John Hinckley (the person who attempted to assassinate President Ronald Reagan)—seem to have the greatest ability to provoke public outrage and suspicion (Rogers, 1987).

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Criminal Commitment and Mental State of Defendant

The Insanity Defense

Competency to Stand Trial Refers to mental state at time of psychiatric examination after arrest and before trial

Plea: Innocent by reason of insanity; refers to mental state at time of the crime

American Law Institute Test

M'Naghten Test Does the person know right from wrong?

Can the person appreciate the criminality of the act and conform his/her behavior to the requirements of the law?

Irresistible Impulse Test Did the person lack the willpower to control his/her actions?

FIGURE

1. Factual understanding of proceedings? 2. Rational understanding of proceedings? 3. Able to consult with counsel in her or his defense?

Durham Test Was the act a product of mental disease or defect?

17.1 LEGAL STANDARDS THAT ADDRESS THE MENTAL STATE OF DEFENDANTS

Legal Precedents In this country, a number of different standards are used as legal tests of insanity. One of the earliest is the M’Naghten Rule. In 1843, Daniel M’Naghten, a grossly disturbed woodcutter from Glasgow, Scotland, claimed that he was commanded by God to kill the English Prime Minister, Sir Robert Peel. He killed a lesser minister by mistake and was placed on trial, at which it became obvious that M’Naghten was quite delusional. Out of this incident emerged the M’Naghten Rule, popularly known as the “right-wrong” test, which holds that people can be acquitted of a crime if it can be shown that, at the time of the act, they (1) had such defective reasoning that they did not know what they were doing or (2) were unable to comprehend that the act was wrong. The M’Naghten Rule has come under tremendous criticism from some who regard it as being exclusively a cognitive test (knowledge of right or wrong), which does not consider volition, emotion, and other mental activity. Further, it is often difficult to evaluate a defendant’s awareness or comprehension. The second major precedent that strengthened the insanity defense was the irresistible impulse test. In essence, the doctrine says that a defendant is not criminally responsible if he or she lacked the will power to control his or her behavior. Combined with the M’Naghten Rule, this rule broadened the criteria for using the insanity defense. In other words, a verdict of not guilty by reason of insanity could be obtained if it was shown that the defendant was unaware of or did not comprehend the act (M’Naghten Rule) or was irresistibly impelled to commit the act. Criticisms of the irresistible impulse defense revolve around what constitutes an irresistible impulse. Shapiro (1984, p. 30) asked the question, “What is the difference between an irresistible impulse (unable to exert control) and an unresisted impulse (choosing not to exert control)?” For example, is a person with a history of antisocial behavior unable to resist his or her impulses, or is he or she choosing not to exert control?

criminal commitment

incarceration of an individual for having committed a crime insanity defense the legal argument used by defendants who admit they have committed a crime but who plead not guilty because they were mentally disturbed at the time the crime was committed M’Naghten Rule a cognitive test of legal insanity that inquires whether the accused knew right from wrong when he or she committed the crime irresistible impulse test

one test of sanity, which states that a defendant is not criminally responsible if he or she lacked the will power to control his or her behavior

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Did You Know?

C

onfessed Hillside Strangler Kenneth Bianchi attempted to fake mental illness for his part in raping, torturing, and murdering a number of young women in the late 1970s. Wanting to use the insanity plea to get a reduced sentence, Bianchi tried to convince psychiatrists that he suffered from multiple-personality disorder (now called dissociative identity disorder). His scheme was exposed as a fake by psychologist and hypnosis expert Dr. Martin Orne, and Bianchi was found guilty of murder and sentenced to life in prison without parole.

Durham standard a test of legal insanity known as the products test—an accused person is not responsible if the unlawful act was the product of mental disease or defect American Law Institute (ALI) Model Penal Code a test of

legal insanity that combines both cognitive criteria (diminished capacity) and motivational criteria (specific intent); its purpose is to give jurors increased latitude in determining the sanity of the accused

Neither the mental health profession nor the legal profession has answered this question satisfactorily. In the case of Durham v. United States (1954), the U.S. Court of Appeals broadened the M’Naghten Rule with the so-called products test or Durham standard. An accused person is not considered criminally responsible if his or her unlawful act was the product of mental disease or defect. It was Judge David Bazelon’s intent to (1) give the greatest possible weight to expert evaluation and testimony and (2) allow mental health professionals to define mental illness. The Durham standard also has its drawbacks. The term product is vague and difficult to define because almost anything can cause anything (as you have learned by studying the many theoretical viewpoints in this text). Leaving the task of defining mental illness to mental health professionals often results in having to define mental illness in every case. In many situations, relying on psychiatric testimony serves only to confuse the issues, because both the prosecution and defense bring in psychiatric experts, who often present conflicting testimony (Otto, 1989; Shuman & Greenberg, 2003). Interestingly, Judge Bazelon eventually recognized these problems and withdrew support for the test. In 1962, the American Law Institute (ALI), in its Model Penal Code, produced guidelines to help jurors determine the validity of the insanity defense on a case-bycase basis. The guidelines combined features from the previous standards. 1. A person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law. 2. As used in the Article, the terms “mental disease or defect” do not include an abnormality manifested by repeated criminal or otherwise antisocial conduct (Sec. 401, p. 66). It is interesting to note that the second point was intended to eliminate the insanity defense for people diagnosed as antisocial personalities. With the attempt to be more specific and precise, the ALI guidelines moved the burden of determining criminal responsibility back to the jurors. As we have seen, previous standards, particularly the Durham standard, gave great weight to expert testimony, and many feared that it would usurp the jury’s responsibilities. By using phrases such as “substantial capacity,” “appreciate the criminality of his conduct,” and “conform his conduct to the requirements of the law,” the ALI standard was intended to allow the jurors the greatest possible flexibility in ascribing criminal responsibility. In some jurisdictions, the concept of diminished capacity has also been incorporated into the ALI standard. As a result of a mental disease or defect, a person may lack the specific intent to commit the offense. For example, a person under the influence of drugs or alcohol may commit a crime without premeditation or intent; a person who is grief-stricken over the death of a loved one may harm the one responsible for the death. Although diminished capacity has been used primarily to guide the sentencing and disposition of the defendant, it is now introduced in the trial phase as well. Such was the trial of Dan White, a San Francisco supervisor who killed Mayor George Moscone and Supervisor Harvey Milk on November 27, 1978. White blamed both individuals for his political demise. During the trial, his attorney used the nowfamous “Twinkie defense” (White gorged himself on junk food such as Twinkies, chips, and soda) as a partial explanation for his client’s actions. White’s attorney attempted to convince the jury that the high sugar content of the junk food affected his cognitive and emotional state and was partially to blame for his actions. Because of the unusual defense (the junk food diminished his judgment), White was convicted only of voluntary manslaughter and sentenced to less than eight years in jail. Of course, the citizens of San Francisco were outraged by the verdict and never forgave Dan White. Facing constant public condemnation, he eventually committed suicide after his release.

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Guilty, but Mentally Ill Perhaps no other trial has more greatly challenged the use of the insanity plea than the case of John W. Hinckley, Jr. Hinckley’s attempt to assassinate President Ronald Reagan and his subsequent acquittal by reason of insanity outraged the public, as well as legal and mental health professionals. Even before the shooting, the increasingly successful use of the insanity defense had been a growing concern in both legal circles and the public arena. Many had begun to believe that the criteria for the defense were too broadly interpreted. These concerns were strong, even though findings indicate that the insanity defense is used in less than 1 percent of cases, that its use is rarely successful, and that few defendants fake or exaggerate their psychological disorders (Callahan et al., 1991; Silver, Cirincione, & Steadman, 1994; Steadman et al., 1993). For quite some time, the Hinckley case aroused NOT GUILTY BY REASON OF INSANITY John Hinckley, Jr., was charged with such strong emotional reaction that calls for the attempted murder of President Ronald Reagan. His acquittal by reason of insanity created a furor among the American public over use of the insanity reform were rampant. The American Psychiatric defense. The outrage forced Congress to pass the Insanity Reform Act. Association (1983), the American Medical Association (Kerlitz & Fulton, 1984), and the American Bar Association (1984) all advocated a more stringent interpretation of insanity. As a result, Congress passed the Insanity Reform Act of 1984, which based the definition of insanity totally on the individual’s ability to understand what he or she did. The American Psychological Association’s position on the insanity defense ran counter to these changes (Rogers, 1987). Its position is that even though a given verdict might be wrong, the standard is not necessarily wrong. Nevertheless, in the wake of the Hinckley verdict, some states have adopted alternative pleas, such as “culpable and mentally disabled,” “mentally disabled, but neither culpable nor innocent,” and “guilty, but mentally ill.” These pleas are attempts to separate mental illness from insanity and to hold people responsible for their acts (Slovenko, 1995; Steadman et al., 1993). Such pleas allow jurors to reach a decision that not only convicts individuals for their crimes and holds them responsible but also ensures that they will be given treatment for their mental illnesses. Just such a decision was handed down in the case of twenty-eight-year-old Nader Ali, who admitted to using an aluminum bat to beat twenty-five-year-old Lea Sullivan to death near the Whole Foods grocery store in Philadelphia. Both were classmates, and the prosecution claimed that Ali stalked and killed Sullivan in a premeditated manner. During the trial, the defense presented compelling evidence that Ali suffered from schizophrenia and a bipolar disorder. They claimed Ali was not guilty by reason of insanity. His attempt to use the insanity plea, however, failed, and the jury returned a verdict in 2006 of guilty, but mentally ill. Despite attempts at reform, however, states and municipalities continue to use different tests of insanity with varying outcomes, and the use of the insanity plea remains controversial.

Competency to Stand Trial The term competency to stand trial refers to a defendant’s mental state at the time of psychiatric examination after arrest and before trial. It has nothing to do with the issue of criminal responsibility, which refers to an individual’s mental state or behavior at the time of the offense. If you recall from the case of Russell Weston, Jr., who killed the two Capitol police officers, the court-appointed psychiatrist declared Weston not competent to stand trial. In such cases, our system of law states that an accused person cannot be tried unless three criteria are satisfied (Shapiro, 1984): 1. Does the defendant have a factual understanding of the proceedings?

competency to stand trial

a judgment that a defendant has a factual and rational understanding of the proceedings and can rationally consult with counsel in presenting his or her own defense; refers to the defendant’s mental state at the time of the psychiatric examination

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2. Does the defendant have a rational understanding of the proceedings? 3. Can the defendant rationally consult with counsel in presenting his or her own defense? Given this third criterion, a defendant who is suffering from paranoid delusions could not stand trial because a serious impairment exists. It is clear that many more people are committed to prison hospitals because of incompetency determinations than are acquitted on insanity pleas (Rogers, 1987; Steadman et al., 1993). It is estimated, for example, that some twenty-five thousand people in the United States are evaluated for their competency to stand trial and that, as noted, less than 1 percent of felony defenses use an insanity plea (Nicholson & Kugler, 1991; Silver et al., 1994). Determination of competency to stand trial is meant to ensure that a person understands the nature of the proceedings and is able to help in his or her own defense. This effort is an attempt to protect mentally disturbed people and to guarantee preservation of criminal and civil rights. But being judged incompetent to stand trial may have unfair negative consequences as well. A person may be committed for a long period of time, denied the chance to post bail, and isolated from friends and family, all without having been found guilty of a crime. Such a miscarriage of justice was the focus of a U.S. Supreme Court ruling in 1972 in the case of Jackson v. Indiana. In that case, a severely retarded, brain-damaged person who could neither hear nor speak was charged with robbery but was determined incompetent to stand trial. He was committed indefinitely, which in his case probably meant for life, because it was apparent by the severity of his disorders that he would never be competent. His lawyers filed a petition to have him released on the basis of deprivation of due process—the legal checks and balances that are guaranteed to everyone, such as the right to a fair trial, the right to face accusers, the right to present evidence, the right to counsel, and so on. The U.S. Supreme Court ruled that a defendant cannot be confined indefinitely solely on the grounds of incompetency. After a reasonable time, a determination must be made as to whether the person is likely or unlikely to regain competency in the foreseeable future. If, in the hospital’s opinion, the person is unlikely to do so, the hospital must either release the individual or initiate civil commitment procedures.

Civil Commitment

legal checks and balances that are guaranteed to everyone (the right to a fair trial, the right to face accusers, the right to present evidence, the right to counsel, and so on)

due process

the involuntary confinement of a person judged to be a danger to himself or herself or to others, even though the person has not committed a crime

civil commitment

Sometimes action seems necessary when people are severely disturbed and exhibit bizarre behaviors that can pose a threat to themselves or others. Government has a long-standing precedent of parens patriae (“father of the country” or “power of the state”), in which it has authority to commit disturbed individuals for their own best interest. Civil commitment is the involuntary confinement of individuals judged to be a danger to themselves or others, even though they have not committed a crime. Factors relevant to civil commitment are displayed in Figure 17.2. The commitment of a person in acute distress may be viewed as a form of protective confinement (Bednar et al., 1991) and concern for the psychological and physical well-being of that person or others. Hospitalization is considered in the case of potential suicide or assault, bizarre behavior, destruction of property, and severe anxiety leading to loss of impulse control. Involuntary hospitalization should, however, be avoided if at all possible because it has many potentially negative consequences. It may result in the lifelong social stigma associated with psychiatric hospitalization, major interruption in the person’s life, losing control of his or her life and being dependent on others, and loss of self-esteem and self-concept. To this we would add a possible loss or restriction of civil liberties—a point that becomes even more glaring when we consider that the person has actually committed no crime other than being a nuisance or assailing people’s sensibilities. Larry Hogue, described earlier, had committed no crime, although he violated many social norms. But at what point do we

Civil Commitment Civil Commitment

Criteria for Commitment

Procedures for Commitment

• Clear and imminent danger to self or others • Inability to care for self • Inability to make responsible decisions • State of panic or high anxiety

• Petition court for examination • Court decides on validity • If yes, an exam is ordered by mental health professional • Formal hearing is held • Finite period of treatment is ordered

Rights of Mental Patients

Right to Treatment

Right to Refuse Treatment • Least intrusive forms of treatment • Least restrictive environment

FIGURE

17.2 FACTORS IN THE CIVIL COMMITMENT OF A NONCONSENTING PERSON

confine people simply because they fail to conform to our standards of “decency” or “socially appropriate” behavior?

Criteria for Commitment States vary in the criteria used to commit a person, but there do appear to be certain general standards. It is not enough that a person be mentally ill; additional conditions need to exist before hospitalization is considered (Corey, Corey, & Callanan, 2003; Turkheimer & Parry, 1992). 1. The person presents a clear and imminent danger to him- or herself or others. An example is someone who is displaying suicidal or bizarre behavior (such as walking out on a busy freeway) that places the individual in immediate danger. Threats to harm someone or behavior viewed to be assaultive or destructive are also grounds for commitment. 2. The person is unable to care for himself or herself or does not have the social network to provide for such care. Most civil commitments are based primarily on this criterion. The details vary, but states generally specify an inability to provide sufficient forms of the following: • Food (person is malnourished, food is unavailable, and person has no feasible plan to obtain it) • Clothing (attire is not appropriate for climate or is dirty or torn, and person has no plans for obtaining others) • Shelter (person has no permanent residence, insufficient protection from climatic conditions, and no logical plans for obtaining adequate housing) 3. The person is unable to make responsible decisions about appropriate treatment and hospitalization. As a result, there is a strong chance of deterioration. 4. The person is in an unmanageable state of fright or panic. Such people may believe and feel that they are on the brink of losing control. In the past, commitments could be obtained solely on the basis of mental illness and a person’s need for treatment, which was often determined arbitrarily. Increasingly,

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the courts have tightened up civil commitment procedures and have begun to rely more on a determination of whether the person presents a danger to him- or herself or others. How do we determine this possibility? Many people would not consider Larry Hogue a danger to himself or others. Some, however, might believe that he could be assaultive to others and injurious to himself. Disagreements among the public may be understandable, but are trained mental health professionals more accurate in their predictions? Let’s turn to that question. Assessing Dangerousness As noted earlier, most studies have indicated that mental health professionals have difficulty predicting whether their clients will commit dangerous acts and that they often overpredict violence (Buchanan, 1997; McNiel & Binder, 1991; Monahan & Walker, 1990). The fact that civil commitments are often based on a determination of dangerousness—the person’s potential for doing harm to himself or herself or to others—makes this conclusion even more disturbing. The difficulty in predicting this potential seems linked to four factors. 1. The rarer something is, the more difficult it is to predict. As a group, psychiatric patients are not dangerous! Although some evidence suggests that individuals suffering from severe psychotic disorders may have slightly higher rates of violent behavior (Hodgins et al., 1996; Junginger, 1996; Monahan, 1993), the risk is not considered a major concern. A frequent misconception shared by both the public and the courts is that mental illnesses are in and of themselves dangerous. Studies have indicated that approximately 90 percent of people suffering from mental disorders are neither violent nor dangerous (Swanson et al., 1990), and few psychotic patients are assaultive: estimates range from 10 percent of hospitalized patients to about 3 percent in outpatient clinics (Tardiff, 1984; Tardiff & Koenigsburg, 1985; Tardiff & Sweillam, 1982). Homicide is even rarer: a psychiatric patient is no more likely to commit a homicide than is someone in the population at large (Monahan, 1981). 2. Violence seems as much a function of the context in which it occurs as a function of the person’s characteristics. Although it is theoretically possible for a psychologist to accurately assess an individual’s personality, we can have little idea about the situations in which people will find themselves. Shapiro (1984) advocated that the mental health professional needs to help the court define the term dangerous so that testimony can be restricted to a description of the patient’s personality and the kinds of situations in which personality may deteriorate, lead to assaultive behavior, or both. 3. The best predictor of dangerousness is probably past criminal conduct or a history of violence or aggression. Such a record, however, is frequently ruled irrelevant or inadmissible by mental health commissions and the courts. 4. The definition of dangerousness is itself unclear. Most of us would agree that murder, rape, torture, and physical assaults are dangerous. But are we confining our definition to physical harm only? What about psychological abuse or even destruction of property?

Procedures in Civil Commitment

a person’s potential for doing harm to himself or herself or to others

dangerousness

Despite the difficulties in defining dangerousness, once someone believes that a person is a threat to himself or herself or to others, civil commitment procedures may be instituted. The rationale for this action is that it (1) prevents harm to the person or to others, (2) provides appropriate treatment and care, and (3) ensures due process of law (that is, legal hearing). In most cases, people deemed in need of protective confinement can be persuaded to voluntarily commit themselves to a period of hospitalization. This process is fairly straightforward, and many believe that it is the preferred one. Involuntary commitment occurs when the client does not consent to hospitalization. Involuntary commitment can be a temporary emergency action or a longer period of detention that is determined at a formal hearing. All states recognize that cases arise in which a person is so grossly disturbed that immediate detention is required.

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Because formal hearings may take a long time, delaying commitment might prove adverse to the person or to other individuals. Formal civil commitment usually follows a similar process, regardless of the state in which it occurs. First, a concerned person, such as a family member, therapist, or family physician, petitions the court for an examination of the person. If the judge believes there is responsible cause for this action, he or she will order an examination. Second, the judge appoints two professionals with no connection to each other to examine the person. In most cases, the examiners are physicians or mental health professionals. Third, a formal hearing is held in which the examiners testify to the person’s mental state and potential danger. Others, such as family members, friends, or therapists, may also testify. The person is allowed to speak on his or her own behalf and is represented by counsel. Fourth, if it is determined that the person must enter treatment, a finite period may be specified; periods of six months to one year are common. Some states, however, have indefinite periods subject to periodic review and assessment. Protection Against Involuntary Commitment We have said that involuntary commitment can lead to a violation of civil rights. Some have even argued that criminals have more rights than the mentally ill. For example, a person accused of a crime is considered innocent until proven guilty in a court of law. Usually, he or she is incarcerated only after a jury trial, and only if a crime is committed (not if there is only the possibility or even high probability of crime). Yet a mentally ill person may be confined A TRAGIC CASE OF FAILING TO PREDICT without a jury trial and without having committed a crime if it is thought DANGEROUSNESS Convicted serial killer Jeffrey possible that he or she might do harm to him- or herself or others. In other Dahmer killed at least seventeen men and words, the criminal justice system will not incarcerate people because they young boys over a period of many years. Besides might harm someone (they must already have done it), but civil commit- torturing many of his victims, Dahmer admitted ment is based on possible future harm. It can be argued that in the former to dismembering and devouring their bodies. case, confinement is punishment, whereas in the latter case it is treatment Although Dahmer had been imprisoned in 1988 for sexual molestation, it would have been difficult (for the individual’s benefit). For example, it is often argued that mentally ill people may be incapable of determining their own treatment, and that, to predict his degree of dangerousness. Despite an attempt to use the insanity plea, Dahmer was once treated, they will be grateful for the treatment they received. If people found guilty in 1994 and imprisoned. He was resist hospitalization, they are thus being irrational, which is a symptom of subsequently killed by another inmate. their mental disorder. Critics do not accept this reasoning. They point out that civil commitment is for the benefit of those initiating commitment procedures (society) and not for the individual. Even after treatment, people rarely appreciate it. These concerns have raised and heightened sensitivity toward patient welfare and rights, resulting in a trend toward restricting the powers of the state over the individual.

Rights of Mental Patients Many people in the United States are concerned about the balance of power among the state, our mental institutions, and our citizens. The U.S. Constitution guarantees certain “inalienable rights” such as trial by jury, legal representation, and protection against self-incrimination. The mental health profession has great power, which may be used wittingly or unwittingly to abridge individual freedom. In recent decades, some courts have ruled that commitment for any purpose constitutes a major deprivation of liberty that requires due process protection. Until 1979, the level of proof required for civil commitments varied from state to state. In a case that set a legal precedent, a Texas man claimed that he was denied due process because the jury that committed him was instructed to use a lower standard than “beyond a reasonable doubt” (more than 90 percent certainty). The appellate court agreed with the man, but when the case finally reached the Supreme Court in April 1979 (Addington v. Texas), the Court ruled that the state must provide only “clear and convincing evidence” (approximately 75 percent certainty) that a person is mentally ill and potentially dangerous before that person can be committed. Although

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critical thinking

Predicting Dangerousness: The Case of Serial Killers and Mass Murderers

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effrey L. Dahmer admitted to killing his first victim in 1978 near his boyhood home. After killing his second victim, Dahmer stated he began to lose control of his necrophilia, a desire to have sex with the dead. Over a period of years until 1991 when he was arrested, he killed fifteen other men or young boys. Not only did he murder them, but he often killed them in hideous and torturous ways. Once they were dead he would have sex with them, dismember their bodies, and feed on them in cannibalistic fashion. Dahmer pleaded “not guilty by reason of mental disease or defect,” but he was subsequently found guilty and was killed by another inmate in prison. In 2007, nineteen-year-old Robert Hawkins, a school dropout, shot and killed eight people in a Nebraska shopping mall with an assault rifle that he smuggled into the building wrapped in a sweatshirt. He apparently selected his victims at random, and security cameras captured his image as he aimed and shot his victims who ranged in age from twentyfour to sixty-six. After the bloodbath, he committed suicide by shooting himself. He had recently lost his job and girlfriend; in his suicide note he stated “I’m a piece of shit” and “but I’m going to be famous now.” And who can forget April 20, 1999, when Eric Harris and Dylan Klebold went on a shooting rampage at Columbine High School, killing twelve students and a teacher before they both committed suicide. These examples of serial killers and mass murderers often make us wonder why such people were never identified as being potentially dangerous. Jeffrey Dahmer, for example, tortured animals as a small boy and was arrested in 1988

for molesting a child. Even though his father suspected his son was dangerous, Jeffrey Dahmer was released. And there appears to be sufficient evidence to suggest that mass murderer Hawkins was a deeply disturbed young man who harbored great resentment and anger waiting to explode. Harris and Klebold created a Web site that seemed to foretell their proclivity toward violence. In all three situations, aberrant thoughts and behaviors appeared to go unrecognized or ignored. Lest we be too harsh on psychologists and law enforcement officials, it is important to realize that few serial killers or mass murderers willingly share their deviant sexual or asocial fantasies. Furthermore, many of the problems in predicting whether a person will commit dangerous acts lie in (1) limited knowledge concerning the characteristics associated with violence, (2) lack of a oneto-one correspondence between danger signs and possible violence, (3) increasing knowledge that violent behavior is most often the result of many variables, and (4) recognition that incarceration—both criminal and civil—cannot occur on the basis of “potential danger” alone. Nevertheless, our limited experiences with mass murderers and serial killers have produced patterns and profiles of interest to mental health practitioners and law enforcement officials. Although similar, the profiles of mass murderers and serial killers also differ in some major ways. Profile of Serial Killers Serial killers are usually white males, and they often suffer from some recognized psychiatric disorder, such as sexual

these standards for confinement are higher than those advocated by most mental health organizations, this ruling nevertheless represented the first time that the Supreme Court considered any aspect of the civil commitment process. Due to decisions in several other cases (Lessard v. Schmidt, 1972, Wisconsin Federal Court; and Dixon v. Weinberger, 1975), states must provide the least restrictive environment for people. This means that people have a right to the least restrictive alternative to freedom that is appropriate to their condition. Only patients who cannot adequately care for themselves are confined to hospitals. Those who can function acceptably should be given alternative choices, such as boarding homes and other shelters.

Right to Treatment least restrictive environment

a person’s right to the least restrictive alternative to freedom that is appropriate to his or her condition the concept that mental patients who have been involuntarily committed have a right to receive therapy that would improve their emotional state

right to treatment

One of the primary justifications for commitment is that treatment will improve a person’s mental condition and increase the likelihood that he or she will be able to return to the community. If we confine a person involuntarily and do not provide the means for release (therapy), isn’t this deprivation of due process? Several cases have raised this problem as a constitutional issue. Together, they have determined that mental patients who have been involuntarily committed have a right to treatment—a right to receive therapy that would improve their emotional state. In 1966, in a lawsuit brought against St. Elizabeth’s Hospital in Washington, D.C. (Rouse v. Cameron), the court held that (1) right to treatment is a constitutional right and (2) failure to provide treatment cannot be justified by lack of resources. In

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sadism, antisocial personality, extreme narcissism, and borderline personality disorder. Few are psychotic, and psychoses do not appear to be the cause of their compulsion to kill. Almost all, however, entertain violent sexual fantasies and have experienced traumatic sex at a young age. Their earlier years are troubled with family histories of abuse, alcoholism, and criminal activity. Dahmer, for example, was sexually molested as a youngster. Most serial killers seem to exhibit little remorse for their victims, have little incentive to change, and seem to lack a value system. The compulsion to kill is often associated with what has been described as “morbid prognostic signs” (Schlesinger, 1989): breaking and entering for nonmonetary purposes; unprovoked assaults and mistreatment of women; a fetish for female undergarments and destruction of them; showing hatred, contempt, or fear of women; violence against animals, especially cats; sexual identity confusion, including underlying homosexual feelings; a “violent and primitive fantasy life”; and sexual inhibitions and preoccupation with rigid standards of morality (Youngstrom, 1991, p. 32). Although we have come a long way in being able to compile a composite description of serial killers, some have challenged the accuracy of such profiles. Two highly visible examples appear to break this mold. On April 16, 2007, Seung Hui Cho, a Korean American, used two semiautomatic handguns on the Virginia Tech campus to kill thirty-two people before committing suicide. The incident was the deadliest mass shooting in modern U.S. history. In the 2002 Washington, D.C., sniping case, in which ten innocent people were shot (eight fatally), John Allen Muhammad and teenager

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Lee Boyd Malvo did not fit the descriptions profiled by experts, either. They were originally thought to be angry white men, with no military background and probably local residents. As it turned out, the snipers were African Americans, one had combat experience, and they were drifters. Profile of Mass Murderers Mass murderers are usually men who are social isolates and seem to exhibit inadequate social and interpersonal skills. They have been found to be quite angry and to be filled with rage. The anger appears to be cumulative and is triggered by some type of event, usually a loss. For example, they may view the end of a job or a relationship as a catastrophic loss. Most have strong mistrust of people and entertain paranoid fantasies, such as a wide-ranging conspiracy against them. They tend to be rootless and have few support systems such as family, friends, or religious or fraternal groups. Many researchers believe that the number of mass murders will increase as firearms proliferate in our society. Other social correlates affecting mass murders are an increasing sense of rootlessness in the country, general disenchantment, and loneliness. The more random the killings, the more disturbed, delusional, and paranoid the person is likely to be. What criteria would you use to determine whether someone is dangerous or not? Can you identify the weaknesses or possible dangers to using this set of criteria? Can you give specific examples of cases in which they would prove problematic to apply? How does one balance applying and implementing criteria of dangerousness with the loss of civil liberties of citizens?

other words, a mental institution or the state could not use lack of funding facilities or labor power as reasons for not providing treatment. Although this decision represented a major advance in patient rights, the ruling provided no guidelines for what constitutes treatment. This issue was finally addressed in 1972 by U.S. District Court Judge Frank Johnson in the Alabama federal court. The case (Wyatt v. Stickney) involved a boy with mental retardation who not only was not given treatment but also was made to live in an institution that was unable to meet even minimum standards of care. Indeed, the living conditions in two of the hospital buildings resembled those found in early asylums of the eighteenth century. Less than 50 cents a day was spent on food for each patient; the toilet facilities were totally inadequate and filthy; patients were crowded in group rooms with minimal or no privacy; and personnel (one physician per two thousand patients) and patient care were practically nonexistent. Judge Johnson not only ruled in favor of the right to treatment but also specified standards of adequate treatment, such as staff-patient ratios, therapeutic environmental conditions, and professional consensus about appropriate treatment. The court also made it clear that mental patients could not be forced to work (scrub floors, cook, serve food, wash laundry, and so on) or to engage in work-related activities aimed at maintaining the institution in which they lived. This practice, widely used in institutions, was declared unconstitutional. Moreover, patients who volunteered to perform tasks had to be paid at least the minimum wage to do them instead of merely

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he legal system uses three different standards of proof. Beyond a reasonable doubt is confined to criminal trials and is generally accepted to be 95% certainty; clear and convincing evidence is used in civil commitments (75% certainty); and preponderance of evidence is generally used in civil actions (51% certainty). For mental health purposes, the burden of proof standard falls in between the two extremes.

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eung Hui Cho, the Virginia Tech mass murderer, was believed to be of imminent danger to himself and others. It was recommended that he be committed, but a court magistrate implemented the “least restrictive environment” criterion to guard against a restriction of his civil liberties. Instead, it was determined that an alternative choice, outpatient treatment, was more appropriate. As we now know, Cho failed to show for his therapy sessions and shortly carried out the massacre of thirty-two people.

being given token allowances or special privileges. This landmark decision ensures treatment beyond custodial care and protection against neglect and abuse. Another important case (tried in the U.S. District Court in Florida), O’Connor v. Donaldson (1975), has also had a major impact on the right-to-treatment issue. It involved Kenneth Donaldson, who at age forty-nine was committed for twenty years to the Chattahoochee State Hospital on petition by his father. He was found to be mentally ill, unable to care for himself, easily manipulated, and dangerous. Throughout his confinement, Donaldson petitioned for release, but Dr. O’Connor, the hospital superintendent, determined that the patient was too dangerous. Finally, Donaldson threatened a lawsuit and was reluctantly discharged by the hospital after fourteen years of confinement. He then sued both O’Connor and the hospital, winning an award of $20,000. The monetary award is insignificant compared with the significance of the ruling. Again, the court reaffirmed the client’s right to treatment. It ruled that Donaldson did not receive appropriate treatment and said that the state cannot constitutionally confine a nondangerous person who is capable of caring for himself or herself outside of an institution or who has willing friends or family to help. Further, it said that physicians, as well as institutions, are liable for improper confinements. One major dilemma facing the courts in all cases of court-ordered treatment is determining what constitutes treatment. Treatment can range from rest and relaxation to psychosurgery, medication, and aversion therapy. Mental health professionals believe that they are in the best position to evaluate the type and efficacy of treatment, a position supported by the case of Youngberg v. Romeo (1982). The court ruled that Nicholas Romeo, a boy with mental retardation, had a constitutional right to “reasonable care and safety,” and it deferred judgment to the mental health professional as to what constitutes therapy.

Right to Refuse Treatment Russell Weston, the man suffering from paranoid schizophrenia who killed two U.S. Capitol police officers in 1998, refused antipsychotic drugs. As you recall, he was declared mentally incompetent to stand trial, and he refused to take medication to make him competent. Court-appointed psychiatrists testified that his mental condition had worsened and that without treatment he could be dangerous. His attorneys, however, supported his right to refuse treatment and fought government officials on this point. Many believe that the refusal was based on a Supreme Court ruling (Ford vs. Wainwright) that stated that the government cannot execute an incompetent convict. Thus it would seem ironic for any prisoner to agree to medication only to be executed. As noted earlier, in January 2002, Russell Weston was forced by the courts to take antipsychotic medication based on the likelihood of improvement. Several other cases have come before the courts since then. In June 2003, the Supreme Court placed strict limits on the ability to medicate mentally ill defendants forcibly to make them competent to stand trial. Such actions must be, according to the court, in the “best interest of the defendant.” What this means will have to be played out in the future. As of 2007, Weston remains in a mental institution and has yet to be tried in court. Although it may be easy for us to surmise the reason for Weston’s attorneys refusing treatment to make him better, does it make sense for others? Patients frequently refuse medical treatment on religious grounds or because the treatment would only prolong a terminal illness. In many cases, physicians are inclined to honor such refusals, especially if they seem to be based on reasonable grounds. But should mental patients have a right to refuse treatment? At first glance, it may appear illogical. After all, why commit patients for treatment and then allow them to refuse it? Furthermore, isn’t it possible that mental patients may be incapable of deciding what is best for themselves? For example, a man with a paranoid delusion may refuse treatment because he believes the hospital staff is plotting against him. If he is allowed to refuse medication or other forms of therapy, his condition may deteriorate more. The result is that the client may become even more dangerous or incapable of caring for himself outside of hospital confinement.

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controversy

Court-Ordered Assisted Treatment: Coercion or Caring?

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n January 1999, Kendra Webdale waited for a subway train at a midtown Manhattan station. It was reported that Andrew Goldstein, twenty-nine years old, moved toward the woman and pushed her onto the tracks as a subway train pulled into the station. Riders watched in horror as the train struck Kendra Webdale, killing her on that fateful morning. Passengers surrounded the suspect and held him until the police arrived. It was found that Goldstein was carrying medical papers indicating that he was under psychiatric care at an outpatient clinic and had a history of multiple hospitalizations. Many people were outraged because they believed that Goldstein had failed to take his antipsychotic medication. Although his first trial resulted in a hung jury, he was convicted in the second trial and sentenced to twenty-five years to life in prison. The incident, along with a similar one, evoked such a large public outcry about protecting the public from psychiatric patients that New York State passed an assisted outpatient commitment law, known as “Kendra’s Law” (in memory of Kendra Webdale). Kendra’s Law has caused considerable controversy among the public, civil rights advocates, and mental health practitioners. As mentioned earlier, most forms of civil commitment are based on the criteria of “imminent danger to self or others.” The New York Court of Appeals’ landmark ruling, Rivers v. Katz (67 NY2d 485, 1986) specifically states that every adult of sound mind has a right to determine what shall be done with his or her body and to control his or her own course of medical treatment. But what about people who are not determined to be dangerous and

who refuse treatment that might help them or prevent potential harmful actions? The case is not unlike that of Russell Weston, although the implications for civil liberties in Kendra’s Law are much more likely to affect many more people. As a result, debates on individual rights, constitutionality of the law, and public safety have all given answers to the question as to whether the law is one of “caring” or “coercion.” Kendra’s Law allows court-ordered treatment without meeting the criteria for imminent dangerousness. As of this writing, ten states have statutes that allow for court-ordered outpatient treatment without manifesting the criteria of dangerousness: Alabama, Georgia, Hawaii, Mississippi, Montana, New York, North Carolina, Oregon, South Carolina, and Texas. The statutes all allow for compliance in medication, blood tests, urinalysis, psychotherapy, and day programs. Patients must meet the criteria of age (eighteen years) and a history of significant noncompliance with treatment. Any number of significant individuals can petition the court to force assisted outpatient treatment. Some claim that many homeless people would benefit from assisted outpatient treatment. For Further Consideration 1. As part of our guaranteed civil liberties, shouldn’t we have the right to refuse treatment? Under what conditions would you take away the right of patients to refuse treatment? 2. When examining these conditions, can you make a case for how they might be problematic?

Proponents of the right to refuse treatment argue, however, that many forms of treatment, such as medication or electroconvulsive therapy (ECT), may have long term side effects, as discussed in earlier chapters. They also point out that involuntary treatment is generally much less effective than treatment accepted voluntarily (Shapiro, 1984). People forced into treatment seem to resist it, thereby nullifying the potentially beneficial effects. The case of Rennie v. Klein (1978) involved several state hospitals in New Jersey that were forcibly medicating patients in nonemergency situations. The court ruled that people have a constitutional right to refuse treatment (psychotropic medication) and to be given due process. In another related case, Rogers v. Okin (1979), a Massachusetts court supported these guidelines. Both cases made the point that psychotropic medication was often used only to control behavior or as a substitute for treatment. Further, the decisions noted that drugs might actually inhibit recovery. In these cases, the courts supported the right to refuse treatment under certain conditions and extended the least restrictive alternative principle to include least intrusive forms of treatment. Generally, psychotherapy is considered less intrusive than somatic or physical therapies (ECT and medication). Although this compromise may appear reasonable, other problems present themselves. First, how do we define intrusive treatment? Are insight therapies as intrusive as behavioral techniques (punishment and aversion procedures)? Second, if patients are allowed to refuse certain forms of treatment and if the hospital does not have alternatives for them, can clients sue the institution? These questions remain unanswered.

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JOB TRAINING FOR THE MENTALLY CHALLENGED Increasingly, it is recognized that the mentally challenged or those suffering from mental disorders can be helped if they are taught functional skills in self-care and those related to employment. Here we see such a program in action, in which basic skills such as cooking, grooming, and conversation starters are taught.

Deinstitutionalization

deinstitutionalization

the shifting of responsibility for the care of mental patients from large central institutions to agencies within local communities mainstreaming integrating mental patients as soon as possible back into the community

Deinstitutionalization is the shifting of responsibility for the care of mental patients from large central institutions to agencies within local communities. When originally formulated in the 1960s and 1970s, the concept excited many mental health professionals. Since its inception, many state-run hospitals have experienced a reduction of more than 50 percent in the hospital population and a 75 percent decrease in the average daily number of committed patients (Turkheimer & Parry, 1992). The impetus behind deinstitutionalization came from several quarters. First, there was (and still is) a feeling that large hospitals provide mainly custodial care, that they produce little benefit for the patient, and that they may even impede improvement. Court cases discussed earlier (Wyatt v. Stickney and O’Connor v. Donaldson) exposed the fact that many mental hospitals are no better than “warehouses for the insane.” Institutionalization was accused of fostering dependency, promoting helplessness, and lowering self-sufficiency in patients. The longer patients were hospitalized, the more likely they were to remain hospitalized, even if they had improved. Further, symptoms such as flat affect and nonresponsiveness, which were thought to be clinical signs of schizophrenia, may actually result from hospitalization. Second, the issue of patient rights was receiving increased attention. Mental health professionals became very concerned about keeping patients confined against their will and began to discharge patients whenever they approached minimal competencies. It was believed that mainstreaming—integrating mental patients as soon as possible back into the community—could be accomplished by providing local outpatient or transitory services (such as board-and-care facilities, halfway houses, and churches). In addition, advances in tranquilizers and other drug treatment techniques made it possible to medicate patients, which made them manageable once discharged. Third, insufficient funds for state hospitals almost forced these institutions to release patients back into communities. Overcrowded conditions made mental health administrators view the movement favorably; state legislative branches encouraged the trend, especially because it reduced state costs and funding. What has been the impact of deinstitutionalization on patients? Its critics believe that deinstitutionalization is a policy that allows states to relinquish their responsibility to care for patients unable to care for themselves. There are alarming indications

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THE DOWNSIDE OF DEINSTITUTIONALIZATION Homelessness has become one of the great social problems of urban communities. Many believe that deinstitutionalization has contributed to the problem, although it is not clear what proportion of homeless people are mentally ill. Scenes such as this one, however, are becoming all too common in large urban areas.

that deinstitutionalization has been responsible for placing or “dumping” on the streets up to 1 million former patients who should have remained institutionalized (Toro & Wall, 1991). Critics believe that the “Wild Man of West 96th Street” is an example of the human cost and tragedy of such a policy. Most of these people appear severely disabled, have difficulty coping with daily living, suffer from schizophrenia, and are alcoholic (Fischer & Breakey, 1991; Lamb, 1984; Toro & Wall, 1991). It appears that millions of mentally ill individuals have joined the ranks of the homeless and that existing programs are woefully fragmented and inadequate in delivering needed services (U.S. Department of Health and Human Services, 2003). Thus it is becoming apparent that many mentally ill people are not receiving treatment. Approximately 750,000 of them now live in nursing homes, board-and-care homes, or group residences (Applebaum, 1987). The quality of care in many of these places is marginal, forcing continuing and periodic rehospitalization of their residents (Turkheimer & Parry, 1992). People with mental illnesses constitute a substantial portion of the homeless population (Fischer & Breakey, 1991; Levine & Rog, 1990). Much of the problem with deinstitutionalization appears to be the community’s lack of preparation and resources to care for people with chronic mental illness. Many patients lack family or friends who can help them make the transition back into the community; many state hospitals do not provide patients with adequate skills training; many discharged patients have difficulty finding jobs; many find substandard housing that is worse than the institutions from which they came; many are not adequately monitored and receive no psychiatric treatment; and many become homeless (Westermeyer, 1987). It is difficult to estimate how many discharged mental patients have been added to the burgeoning ranks of the homeless. We do know that homelessness in the United States, especially in large, urban areas, is increasing at an alarming pace (Kondratas, 1991; Toro & Wall, 1991). Certainly, it is not difficult to see the number of people who live in transport terminals, parks, flophouses, homeless shelters, cars, and storefronts. It is hard to determine how many of these homeless people were deinstitutionalized before adequate support services were present in a community. We do know, however, that the homeless have significantly poorer psychological adjustment and higher arrests and conviction records (U.S. Department of Health and Human Services, 2003). The solution, although complex, probably does not call for a return to the old institutions of the 1950s but rather for the provision of more and better community-based treatment facilities and alternatives (Kiesler, 1991).

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For patients involved in alternative community programs, the picture appears somewhat more positive. After reviewing reports of experimental studies on alternative treatment, a group of researchers concluded that such patients fared at least as well as those in institutions. Where differences were found, they favored the alternative programs (Braun et al., 1981). Such studies are few, however, and much remains to be done if deinstitutionalized patients are to be provided with the best supportive treatment.

The Therapist-Client Relationship The therapist-client relationship involves a number of legal, moral, and ethical issues. Three primary concerns are issues of confidentiality and privileged communication; the therapist’s duty to warn others of a risk posed by a dangerous client; and the therapist’s obligation to avoid sexual intimacies with clients.

Confidentiality and Privileged Communication Basic to the therapist-patient relationship is the premise that therapy involves a deeply personal association in which clients have a right to expect that whatever they say will be kept private. Therapists believe that genuine therapy cannot occur unless clients trust their therapists and believe that they will not divulge confidential communications. Without this guarantee, clients may not be completely open with their thoughts and may thereby lose the benefits of therapy. Confidentiality is an ethical standard that protects clients from disclosure of information without their consent. The importance of confidentiality is also shared by the public; in one study it was found that 74 percent of respondents thought everything told to a therapist should be confidential; indeed, 69 percent believed that whatever they discussed was never disclosed (Miller & Thelen, 1986). Confidentiality, however, is an ethical, not a legal, obligation. Privileged communication, a narrower legal concept, protects privacy and prevents the disclosure of confidential communications without a client’s permission (Corey et al., 2003; Herlicky & Sheeley, 1988). An important part of this concept is that the “holder of the privilege” is the client, not the therapist. In other words, if a client waives this privilege, the therapist has no grounds for withholding information. Our society recognizes how important certain confidential relationships are and protects them by law. These relationships are the husband-wife, attorney-client, pastor-congregant, and therapist-client relationships. Psychiatric practices are regulated in all fifty states and the District of Columbia, and most have privileged-communication statutes.

confidentiality an ethical standard

that protects clients from disclosure of information without their consent; an ethical obligation of the therapist privileged communication

a therapist’s legal obligation to protect a client’s privacy and to prevent the disclosure of confidential communications without a client’s permission

Exemptions from Privileged Communication Although states vary considerably, all states recognize certain situations in which communications can be divulged (Brown & Srebalus, 2003). Corey and associates (1998) summarized these conditions: 1. In situations that deal with civil or criminal commitment or competency to stand trial, the client’s right to privilege can be waived. 2. Disclosure can also be made when a client sees a therapist and introduces his or her mental condition as a claim or defense in a civil action. 3. When the client is younger than sixteen years of age or is a dependent elderly person and information leads the therapist to believe that the individual has been a victim of crime (incest, rape, or child and elder abuse), the therapist must provide that information to the appropriate protective services agency. 4. When the therapist has reason to believe that a client presents a danger to himself or herself (possible injury or suicide) or may potentially harm someone else, the therapist must act to ward off the danger. Privilege in communication is not absolute. Rather, it strikes a delicate balance between the individual’s right to privacy and the public’s need to know certain information (Leslie, 1991). Problems arise when we try to determine what the balance should be and how important various events and facts are in individual cases.

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The Duty-to-Warn Principle At the beginning of the chapter, we briefly described the case of Prosenjit Poddar (Tarasoff v. Board of Regents of the University of California, 1976), a graduate student who killed Tatiana Tarasoff after notifying his therapist that he intended to take her life. Before the homicide, the therapist had decided that Poddar was dangerous and likely to carry out his threat, and he had notified the director of the psychiatric clinic that the client was dangerous. He also informed the campus police, hoping that they would detain the student. Surely the therapist had done all that could be reasonably expected. Not so, ruled the California Supreme Court. In the Tarasoff ruling, the court stated that when a therapist determines, according to the standards of the mental health profession, that a patient presents a serious danger to another, the therapist is obligated to warn the intended victim. The court went on to say that protective privilege ends where public peril begins. In general, courts have ruled that therapists have a responsibility to protect the public from dangerous acts of violent clients and have held therapists accountable for (1) failing to diagnose or predict dangerousness, (2) failing to warn potential victims, (3) failing to commit dangerous individuals, and (4) prematurely discharging dangerous clients from a hospital. Criticism of the Duty-to-Warn Principle The Tarasoff ruling seems to place the therapist in the unenviable role of being a double agent (Bednar et al., 1991). Therapists have an ethical and legal obligation to their clients, but they also have legal obligations to society. Not only can these dual obligations conflict with one another, but they can also be quite ambiguous. Many situations exist in which state courts must rule to clarify the implications and uncertainties of the “duty-to-warn” rule (Fulero, 1988). Siegel (1979) loudly criticized the Tarasoff ruling, stating that the outcome was a hollow victory for individual parties, but it was devastating for the mental health professions. He reasoned that if confidentiality had been an absolute policy, Poddar might have been kept in treatment, thus ultimately saving Tarasoff’s life. Other mental health professionals have echoed this theme in one form or another. Hostile clients with pent-up feelings and emotions may be less likely to act out or become violent when allowed to vent their thoughts. The irony, according to critics, is that the duty-to-warn principle may actually be counterproductive to its intent to protect the potential victim. The Family Educational Rights and Privacy Act and Confidentiality of College Student Life Elizabeth Shin, a nineteen-year-old sophomore at the Massachusetts Institute of Technology (MIT), was believed to have set fire to herself and died on April 14, 2000. Two years after the death, her parents filed a $27 million wrongful death suit against MIT, accusing them of breach of contract, medical malpractice, and negligence on the part of university psychiatrists, student life staff, and campus police. The Shins contend that MIT knew their daughter had made suicide attempts, cut herself frequently, and suffered from depression but failed to inform them of her deteriorating mental state. Had they done so, they assert, Elizabeth Shin might still be alive today. They further claim that MIT broke the “business contract” with the family, which they say is implied in their daughter’s college enrollment at MIT. Not unlike the Tarasoff case, the outcome of the Shins’ lawsuit had the power to set legal precedence and potentially radically change the Family Educational Rights and Privacy Act that prevents colleges and universities from disclosing any personal information about students, even to their parents. Colleges and universities generally assume that students are adults, and if they were required to report every problem to parents, they would infantilize students by sending the wrong message. Students may also be less inclined to share personal information with school officials if they knew that such information may be reported back to their parents. Yet institutions of higher education are very aware that they are grappling to minister to an undergraduate population that seems to require more coddling and mental health care than ever before. One national study of counseling center client problems over thirteen years reveals that students are entering with more severe problems than in the past

A DUTY TO WARN Tatiana Tarasoff, a college student, was stabbed to death in 1969 by Prosenjit Poddar, a graduate student at the University of California at Berkeley. Although Poddar’s therapist notified the university that he thought Poddar was dangerous, the California Supreme Court ruled that the therapist should have warned the victim as well.

Tarasoff ruling often referred to as the “duty-to-warn” principle; obligates mental health professionals to break confidentiality when their clients pose clear and imminent danger to another person

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C H A P T E R 1 7 • L E G A L A N D E T H I C A L I S S U E S I N A B N O R M A L P S Y C H O LO G Y

(Benton et al., 2003). The lawsuit never tested the issue of student confidentiality and privacy, because the case was settled out of court in 2005 for an undisclosed sum and an agreement by MIT that the Shins’ daughter died by accident rather than suicide to protect both parties involved.

Sexual Relationships with Clients Therapeutic practice can also be legally regulated by civil lawsuits brought by clients against their therapists for professional malpractice. To be successful, however, these lawsuits must satisfy four conditions: (1) the plaintiff must have been involved in a professional therapeutic relationship with the therapist, (2) there must have been negligence in the care of the client, (3) demonstrable harm must have occurred, and (4) there must be a cause-effect relationship between the negligence and harm. If these four conditions are demonstrated, a jury may find the therapist guilty and award the plaintiff monetary damages. Although malpractice claims can be brought in any number of situations, by far the most common type involves sexual intimacies with a current or former client (Corey et al., 2003; Olarte, 1997). Traditionally, mental health practitioners have emphasized the importance of separating their personal and professional lives. They reasoned that therapists need to be objective and removed from their clients because becoming emotionally involved with them was nontherapeutic. A therapist in a personal relationship with a client may be less confrontative, may fulfill his or her own needs at the expense of the client’s, and may unintentionally exploit the client because of his or her position (Corey et al., 1998, 2003). Although some people question the belief that a social or personal relationship is necessarily antitherapeutic, matters of personal relations with clients, especially those dealing with erotic and sexual intimacies, are receiving increasing attention. Sexual misconduct of therapists is considered to be one of the most serious of all ethical violations. Indeed, virtually all professional organizations condemn sexual intimacies in the therapist-client relationship. The American Psychological Association (1995) states explicitly, “Psychologists do not engage in sexual intimacies with current patients or clients” (p. 474). But how do practitioners view sexual intimacies with clients? How often do such intimacies really occur? Who does what to whom? Some studies indicate that being sexually attracted to a client or engaging in sexual fantasy about one is not uncommon among therapists (Pope & Tabachnick, 1993; Pope, Tabachnick, & Keith-Spiegel, 1987). Furthermore, complaints to state licensing boards about sexual misconduct by therapists have increased significantly (Zamichow, 1993). Although these are indisputable facts, the vast majority of psychologists are able to control their sexual feelings and to behave in a professional manner.

Cultural Competence and the Mental Health Profession Many mental health professionals assert that the prevailing concepts of mental health and mental disorders are culture bound and that contemporary theories of therapy are based on values specific to a middle-class, white, highly individualistic, and ethnocentric population (American Psychological Association, 2003; Sue & Sue, 2008a). There are strong concerns that the services offered to culturally different clients are frequently antagonistic or inappropriate to their life experiences and that these services not only lack sensitivity and understanding but may also be oppressive and discriminating toward minority populations. These assertions about counseling and psychotherapy are echoed by other marginalized groups (women, gays/lesbians, disabled, etc.) in our society as well. The American Psychological Association (2002), in its most recent Ethical Principles of Psychologists and Code of Conduct, has made it clear that working with culturally different clients is unethical unless the mental health professional has adequate training and expertise in multicultural psychology. Such a position has resulted in the development of “Guidelines for Providers of Psychological Services to Ethnic,

Cultural Competence and the Mental Health Profession

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CHANGING DEMOGRAPHICS AND THERAPY The Teaching Tolerance program, founded in 1991 by the Southern Poverty Law Center, supports the efforts of K–12 teachers and other educators to promote respect for differences and appreciation of diversity. This photo was taken at the Mix It Up at Lunch Day program, which encourages students to step outside their social boundaries through various activities.

Linguistic, and Culturally Diverse Populations” (American Psychological Association, 1993) and “Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients” (American Psychological Association, 2000). In a historic move by the American Psychological Association (2003), the Council of Representatives passed “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists.” This document has now become official policy of the American Psychological Association and extends to nearly every realm of psychological practice. One of the most comprehensive guidelines on racial/ethnic minorities to be proposed, the document makes it clear that service providers need to become aware of how their own culture, life experiences, attitudes, values, and biases have influenced them. It also emphasizes the importance of cultural and environmental factors in diagnosis and treatment, and it insists that therapists respect and consider using traditional healing approaches intrinsic to a client’s culture. Finally, it suggests that therapists learn more about cultural issues and seek consultation when confronted with culturalspecific problems. Inherent in all these documents is their call for “cultural competence” and the conclusion that psychotherapy may represent biased, discriminatory, and unethical treatment if the racial/cultural backgrounds of clients are ignored and if the therapist does not possess adequate training in working with a culturally diverse population. From this perspective, mental health professionals have a moral and professional responsibility to become culturally competent if they work with people who differ from them in terms of race, culture, ethnicity, gender, sexual orientation, and so forth. To become culturally competent requires mental health professionals to strive toward attaining three goals (Sue & Sue, 2008a): (1) to become aware of and deal with the biases, stereotypes, and assumptions that affect their practice; (2) to become aware of the culturally different client’s values and worldview; and (3) to develop appropriate intervention strategies that take into account the social, cultural, historical, and environmental influences on culturally different clients. As we have seen, the increased awareness of multicultural influences in our understanding of abnormal psychology is reflected in the most recent version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR; American Psychiatric Association, 2000a). For the first time since its publication in 1952, DSM is acknowledging the importance of culture in the diagnosis and treatment of mental disorders.

I M P L I C AT I O N S

It is clear that psychology is increasingly serving a larger and larger role in our legal system. From evaluating the mental state of people to aiding in decisions regarding the care and treatment of patients, psychological knowledge has informed and been informed by legal statutes that guide our behavior. More important, mental health professionals realize that they do not work in isolation from the broader society and that clinical decisions must take into consideration changing legal precedents and the law. Just as psychological science may produce new knowledge that will affect the legal system and change our roles (such as better prediction of dangerousness and violence), so too the legal landscape may change and affect the field of abnormal psychology as well. None of us can accurately predict the nature and form of future laws that may potentially affect the role of psychologists and our perspectives on abnormal behavior.

Summary 1. What are the criteria used to judge insanity, and what is the difference between being insane and being incompetent to stand trial? ■ Insanity is a legal concept. Historically, several standards have been used. ■ The M’Naghten Rule holds that people can be acquitted of a crime if it can be shown that their reasoning was so defective that they were unaware of their actions or, if aware of their actions, were unable to comprehend the wrongness of them. The irresistible impulse test holds that people are innocent if they are unable to control their behavior. The Durham decision acquits people if their criminal actions were products of mental disease or defects. The American Law Institute guidelines state that people are not responsible for a crime if they lack substantial capacity to appreciate the criminality of their conduct or to conform their conduct to the requirements of the law. ■ The phrase “competency to stand trial” refers to defendants’ mental state at the time they are being examined. It is a separate issue from criminal responsibility, which refers to past behavior at the time of the offense. Accused people are considered incompetent if they have difficulty understanding the trial proceedings or cannot rationally consult with attorneys in their defense. Although competency to stand trial is important in ensuring fair trials, being judged incompetent can have negative consequences, such as unfair and prolonged denial of civil liberties. 2. Under what conditions can a person be involuntarily committed to a mental institution? ■ People who have committed no crime can be confined against their will if it can be shown that (1) they present a clear and imminent danger to themselves or others, (2) they are unable to care for themselves, (3) they are

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■

unable to make responsible decisions about appropriate treatment and hospitalization, and (4) they are in an unmanageable state of fright or panic. Courts have tightened criteria and rely more than ever on the concept of dangerousness. Mental health professionals have great difficulty in predicting dangerousness because dangerous acts depend as much on social situations as on personal attributes and because the definition is unclear.

3. What rights do mental patients have with respect to treatment and care issues? ■ Concern with patients’ rights has become an issue because many practices and procedures seem to violate constitutional guarantees. As a result, court rulings have established several important precedents. Among these are the right to treatment and the right to refuse treatment. 4. What is deinstitutionalization? ■ During the 1960s and 1970s, the policy of deinstitutionalization became popular: the shifting of responsibility for the care of mental patients from large central institutions to agencies within the local community. Deinstitutionalization was considered a promising answer to the “least restrictive environment” ruling and to monetary problems experienced by state governments. Critics, however, have accused the states of “dumping” former patients and avoiding their responsibilities under the guise of mental health innovations. 5. What legal and ethical issues govern the therapist-client relationship? ■ Most mental health professionals believe that confidentiality is crucial to the therapist-client relationship. Exceptions to this privilege include situations that involve (1) civil or criminal commitment and competency to

Summary

■

■

stand trial, (2) a client’s initiation of a lawsuit for malpractice or a civil action in which the client’s mental condition is introduced, (3) the belief that child or elder abuse has occurred, (4) a criminal action, or (5) the danger a client poses to himself or herself or to others. Although psychologists have always known that privileged communication is not an absolute right, the Tarasoff decision makes therapists responsible for warning a potential victim to avoid liability. Sexual misconduct by therapists is considered to be one of the most serious of all ethical violations by virtually all professional organizations.

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6. What is cultural competence in the mental health profession? ■

Major demographic changes are forcing mental health professionals to consider culture, ethnicity, gender, and socioeconomic status as powerful variables in (1) the manifestation of mental disorders and (2) the need to provide culturally appropriate intervention strategies for minority groups. Increasingly, mental health organizations are taking the position that it is unethical to treat members of marginalized groups without adequate training and expertise in multicultural psychology.

CHAPTER 18

Therapeutic Interventions Biology-Based Treatment Techniques Electroconvulsive Therapy Psychosurgery Psychopharmacology

Psychotherapy Insight-Oriented Approaches to Individual Psychotherapy Psychoanalysis Humanistic-Existential Therapies

Action-Oriented Approaches to Individual Psychotherapy Classical Conditioning Techniques Operant Conditioning Techniques Observational Learning Techniques Cognitive-Behavioral Therapy Health Psychology

Evaluating Individual Psychotherapy Meta-analysis and Effect Size

Group, Family, and Couples Therapy Group Therapy Family Therapy Couples Therapy

Systematic Integration and Eclecticism Culturally Diverse Populations and Psychotherapy African Americans Asian Americans/Pacific Islanders Latino or Hispanic Americans Native Americans

Community Psychology Managed Health Care Prevention of Psychopathology

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FOCUS QUESTIONS ■ What forms of medical treatment have been found to be successful in

treating mental disorders? ■ What is psychotherapy? ■ What are the different approaches to psychotherapy? ■ How successful is therapy in treating mental disorders? ■ How are group forms of therapy different from individual ones? ■ Is there a way to combine or integrate the best features of effective

therapies? ■ Is therapy with racial/ethnic minority groups different from working with

European American groups? ■ What can society do to make the social environment a healthy place

to live?

A

t some time in our lives, all of us have experienced personal, social, and emotionally distressing problems. Although many of us have been fortunate enough to handle such difficulties on our own, others have been greatly helped by discussing them with someone who could reassure and advise them. People have always relied on friends, relatives, members of the clergy, teachers, and even strangers for advice, emotional and social support, approval, and validation. In our society, however, this function has been increasingly taken over by psychotherapists. In preceding chapters, we have examined a wide variety of disorders, ranging from personality disturbances to schizophrenia. We have also examined the treatment approaches that seem to help people suffering from these disorders. In this chapter, we provide a more rounded view of the various techniques used to treat psychopathology: biology-based approaches, individual psychotherapy (both insight and action approaches), and group, family, and couples therapies. We also provide insights into therapeutic approaches in working with four major racial/ethnic minority groups: African Americans, Asian Americans/Pacific Islanders, Latino or Hispanic Americans, and Native Americans. We end the chapter with a brief examination of community psychology.

Biology-Based Treatment Techniques Biological or somatic treatment techniques use physical means to alter the patient’s physiological state and

hence his or her psychological state (Kolb, Gibb, & Robinson, 2003; Lickey & Gordon, 1991; Miller & Keller, 2000). The basic philosophy underlying this approach can be traced to ancient times, beginning with the practices of trephining (see the chapter on abnormal behavior) and bleeding and purging (laxatives and emetics) unwanted substances from the body. These primitive and barbaric methods of treatment have given way to more enlightened and benign forms. As our understanding of human physiology and brain functioning has increased, so has our ability to provide more effective biologically based therapies for the mentally ill (Department of Health and Human Services [DHHS], 1999). Three such techniques are examined here: electroconvulsive therapy, psychosurgery, and psychopharmacology (medication or drug therapy).

Electroconvulsive Therapy Many people consider physically shocking the patient’s body an abhorrent form of treatment. But electroconvulsive therapy (ECT) can be used successfully to treat certain mental disorders. This is especially true for severe depressive reactions, in which it can effect quite dramatic improvements (National Institute of Mental Health, 1985; Sackheim, Prudic, & Devanand, 1990). But how ECT acts to improve depression is still unclear. Whatever the mechanism, ECT seems to be effective against severe depression. Indeed, psychologist Norman Endler (1990) wrote a biography about his own struggle with depression and how ECT greatly helped his recovery. Evidence

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suggests that the treatment is particularly useful for endogenous cases of depression—those in which some internal cause can be determined (Klerman et al., 1994; see also the chapter on mood disorders). The first therapeutic use of shock was insulin shock treatment, introduced in the 1930s by psychiatrist Manfred Sakel. Insulin was injected into the patient’s body, drastically reducing the blood sugar level. The patient then went into convulsions and coma. The behavior of some patients with schizophrenia improved after awakening from this shock treatment. Also in the 1930s, another psychiatrist, Lazlo von Meduna, hypothesized that schizophrenia and epileptic seizures are antagonistic (seizures seem to prevent schizophrenic symptoms) and that by inducing convulsions in people with schizophrenia he could eliminate their bizarre behaviors. Meduna injected patients with the drug metrazol to induce the seizures. Neither insulin nor metrazol shock treatment was very effective, however, and their use declined with the advent of electroconvulsive therapy. In 1938, two Italian psychiatrists, Ugo Cerletti and Lucio Bini, introduced electroconvulsive therapy (ECT), or electroshock treatment. ECT is the application of electric voltage to the brain to induce convulsions. The patient lies on a padded bed or couch and is first injected with a muscle relaxant to minimize the chance of self-injury during the later convulsions. Then 65 to 140 volts of electricity are applied to the temporal region of the patient’s skull, through electrodes, for 0.1 to 0.5 seconds. Convulsions occur, followed by coma. On regaining consciousness, the patient is often confused and suffers a memory loss for events immediately before and after the ECT. Research indicates that unilateral shock (applying shock to only one hemisphere) causes less confusion and memory loss and is just as effective as bilateral shock (Abrams & Essman, 1982; Horne, Pettinati, Sugerman, & Varga, 1985). For several reasons, the use of ECT declined in the 1960s and 1970s, despite its success. The first reason was concern that ECT might cause permanent damage to important parts of the brain. Indeed, animals that have undergone ECT treatment show brain damage. Would it be unreasonable to expect similar damage in human beings? Second, a small percentage of patients fracture or dislocate bones during treatment. Although modern techniques have reduced pain and side effects (the convulsions are now almost unnoticeable), many patients anticipate a very unpleasant experience. Third, clinicians often argue that the “beneficial changes” initially observed in patients after ECT do not persist over the long term. Fourth, the abuses and side effects of ECT have been dramatized—often sensationally—in the mass media. In the movie One Flew

Shocking the Brain Electroconvulsive therapy involves the administration of electric shock to the brain. The treatment appears to be effective, especially with severe depression, although the precise reasons for its effectiveness are unclear.

Over the Cuckoo’s Nest, for instance, ECT was administered repeatedly to the protagonist because he would not conform to regulations while in a mental hospital (such use of ECT is now illegal and probably nonexistent). Fifth, and most important, recent advances in medication have diminished the need for ECT, except in the treatment of people with profound depression for whom medications act too slowly.

Psychosurgery As noted in the chapter on cognitive disorders, damage to brain tissue can dramatically alter a person’s emotional characteristics and intellectual functioning. In the 1930s, the Portuguese neurologist Egas Moniz theorized that destroying certain connections in the brain, particularly in the frontal lobes, could disrupt psychotic thought patterns and behaviors. During the 1940s and 1950s, psychosurgery—brain surgery performed for the purpose of correcting a severe mental disorder—became increasingly popular. The treatment was used most often with patients suffering from schizophrenia and severe depression, although many who had personality and anxiety disorders also underwent psychosurgery. Psychosurgery is a term applied to several procedures or techniques. In a prefrontal lobotomy holes are drilled in the skull, and a leukotome (a hollow tube that extrudes a cutting wire) is inserted through the holes to cut nerve fibers between the frontal lobes and the thalamus or hypothalamus. In transorbital lobotomy, the instrument is inserted through the eye socket, eliminating the need to drill holes in the skull. In a lobectomy, some or all of the frontal lobe is removed (to treat such disorders as brain tumors). Parts of the

Biology-Based Treatment Techniques

brain may also be subjected to electrical cauterization (searing or burning), which destroys selected brain tissue. Psychosurgical techniques have been refined to the point at which it is possible to operate on extremely small and contained areas of the brain. For example, videolaserscopy allows the surgeon to use a video camera in making extremely small incisions with a laser (Cowley, 1990). Critics of psychosurgical procedures have raised both scientific and ethical objections. In the case of lobotomies, for example, initial reports of results were enthusiastic, but later evaluations indicated that the patient’s improvement or lack of improvement was independent of the psychosurgical treatment. In addition, serious negative and irreversible side effects were frequently observed. Although postlobotomy patients often became quite manageable, calm, and less anxious, many emerged from surgery with impaired cognitive and intellectual functioning, were listless (even vegetative), or showed uninhibited impulsive behavior. Some such patients were described as “robots” or “zombies.” A small number suffered from continuing seizures and, in rare cases, some died from the surgery. Finally, because psychosurgery always produces permanent brain damage, some critics called for a halt to this form of treatment on humanitarian grounds. On the whole, restriction and regulation of its use seem wise.

Psychopharmacology Psychopharmacology is the study of the effects of drugs on the mind and on behavior; it is also known as medication or drug therapy. The use of medications has generally replaced shock treatment and psychosurgery for treating serious behavior disorders. Since the 1950s medication has been a major factor in allowing the early discharge of hospitalized mental patients and permitting them to function in the community. Medication is now widely used throughout the United States: more mental patients receive drug therapy than receive all other forms of therapy combined (Levinthal, 2005). Table 17.1 lists the generic and brand names of the drugs most frequently prescribed to treat psychological disorders. The rise in the use of minor tranquilizers has become a concern to society because of possible abuses and because of their addictive qualities. Some researchers have also noted that gender bias may operate in the extent to which they are prescribed for women. Studies indicate that women receive twice as many antianxiety medication prescriptions than are given to men; that although women make up only slightly more than one-half of the patients seen by psychiatrists, they receive 73 percent of all prescriptions;

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and that male psychiatrists prescribe medication twice as often as their female counterparts (Cypress, 1980; Hohmann, Larson, Thompson, & Beardsley, 1988; Rossiter, 1983). These issues will become even more prominent because many psychologists are advocating for the right to prescribe medication to their psychiatric patients, a right that has been largely limited to physicians (Gutierrez & Silk, 1998; Norfleet, 2002). We discuss four major categories of medication in this section. These are the antianxiety drugs (or minor tranquilizers), the antipsychotic drugs (or major tranquilizers), the antidepressant drugs (which relieve depression by elevating one’s mood), and antimanic drugs (such as lithium). Many of these will be familiar to you from our earlier discussions in the context of specific disorders. Antianxiety Drugs (Minor Tranquilizers) Before

the 1950s, barbiturates were often prescribed to relieve anxiety. Barbiturates are sedatives that have a calming effect but that are also highly addictive. Many people who take barbiturates develop a physical tolerance to these medications and require increasing doses to obtain the same effects. An overdose can result in death, and discontinuing the medication can produce agonizing withdrawal symptoms. Moreover, physical and mental disturbances, such as muscular incoordination and mental confusion, can result even from normal dosages. For these reasons, the barbiturates were replaced with antianxiety drugs almost as soon as the latter became available. During the 1940s and 1950s, the propanediols (meprobamate compounds) and benzodiazepines took over as the preferred medications. Researchers first developed meprobamate (the generic name of Miltown and Equanil) for use as a muscle relaxant and anxiety reducer. Within a few years, it was being prescribed for patients who complained of anxiety and nervousness or who had psychosomatic problems. Soon other antianxiety drugs, the benzodiazepines (Librium and Valium), also entered the market. Studies suggest that the benzodiazepines work by binding to specific receptor sites at the synapses and blocking transmission, which is another piece of evidence that supports the hypothesis that anxiety, like many other mental conditions, is linked to brain structure and physiology (Hayward, Wardie, & Higgitt, 1989). The antianxiety medications can be addictive and can impair psychomotor skills; discontinuing them after prolonged usage at high doses can result in withdrawal symptoms (DHHS, 1999). But they are considered safer than barbiturates, and there is little doubt that they effectively reduce anxiety and the behavioral symptoms of anxiety disorder.

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TABLE 17.1

Therapeutic Interventions

Drugs Most Commonly Used in Drug Therapy

Category

Generic Name

Brand Name

Examples of Clinical Use

Antianxiety

alprazolam

Xanax

Anxiety

meprobamate

Miltown and Equanil

chlordiazepoxide

Librium

diazepam

Valium

Antipsychotic drugs

Antidepressants

Antimanic drugs Stimulants

chlorpromazine

Thorazine

trifluoperazine

Stelazine

fluphenazine

Prolixin

haloperidol

Haldol

clozapine

Clozaril

phenelzine

Nardil

tranylcypromine

Parnate

imipramine

Tofranil

doxepin

Sinequan

amitriptyline

Elavil

fluoxetine

Prozac

paroxetine

Paxil

sertraline

Zoloft

lithium carbonate

Eskalith

carbamazapine

Tegretol

methylphenadate

Ritalin

pemoline

Cylert

The major problem with the minor tranquilizers is the great potential for overuse and overreliance. Because of its selective ability to diminish anxiety and leave adaptive behavior intact, Valium has been widely prescribed in the past. In addition, antianxiety drugs have gained in popularity among the general public, and they are widely used in relieving psychological problems. Almost everyone feels anxious at one time or another, and the antianxiety drugs are effective, readily available, low in cost, and easy to administer. They are a quick, easy alternative to developing personal coping skills. As a result, people tend to choose the short-term relief offered by these medications over the long-term but more gradual gains of developing the ability to manage stress and to learn to solve one’s own problems. Antipsychotic

Drugs

(Major

Tranquilizers)

Although the antianxiety medications seem to relax and reduce anxiety in patients, they have minimal

Schizophrenia, psychosis

Depression, anxiety

Mania Attention deficit/hyperactivity disorder

impact on the hallucinations and distorted thinking of highly agitated patients and patients with schizophrenia. In 1950 a synthetic sedative was developed in France. This medication, chlorpromazine (the generic name of Thorazine), had an unexpected tranquilizing effect that decreased patients’ interest in the events taking place around them. Within less than a year after its introduction, some 2 million patients used Thorazine. Chlorpromazine also seemed to reduce psychotic symptoms (believed to be a biochemical effect of blocking dopamine receptors). Thereafter, a number of other major tranquilizers were developed, mainly for administration to patients with schizophrenia. (The chapter on schizophrenia discusses use of medication as a treatment for this disorder.) Several experimental studies have demonstrated the efficacy of antipsychotic drugs in treating schizophrenia (Klerman et al., 1994). A review of many large-scale controlled studies indicates that the ben-

Biology-Based Treatment Techniques

eficial effects of Thorazine, Stelazine, Prolixin, and other antipsychotic drugs have allowed institutions to release thousands of chronic “incurable” mental patients throughout the country (Lickey & Gordon, 1991; Wender & Klein, 1981). When patients hospitalized with schizophrenia were given phenothiazines (a class of major tranquilizers), they showed more social interaction with others, better self-management, and less agitation and excitement than when they were given placebos. Despite their recognized effectiveness, antipsychotic drugs do not always reduce anxiety, and they can produce side effects. Patients may develop psychomotor symptoms resembling those of Parkinson’s disease, sensitivity to light, dryness of the mouth, drowsiness, or liver disease. After an extended period of continuous treatment with antipsychotic drugs, some patients (usually patients older than forty years of age) develop tardive dyskinesia—a disorder characterized by involuntary movement of the head, tongue, and extremities. Patients discharged from hospitals typically show only marginal adjustments to community life, and psychotic symptoms usually return when the medication is discontinued. As a result, the rehospitalization rate is high. Nevertheless, medication or drug therapy is very important in treating schizophrenia, and nearly all psychiatric institutions use it. Antipsychotic drugs have dramatically increased the proportion of patients with this disorder who can return to and function in the community, even though they may show residual symptoms.

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Antidepressant Drugs As in the case of antipsy-

chotic drugs, the development of antidepressants was aided by a fortunate coincidence. During the 1950s, clinicians noticed that patients treated with the antituberculosis medication iproniazid became happier and more optimistic. When tested on people diagnosed with depression, the medication was found to be effective as an antidepressant. Unfortunately, liver damage and fatalities caused by the medication were relatively high. Continued interest in antidepressants has led to the identification of three large classes of the compounds: monoamine oxidase inhibitors, tricyclics, and selective serotonin reuptake inhibitors (a type of tricyclic). Monoamine oxidase (MAO) inhibitors are antidepressant compounds that are believed to correct the balance of neurotransmitters in the brain. A number of the MAO inhibitors, such as phenelzine, were found to be less dangerous but similar in effect to iproniazid. It is hypothesized that the MAO inhibitors work primarily to correct a deficiency in concentrations of neurotransmitters in the brain. They block the action of monoamine oxidase, thereby preventing the breakdown of norepinephrine and serotonin. As you may recall from the chapters on abnormal behavior and on mood disorders, the lack of these neurotransmitters at pertinent synaptic sites has been implicated in depression. Although the MAO inhibitors relieve depression, they produce certain toxic effects and require careful dietary monitoring. (Certain foods and other drugs, when taken with an MAO inhibitor, could cause severe illness.) More frequently used in cases of depression are the tricyclics, antidepressant compounds that relieve symptoms of depression and seem to work like the MAO inhibitors but produce fewer of the side effects associated with prolonged drug use. The medication imipramine, a tricyclic, has been at least as effective as psychotherapy in relieving the symptoms of depression (Elkin et al., 1995). Until recently, the tricyclics were the most widely used medication in treating depression. Medications that may replace tricyclics as the preferred medication for treating depression are selective serotonin reuptake inhibitors (SSRIs). They work by inhibiting the central nervous system’s neuronal uptake of serotonin—a mechanism that appears to be the treatment of choice for unipolar depression (Seligman & Levant, 1998). SSRIs include the drugs Prozac (fluoxetine hydrochloride), Paxil (paroxetine), and Zoloft (sertraline). The use of SSRIs has increased dramatically. These drugs affect serotonin but not other neurotransmitters, take effect in a shorter period of time than other antidepressants, have fewer side effects than the tricyclics, and are less likely to result in overdosing. However,

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reported side effects include feeling jittery and having stomach irritation. In October 2004, the Food and Drug Administration issued a “black box” warning on the use of antidepressants with children and adolescents. Ironically, it was shown that the use of many popular antidepressants increased the risk of children’s suicidal thinking and/or behaviors. Research is being conducted to determine which antidepressants have this unfortunate effect and what would explain susceptibility to suicidal ideation and behavior. Antimanic Drugs Lithium is another mood-controlling (antimanic) medication that has been very effective in treating bipolar disorders, especially mania (Klerman et al., 1994). About 70 to 80 percent of manic states can be controlled by lithium, and it also controls depressive episodes. How lithium works remains highly speculative. One hypothesis is that it somehow limits the availability of serotonin and norepinephrine at the synapses and produces an effect opposite from that of the antidepressants. Yet lithium’s ability to relieve depression appears to contradict this explanation. Other speculations involve electrolyte changes in the body, which alter neurotransmission in some manner. Strangely enough, lithium, which is administered as a salt, has no known physiological function. Yet with proper administration of lithium—a single tablet in the morning and another in the evening—patients’ manic and depressive cycles can be modulated or prevented. However, cautions limit its use in treating bipolar disorders. First, it is largely preventive and must be taken before symptoms appear. Once a manic or depressive state occurs, lithium’s effect is minimal. Second, it is often extremely difficult to determine a patient’s appropriate dosage. The effective dosage level often borders on toxicity, which can cause convulsions, delirium, and other bad effects. Careful and constant monitoring of the lithium level in a patient’s blood is very important. Psychopharmacological Considerations A major issue in psychopharmacology is deciding which medication to use with which kind of patient under what circumstances (Grilly, 2002). For example, although imipramine is more effective with longstanding and severe depressions without specific situational causes, antidepressants often do not begin to help patients until two to three weeks after treatment begins. The SSRI drugs appear to work more quickly. If very rapid improvement is necessary, ECT may be used as a last resort to treat a patient with severe depression or suicidal ideation.

The use of antidepressant, antianxiety, and antipsychotic drugs has greatly changed therapy. Patients who take them report that they feel better, that symptoms decline, and that overall functioning improves. Long periods of hospitalization are no longer needed in most cases, and patients are more amenable to other forms of treatment, such as psychotherapy. Remember, however, that medications do not cure mental disorders. Some would characterize their use as “control measures,” somewhat better than traditional hospitalization, “straitjackets,” or “padded cells.” Furthermore, medications seem to be most effective in treating “active” symptoms such as delusions, hallucinations, and aggression and much less effective with “passive” symptoms such as withdrawal, poor interpersonal relationships, and feelings of alienation. Medication does not help patients improve their living skills. A large number of patients discharged from mental hospitals require continuing medication to function even minimally in the community. Unfortunately, many of them do not continue to take their medication after leaving the hospital. Some do not realize the importance of continued and timely medication. Others are unable to pay for medication, either individually or through an insurance plan. Others’ lifestyles are not conducive to taking the medications. Once they discontinue their medications, patients may again experience the same disorder that led to their hospitalization. Finally, both medication and psychotherapy (administered together or alone) appear to be of benefit to clients (Gould, Buckminster, Pollack, Otto, & Yap, 1997).

Psychotherapy In most cases, biological treatments such as medication are used as an adjunct to psychotherapy. But beyond general agreement that psychotherapy is an internal approach to treating psychopathology, involving interaction between one or more clients and a therapist, there is little consensus on exactly what else it is. Psychotherapy has been called “a conversation with a therapeutic purpose”; it has also been called “the talking cure” or the “purchase of friendship” (Sue & Sue, 2003). For our purposes, psychotherapy may be defined as the systematic application, by a trained and experienced professional therapist, of techniques derived from psychological principles, for the purpose of helping psychologically troubled people (Day, 2004; Sommers-Flanagan & Sommers-Flanagan, 2004). We cannot be more succinct or precise without getting involved in specific types of therapy. Depending on their perspective and theoretical orientation, therapists may seek to modify attitudes, thoughts, feelings, or

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Science, Art, or a Mix of Both? Psychotherapy relies on the systematic use of techniques based on psychological principles to provide the client with an opportunity not only for catharsis but also for the acquisition of new behaviors and expectancies to help overcome psychological problems.

behaviors; to facilitate the patient’s self-insight and rational control of his or her own life; to cure mental illness; to enhance mental health and self-actualization; to make clients “feel better”; to remove a cause of a disorder; to change a self-concept; or to encourage adaptation (Corey, 2005). Psychotherapy is practiced by many different kinds of people in many different ways—a fact that seems to preclude establishing a single set of standard therapeutic procedures. And— despite our emphasis on the scientific basis of therapy—in practice it is often more art than science. Diverse psychotherapies do seem to share some common therapeutic factors. In one study the investigators examined fifty publications on psychotherapy and found that the characteristics common to most of them were (1) development of a therapeutic alliance, (2) opportunity for catharsis, (3) acquisition and practice of new behaviors, and (4) the clients’ positive expectancies (Grencavage & Norcross, 1990). These characteristics are very consistent with those first proposed by Korchin (1976) nearly thirty years ago: ■

■

Psychotherapy is a chance for the client to relearn. Many people say to their psychotherapists, “I know I shouldn’t feel or act this way, but I just can’t help it.” Psychotherapy provides a chance to unlearn, relearn, develop, or change certain behaviors or levels of functioning. Psychotherapy helps generate the development of new, emotionally important experiences. A person questioning the value of psychotherapy may ask,

“If I talk about my problems, how will that cause me to change, even though I may understand myself better? I talk things over now, with friends.” But psychotherapy is not merely a “talking cure.” It involves the reexperiencing of emotions that clients may have avoided, along with the painful and helpless feelings fostered by these emotions. This experiencing allows relearning, as well as emotional and intellectual insight into problems and conflicts. ■

A therapeutic relationship exists. Therapists have been trained to listen, to show empathic concern, to be objective, to value the client’s integrity, to communicate understanding, and to use their professional knowledge and skills. Therapists may provide reassurance, interpretations, self-disclosures, reflections of the client’s feelings, or information, each at appropriate times. As a team, therapist and client are better prepared to venture into frightening areas that the client would not have faced alone.

■

Clients in psychotherapy have certain motivations and expectations. Most people enter therapy with both anxiety and hope. They are frightened by their emotional difficulties and by the prospect of treatment, but they expect or hope that therapy will be helpful.

The goals and general characteristics of psychotherapy as described seem admirable, and most people consider them so. Nevertheless, psychotherapy itself has been criticized as being biased and inappropriate to the lifestyles of many clients, including members of minority

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groups. Indeed, many psychologists have called for psychotherapy approaches that can better relate to the cultures of different ethnic groups (Carter & McGoldrick, 2005; Ivey, D’Andrea, Ivey, & Simek-Morgan, 2002; Sue & Sue, 2003). As we shall shortly see, racial/ethnic minority status must be considered in the provision of psychological services to these populations. In the next two sections we discuss individual psychotherapy, in which one therapist treats one client at a time. We also distinguish between insight- and action-oriented approaches to individual therapy. This distinction separates approaches that stress awareness, understanding, and consciousness of one’s own motivations (that is, insight) from those approaches that stress actions, such as changing one’s behavior or thoughts. The first set includes the psychoanalytic and humanistic-existential therapies, whereas the second set involves mainly behavioral therapies. Following those two discussions, we turn to group, family, and couples therapy. Despite this variety of approaches, many therapists use similar treatment strategies. And, as noted in the chapter on abnormal behavior, many therapists choose relevant techniques from all the various “pure” approaches to develop the most effective integrative approach for each particular client.

Insight-Oriented Approaches to Individual Psychotherapy The theoretical bases of the major insight-oriented psychotherapies were discussed in the chapter on models of abnormal behavior. Here we briefly review these theoretical bases and then discuss the most common treatment techniques.

Psychoanalysis According to Freud’s theory of personality, people are born with certain instinctual drives, urges that constantly seek to discharge or express themselves. As the personality structure develops, conflicts occur among the id, ego, and superego. If conflicts remain unresolved, they will resurface during adulthood. The relative importance of such an unresolved conflict depends on the psychosexual stage (oral, anal, phallic, or genital) in which it occurs. The earlier the stage in which an unresolved conflict arises, the greater the conflict’s effect on subsequent behaviors. Repressing unacceptable thoughts and impulses (within the unconscious) is the primary way that people defend themselves against such thoughts. Psychoanalytic therapy, or psychoanalysis, seeks to overcome defenses so that (1) repressed material can be uncovered, (2) the client can achieve insight into his or

her inner motivations and desires, and (3) unresolved childhood conflicts can be controlled. Traditional psychoanalysis requires many sessions of therapy over a long period of time. It may not be appropriate for certain types of people, such as nonverbal adults, young children who cannot be verbally articulate or reasonable, people with schizoid disorders, those with urgent problems requiring immediate reduction of symptoms, and people with mental retardation. Psychoanalysts traditionally use four methods to achieve their therapeutic goals: free association and dream analysis, analysis of resistance, transference, and interpretation. Free Association and Dream Analysis In free

association the patient says whatever comes to mind, regardless of how illogical or embarrassing it may seem, for the purpose of revealing the contents of the patient’s unconscious. Psychoanalysts believe the material that surfaces in this process is determined by the patient’s psychic makeup and that it can provide some understanding of the patient’s conflicts, unconscious processes, and personality dynamics. Simply asking patients to talk about their conflicts is fruitless, because they have repressed the most important material from their consciousness. Instead, reports of dreams, feelings, thoughts, and fantasies reflect a patient’s psychodynamics; the therapist’s tasks are to encourage continuous free association of thoughts and to interpret the results. Similarly, dream analysis is a very important therapeutic tool that depends on psychoanalytic interpretation of hidden meanings in dreams. Freud is often credited with referring to dreams as “the royal road to the unconscious.” According to psychoanalytic theory, when people sleep, defenses and inhibitions of the ego weaken, allowing unacceptable motives and feelings to surface. This material comes out in the disguised and symbolic form of a dream. The portion we remember is called the manifest content, and the deeper, unacceptable impulse is the latent content. The therapist’s job is to uncover the disguised symbolic meanings and let the patient achieve insight into the anxietyprovoking implications. Analysis of Resistance Throughout the course of

psychoanalytic therapy, the patient’s unconscious may try to impede the analysis, in a process known as resistance, by preventing the exposure of repressed material. In free association, for example, the patient may suddenly change the subject, lose the train of thought, go blank, or become silent. Such resistance may also show up in a patient’s late arrival or failure to keep an appointment. A trained analyst is alert to telltale signs of resistance because they indicate that a

Insight-Oriented Approaches to Individual Psychotherapy

sensitive area is being approached. The therapist can make therapeutic use of properly interpreted instances of resistance to show the patient that repressed material is coming close to the surface and to suggest means of uncovering it. Transference When a patient begins to perceive, or behave toward, the analyst as though the analyst were an important person in the patient’s past, the process of transference is occurring. In transference the patient reenacts early conflicts by carrying over and applying to the analyst feelings and attitudes that the patient had toward significant others—primarily parents—in the past. These feelings and attitudes then become accessible to understanding. They may be positive, involving feelings of love for the analyst, or negative, involving feelings of anger and hostility. Part of the psychoanalyst’s strategy is to remain “unknown” or ambiguous, so that the client can freely develop whatever kind of transference is required. The patient is allowed, even encouraged, to develop unrealistic expectations and attitudes regarding the analyst. These expectations and attitudes are used as a basis for helping the patient deal realistically with painful early experiences. In essence, a miniature neurosis is re-created; its resolution is considered crucial to the therapy. At the same time, the analyst must be careful to recognize and control any instances of countertransference. In this process, the analyst—who is also a human being with feelings and fears—transfers those feelings to the patient. This is one reason that Freud believed so strongly that all psychoanalysts need to undergo psychoanalysis themselves.

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Sandy: Huh? Therapist: Who’s the “he” who’d be waiting? Sandy: John—I mean, my father—you’re confusing me now. … My father would sit there—smoking his pipe. I knew what he was thinking, though—he didn’t have to say it—he was thinking I was a slut! Someone—who, who was a slut! So what if I stayed up late and had some fun? What business was it of his? He never took any interest in any of us. [Begins to weep.] It was my mother—rest her soul—who loved us, not our father. He worked her to death. Lord, I miss her. [Weeps uncontrollably]—I must sound angry at my father. Don’t you think I have a right to be angry? Therapist: Do you think you have a right to be angry? Sandy: Of course, I do! Why are you questioning me? You don’t believe me, do you? Therapist: You want me to believe you. Sandy: I don’t care whether you believe me or not. As far as I’m concerned, you’re just a wall that I’m talking to—I don’t know why I pay for this rotten therapy.—Don’t you have any thoughts or feelings at all? I know what you’re thinking—you think I’m crazy—you must be laughing at me—I’ll probably be a case in your next book! You’re just sitting there—smirking—making me feel like a bad person—thinking I’m wrong for being mad, that I have no right to be mad. Therapist: Just like your father. Sandy: Yes, you’re just like my father.—Oh my God! Just now—I—I—thought I was talking to him. Therapist: You mean your father.

Interpretation Through interpretation—the expla-

nation of a patient’s free associations, reports of dreams, and the like—a sensitive analyst can help the patient gain insight (both intellectual and emotional) into his or her repressed conflicts. By pointing out the symbolic attributes of a transference relationship or by noting the peculiar timing of symptoms, the analyst can direct the patient toward conscious control of unconscious conflicts. The following example shows the timely interpretation of an important instance of transference: Sandy (the patient): John [her ex-husband] was just like my father. Always condemning me, always making me feel like an idiot! Strange, the two of them—the most important men in my life—they did the most to screw me up. When I would have fun with my friends and come home at night, he would be sitting there—waiting—to disapprove. Therapist (male): Who would be waiting for you?

Sandy: Yes—I’m really scared now—how could I have—can this really be happening to me? Therapist: I know it must be awfully scary to realize what just happened—but don’t run away now, Sandy. Could it be that your relationship with your father has affected many of the relationships you’ve had with other men? It seems that your reaction to me just now, and your tendency to sometimes refer to your ex-husband as your father— Sandy: God!—I don’t know—what should I do about it?—Is it real? Modern Psychodynamic Therapy In the chapter

on models of abnormal behavior, we noted the contemporary changes in theoretical formulations of psychodynamic theory, especially the increased importance of the ego (ego autonomy theorists) and past interpersonal relationships (object relations theorists). Among the ego autonomy theorists were people such as Anna Freud,

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Heinz Hartmann, and Erik Erikson, who believed that cognitive processes of the ego were often constructive, creative, and productive (independent from the id). Likewise, object relations theorists such as Melanie Klein, Margaret Mahler, Otto Kernberg, and Heinz Kohut stressed the importance of interpersonal relationships and the child’s separation from the mother as important in one’s psychological growth. The contributions of these theorists and practitioners expanded and loosened the rigid therapeutic techniques of traditional psychoanalysis (James & Gilliland, 2003). Today, very few psychodynamic therapists practice traditional psychoanalysis. Most are more active in their sessions, restrict the number of sessions they have with clients, place greater emphasis on current rather than past factors, and seem to have adopted a number of clientcentered techniques in their practice (Nystul, 2003). The Effectiveness of Psychoanalysis Psycho-

analysis has been criticized for a number of reasons. Psychoanalysts tend to select certain kinds of clients for treatment, usually those who are young, white, and highly educated (Garfield, 1994). This means that psychoanalysis has been limited in addressing the needs of a larger population. Providing operational definitions for such constructs as the unconscious and the libido has been problematic, making it extremely difficult to confirm the various aspects of the theory. For example, psychoanalytic theory suggests that neurotic or anxiety symptoms are caused by underlying emotional conflicts. (DSM in the past had a diagnostic category for “neurotic disorders,” which is no longer used. Psychoanalysts often refer to neuroses or neurotic disorders because the disorders have played an important role in conceptualizing psychoanalytic views.) When these symptoms are eliminated without removing the conflict, the person merely expresses the neurosis in other ways and shows other symptoms—a phenomenon known as symptom substitution. Many researchers, particularly behavior therapists, assert that it is possible to eliminate neurotic or anxiety symptoms without symptom substitution occurring. Furthermore, they contend that when the symptoms are eliminated, the neurosis or anxiety disorder is cured. Thus psychoanalysis has encountered many problems despite its vast influence in the field of psychotherapy. Although it is still widely practiced, many therapists do not strictly follow all psychoanalytic procedures, preferring psychodynamic or ego psychological modifications. Many psychotherapists predict that the use of psychoanalysis will decline in the future (Norcross & Freedheim, 1992).

Humanistic-Existential Therapies In contrast to the psychic determinism implicit in psychoanalysis, the humanistic-existential therapies stress

the importance of self-actualization, self-concept, free will, responsibility, and the understanding of the client’s phenomenological world. The focus of therapy is on qualities of “humanness”; human beings cannot be understood without reference to their personal uniqueness and wholeness. Among the several humanistic-existential therapies are person-centered therapy, existential analysis, and gestalt therapy. Person-Centered

Therapy Carl Rogers, the founder of person-centered therapy, believed that people could develop better self-concepts and move toward self-actualization if the therapist provided certain therapeutic conditions. These are the conditions in which clients use their own innate tendencies to grow, to actively negotiate with their environment, and to realize their potential. Therefore, therapists must accept clients as people, show empathy and respect, and provide unconditional positive regard for them. A therapist should not control, inhibit, threaten, or interpret a client’s behaviors. These actions are manipulative, and they undermine the client’s ability to find his or her own direction. Person-centered therapy thus emphasizes the kind of person the therapist should be in the therapeutic relationship rather than the precise techniques to use in therapy. Particular details of this therapeutic approach were discussed in the chapter on models of abnormal behavior.

Existential Analysis Existential analysis follows no single theory or group of therapeutic techniques. Instead, it is concerned with the person’s experience and involvement in the world as a being with consciousness and self-consciousness. Existential therapists believe that the inability to accept death or nonbeing as a reality restricts self-actualization. In contemporary society, many people feel lonely and alienated; they lose a sense of the meaning of life, of self-responsibility, and of free will. This state of mind is popularly called “existential crisis.” The task of the therapist is to engage clients in an encounter in which they can experience their own existence as being real. The encounter should involve genuine sharing between partners, in which the therapist, too, may grow and be influenced. When clients can experience their existence and nonexistence, then feelings of responsibility, choice, and meaning reemerge. (Again, see the chapter on models of abnormal behavior for additional details.) Existential approaches to therapy are strongly philosophical in nature. They have not received any research scrutiny because many existential concepts and methods are difficult to define operationally for research purposes. Furthermore, existential therapists

Action-Oriented Approaches to Individual Psychotherapy

point out that therapist and client are engaged in a complex encounter that cannot be broken down into components for empirical observation, so research studies are incapable of assessing the impact of therapy. Although impressive case histories indicate its effectiveness, little empirical support for existential analysis exists.

509

mal behavior. Treatment based on classical conditioning, operant conditioning, observational learning, and cognitive-behavioral processes has gained widespread popularity (DHHS, 1999; Norcross & Freedheim, 1992). Behavior therapists typically use a variety of techniques, many of which were discussed in preceding chapters. This section presents a selection of the most important behavioral techniques.

Gestalt Therapy The German word gestalt means

“whole.” As conceptualized by Fritz Perls in 1969, gestalt therapy emphasizes the importance of a person’s total experience, which should not be fragmented or separated. Perls believed that when affective and cognitive experiences are isolated, people lack full awareness of their complete experience. In gestalt therapy, clients are asked to discuss the totality of the here and now. Only experiences, feelings, and behaviors occurring in the present are stressed. Past experiences or anticipated future experiences are brought up only in relation to current feelings. Interestingly, Perls was originally trained as a psychoanalyst, but he later rejected Freudian theory. He did, however, incorporate dream analysis in his work. Dreams, too, are interpreted in relation to the here and now in gestalt therapy. As a means of opening clients to their experiences, therapists encourage clients to: 1. Make personalized and unqualified statements that help them “act out” their emotions. For example, instead of hedging by saying, “It is sometimes upsetting when your boss yells at you,” a client is encouraged to say, “I get scared when my boss yells at me.” 2. Exaggerate the feelings associated with behaviors to gain greater awareness of their experiences and to eliminate intellectual explanations for them. 3. Role-play situations and then focus on what was experienced during the role playing. Like existential analysis, gestalt therapy has generated little research. Thus it is difficult to evaluate its effectiveness. Proponents of gestalt therapy are convinced that clients are helped, but sufficient empirical support has never emerged. (You might be interested in reading Perls’s remarkable book Gestalt Therapy Verbatim, 1969, for a fuller explanation of this approach.)

Action-Oriented Approaches to Individual Psychotherapy The principles underlying the action-oriented or behaviorist approaches to abnormal behavior were discussed in depth in the chapter on models of abnor-

Classical Conditioning Techniques Using the classical conditioning principles described in the chapter on models of abnormal behavior, Joseph Wolpe (1973) used systematic desensitization as treatment for anxiety. This technique attempts to reduce anxiety in response to a stimulus situation by eliciting in the given situation an alternative response that is incompatible with anxiety. For example, if a woman is afraid of flying in a jet plane, her anxiety response could be reduced by training her to relax while in airplanes. Systematic desensitization typically includes training in relaxation, the construction of a fear hierarchy, and the combination of relaxation and imagined scenes from the fear hierarchy. This process is described in detail in the chapter on anxiety disorders, but we can illustrate the process using the example of the woman who wants to overcome her fear of flying. The therapist would first train her to relax, probably employing a progressive relaxation method in which she learns to alternately tense and relax her muscles. Working with the therapist, the client would construct a fear hierarchy for flying, rating the level of fear in various scenarios on a scale of 1 to 100, as in Table 17.2. Notice that self-reported anxiety increases as the task approaches, and a high level of fear occurs in response to a scene in which the plane is shaking due to turbulence while flying. If there are large increases in anxiety from one consecutive scene to the next, other scenes may be constructed that occupy an intermediate position. For example, a 20-point difference occurs in Table 17.2 between scenes 5 and 6 (and between scenes 6 and 7). The client and therapist may find another scene that the client rates as 50 on the hierarchy—for example, she might imagine getting a boarding pass and checking in her luggage. The client is then asked to imagine herself in each of these situations. Most clients experience anxiety when they imagine such situations, and it is obviously more convenient to imagine them than to actually go through them. If the client is actually present in the fear-provoking situations, the approach is known as an in vivo approach. The development of a fear hierarchy is important in systematic desensitization when an in vivo approach is not used.

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Once the person is able to relax, the therapist asks the client first to imagine a low-anxiety scene (such as making flight reservations) and to relax at the same time. The client then proceeds up the fear hierarchy, imagining each situation in order. If a particular situation elicits too much anxiety, the client is told to return to a less anxiety-provoking one. This procedure is repeated until the client can imagine the entire hierarchy without anxiety.

A Systematic Desensitization Fear Hierarchy for a Client with a Fear of Flying

TABLE 17.2

Scene 1. Encountering turbulence while flying

Fear Rating 99

2. Flying at 35,000 feet

95

3. Taking off

90

4. Fastening the seatbelt

85

5. Boarding the plane

80

6. Waiting to board the plane

60

7. Taking a taxi to the airport

40

8. Packing for a trip

25

9. Making airline reservations

20

10. Thinking about a trip involving flying

Facing the Problem Head-On Fear of snakes is not uncommon in the general population. Some people, however, have such intense fears that they are considered phobic. In such cases, desensitization procedures may be used to help reduce or eradicate the emotional reaction. In this session, a client is helped by the therapist to overcome her fear. The technique being used is flooding, which uses a real snake. According to classical conditioning principles, the anxiety and fear should be extinguished in the absence of any negative consequences happening.

10

Behavior therapists believe that systematic desensitization is more effective than psychotherapy for certain kinds of problems such as simple phobias; it certainly requires fewer sessions to achieve desired results (Wolpe, 1973). Systematic desensitization has stimulated a great deal of research, and its efficacy in reducing fears has been well documented. Some researchers question the need for certain procedural aspects of the treatment approach. For example, Wolpe’s rather rigid format for desensitization may be unnecessary, and alternatives to relaxation, such as talking about the fear or listening to soothing music, may be used in the process. Flooding and Implosion Two other techniques that

use the classical conditioning principles of extinction are flooding and implosion (Sommers-Flanagan & Sommers-Flanagan, 2004). The two are very similar. Flooding attempts to extinguish fear by placing the client in a real-life anxiety-provoking situation at full intensity. Implosion attempts to extinguish fear by having the client imagine the anxiety-provoking situation at full intensity. The difference between systematic desensitization and flooding and implosion lies in the speed with which the fearful situation is introduced to the client. Systematic desensitization introduces it more slowly. Flooding and implosion require the client to immediately confront the feared situation in its full intensity. The belief is that the client’s fears will be extinguished if he or she is not allowed to avoid or escape the situation. In flooding, for example, a client who is afraid of heights may be taken to the top of a tall building, mountain, or bridge and physically prevented from leaving. Some studies have indicated that flooding effectively eliminates

Action-Oriented Approaches to Individual Psychotherapy

specific fears such as phobias (Bornas, Fullana, TortellaFeliu, Llabres, & de la Banda, 2001; Garcia-Palacios, Hoffman, Carlin, Furness, & Botella, 2002). In implosion therapy, the client is forced to imagine a feared situation. For example, a therapist might ask a client who is afraid of flying to close her eyes and imagine the following: You are flying in an airplane. Suddenly the plane hits an air pocket and begins to shake violently from side to side. Meal trays fly around, and passengers who do not have their seatbelts fastened are thrown from their seats. People start to scream. As you look out the window, the plane’s wing is flying by. The pilot’s frantic voice over the loudspeaker is shouting: “Prepare to crash, prepare to crash!” Your seatbelt breaks and you must hang on for dear life, while the plane is spinning around and careening. You can tell that the plane is falling rapidly. The ground is coming up toward you. The situation is hopeless—all will die.

Presumably the client feels intense anxiety, after which she is told to “wake up.” Repeated exposure to such a high level of anxiety eventually causes the stimulus to lose its power to elicit anxiety and leads to extinction. The developers of implosion and flooding believe that they can be effective, though some clients find the procedures too traumatic and discontinue treatment. In general, these methods have not been scrutinized as carefully as systematic desensitization has been, but they appear to be equally effective with clients with phobias (Emmelkamp, 1994). Aversive Conditioning In aversive conditioning, a widely used classical conditioning technique, the undesirable behavior is paired with an unpleasant stimulus to suppress the undesirable behavior. For example, aversive conditioning has been used to modify the smoking behaviors of heavy smokers. In the rapid smoking technique, smokers who are trying to quit are asked to puff cigarettes at a fast rate (perhaps a puff every six or seven seconds). Puffing at this rate usually brings on nausea, so the nausea from puffing is associated with smoking behaviors. After repeated pairings, many smokers find cigarette smoke aversive and are more motivated to quit. Aversive conditioning has also been used in therapy with people who have drug or alcohol addictions or sexual disorders, again with varying degrees of success. The noxious stimuli have included electric shock, drugs, odors, verbal censure, and reprimands. Some aversive conditioning programs also provide positive reinforcement for alternative behaviors that are deemed appropriate (Emmelkamp, 1994).

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Several problems have been encountered in the use of aversive conditioning. First, because noxious stimuli are used, many people in treatment discontinue therapy, as in the smoking-reduction program just described. Second, aversive methods often suppress the undesirable behavior only temporarily, especially when punishment for those behaviors is applied solely in a laboratory situation that bears little resemblance to real life. Third, the client may become anxious and hostile. And some critics argue that punishment is unethical or has the potential for misuse and abuse. Partially as a response to these criticisms, as well as for practical reasons, some therapists advocate the use of covert sensitization. Like implosion, it requires imagining the aversive situation, along with the behavior one is trying to eliminate. A person who wants to stop smoking may be asked to imagine a smoke-filled room, becoming nauseated, suffocating, and dying slowly of lung cancer and emphysema.

Operant Conditioning Techniques Behavior modification using operant methods has flourished, and many ingenious programs have been developed. As in the case of classical conditioning, only a few important examples are presented here. Token Economies Treatment programs that reward patients with tokens for appropriate behaviors are known as token economies. The tokens may be exchanged for hospital privileges, food, or weekend passes. The goal is to modify patient behaviors using a secondary reinforcer (the tokens). In much the same way, money operates as a secondary reinforcer for people who work. Three elements are necessary to a token economy: (1) the designation by hospital staff of certain patient behaviors as desirable and reinforceable; (2) a medium of exchange, such as coinlike tokens or tallies on a piece of paper; and (3) goods, services, or privileges that the tokens can buy (Christophersen & Mortweet, 2001; Watson & Tharp, 1997). It is up to the hospital staff to dispense the tokens for desirable patient behaviors. For example, tokens can be exchanged for hospital passes, cigarettes, food, television viewing, and the choice of dining room tablemates. Patients can be given tokens for good grooming and neat physical appearance or for washing dishes and performing other chores. Token economy programs are used in a variety of settings, with such different types of people as juvenile delinquents, schoolchildren, people with mental retardation, and patients in residential community homes (Kazdin, 1994). Although such programs have been

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extremely successful in modifying behaviors in institutional settings, problems remain. Some patients do not respond to token economies. Complex behaviors, such as those involving language, are difficult to modify with this technique. A final criticism is that desirable patient behaviors that are exhibited in a hospital may not be continued outside the hospital setting. Punishment When less drastic methods are ineffective, punishment is sometimes used in treating children with autism and schizophrenia (Prochaska & Norcross, 2003). In an early study, Lovaas (Lovaas, 1977; Lovaas, Schaeffer, & Simmons, 1965) attempted to modify the behaviors of five-year-old identical twins, both diagnosed with schizophrenia. The children had shown no response to conventional treatment and were largely unresponsive in everyday interpersonal situations. They showed no reaction to speech and did not themselves speak. They did not recognize adults or each other, and they engaged in temper tantrums, selfdestructive behaviors, and inappropriate handling of objects. The experimenters decided to use electric shock as a punishment for the purpose of modifying the children’s behaviors. A floor gridded with metal tape was constructed so that a painful but not physically damaging shock could be administered to their bare feet. By turning the shock on and off, the experimenters were able to condition desired behaviors in the children. Affectionate responses such as kissing and hugging were developed, and tantrum behaviors were eliminated—all via the use of shock as an aversive stimulus. Lovaas (1987) has also used a loud “No,” as well as a slap to the thigh of a child, to reduce undesirable or self-destructive behaviors. Lovaas’s work has shown that operant conditioning is a powerful technique for changing the behavior of children who have autism and have failed to respond to other forms of treatment. Because of the ethical issues raised by the use of electric shocks, however, use of this punishment technique has declined in recent years.

Observational Learning Techniques As discussed in the chapter on models of abnormal behavior, observational learning is the acquisition of new behaviors by watching them being performed. The process of demonstrating these behaviors to a person or an audience is called modeling. Modeling has been shown to be effective in helping people acquire more appropriate behaviors. In one experiment, young adults who showed an intense fear of snakes were assigned to four groups: 1. The live modeling with participation group watched a live model who initiated progressively

more fear-evoking activities with the snake. Participants were then guided to imitate the model and were encouraged to touch the snake, first with a gloved hand and then with a bare hand. 2. The symbolic modeling group underwent relaxation training and then viewed a film in which children and adults were seen handling snakes in progressively more fear-evoking circumstances. 3. The systematic desensitization group received systematic desensitization treatment for snake phobias. 4. The control group received no treatment. Before treatment, the approach behaviors of all four groups of participants toward snakes were equally few. After treatment, the ability to approach and touch snakes had increased for members of all treated groups, who performed better than individuals in the control group. Group 1, in which treatment involved live modeling with participation, showed the greatest change: nearly all its members voluntarily touched the snake (Bandura, Blanchard, & Ritter, 1969). Observation of models who verbalize how to perform a task and who make a few mistakes while completing the task has been found to be more effective than viewing models who do not verbalize or who perform with no anxiety or mistakes (Braswell & Kendall, 1988). The modeling of behaviors shown in films has been successfully used in medical and dental practices to reduce fears of medical procedures (Wilson & O’Leary, 1980), in teaching social and problemsolving skills (Bellack, Hersen, & Himmelhoch, 1983; Braswell & Kendall, 1988), and in reducing compulsions and phobias (Rachman & Hodgson, 1980).

Cognitive-Behavioral Therapy In the chapter on models of abnormal behavior, we discussed in some detail how cognitive-behavioral approaches rest on the belief that psychopathology stems from irrational, faulty, negative, and distorted thinking or self-statements that a person makes to himself or herself. As a result, most cognitive approaches share several elements. First, cognitive restructuring is used to change a client’s irrational, self-defeating, and distorted thoughts and attitudes to more rational, positive, and appropriate ones. Second, skills training is used to help clients learn to manage and overcome stress. Third, problem solving provides clients with strategies for dealing with specific problems in living. Initially, Albert Ellis’s rational-emotive therapy, or RET (Ellis, 1962), was not well received by therapists. Attitudes soon changed, however, when the behaviorists became increasingly interested in mediating cognitive

Action-Oriented Approaches to Individual Psychotherapy

processes. In addition, RET and the behavioral strategies are similar in a number of ways. For example, RET incorporates cognitive restructuring, skills training, and problem-solving skills (Corey, 2005). Cognitive restructuring specifically is used to help clients deal with their irrational thoughts and beliefs. For example, a client’s belief that he or she should be loved by everyone is attacked directly by the therapist: “What is so awful about not being loved by everyone? If your father doesn’t love you, that’s his problem!” Once the client begins to restructure his or her thoughts, the therapist begins the task of helping the client learn new ways to appraise and evaluate situations. Finally, homework assignments (behavioral rehearsal) are given to help the client learn new strategies to deal with situations. Aaron Beck (1976, 1985; Beck & Weishaar, 1989) has also been a major contributor to cognitivebehavioral therapy. Originally using this approach to treat depression, he extended his treatment to other disorders such as anxiety and phobias. Beck holds that emotional disorders are primarily caused by negative patterns of thought, which he labels the “cognitive triad”—errors in how we think about ourselves (such as “I’m worthless”), our world (“Everything bad happens to me”), and our future (“Nothing is ever going to change”) (see Table 17.3). Whereas RET engages the client in a rational or Socratic “debate,” Beck’s approach emphasizes the client’s capacity for selfdiscovery. Less hurried and confrontative, the therapist and client work as a team to uncover underlying assumptions, to test them in the client’s everyday life situations, and to determine by logical means whether they are valid. As in systematic desensitization, smaller challenges are assigned first, and more difficult ones are tackled as successes are experienced.

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Other variations of cognitive-behavioral methods have been developed, and all are based on similar assumptions. For example, stress inoculation therapy was developed by Meichenbaum (Meichenbaum, 1985; Meichenbaum & Cameron, 1982). The assumption behind stress inoculation training is that people can be taught better ways to handle life stresses. Meichenbaum uses cognitive preparation and skill acquisition, rehearsal, application, and practice.

Beck’s Cognitive Triad of Depression

TABLE 17.3

Negative View of Self—”I’m Worthless” Believing that one is worthless, defective, inadequate, and undesirable. A person with depression may interpret negative events as being caused by personal inadequacies and failures. Negative View of the World—”Everything Bad Happens to Me” Perceiving the world and one’s environment as being unreceptive, frustrating, and demanding. A person with depression may see the world in the most pessimistic and cynical manner. Negative View of the Future—”Nothing Is Ever Going to Change” Perceiving the future as hopeless and believing that negative events will continue to occur. The person with depression believes that one is helpless and powerless to improve the situation in the future.

Albert Ellis (left) (b. 1913) and Aaron Beck (right) (b. 1921) Ellis’s rationalemotive therapy (RET) and Beck’s cognitive triad have been widely used in promoting the cognitive restructuring that is the foundation of cognitivebehavioral therapies.

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Cognitive-behavioral therapy shows much promise. Studies have indicated successful use of rationalemotive therapy, of Beck’s approach, and of stress inoculation therapy (Chambless et al., 1998; Foa, Rothbaum, & Furr, 2003). Furthermore, some evidence suggests that the approaches may be at least as effective as medication or drug therapy for certain situational and specific depressions (Hollon & Beck, 1994; Lipman & Kendall, 1992). In one survey of psychotherapists, cognitive-behavioral approaches were rated as a therapeutic orientation that will continue to grow in popularity (Norcross & Freedheim, 1992).

Health Psychology Health psychology integrates behavioral and biomedical science (Lewis, 2001). The two fields merged because people realized that psychological factors were often related to the cause and treatment of physical illnesses (Chiles, Lambert, & Hatch, 1999). The term psychobiology has also been used to address the importance of viewing the totality of the human condition (both biology and experience) in explaining and understanding behavior (Dewsbury, 1991). The goal of clinical health psychology is to help people change their lifestyles to prevent illness or to enhance the quality of their lives (Belar & Deardorff, 1995). As discussed in the chapter on psychological factors affecting medical conditions, heart disease, strokes, and cancer have been correlated with lack of exercise, diet, smoking, alcohol consumption, and other behaviors of a particular lifestyle. Health psychology makes people aware of the effects of these behaviors and helps them to develop healthier patterns of living. One way to do this is through biofeedback therapy, which combines physiological and behavioral approaches. A patient receives information, or feedback, regarding particular autonomic functions, such as heart rate, blood pressure, and brain wave activity, and is rewarded for influencing those functions in a desired direction. Monitoring devices supply the information; the rewards vary, depending on the patient and the situation. Studies have found that biofeedback therapy can help reduce high blood pressure (Blanchard, 1992). In an early study, researchers attempted to help patients with essential hypertension (elevated blood pressure) lower their systolic pressure. They used an operant conditioning feedback system in which patients saw a flash of light and heard a tone whenever their systolic blood pressure decreased. They were told that the light and tone were desirable and were given rewards— slides of pleasant scenes and money—for achieving a certain number of light flashes and tones. The patients gradually reduced their blood pressure at succeeding

biofeedback sessions. When they reached the point at which they were unable to reduce their pressure further for five consecutive sessions, the experiment was discontinued (Benson, Shapiro, Tursky, & Schwartz, 1971). Meyer Friedman (1984) reported a study in which coronary patients who changed their lifestyles drastically reduced their recurrence of heart attacks. The investigation discovered that 95 percent of patients who suffer heart attacks exhibit what is called “Type A” behavior (discussed in the chapter on psychological factors affecting medical conditions), which is characterized by time urgency (the compulsion to finish tasks early, to be early for appointments, and to always race against the clock), attempts to perform several tasks at once, a propensity to anger quickly when others do not perform as expected, and rapid speech and body movements. The patients in Friedman’s Recurrent Coronary Prevention Project learned, through counseling and practice drills, to control and change their Type A behaviors. Although the Type A hypothesis has proven to have a number of shortcomings (H. S. Friedman & Booth-Kewley, 1988), health psychology techniques, which focus on lifestyle changes, have proven very beneficial. Some of these are listed here: 1. Establish priorities. It is important for each of us to determine where to put our time and energies. Establishing a daily or weekly priority list, including everything that must be done, is a helpful strategy. If time is limited, learn to postpone the low-priority items without feeling guilty. 2. Avoid stressful situations. Do not put yourself in situations that involve unnecessary stress. For example, if you know that a particular traffic route involves constant tie-ups, consider another time for your commuting or take another route. Remember, we can and do have control over much of our lives. 3. Take time out for yourself. We all need to engage in activities that bring pleasure and gratification. Whether they involve going fishing, playing cards, talking to friends, or taking a vacation, they are necessary for physical and mental health. And they give the body time to recover from the stresses of everyday life. 4. Exercise regularly. Exercise is effective in reducing anxiety and increasing tolerance for stress. Furthermore, a healthy body gives us greater energy to cope with stress and greater ability to recover from a stressful situation. 5. Eat right. You have heard this advice before, but it happens to be excellent advice: eat well-balanced meals that are high in fiber and protein but low in

Evaluating Individual Psychotherapy

fat and cholesterol. Nutritional deficiencies can lower our resistance to stress. 6. Make friends. Good friends share our problems, accept us as we are, and laugh and cry with us. Their very presence enables us to reduce or eliminate much of the stress we may be experiencing. 7. Learn to relax. A major finding of stress management research is that tense, “uptight” people are more likely to react negatively to stress than are relaxed people. Relaxation can do much to combat the autonomic effects of anxiety and stress; thus the various relaxation techniques are helpful in eliminating stress. Health psychology approaches have also been used to address a wide range of problems, including chronic pain, recurring headaches, and insomnia.

Evaluating Individual Psychotherapy Both insight- and action-oriented approaches have attracted firm followers and loud critics (Kottler, 2002). Behavioral therapists, for example, believe that their action-oriented approach has solid theoretical support and empirical justification; that it provides a rapid means of changing behaviors; and that (unlike the insightoriented approaches) it includes specific goals, procedures, and means of assessing its effectiveness. Critics have argued that behavioral therapy is dehumanizing,

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mechanical, and manipulative; that its relationship to learning theory is more apparent than real; and that it is applicable only to a narrow range of problems. Whether one argues for either insight- or actionoriented therapies depends largely on whether one believes that human behavior is determined primarily by internal or external factors. Interestingly, Norcross and Freedheim (1992) surveyed a group of prominent psychotherapists and psychotherapy researchers about which therapeutic orientations would grow or decline in use during the next decade. As indicated in Figure 17.1, the respondents predicted that theoretical integration, eclecticism, and cognitive orientations would gain popularity, whereas psychoanalysis and transactional analysis would decrease in use. More than fifty years ago, Hans Eysenck (1952) concluded that there was no evidence that psychotherapy facilitates recovery from what were then classified as neurotic disorders. According to the criteria he used, patients receiving no formal psychotherapy recovered at least as well as those who were treated! Since that time, others have also claimed that psychotherapy’s success has been oversold and that both its practitioners and its clients are wasting time, money, and effort (Masson, 1998; Carey, 2004). Some opponents feel so strongly that they advocate a “truth in packaging” policy: prospective clients should be warned that “psychotherapy will probably not help you very much.” In a thought-provoking article, Persons (1991) pointed out that past outcome studies showing no

Laugh and the World Laughs with You A basic premise of behavioral medicine and health psychology is getting individuals to reduce stress. The Laughing Club of India reflects an interesting way to do this. According to the club’s founder, Dr. Madan Kataria, laughter reduces stress. Shown here, the members breathe yoga-like, reach for the sky to reduce inhibitions, and then force a “ho, ho, ha, ha” until the laughter becomes contagious.

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FIGURE 17.1 Predictions of the Theoretical Orientations of the Future These ratings are averages compiled from the responses of prominent psychotherapists and psychotherapy researchers who were asked to predict the use of various psychotherapeutic orientations in the next decade. The ratings were made on a scale ranging from 1 (representing great decrease) to 7 (representing great increase). 7

Mean ratings

6 5 4 3 2 1

Source: Data from Norcross & Freedheim (1992).

Hans Eysenck (b. 1916) Hans Eysenck started a controversy by asserting in 1952 that there was no evidence that psychotherapy was effective. Research, however, indicates that psychotherapy is effective and that the real issues concern types of treatment and their suitability for clients and their particular circumstances.

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positive effects from psychotherapy or no difference in outcome in the use of different therapies suffered from major methodological flaws. They were based on poorly controlled studies, issues of diagnostic severity were not addressed, and the improvement measures were simplistic or poor. Taken together, these three points led Persons (1991) to conclude that contemporary outcome studies did not accurately represent psychotherapy. Furthermore, attempts to study psychotherapy and treatment outcomes often simplify human interactions, which are ongoing, context bound, and difficult to measure. There is now an increasing distinction between efficacy research and effectiveness research (Seligman, 1995, 1998). An efficacy study is a laboratory distillation of treatment. It consists of a brief, well-controlled, and well-designed research investigation into the outcome of a treatment—a “laboratory” study of treatment. In contrast, an effectiveness study examines the outcome of treatment as it is actually delivered in real life, without the rigorous controls and designs found in efficacy studies. Importantly, in contrast to efficacy studies, effectiveness research demonstrates greater patient improvement and improvements across different kinds of therapies.

Meta-analysis and Effect Size A form of statistical analysis (meta-analysis) has been found to be an extremely useful tool in analyzing therapy outcome studies. Meta-analysis allows us to analyze a large number of different studies by looking at

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effect size, a term that refers to treatment-produced change. To determine effect size, researchers subtract the mean of the control group from the mean of the treatment group. The difference is then divided by the standard deviation of the control group. The larger the numerical figure obtained, the larger is the effect of the treatment. Ideally, this comparison of effect size in many studies allows us to determine the effectiveness of different treatment approaches. It is important to note that meta-analysis is controversial; it has both staunch supporters (Shapiro & Shapiro, 1983; Smith, Glass, & Miller, 1980) and detractors (Erwin, 1986; Paul, 1985). Meta-analytic studies strongly support the conclusion that psychotherapy is effective, and they allow researchers to estimate how large the effect is. Figure 17.2 graphically displays the effect of treatment based on two meta-analytic studies (Lambert & Bergin, 1994). As can be seen, individuals who receive psychotherapy are better off than 79 percent of individuals who receive no treatment. Those receiving minimal treatment (for example, a placebo) are better off than 66 percent of the people in no-treatment control groups. Many reviews of outcome research have indicated that psychotherapy is effective and that people who are treated show more desirable and larger changes than those who do not receive formal psychotherapy (Garfield & Bergin, 1994; Shadish et al., 1997; Sloane et al., 1975; Smith & Glass, 1977; Smith et al., 1980). In addition, the largest gains in treatment tend to occur within the first few months and tend to endure (Lambert, Shapiro, & Bergin, 1986; Nicholson & Berman, 1983; Smith et al., 1980). Howard (1994) argues that psychotherapy is one of the best documented and most studied treatment interventions and that research clearly attests to its beneficial impact in people’s lives. One recent trend in psychotherapy research is the designation of empirically supported treatments (ESTs), clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population (Chambless & Hollon, 1998). In other words, ESTs are those treatments for which rigorously designed research has demonstrated effectiveness in benefiting clients. Among the many ESTs are cognitive-behavioral treatment for anxiety and depression, interpersonal therapy for depression and bulimia, and behavioral therapy for sexual dysfunctions. Obviously, other forms of treatment may be effective, but they are not designated as ESTs because they have not yet been rigorously studied. This distinction has provoked some controversy. Critics of EST note that those treatments that are empirically supported tend to be either behavioral in nature or narrowly defined

FIGURE 17.2 Effect Sizes for Psychotherapy, Placebo,

and No-Treatment Groups Effect size is the result of calculations that reflect the changes produced by treatment. The effect size of psychotherapy is much higher than that of the placebo condition, which in turn is higher than the no-treatment condition. In terms of percentage improved, the figure can be interpreted as follows: the average client undergoing a placebo treatment is better off than 66 percent of the no-treatment controls; the average client undergoing psychotherapy appears to be better off than 79 percent of the no-treatment controls.

Average (no-treatment) control effect size

Average psychotherapy effect size

Average (minimal treatment) placebo effect size

Source: Based on Lambert & Bergin (1994).

kinds of treatment, implying that other forms of treatment are being ignored and are not the focus of research attention (Carey, 2004; Nathan, 1998). The controversy has resulted in a polarization between those who emphasize the common therapeutic factors that exist across all therapies and those who emphasize empirically supported therapies (Day, 2004). The “common factors” advocates identify four common dimensions of curative influence in therapy (Lambert, 1992). First, improvement is influenced by extratherapeutic variables such as degree of psychopathology, motivation, ego strength, psychological-mindedness, and support in the environment. Second, the therapeutic change is affected by the relationship with the therapist, or the therapeutic alliance. Third, expectancy effects (hope for change) seem to play a role. Last, techniques, or the theoretical orientation, seem to play a role as well. In an empirical analysis of the contributions of common factors to therapeutic improvement, it was concluded that extratherapeutic variables accounted for 40 percent of the change, the therapeutic relationship for 30 percent, expectancy or placebo effects for 15 percent, and techniques for 15 percent (Lambert, 1992). Regardless of the debate over the common factors approach versus the ESTs approach, we believe that

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CRITICAL THINKING What Kind of Therapist Do You Want? In general, people who experience emotional and behavioral problems benefit from psychotherapy. Yet benefits often vary according to client, therapist, and treatment characteristics. Given this fact, it is surprising that many individuals in need of therapy do little prior thinking about the kind of therapist they would like to see or about how and where to find “good” therapists. If you were depressed or anxious, what kind of therapist would you like to find? What characteristics are important to you? What characteristics do you consider to be relatively unimportant? Why? The answers to these questions are complex and vary from person to person. Let us examine some of the factors that might be important and then provide an example of the kind of issues that can be raised. ■

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Demographic characteristics of the therapist These include age, gender, educational and experi-

ential background, ethnicity, and other similar characteristics. For example, would you mind seeing a therapist who had just recently completed training in psychotherapy? Overall reputation and professional standing How can you determine how effective or successful a therapist is? Experience with clients having problems similar to yours Does it matter whether the therapist specializes in your problem or is a general practitioner? Therapeutic orientation (such as psychodynamic, behavioral, spiritual, and so on) Would you want to work with a therapist who believes that meditation is the primary tool to use against mental disorders? Interpersonal style (such as humorous, serious, formal, informal, dominant, and submissive) Would you like a therapist who provides only mini-

psychotherapy is valuable and would best be served by emphasizing an integration of both views (Prochaska & Norcross, 1999). Increasingly, research now supports the effectiveness of psychotherapy (Ahn & Wampold, 2001; Hubble, Duncan, & Miller, 1999; Seligman, 1995). We also believe its maximal value is attained not by unreservedly accepting or rejecting any group of treatments, either behavioral or insight-oriented, but by using research to find the best match that can be made among therapist, client, and situational variables. The Critical Thinking feature discusses some options that should be considered in choosing a therapist.

Group, Family, and Couples Therapy The classic form of psychotherapy is a one-to-one relationship between one therapist and one client. Group, family, and couples therapies are forms of treatment that involve the simultaneous treatment of two or more clients and may involve more than one therapist

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mal verbal responses in order to allow you all the time to talk? Values and beliefs If you were a Christian fundamentalist, how comfortable would you feel working with an agnostic therapist?

Undoubtedly, many other important factors and issues can be listed. Your preferences will reflect your culture, feelings, beliefs, and needs. In “A Buyer’s Guide to Psychotherapy,” psychotherapist Frank Pittman (1994) considers the client as a consumer who should not be afraid to ask questions of therapists in order to ascertain if they seem suitable. He recommends that the consumer should hire a therapist who has worked effectively with people the consumer knows, who leads a life that seems desirable to the consumer, and who treats a consumer with respect. In other words, Pittman argues that clients should become informed and selective in choosing a therapist.

Corey, 2004). Their increasing popularity stems from certain economic and therapeutic advantages: because the therapist sees several clients at each session, he or she can provide much more mental health service to the community. And, because several clients participate in the sessions, the cost to each person is noticeably reduced. Saving time and money is important, but the increasing use of group therapy seems also to be related to the fact that many psychological difficulties are basically interpersonal in nature—they involve relationships with others, and these problems are best treated within a group rather than individually. Most of the techniques of individual psychotherapy are also used in group forms of treatment. Rather than repeat them here, we first discuss some general features of group therapy, family therapy, and couples therapy.

Group Therapy There is now a great variety of group therapies, reflecting the many dimensions along which a therapeutic

Group, Family and Couples Therapy

group may be characterized (Corey, 2004). One obvious dimension is the type of people who make up the group. In couples (which includes marital) and family therapy, they are related; in most other groups, they are initially strangers. Group members may share various characteristics. Groups may be formed to treat older clients, unemployed workers, or pregnant women; to treat clients with similar psychological disturbances; or to treat people with similar therapeutic goals. Therapeutic groups also differ with regard to psychological orientation and treatment techniques, number of members, frequency and duration of meetings, and the role of the therapist or group leader. Some groups work without a leader. Others have leaders who play active or passive roles within the group. Moreover, the group may focus either on interrelationships and the dynamics of interaction or on the individual members. And groups may be organized to prevent problems, as well as to solve them; for example, group therapy has been suggested for divorced people who are likely to encounter stress. Despite their wide diversity, successful groups and group approaches share several features that promote beneficial change in clients (Corey, 2004; Kottler & Brown, 1992; Yalom, 1970): 1. The group experience allows each client to become involved in a social situation and to see how his or her behavior affects others. An underlying assumption of group therapy is that problems are most likely manifested in interpersonal interactions with others. Once the group member can view his or her interactions realistically, problems can be identified and then resolved.

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2. In group therapy the therapist can see how clients respond in a real-life social and interpersonal context. In individual therapy, the therapist either must rely on what clients say about their social relationships or must assess those relationships on the basis of client-therapist interactions. But data gathered thus are often unrepresentative or inaccurate. In the group context, response patterns are observed rather than communicated or inferred. 3. Group members can develop new communication skills, social skills, and insights. (This is one of the most powerful mechanisms of group therapy.) The group provides an environment for imitative learning and practice. 4. Groups often help their members feel less isolated and fearful about their problems. Many clients enter therapy because they believe that their problems are unique: no one else could possibly be burdened with such awful impulses, evil or frightening thoughts, and unacceptable ways. The fear of having others find out how “sick” they are may be as problematic to clients as their actual disorders. But when they suddenly realize that their problems are common, that others also experience them, and that others have similar fears, their sense of isolation is eased. This realization allows group members to be more open about their thoughts and feelings. 5. Groups can provide their members with strong social and emotional support. The feelings of intimacy, belonging, protection, and trust (which members may not be able to experience outside the group) can be a powerful motivation to confront

Sharing the Problems and Solutions Group therapy may be used in place of, or in conjunction with, individual therapy. In a group setting, participants often gain a sense of connection with others, achieve feelings of mutual support and assistance, and experience a decreased sense of isolation as they work toward solutions as part of a collective.

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one’s problems and actively seek to overcome them. The group can be a safe environment in which to share one’s innermost thoughts and to try new adaptive behaviors without fear of ridicule or rejection. Evaluating Group Therapy Clients are sometimes treated in group and individual psychotherapy simultaneously. There are no simple rules for determining when one or the other, or both, should be employed. The decision is usually based on the therapist’s judgment, the client’s wishes, and the availability (or unavailability) of one treatment or the other. Of course, people who are likely to be disruptive are generally excluded from group therapy. As desirable as it would be to base decisions regarding treatment techniques on the observed effectiveness of group therapy, little substantial research has been done on that topic. Reviews of studies have suggested that group therapy results in improvement, compared with no treatment or placebo treatment (Bednar & Kaul, 1978, 1994; Kaul & Bednar, 1986). The problems encountered in evaluating the success of group therapy include all those problems involved in assessing individual therapy, compounded by group variables and the behaviors of group members. Indeed, some have even questioned whether group therapy is really any different from individual therapy because the same therapeutic variables are involved (Hills, 1990). Group therapy also has some disadvantages. For example, groups cannot give intensive and sustained attention to the problems of individual clients. Moreover, clients may not want to share some of their

Treating the Family Not Just the Individual Family therapy is a group approach that works with the family as a unit, not just one individual, to modify behaviors within the family system. In this photo, a family meets with a therapist to discuss issues regarding disagreements and miscommunications between the parents and their teenaged daughter. The therapist must be well versed in family counseling strategies and be aware of multicultural issues that may alter her conceptualization of the family.

problems with a large group, and the sense of intimacy with one’s therapist is often lost in a group. Group pressures may prove too strong for some members, or the group may adopt values or behaviors that are themselves deviant. And, in leaderless groups, the group members may not recognize or be able to treat people with psychotic or suicidal impulses.

Family Therapy Family therapy may be broadly defined as group therapy that seeks to modify relationships within a family to achieve harmony. We use this definition to include all forms of therapy that involve more than one family member in joint sessions, including marital therapy and parent-child therapy. The important point is that the focus is not on an individual but on the family as a whole (Nichols & Schwartz, 2005). Family therapy is based on three assumptions: (1) it is logical and economical to treat together all those who exist and operate within a system of relationships (here, the primary nuclear family); (2) the problems of the “identified patient” are only symptoms, and the family itself is the client; and (3) the task of the therapist is to modify relationships within the family system (Corey, 2004; Day, 2004). Two general classes of family therapy have been identified: the communications approach and the systems approach (Foley, 1989). Let us look briefly at each of them. The Communications Approach The communi-

cations approach to family therapy is based on the

Group, Family and Couples Therapy

assumption that family problems arise from communication difficulties. Many family communication problems are both subtle and complex. Family therapists may have to concentrate on improving not only faulty communications but also interactions and relationships among family members (Satir, 1967). The ways in which rules, agreements, and perceptions are communicated among members may also be important (Haley, 1963). The therapist’s role in repairing faulty family communications is active but not dominating. He or she must seek to show family members how they are now communicating with one another; to prod them into revealing what they feel and think about themselves and other family members and what they want from the family relationship; and to persuade them to practice new ways of responding.

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The Systems Approach People who favor the sys-

tems approach to family therapy also consider communication important, but they especially emphasize the interlocking roles of family members (Minuchin, 1974). Their basic assumption is that the family system itself contributes to pathological behavior in the family. A family member becomes “sick” because the family system requires a sick member. Treating that person outside the system may result in transitory improvement, but once the client returns to the family system, he or she will be forced into the “sick role” again. Thus family systems therapy is directed at the organization of the family. It stresses accurate assessment of family roles and dynamics and intervention strategies to create more flexible or changed roles that foster positive interrelationships.

Couples Therapy Although the term marital therapy is often used in the mental health field, we prefer to use the more inclusive term couples therapy because it includes both marital relationships and intimate relationships between unmarried partners. It is a treatment aimed at helping couples understand and clarify their communications, role relationships, unfulfilled needs, and unrealistic or unmet expectations. Couples therapy has become an increasingly popular treatment for those who find that the quality of their relationship needs improvement (Nichols & Schwartz, 2005). Indeed, seeing only one partner has proven less effective in resolving interpersonal problems than seeing both together (Gurman & Kniskern, 1978). Couples therapists work on the assumption that it is normal for partners in an intense long-term relationship to experience conflicts. For example, the husband may find it difficult to express affectionate feelings toward his wife, who may have a

strong need to be nurtured and loved. Or the couple may be locked in a power struggle involving financial decisions. Or the wife may resent a husband who shows any sign of weakness, because the man she married was supposed to be “strong and invulnerable.” In all these cases, couples therapy attempts to clarify and improve the communications, interactions, and role relationships between the couple. Note that it is not the purpose of couples therapy to “save a relationship or marriage,” as many couples believe when they first enter treatment. The decision to remain together, to separate, or to leave or divorce is a decision that must be made by the couple. The role of the therapist is to help the couple understand the nature of their relationship, how it may be contributing to conflicts and unhappiness, their available options, and, if they want, how to work toward a healthier and happier relationship. Research on the effects of family and couples therapy has been consistent in pointing to the value of therapy compared with no-treatment and alternativetreatment control groups. However, research studies have generally not been rigorous in design; they often lacked appropriate control groups, follow-up periods of outcome, or good measures of outcome (Alexander, Holtzworth-Munroe, & Jameson, 1994). As a result, no strong conclusions are warranted at this time.

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Systematic Integration and Eclecticism The therapies discussed in this chapter share the common goal of relieving human suffering. Yet as we have seen, they differ considerably in their basic conceptions of psychopathology and in the methods they use to treat mental disorders. Many theories and techniques seem almost diametrically opposed to one another. For example, early criticisms of psychoanalysis concentrated on the mystical and unscientific nature of its explanation and treatment of behavioral pathology. Most of these criticisms came from behaviorists, who were likewise attacked by psychoanalysts as being superficial and concerned with “symptom removal” rather than with the cure of “deeper conflicts in the psyche.” There have been attempts at rapprochement between psychodynamic therapy and behavior therapy (Davis, 1983; Goldfried, Greenberg, & Marmar, 1990; Marmor & Woods, 1980; Murray, 1983; Wachtel, 1982). But even these sophisticated attempts have come under fire as being empirically and theoretically inconsistent. As we stated in the chapter on abnormal behavior, most practicing clinicians consider themselves eclectics (Garfield & Bergin, 1994). Relying on a single theory and a few techniques appears to be correlated with inexperience; the more experienced the clinician, the greater the diversity and resourcefulness used in a session (Norcross & Prochaska, 1988). Therapeutic eclecticism has been defined as the “process of selecting concepts, methods, and strategies from a variety of current theories which work” (Brammer & Shostrom, 1982, p. 35). An example is the early “technical eclecticism” of Arnold Lazarus (1967), which has been refined into a theoretical model called multimodal behavior therapy (Lazarus, 1967, 1984). Although behavioral in basis, this approach embraces many cognitive and affective concepts as well. The eclectic model calls for openness and flexibility, but it can also encourage the indiscriminate, haphazard, and inconsistent use of therapeutic techniques and concepts. As a result, therapists who call themselves eclectic have been severely criticized as confused, inconsistent, contradictory, lazy, and unsystematic (Goldfried & Safran, 1986; Patterson, 1980). The resulting negative reception of the term eclecticism has led to other terms (including creative synthesis, masterful integration, and systematic eclecticism) that are more positively associated with attempts to integrate, to be consistent, to validate, and to create a unique and personalized theoretical position. Indeed, evidence indicates that practitioners prefer the term integrative to eclectic (Norcross & Prochaska, 1988). There is, of course, no single integrative theory or position. Rather, an integrative approach recognizes

that no one theory or approach is sufficient to explain and treat the complex human organism (SommersFlanagan & Sommers-Flanagan, 2004). All the therapies that we have discussed have both strengths and weaknesses; no one of them can claim to tell “the whole truth.” The goal of the eclectic approach is to integrate those therapies that work best with specific clients who show specific problems under specific conditions (Corey, 2005). Thus in one sense, all therapists are eclectics—that is, each has his or her own personal and unique approach to therapy.

Culturally Diverse Populations and Psychotherapy Just as the European American worldview is reflected throughout our society, Western psychology and mental health concepts are often characterized by an assumption that they are universal and that the human condition is governed by universal principles (Ridley, 1995; Sue et al., 1998). For example, cultural components of psychotherapy encompass the following characteristics: (1) healthy functioning is equated with individualism and independence, (2) clients can and should master and control their own lives and the universe, (3) self-awareness and personal growth are goals of the therapeutic process (DHHS, 1999). Many racial/ethnic minority groups possess values and beliefs that are at odds with these culture-bound traits: interdependence and collectivism are valued over individualism, concern is with group rather than selfdevelopment, and being in harmony with the universe is preferred over mastering it. The Surgeon General’s Report on Mental Health (DHHS, 1999) makes it explicitly clear that using European American standards to judge normality and abnormality is fraught with dangers; that it may result in denying appropriate treatment to minority groups; that it may oppress rather than help culturally different clients; and that it is important for mental health practitioners to recognize and respond to cultural concerns of African Americans, Asian Americans/Pacific Islanders, Latino or Hispanic Americans, and Native Americans (Boyd-Franklin, 2003; Flores & Carey, 2000; Ridley, 1995). Further, many ethnic minority researchers (Takeuchi & Uehara, 1996; Sue & Sue, 2003) have pointed out the appalling lack of research on the effectiveness of therapy for minority groups; few studies exist on empirically supported treatments with minority populations. Many minority mental health professionals have advocated the development of culture-specific treatments that recognize the cultural values, life experiences, and minority status of these populations in the United States (Ivey et al., 2002).

Culturally Diverse Populations and Psychotherapy

-YTH vs Reality Myth: Psychotherapy is equally effective across all populations and problems. There is no major need to adapt the techniques and strategies when working with different racial/ethnic minority groups. Reality: There is considerable truth to this statement, but current clinical work and research reveal that the most effective forms of therapy are those that adapt to the clients’ cultural values, lifestyles, and experiences. It is important to note that all therapy arises from a particular cultural context and that it is culture bound. Thus therapy techniques developed for one group may not be applicable to another.

African Americans African Americans number between 34 and 35 million, or 13 percent of the population. The prevalence of mental disorders among African Americans is believed to be higher than that of the general population (DHHS, 1999). Further, they are underrepresented in privately financed care but overrepresented in public inpatient psychiatric care in relation to whites (Snowden & Cheung, 1990; Sue & Sue, 2003). These differences do not appear to be the result of intrinsic differences between racial groups but a function of socioeconomic, cultural, and stress factors such as racism. The poverty rate for African Americans, for example, remains nearly three times higher than that of white Americans, and unemployment rates are twice as high (U.S. Bureau of the Census, 1995). Black Americans have also been subjected to continual prejudice and discrimination in society, making it understandable that these forces may cause greater personal distress and health problems (DHHS, 1999). African Americans who seek therapy often have a negative view of mental health services and possess “historical hostility,” triggering mistrust of the white therapist. Some minority therapists believe that it is important for the therapist to acknowledge the existence of historical hostility if effective psychotherapy is to be conducted with African Americans (Parham, White, & Ajamu, 1999; Vontress & Epps, 1997). In addition, these researchers believe that white therapists who work with minority populations must become aware of their own stereotypes, biases, and preconceived notions concerning African Americans. In one study, for example, African American and European American psychologists were presented a photograph and case information on an African American female and asked to rate the client on her attractiveness and ability to benefit from therapy (Atkinson et al., 1996).

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White psychologists were more likely to rate the black female as less attractive, suffering from a more severe disorder, and less likely to be helped in therapy. Another barrier to providing effective treatment for African Americans lies in the belief that therapies developed on European American populations are equally applicable across racial groups. Most forms of treatment are insight oriented, focus on individual development, are intrapsychic in orientation, and occur in the office on a one-to-one basis. As a group, African Americans tend to be more group centered and sensitive to interpersonal matters, to have strong kinship bonds, to be work and education oriented, and to have a strong commitment to religious values and church participation (Parham et al., 1999). They are more likely to believe that their problems are not internal but external: they live with discrimination, prejudice, racism, poverty, and other environmental concerns. Effective therapy for African Americans may mean understanding conflicting values in the therapeutic process and being able to play a more active role in helping African American clients deal with external problems rather than internal ones (Ridley, 1995). Some guidelines in working with African American clients have been suggested by a number of multicultural specialists (Boyd-Franklin, 2003; Carter & McGoldrick, 2005; Nwachuku & Ivey, 1991; Parham 2002; Sue & Sue, 2003): ■

During the first session, it may be beneficial for the white therapist to bring up the issue of racial difference between the two.

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Try to understand the worldview of African American clients before making an interpretation; determine how they view the problem and the possible solutions.

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Do not pathologize or prejudge the client’s initial suspiciousness and reluctance to self-disclose. See it as a survival mechanism developed by the client to deal with issues of racism.

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Many African Americans have experienced racism as part of their life experiences. Don’t be afraid to freely discuss issues of prejudice and discrimination.

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Assess the positive assets of the client, such as family (including relatives and nonrelated friends), community resources, and the church.

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Consider external factors related to the problem. This may involve contact with outside agencies and not dismissing issues of racism as “just an excuse.”

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Use problem-solving approaches to deal with external issues.

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Above all, know that these are guidelines and should not be rigidly applied to all African Americans.

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Cultural Diversity The increasing diversification of the United States has introduced many new customs, celebrations, and cultural events. In these photos, teenagers participate in a Dragon Dance in Chinatown (immediate right); a Latino family celebrates Christmas; an African American family celebrates Kwanzaa (a cultural rather than a religious holiday) (below, left and right); and a group of American Indians perform the Buffalo Dance during New Mexico’s American Indian Day (far right).

Asian Americans/Pacific Islanders Between 10 and 12 million people in the United States are Asian Americans (including Chinese, Filipinos, Koreans, Asian Indians, Vietnamese, Laotians, Japanese) and between 345,000 and 750,000 are Pacific Islanders (including Hawaiians, Guamanians, Samoans), forming a combined 4.1 percent of the population. Asian Americans are among the fastest growing minority groups in the United States (U.S. Bureau of the Census, 2001). Although they are generally lumped together, their population comprises at least forty distinct subgroups that differ in language, religion, and values (Sandhu, 1997). The contemporary image of Asian Americans is that of a highly successful minority who have “made it” in society. Indeed, a close analysis of census figures (U.S. Bureau of the Census, 1995) seems to support this contention. Mental health

statistics, for example, reinforce the belief that Asians in America are relatively well adjusted, function effectively in society, and experience few difficulties. Studies consistently reveal that they have low official rates of juvenile delinquency, divorce, psychiatric contact, and hospitalization (Sue & Sue, 2003). Whether Asian Americans’ underutilization of mental health facilities, however, is due to low rates of mental disorders, to discriminatory mental health practices, and/or to cultural values that inhibit self-referral is not known. It is becoming clear that many of the mental disorders, adjustment problems, and character disorders among Asians are hidden. Increasing evidence suggests that the discrepancy between official and real rates may be due to such cultural factors as the shame and disgrace associated with admitting to emotional problems, the desire to handle problems within the family rather than relying on outside resources, and the

Culturally Diverse Populations and Psychotherapy

manner of symptom formation, such as a low prevalence of acting-out disorders (DHHS, 1999; Sue & Sue, 2003). Many Southeast Asian refugees show psychiatric symptoms associated with past traumas and current resettlement problems. Very high levels of posttraumatic stress disorder and depression have been identified among this population. Further, to believe that the issue of racism is not central to the life experiences of Asian Americans and Pacific Islanders is to deny social reality. Yet this appears to be a belief held by many mental health practitioners in our society. This belief is ironic in light of the historical and continuing bias directed at Asians. Denied the rights of citizenship and ownership of land and interned during World War II, Asians in America have been subjected to some of the most appalling forms of discrimination ever perpetrated against any immigrant group (Ina, 1997). Even more disturbing was a recent study indicating that 25 percent of the American public harbor negative attitudes toward and stereotypes about Chinese Americans, that 23 percent would be uncomfortable supporting an Asian American presidential candidate (as opposed to 15 percent who would be uncomfortable with an African American candidate), and that the public did not distinguish between Chinese Americans and other Asian American/Pacific Islander groups (“Asian Americans seen negatively,” 2001). Like their African American counterparts, Asian Americans and Pacific Islanders may also approach mental health services with considerable suspiciousness. Another potential barrier to effective therapeutic services for Asian Americans and Pacific Islanders lies

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in both the process and the goals of therapy that may prove antagonistic to their cultural values. First, mental health and psychotherapy are foreign concepts in Asian countries. Many refugees and immigrants have limited faith in talking about problems. Second, therapy often asks the clients to self-disclose their most intimate thoughts and feelings. Yet Asian cultural values make it clear that talking about one’s personal life and family concerns to a stranger is inappropriate. Third, traditional Asian values regarding restraint of strong feelings contrast sharply with the more open and free expression of feelings in therapy. In light of these factors, several suggestions have been offered for working with Asian American populations (Ina, 1997; Sandhu, 1997; Sue & Sue, 2003): ■

Therapists should be aware of potential social stigma attached to seeking mental health services; issues of confidentiality should be strongly stressed.

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Be aware that Asian Americans and Pacific Islanders are more likely to express psychological conflicts via somatic complaints and/or other socially acceptable issues (educational and vocational problems).

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Consider the possibility that client reluctance to self-disclose and to freely express feelings and/or lower levels of verbalization in the therapy session may be due to cultural factors and not indicative of pathology.

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The therapist should consider explaining the purpose of therapy, the expectations, and the process itself.

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A more action-oriented problem-solving approach may be more consistent with the therapeutic expectations of the client.

Latino or Hispanic Americans More than 35 million people, approximately 13 percent of the population, are Latino or Hispanic Americans. In physical characteristics, the appearance of Latinos varies greatly and may include resemblance to North American Indians, Blacks, Asians, or Latins and Europeans, depending on their country of origin. The U.S. Census classifies Hispanics not as a racial but as an ethnic group. As such, they can be members of any racial group. Latinos are overrepresented among the poor, they have lower levels of education and high unemployment, and they often live in substandard housing. They have lower annual incomes, higher rates of poverty, greater rates of medical problems, and less access to adequate health care than whites (DHHS, 1999; Flack et al., 1995; U.S. Bureau of Census, 1995). For Hispanic Americans, family unity is seen as very important, as is respect for and loyalty to the family. For many Hispanic Americans, the extended family includes not only relatives but also “relatives” (though not by blood) such as the best man (padrino), maid of honor (madrina), and godparents (compadre and comadre). Each member of the family has a role: grandparents (wisdom), father (responsibility), children (obedience), and godparents (resourcefulness; Ruiz, 1995). Because of these relationships and resources, they generally do not seek outside help until after they obtain advice from the extended family and close friends (Flores & Carey, 2000; Paniagua, 1998; Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002; Sue & Sue, 2003). Epidemiological studies indicate that the lifetime rates of mental illness of whites and Latino Americans are no different (DHHS, 1999; Robins & Regier, 1991). Nevertheless, there do appear to be differences in the stressors experienced by Latinos, cultural differences that must be considered and unique problems related to mental health care access. First, because many Hispanics suffer from external factors such as prejudice, discrimination, and poverty, some professionals have argued for social change (Paniagua, 1998). The role of therapists should be to help Hispanic clients become more aware of the oppression they face and to attain personal and collective liberation. As a result, it is important for therapists to understand the psychosocial, economic, and political needs of the Hispanic client (Flores & Carey, 2000).

Second, the most appropriate therapist to work with traditional Hispanic clients would be bilingual and bicultural. Yet the lack of bilingual therapists poses communication problems with Hispanics who are not conversant in English. It has been found, for example, that Mexican American clients are seen as suffering from greater pathology when they are interviewed in English rather than in Spanish (Sue & Sue, 2003). Further, the use of interpreters causes as many problems as it cures. Interpreters often misinterpret or distort the communication, become embarrassed with the topics discussed, fail to understand the therapeutic need for confidentiality, lack adequate psychiatric knowledge to work effectively, and may form an unhealthy alliance with the therapist or the client. Third, the family structure of the traditional Hispanic family tends to be patriarchal, and sex roles are clearly defined. In working with Hispanic Americans, the therapist will often face problems dealing with conflicts over sex roles. In dealing with sexrole conflicts, the therapist faces a dilemma and a potential value conflict of his or her own. If therapists believe in equal relationships, should they move clients in this direction, or should they respect the cultural values of the group? Doing the former may be imposing one’s view on the culturally different client. Doing the latter raises the question of whether the culture justifies a practice. Clear answers to these questions are difficult to find. Nevertheless, some suggestions can be given when working with Hispanic clients (Munoz & Sanchez, 1996; Paniagua, 1998; Sue & Sue, 2003; Vazquez, 1997): ■

Because interpersonal relationships are so valued in Hispanic culture (personalismo), it is important for the therapist to engage the client in a warm and respectful manner while maintaining a more formal persona.

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The therapist must be sensitive to the possibility of linguistic misunderstandings, especially if the client speaks limited English. Determine whether a translator is needed.

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Explaining therapy goals to the client is important.

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Guard against misinterpretations. Lack of eye contact, silences, and other nonverbal behaviors may be an indicator of respect for the therapist rather than depression or cognitive dysfunction.

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Determine the positive assets and resources available to the client and his or her family. Remember that the extended family system of the Hispanic family is often a source of help for the client.

Community Psychology

Native Americans Native Americans, with a population of approximately 3.5 million, make up slightly less than 1 percent of the U.S. population. They form a highly heterogeneous group composed of more than 550 distinct tribes. The population is young, with 39 percent under twenty-nine years of age, as compared with 29 percent of the total U.S. population. It is difficult to describe the Indian family, because tribes vary from matriarchal structures (Navajo) to patriarchal ones. Nevertheless, we know that as a group they have higher rates of poverty than their white counterparts, die at younger ages, have less education, and suffer from high unemployment rates. Although their diversity is great, certain generalizations can be made about their values: (1) honor and respect in a tribe is gained from sharing and giving, (2) cooperation to achieve mutually shared goals is valued over individual competition, (3) the concept of noninterference is valued over action and taking charge, (4) present time rather than the future is valued—punctuality or planning for the future is less important than experiencing the current moment, (5) the extended family is the unit of operation, and (6) harmony with nature is stressed (Carter & McGoldrick, 2005; Herring, 1999). These value differences can produce problems, especially when interpreted from a non-Indian perspective. Wars and diseases that resulted from contact with Europeans decimated the Native American population so that by the end of the eighteenth century their population had decreased to only 10 percent of its original numbers. The experience of Native Americans in the United States is not comparable to that of any other ethnic group. They were the original people who lived on this land until it was taken from them due to federal and state policies (Johnson et al., 1995). During the 1930s, over 125,000 Native Americans from different tribes were forced from their homes in many different states to reservations. The move was and continues to be a traumatic one for Native American families, in many cases, disrupting their cultural traditions, forcing them into English-speaking schools, and removing children from their homes until the Child Welfare Act was passed in 1978. No wonder Native Americans are very suspicious of the motives of the majority culture and almost expect to be treated unfairly by non–Native American agencies (Johnson et al., 1995). Many multicultural psychologists believe that the oppressive acts of the United States government toward Native Americans have resulted in the many mental health disorders in this group. The suicide epidemic among Native Americans is thought to be the result of poverty, a breakdown in family values caused by the

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disruption of the family, and prejudice and discrimination. American Indians have twice the rate of attempted and completed suicide as other youths (DHHS, 1999). Substance abuse is one of the greatest problems faced by Native Americans; they are more likely to die of alcohol-related causes than the general U.S. population (Penn, Kar, Kramer, Skinner, & Zambrana, 1995). In working with Native Americans, some therapists have recommended the following guidelines (Carter & McGoldrick, 2005; DHHS, 1999; Herring, 1999; Sue & Sue, 2003): ■

The therapist must be patient. Expectations that the client will rapidly and easily talk about sensitive materials may be unrealistic; it may take longer for clients to open up, because trust must be established first.

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Basic needs should be addressed first. Problems related to nourishment, health care, poverty, shelter, child care, and employment should receive top priority in the sessions, and appropriate action should be taken.

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The value of noninterference and the reality that problems reside in the client’s environment may mean that the therapist should use a combination of therapeutic approaches. For example, personcentered strategies of respect and acceptance of the client and allowing the client to develop his or her solutions to the problem must be balanced with more behavioral/cognitive approaches to dealing with systemic issues.

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The therapist should be aware that communication style differences (eye contact, silences, and the expression of affect) are culturally determined. Making unwarranted psychiatric interpretations should be guarded against.

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Finally, the therapist might benefit from seeking counsel with indigenous healers in the Native American community.

Community Psychology It is difficult to discuss psychotherapy and intervention without reference to the context in which services are provided. The context involves people living in families and communities and functioning within social, economic, educational, political, religious, cultural, and health institutions. Community psychology is an approach to mental health that takes into account the influence of environmental factors and that encourages

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A Shameful Past, a Hope for the Future In the past, patients with mental disorders were often kept in mental hospitals under substandard living conditions, like those shown here. Today, community psychologists work to improve both community resources for people with disorders and the effectiveness of the services provided.

the use of community resources and agencies to eliminate conditions that produce psychological problems. It is concerned with the promotion of well-being and the prevention of mental disturbance. Pertinent issues include managed health care and the prevention of psychopathology.

Managed Health Care The delivery of mental health services is headed for major changes. Concerns have been expressed over

the rising costs of medical and mental health care, the uncertainty of treatment outcome, and the inadequacies in the delivery of treatment to certain segments of the population, such as older individuals and members of ethnic minority groups (Holloway, 2004). As Figure 17.3 indicates, only a small proportion of individuals with mental disorders seek care from the mental health system, and changes are needed to make services accessible, available, and affordable. Reform is occurring in several ways. The following are among the most important. First, mental health care is shifting to health maintenance organizations (HMOs), which operate to reduce costs as much as possible. At the same time, traditional fee-for-service financing of services is diminishing. Many HMOs are turning to managed-care companies to administer their mental health benefit plans. Second, care providers tend to emphasize short-term treatment, intended to enable the client to function, rather than long-term treatment that attempts to “cure” the client. Third, individuals with master’s degrees and others who do not have doctorates are increasingly providing services formerly provided by therapists with M.D.’s, Ph.D.’s or Psy.D.’s. Because doctoral providers’ services cost more, they will be less in demand. Fourth, the effectiveness and cost efficiency of treatments and of clinicians must be continually assessed to reduce cost and inefficiency. Accountability and quality assurance are emphasized to an even greater degree than in the past. Although there is general consensus that problems have existed in the mental health system, managed care has not been enthusiastically embraced by many mental health professionals. For example, there are concerns that health maintenance organizations may FIGURE 17.3 Use of Mental

Total U.S. Population 14.

Health Services Among Individuals with Mental or Addictive Disorders In the

7%

6.7% 8%

28.1% 65.2%

Adults who sought services Adults without disorders who sought services Adults with disorders who sought services Adults with mental or addictive disorders Adults without disorders and who did not seek services

Source: Data from Regier et al. (1993).

Epidemiologic Catchment Area survey of adult Americans, 28.1 percent of the sample said they were experiencing or had experienced a mental or addictive disorder during the previous year. During that year, 14.7 percent of Americans sought mental health services. Because many of those who sought services did not meet the criteria for a mental disorder, only 8 percent of the population had both a mental or addictive disorder and sought services. Thus only 28.5 percent of those with mental or addictive disorders used services (8 percent divided by 28.1 percent).

Community Psychology

attempt to reduce costs simply by reducing the quality or extent of services, expending little effort on preventing problems, hiring providers to give cheap services, and gaining a much stronger voice than providers of services in determining treatment for clients (Holloway, 2004; Karon, 1995; Seligman & Levant, 1998). Clients may have a difficult time obtaining more long-term care. In adapting to the reforms in mental health care, some have pointed out the need for focused training of mental health care providers. These reforms could ensure that clinical health psychologists’ educational background includes behavioral medicine and health psychology, as well as clinical psychology. Other skills in health assessment and intervention and outcome assessment are also needed (Belar, 1995). Reform is also taking place in other ways. For example, the American Psychological Association has endorsed the principle that clinical psychologists with proper training should be able to prescribe medication for patients with mental disorders (Martin, 1995), although some psychologists oppose such a move (Hayes, 1995). Another facet of the reform movement is a systematic attempt that is being made to identify those treatments that have been empirically supported as being effective (Task Force on Promotion and Dissemination of Psychological Procedures, 1995). It is hoped that the effort will make it possible to establish standards for client and therapist treatment decisions based on scientific research. “Manualized” treatment programs are also gaining popularity (Addis, 1997; Woody & Sanderson, 1998). These programs have manuals that instruct therapists (particularly those using cognitive and cognitive-behavioral approaches) to conduct treatment in a planned, systematic, and guided fashion. The assumption is that following treatment manuals will reduce possible ineffective discretionary practices that therapists use when they base procedures largely on their own judgment. The use of manuals in treatment, however, has generated some controversy, especially among those clinicians who believe that discretionary practices are necessary in psychotherapy (see Kazdin, 1998). Finally, the increasing use of computer programs to provide psychotherapy to clients is evident (Marks, Shaw, & Parkin, 1998). Clients describe their problems on a computer and then receive programmed information and advice on the problems and how to deal with them. Proponents see advantages to computer-aided treatments, such as low cost and easy accessibility. Opponents believe that clients need the human contact of a therapist and that a computer cannot consider factors for which it was not programmed. Thus the field of clinical psychology, as well as the other fields

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Reaching Out Before It’s Too Late Groups and organizations often use the media to reach out to people with emotional problems. These communications reinforce the idea that problems can be prevented and offer help in how to go about it. This billboard is intended to not only reach people suffering from schizophrenia but also to educate the public about the need to provide appropriate treatment.

involved in mental health, is changing, and with this change come both opportunities and conflicts.

Prevention of Psychopathology Preventing psychopathology is one of the most innovative functions of community psychology. Prevention programs are attempts to maintain health rather than to treat sickness. The main emphasis is on reducing the number of new cases of mental disorders, the duration of disorders among afflicted people, and the disabling effects of disorders. These three areas of prevention have been called primary, secondary, and tertiary prevention. Primary Prevention Primary prevention is an effort to lower the incidence of new cases of behavioral disorders by strengthening or adding to resources that promote mental health and by eliminating community characteristics that threaten mental health. As an example of the former, Project Head Start was initiated in 1964 with the goal of setting up a new and massive preschool program to help neglected or deprived children develop social, emotional, and intellectual skills. Examples of the latter are efforts to eliminate discrimination against members of minority groups to help them fulfill their potential. Both techniques—introducing new resources and eliminating causal factors—can be directed toward specific groups of people or toward the community as a whole. Munoz and colleagues (Munoz, Glish, Soo-Hoo, & Robertson, 1982; Munoz et al., 1995) have been systematically attempting to prevent depression in a

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Raising Awareness Heather Irish is founder and CEO of Mental Illness Needs Discussion Sessions (MINDS™), a free program that works in urban, suburban, and rural middle and high schools to encourage awareness of and destigmatize mental disorders. During the seminars, students are given two brochures. One describes the symptoms of mental illness, and the other provides a guide to local, state, and national help lines; referral agencies; organizations; and other services.

community-wide project and in primary care patients. The project was particularly interesting. During a twoweek period, nine televised programs intended to prevent depression were broadcast in San Francisco. Each program lasted for four minutes and showed viewers some coping skills, such as how to think positively, engage in rewarding activities, and deal with depression. Telephone interviews were conducted with 294 San Francisco residents. Some respondents were interviewed one week before the television segments were shown; others were interviewed one week after; and still others were interviewed both before and after the segments. Information about respondents’ depression levels was collected during the interviews. (For those who were interviewed before and after the segments, the depression measure was administered twice.) Respondents who were interviewed after the televised segments were also asked to indicate whether they had watched any of the segments. Results indicated that those who saw the segments exhibited a significantly lower level of depression than that found among the nonviewers. The results, however, held only for respondents who had some symptoms of depression to begin with. Watching the television programs did not change the depression levels of those who initially (before the segments) reported little depression. The results indicated that a community-wide prevention program could be beneficial. A large proportion (approximately one-third) of the viewers had some symptoms of depression, and this group showed fewer symptoms after viewing the programs. The long-term

effects of the programs were not assessed. Another problem in the study was that those who benefited from the programs had exhibited some initial symptoms. If they were clinically diagnosable as being depressed, the intervention might be considered secondary rather than primary prevention. (Secondary prevention is discussed in the next section.) Nevertheless, the San Francisco study demonstrated the effects of large-scale interventions that may help disorders. Evidence also exists that early, primary prevention efforts can be successful in reducing the incidence of juvenile delinquency. Zigler, Taussig, and Black (1992) noted that few treatment and rehabilitation programs for juvenile delinquents have had much effect. In their review of early intervention programs aimed at children, they found evidence that these programs, intended to promote social and intellectual competence, have had an expected positive effect on preventing delinquency. The investigators speculated that gaining competence may snowball to generate further success in other aspects of life and prevent delinquency. Although interest in primary prevention continues to grow, resistance to prevention is also strong. First, only through prospective and longitudinal research can developmental processes in primary prevention be uncovered (Lorion, 1990). Primary prevention is futureoriented, in that the benefits of the effort are not immediately apparent. Second, primary prevention competes with traditional programs aimed at treating people who already show emotional disturbances. Third, prevention may require social and environmental changes so that

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stresses can be reduced or resources can be enhanced. Most mental health workers are either unable or unwilling to initiate such changes; many others doubt that people have the ability to modify social structures. Fourth, funding for mental health programs has traditionally been earmarked for treatment. Prevention efforts constitute a new demand on the funding system. And fifth, primary prevention requires a great deal of planning, work, and long-term evaluation. This effort alone discourages many from becoming involved.

detected, it is often difficult to decide what form of treatment will be most effective with a particular patient. Third, prompt treatment is frequently unavailable because of the shortage of mental health personnel and the inaccessibility of services. Indeed, many mental health facilities have long lists of would-be patients who must wait months before receiving treatment. “Walk-in” clinics, crisis intervention facilities, and emergency telephone lines have been established in an attempt to provide immediate treatment.

Secondary Prevention Secondary prevention is an attempt to shorten the duration of mental disorders and to reduce their impact. If the presence of a disorder can be detected early and an effective treatment can be found, it is possible to minimize the impact of the disorder or to prevent its developing into a more serious and debilitating form. For example, classroom teachers can play an important role in secondary prevention by identifying children who are not adjusting to the school environment. Once identified, such children can be helped by teachers, parents, or school counselors. In practice, there are a number of problems associated with secondary prevention. First, traditional diagnostic methods are often unreliable and provide little insight into which treatment procedures to use. It has been suggested that more specialized diagnostic techniques be used, perhaps focusing on certain behaviors or on demographic characteristics that may be related to psychopathology. Second, once a disorder is

Tertiary Prevention The goal of tertiary prevention is to facilitate the readjustment of the person to community life after hospital treatment for a mental disorder. Tertiary prevention focuses on reversing the effects of institutionalization and on providing a smooth transition to a productive life in the community. Several programs have been developed to accomplish this goal. One involves the use of “passes,” whereby hospitalized patients are encouraged to leave the hospital for short periods of time. By spending gradually increasing periods of time in the community (and then returning each time to the hospital), the patient can slowly readjust to life away from the hospital while still benefiting from therapy. Psychologists can also ease readjustment to the community by educating the public about mental disorders. Public attitudes toward mental patients are often based on fears and stereotypes. Factual information can help modify these attitudes so that patients will be more graciously accepted. This help is especially important for

Serving Those in Need Because of client demand, some mental health clinics have waiting lists. Clients, therefore, may not receive immediate treatment unless it is an emergency. Walk-in clinics and drop-in centers like this one allow individuals easy and quick access to services.

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the family, friends, and business associates of patients, who must interact frequently with them. A more difficult problem to deal with is the growing backlash against the discharge of former mental patients into nursing homes or rooming houses in the community.

What forms of medical treatment have been found to be successful in treating mental disorders? ■

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Biological (or somatic) treatments use physical means to alter the physiological and psychological states of patients. The use of electroconvulsive therapy (ECT), or electroshock, has diminished, but it is still used for some patients with severe depression. Because psychosurgery permanently destroys brain tissue, it is now rarely used and strictly regulated. One reason for the declining use of both ECT and psychosurgery is a correspondingly greater reliance on medication or drug therapy. Antianxiety drugs reduce anxiety, antipsychotic drugs help control or eliminate psychotic symptoms, antimanic drugs reduce mania, and antidepressants effectively reduce depression. Medication has enabled many patients to function in the community and to be more amenable to other forms of treatment, particularly insight-oriented and behavioral therapy.

What is psychotherapy? ■

Psychotherapy is the application of techniques derived from psychological principles to help disturbed clients. Clients, who usually have certain hopes and anxiety on entering therapy, have an opportunity to develop a therapeutic relationship with a therapist and, in the process, to learn new ways of dealing with problems and to experience or reexperience important emotions. The techniques therapists use vary widely and depend on the therapist’s theoretical orientation.

What are the different approaches to psychotherapy? ■

The insight-oriented therapeutic approaches include psychodynamic therapy, person-centered therapy, existential analysis, and gestalt therapy. These approaches provide the patient with an opportunity to develop better levels of functioning, to undergo new and emotionally important experi-

Many community members feel threatened when such patients live in their neighborhoods. Again, education programs may help dispel community members’ fears and stereotypes.

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ences, to develop a therapeutic relationship with a professional, and to relate personal thoughts and feelings. Action-oriented or behavior therapies (based on classical conditioning, operant conditioning, modeling, and cognitive restructuring) have been applied to a variety of disorders. Behavioral assessment, procedures, goals, and outcome measures are more clearly defined and more easily subjected to empirical investigation than are insight-oriented approaches. Two promising approaches are behavioral medicine and stress resistance training, which combine behavioral, cognitive, medical, and social knowledge.

How successful is therapy in treating mental disorders? ■

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Some critics claim that the effectiveness of psychotherapy—of whatever orientation—has not been demonstrated. Results from numerous studies and meta-analyses of these studies have pointed to the beneficial impact of treatment. The real issue, however, may be one of finding the best combination of therapies and situational variables for each client. Although critics argue that behavior therapy is dehumanizing, limited to a narrow range of human problems, and mechanical, proponents consider behavior modification both effective and efficient.

How are group forms of therapy different from individual ones? ■ ■

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Group therapy involves the simultaneous treatment of more than one person. Many psychological difficulties are interpersonal in nature, and the group format allows the therapist and clients to work in an interpersonal context. Family and couples therapies consider psychological problems as residing within the family or couple rather than in one individual. The communications approach to family therapy concentrates on improving family communications, whereas the systems approach stresses the understanding and restructuring of family roles and dynamics.

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Is there a way to combine or integrate the best features of effective therapies? ■

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Most practicing therapists are eclectic or integrative in perspective. They try to select therapeutic methods, concepts, and strategies from a variety of current theories that work. Being eclectic is sometimes criticized as being haphazard and inconsistent, but every therapist who fits the therapy to the client is, in fact, eclectic.

Is therapy with racial/ethnic minority groups different from working with European American groups? ■

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There is increasing awareness that psychotherapy is a western European construction that may not be applicable to various racial/ethnic minority groups. Culture-specific strategies in working with African Americans, Asian Americans/Pacific Islanders, Hispanic Americans, and Native Americans seem to require that the therapist take into consideration several important factors in therapy: (1) historical and continuing oppression in the form of prejudice and discrimination, (2) the cultural values and assumptions of the minority group, and (3) recognition that the process and goals of therapy may be antagonistic to the life experiences of the minority group.

aversive conditioning (p. 511) biofeedback therapy (p. 514) community psychology (p. 527) couples therapy (p. 518) electroconvulsive therapy (ECT) (p. 500) existential analysis (p. 508)

family therapy (p. 518) flooding (p. 510) free association (p. 506) gestalt therapy (p. 509) group therapy (p. 518) implosion (p. 510) monoamine oxidase (MAO) inhibitor (p. 503)

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What can society do to make the social environment a healthy place to live? ■

In discussing therapeutic intervention, it is also important to be aware of broader mental health efforts involving community psychology or community mental health. Several developments are necessary to consider. • First, a growing trend in the delivery of mental health services is managed health care. Under managed health care, consideration will be given to cost effectiveness of services and short-term care. Although many mental health providers are critical of managed care, others have called for changes in the role of and services given by providers. • Second, the mental health field is also grappling with issues involving prescription privileges for psychologists, using empirically supported treatments as a guideline for delivery services, and employing treatment manuals in the practice of psychotherapy and behavioral modification. • Third, in addition to treatment, primary, secondary, and tertiary forms of prevention are important in our efforts to enhance mental health and well-being.

person-centered therapy (p. 508) primary prevention (p. 529) psychopharmacology (p. 501) psychosurgery (p. 500) psychotherapy (p. 504) resistance (p. 506) secondary prevention (p. 531)

selective serotonin reuptake inhibitor (SSRI) (p. 503) tertiary prevention (p. 531) token economy (p. 511) transference (p. 507) tricyclic (p. 503)

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Abnormal behavior A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom Abnormal psychology The scientific study whose objectives are to describe, explain, predict, and control behaviors that are considered strange or unusual Acute stress disorder (ASD) Disorder characterized by anxiety and dissociative symptoms that occur within one month after exposure to a traumatic stressor Agoraphobia An intense fear of being in public places where escape or help may not be readily available Alcoholic Person who abuses alcohol and is dependent on it Alcoholism Substance-related disorder characterized by abuse of, or dependency on, alcohol, which is a depressant Alzheimer’s disease (AD) A dementia in which brain tissue atrophies, leading to marked deterioration of intellectual and emotional functioning American Law Institute (ALI) Model Penal Code A test of legal insanity that combines both cognitive criteria (diminished capacity) and motivational criteria (specific intent); its purpose is to give jurors increased latitude in determining the sanity of the accused Amnestic disorder A disorder characterized by memory impairment as manifested by the inability to learn new information and the inability to recall previously learned knowledge or past events Amniocentesis A screening procedure in which a hollow needle is inserted through the pregnant woman’s abdominal wall and amniotic fluid is withdrawn from the fetal sac; used during the fourteenth or fifteenth week of pregnancy to determine the presence of Down syndrome and other fetal abnormalities Amphetamine A drug that speeds up central nervous system activity and produces increased alertness, energy, and,

sometimes, feelings of euphoria and confidence; also called “uppers” Analogue study An investigation that attempts to replicate or simulate, under controlled conditions, a situation that occurs in real life Anorexia nervosa An eating disorder characterized by low body weight, an intense fear of becoming obese, and body image distortion Antisocial personality disorder A personality disorder characterized by a failure to conform to social and legal codes, by a lack of anxiety and guilt, and by irresponsible behaviors Anxiety A fundamental human emotion that produces bodily reactions that prepare us for “fight or flight”; anxiety is anticipatory; the dreaded event or situation has not yet occurred Anxiety disorder Fear or anxiety symptoms that interfere with an individual’s day-to-day functioning Assessment With regard to psychopathology, the process of gathering information and drawing conclusions about the traits, skills, abilities, emotional functioning, and psychological problems of an individual Asthma Chronic inflammatory disease of the airways in the lungs Attention deficit/hyperactivity disorder (ADHD) Disorder of childhood and adolescence characterized by socially disruptive behaviors—either attentional problems or hyperactivity—that are present before age seven and persist for at least six months Autistic disorder A severe childhood disorder characterized by qualitative impairment in social interaction and/or communication; restricted, stereotyped interest and activities; and delays or abnormal functioning in a major area before the age of three Aversion therapy Conditioning procedure in which the response to a stimulus is decreased by pairing the stimulus with an aversive stimulus Avoidant personality disorder A personality disorder characterized by a fear of rejection and humiliation and a reluctance to enter into social relationships

Axon Extension on the cell body that sends signals to neurons, some a considerable distance away Barbiturate Substance that is a powerful depressant of the central nervous system, is commonly used to induce relaxation and sleep, and is capable of inducing psychological and physical dependency; also called “downers” Base rate The rate of natural occurrence of a phenomenon in the population studied Behavioral models Models of psychopathology concerned with the role of learning in abnormal behavior Behaviorism Psychological perspective that stresses the importance of learning and behavior in explanations of normal and abnormal development Binge-eating disorder (BED) An eating disorder that involves the consumption of large amounts of food over a short period of time, an accompanying feeling of loss of control, and distress over the excess eating without regular inappropriate compensatory behavior Biofeedback training A therapeutic approach that combines physiological and behavioral approaches, in which a patient receives information regarding particular autonomic functions and is rewarded for influencing those functions in a desired direction Biological view (organic view) The belief that mental disorders have a physical or physiological basis Biopsychosocial model A model in which mental disorders are the result of an interaction of biological, psychological, and social factors Bipolar disorder A mood disorder in which depression is accompanied by mania, which is characterized by elevated mood, expansiveness, or irritability, often resulting in hyperactivity Body dysmorphic disorder (BDD) Preoccupation with an imagined defect in appearance in a normal-appearing person or an excessive concern over a slight physical defect

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Body mass index (BMI) An estimate of body fat calculated on the basis of a person’s height and weight Borderline personality disorder A personality disorder characterized by intense fluctuations in mood, self-image, and interpersonal relationships Brain pathology A dysfunction or disease of the brain Brief psychotic disorder Psychotic disorder that lasts no longer than one month Bulimia nervosa An eating disorder characterized by recurrent episodes of the rapid consumption of large quantities of food, a sense of loss of control over eating combined with purging (vomiting, use of laxatives, diuretics, or enemas), and/or excessive exercise or fasting in an attempt to compensate for binges Case study An intensive study of one individual that relies on clinical data, such as observations, psychological tests, and historical and biographical information Catatonic schizophrenia A schizophrenic subtype characterized by marked disturbance in motor activity—either extreme excitement or motoric immobility; symptoms may include motoric immobility or stupor; excessive purposeless motor activity; extreme negativism or physical resistance; peculiar voluntary movements; or echolalia or echopraxia Cathartic method A therapeutic use of verbal expression to release pent-up emotional conflicts Cerebral blood flow measurement A technique for assessing brain damage in which the patient inhales radioactive gas and a gamma ray camera tracks the gas—and thus the flow of blood—as it moves throughout the brain Cerebral infarction The death of brain tissue resulting from a decrease in the supply of blood serving that tissue Cerebral tumor A mass of abnormal tissue growing within the brain Civil commitment The involuntary confinement of a person judged to be a danger to himself or herself or to others, even though the person has not committed a crime Classical conditioning A process in which responses to new stimuli are learned through association Classification system With regard to psychopathology, a system of distinct categories, indicators, and nomenclature for different patterns of behavior, thought processes, and emotional disturbances

Cluster headache Excruciating stabbing or burning sensations located in the eye or cheek Cocaine Substance extracted from the coca plant; induces feelings of euphoria and self-confidence in users Cognitive disorder A disorder that affects thinking processes, memory, consciousness, and perception and that is caused by brain dysfunction Cognitive models Models based on the assumption that conscious thought mediates an individual’s emotional state and/or behavior in response to a stimulus Cognitive restructuring Cognitive strategy that attempts to alter unrealistic thoughts that are believed to be responsible for phobias Cognitive symptom In schizophrenia, a symptom that is associated with problems with attention, memory, and difficulty in developing a plan of action Comorbidity Co-occurrence of different disorders Competency to stand trial A judgment that a defendant has a factual and rational understanding of the proceedings and can rationally consult with counsel in presenting his or her own defense; refers to the defendant’s mental state at the time of the psychiatric examination Compulsion The need to perform acts or to dwell on thoughts to reduce anxiety Compulsive sexual behavior A term used by many sex therapists to describe individuals who seem to crave constant sex at the expense of relationships, work productivity, and daily activities Computerized axial tomography (CT) A neurological test that assesses brain damage by means of x-rays and computer technology Concordance rate The likelihood that both members of a twin pair will show the same characteristic Conditioned response (CR) In classical conditioning, a learned response to a previously neutral stimulus that has acquired some of the properties of another stimulus with which it has been paired Conditioned stimulus (CS) In classical conditioning, a previously neutral stimulus that has acquired some of the properties of another stimulus with which it has been paired Conduct disorder Disorder of childhood and adolescence characterized by a persistent pattern of antisocial behaviors that violate the rights of others; repetitive and persistent behaviors include bullying, lying, cheating, fighting, throwing

temper tantrums, destroying property, stealing, setting fires, cruelty to people and animals, assaults, rape, and truant behavior Confidentiality An ethical standard that protects clients from disclosure of information without their consent; an ethical obligation of the therapist Continuous amnesia An inability to recall any events that have occurred between a specific time in the past and the present time Conversion disorder Physical problems or impairments in sensory or motor functioning controlled by the voluntary nervous system that suggest a neurological disorder but with no underlying organic cause Coronary heart disease (CHD) The narrowing of cardiac arteries, resulting in the restriction or partial blockage of the flow of blood and oxygen to the heart Correlation The extent to which variations in one variable are accompanied by increases or decreases in a second variable Couples therapy A treatment aimed at helping couples understand and clarify their communications, role relationships, unfulfilled needs, and unrealistic or unmet expectations Covert sensitization Aversive conditioning technique in which the individual imagines a noxious stimulus occurring in the presence of a behavior Criminal commitment Incarceration of an individual for having committed a crime Cultural relativism The belief that lifestyles, cultural values, and worldviews affect the expression and determination of deviant behavior Cultural universality The assumption that a fixed set of mental disorders exists whose obvious manifestations cut across cultures Cyclothymic disorder A chronic and relatively continual mood disorder in which the person is never symptom free for more than two months Dangerousness A person’s potential for doing harm to himself or herself or to others Defense mechanism In psychoanalytic theory, an ego-protection strategy that shelters the individual from anxiety, operates unconsciously, and distorts reality Deficit model Early attempt to explain differences in minority groups that contends that differences are the result of “cultural deprivation”

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Deinstitutionalization The shifting of responsibility for the care of mental patients from large central institutions to agencies within local communities Delirium A syndrome characterized by disturbance of consciousness and changes in cognition, such as memory deficit, disorientation, and language and perceptual disturbances Delusion A false belief that is firmly and consistently held despite disconfirming evidence or logic Delusional disorder A disorder characterized by persistent, nonbizarre delusions that are not accompanied by other unusual or odd behaviors Dementia A syndrome characterized by memory impairment and cognitive disturbances, such as aphasia, apraxia, agnosia, or disturbances in planning or abstraction in thought processes Dendrite Short rootlike structure on the cell body whose function is to receive signals from other neurons Dependent personality disorder A personality disorder characterized by reliance on others and an unwillingness to assume responsibility Dependent variable A variable that is expected to change when an independent variable is manipulated in a psychological experiment Depersonalization disorder Disorder characterized by feelings of unreality concerning the self and the environment Depressant (sedative) Substance that causes generalized depression of the central nervous system and a slowing down of responses Depressive disorders Disorders that include major depressive disorder and dysthymic disorder with no history of a manic episode; also called unipolar depression Detoxification Alcohol or drug treatment phase characterized by removal of the abusive substance; after that removal, the user is immediately or eventually prevented from consuming the substance Diathesis-stress theory Theory that holds that people do not inherit a particular abnormality but rather a predisposition to develop illness (diathesis) and that certain environmental forces, called stressors, may activate the predisposition, resulting in a disorder Disorganized schizophrenia A schizophrenic subtype characterized by grossly disorganized behaviors manifested in disorganized speech and behavior and flat or grossly inappropriate affect Dissociative amnesia The partial or total loss of important personal information,

sometimes occurring suddenly after a stressful or traumatic event, due to psychological, not physical, factors Dissociative disorders A group of disorders including dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder, all of which involve some sort of dissociation, or separation, of a part of the person’s consciousness, memory, or identity Dissociative fugue Confusion over personal identity (often involving the partial or complete assumption of a new identity), accompanied by unexpected travel away from home Dissociative identity disorder (DID) A condition in which two or more relatively independent personalities appear to exist in one person; also known as multiple-personality disorder Dopamine hypothesis The suggestion that schizophrenia may result from excess dopamine activity at certain synaptic sites Down syndrome A condition produced by the presence of an extra chromosome (trisomy 21) and resulting in mental retardation and distinctive physical characteristics Due process Legal checks and balances that are guaranteed to everyone (the right to a fair trial, the right to face accusers, the right to present evidence, the right to counsel, and so on) Durham standard A test of legal insanity known as the products test—an accused person is not responsible if the unlawful act was the product of mental disease or defect Dyspareunia Recurrent or persistent pain in the genitals before, during, or after sexual intercourse Dysthymic disorder (dysthymia) Depressed mood which is chronic and relatively continual and does not meet the criteria for major depression Eating disorder not otherwise specified (NOS) A category for individuals with problematic eating patterns who do not fully meet the criteria for one of the eating disorders; currently includes bingeeating disorder Electroencephalograph (EEG) A neurological test that assesses brain damage by measuring the electrical activity of brain cells Encephalitis Brain inflammation that is caused by a viral or bacterial infection and that produces symptoms of lethargy, drowsiness, fever, delirium, vomiting, and headaches

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Encopresis An elimination disorder in which a child who is at least four years old defecates in his or her clothes, on the floor, or other inappropriate places, at least once a month for three months Endophenotypes Measurable characteristics (neurochemical, endocrinological, neuroanatomical, cognitive, or neuropsychological) that can give clues regarding the specific genes involved in disorders Enuresis An elimination disorder in which a child who is at least five years old voids urine during the day or night into his or her clothes or bed or on the floor, at least twice weekly for at least three months Epidemiological research The study of the rate and distribution of mental disorders in a population Epilepsy Any disorder characterized by intermittent and brief periods of altered consciousness, often accompanied by seizures, and excessive electrical discharge from brain cells Essential hypertension A chronic condition characterized by blood pressure of 140 (systolic) over 90 (diastolic) or higher Etiology Causes of disorders Exhibitionism Disorder characterized by urges, acts, or fantasies about the exposure of one’s genitals to strangers Existential approach A set of attitudes that has many commonalities with humanism but is less optimistic, focusing (1) on human alienation in an increasingly technological and impersonal world, (2) on the individual in the context of the human condition, and (3) on responsibility to others, as well as to oneself Exorcism Treatment method used by the early Greeks, Chinese, Hebrews, and Egyptians in which prayers, noises, emetics, flogging, and starvation were used to cast evil spirits out of an afflicted person’s body Experiment A technique of scientific inquiry in which a prediction—an experimental hypothesis—is made about two variables; the independent variable is then manipulated in a controlled situation, and changes in the dependent variable are measured Experimental hypothesis A prediction concerning how an independent variable will affect a dependent variable in an experiment Exposure therapy Therapy that involves gradually introducing the patient to increasingly difficult encounters with a feared situation

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Expressed emotion (EE) A negative communication pattern that is found among some relatives of individuals with schizophrenia and that is associated with higher relapse rates External validity The degree to which findings of a particular study can be generalized to other groups or conditions Factitious disorder A mental disorder in which the symptoms of physical or mental illnesses are deliberately induced or simulated with no apparent incentive Family systems model Model that assumes that the behavior of one family member directly affects the entire family system Fetal alcohol syndrome (FAS) A group of congenital physical and mental defects found in some children born to alcoholic mothers; symptoms include small body size and microcephaly, in which the brain is unusually small and mild retardation may occur Fetishism Sexual attraction and fantasies involving inanimate objects such as female undergarments Female orgasmic disorder A sexual dysfunction in which the woman experiences persistent delay or inability to achieve an orgasm with stimulation that is adequate in focus, intensity, and duration after entering the excitement phase; also known as inhibited female orgasm Female sexual arousal disorder The inability to attain or maintain physiological response and/or psychological arousal during sexual activity Field study An investigative technique in which behaviors and events are observed and recorded in their natural environment Flooding A technique that involves continued actual or imagined exposure to a feararousing situation at high anxiety level Free association Psychoanalytic therapeutic technique in which the patient says whatever comes to mind for the purpose of revealing his or her unconscious Frotteurism Disorder characterized by recurrent and intense sexual urges, acts, or fantasies or touching or rubbing against a nonconsenting person Gender identity disorder (transsexualism) Disorder characterized by conflict between a person’s anatomical sex and his or her gender identity, or selfidentification as male or female General adaptation syndrome (GAS) A three-stage model for understanding the body’s physical and psychological reactions to biological stressors

Generalized amnesia A complete loss of memory of the individual’s entire life Generalized anxiety disorder (GAD) Disorder characterized by persistent, high levels of anxiety and excessive worry over many life circumstances that are present on more days than not for more than six months Genetic linkage studies Studies that attempt to determine whether a disorder follows a genetic pattern Genome All the genetic material in the chromosomes of a particular organism Genotype Person’s genetic makeup Group therapy A form of therapy that involves the simultaneous treatment of two or more clients and may involve more than one therapist Hallucination A sensory perception that is not directly attributable to environmental stimuli Hallucinogen Substance that produces hallucinations, vivid sensory awareness, heightened alertness, or perceptions of increased insight; use does not typically lead to physical dependence, although psychological dependence may occur Histrionic personality disorder A personality disorder characterized by selfdramatization, exaggerated expression of emotions, and attention-seeking behaviors Humanism A philosophical movement that emphasizes human welfare and the worth and uniqueness of the individual Humanistic perspective The optimistic viewpoint that people are born with the ability to fulfill their potential and that abnormal behavior results from disharmony between the person’s potential and his or her self-concept Huntington’s disease A rare, genetically transmitted degenerative disease characterized by involuntary twitching movements and eventual dementia Hypochondriasis A persistent preoccupation with one’s health and physical condition, even in the face of physical evaluations that reveal no organic problems Hypothesis A conjectural statement that usually describes a relationship between two variables Iatrogenic effects Unintended effects of therapy—such as an unintended change in behavior resulting from a medication prescribed or a psychological technique employed by a therapist

Impulse control disorder A disorder in which the person fails to resist an impulse or temptation to perform some act that is harmful to the person or to others; the person feels tension before the act and release after it Incest A form of pedophilia; can also be sexual relations between people too closely related to marry legally Incidence The onset or occurrence of a given disorder over some period of time Independent variable A variable or condition that an experimenter manipulates to determine its effect on a dependent variable Inferiority model Early attempt to explain differences in minority groups that contends that racial and ethnic minorities are inferior in some respect to the majority population Insanity defense The legal argument used by defendants who admit they have committed a crime but who plead not guilty because they were mentally disturbed at the time the crime was committed Intermittent explosive disorder Impulse control disorder characterized by separate and discrete episodes of loss of control over aggressive impulses, resulting in serious assaults on others or destruction of property Internal validity The degree to which changes in the dependent variable are due solely to the effect of changes in the independent variable Internet addiction A new impulse control disorder in the 2012 edition of DSM-V characterized by persons using the Internet so frequently that they isolate themselves from family and friends Irresistible impulse test One test of sanity, which states that a defendant is not criminally responsible if he or she lacked the will power to control his or her behavior Kleptomania An impulse control disorder characterized by a recurrent failure to resist impulses to steal objects Learned helplessness An acquired belief that one is helpless and unable to affect the outcomes in one’s life Learning disorder A disorder characterized by academic functioning that is substantially below that expected in terms of the person’s chronological age, measured intelligence, and age-appropriate education Least restrictive environment A person’s right to the least restrictive alternative

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to freedom that is appropriate to his or her condition Lethality The probability that a person will choose to end his or her life Lifetime prevalence The total proportion of people in the population who have ever had a disorder in their lives Localized amnesia A failure to recall all the events that happened in a specific short period, often centered on some highly painful or disturbing event Loosening of associations In schizophrenia, continual shifting from topic to topic without any apparent logical or meaningful connection between thoughts Magnetic resonance imaging (MRI) A technique to assess brain functioning using a magnetic field and radio waves to produce pictures of the brain Mainstreaming Integrating mental patients as soon as possible back into the community Major depressive disorder A major depressive episode whose symptoms include a depressed mood or a loss of interest or pleasure, weight loss or gain, sleep difficulties, fatigue, feelings of worthlessness, inability to concentrate, and recurrent thoughts of death Male erectile disorder An inability to attain or maintain an erection sufficient for sexual intercourse and/or psychological arousal during sexual activity Male orgasmic disorder Persistent delay or inability to achieve an orgasm after the excitement phase has been reached and sexual activity has been adequate in focus, intensity, and duration; usually restricted to an inability to ejaculate within the vagina; also known as inhibited male orgasm Malingering Faking a disorder to achieve a specific goal Managed health care The industrialization of health care, whereby large organizations in the private sector control the delivery of services Mania Characteristic of bipolar disorder, consisting of elevated mood, expansiveness, or irritability, often resulting in hyperactivity Marijuana The mildest and most commonly used hallucinogen; also known as “pot” or “grass” Masochism A paraphilia in which sexual urges, fantasies, or acts are associated with being humiliated, bound, or made to suffer Mass madness Group hysteria in which a great many people exhibit similar symptoms that have no apparent physical cause

Meningitis Inflammation of the meninges, the membrane that surrounds the brain and spinal cord; can result in the localized destruction of brain tissue and seizures Mental retardation (MR) A disability characterized by significant limitations both in intellectual functioning and in adaptive behaviors as expressed in conceptual, social, and practical adaptive skills Migraine headache Moderate to severe pain resulting from constriction of the cranial arteries followed by dilation of the cerebral blood vessels Milieu therapy A therapy program in which the hospital environment operates as a community and patients exercise a wide range of responsibility, helping to make decisions and to manage wards M’Naghten Rule A cognitive test of legal insanity that inquires whether the accused knew right from wrong when he or she committed the crime Model An analogy used by scientists, usually to describe or explain a phenomenon or process they cannot directly observe Modeling Process of learning by observing models (and later imitating them) Modeling therapy Procedures that include filmed modeling, live modeling, and participant modeling effective in treating certain phobias Mood disorder A disturbance in emotions that causes subjective discomfort, hinders a person’s ability to function, or both Moral treatment movement Movement instituted by Philippe Pinel that resulted in a shift to more humane treatment of the mentally disturbed Multicultural model Contemporary attempt to explain differences in minority groups that suggests that behaviors be evaluated from the perspective of a group’s value system, as well as by other standards used in determining normality and abnormality Multicultural psychology An approach that stresses the importance of culture, race, ethnicity, gender, age, socioeconomic class, and other similar factors in its effort to understand and treat abnormal behavior Multipath model A model of models that provides an organizational framework for understanding the numerous causes of mental disorders, the complexity of their interacting components, and the need to view disorders from a holistic framework Multiple-baseline study A single-participant experimental design in which baselines

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on two or more behaviors or the same behavior in two or more settings are obtained prior to intervention Narcissistic personality disorder A personality disorder characterized by an exaggerated sense of self-importance, an exploitative attitude, and a lack of empathy Narcotic Drug such as opium and its derivatives—morphine, heroine, and codeine—that depresses the central nervous system; acts as a sedative to provide relief from pain, anxiety, and tension; is addictive Negative symptom In schizophrenia, a symptom associated with an inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure; includes avolition, alogia, and flat affect Neuroleptic Antipsychotic drug that can help treat symptoms of schizophrenia but can also produce undesirable side effects, such as symptoms that mimic neurological disorders Neuron Nerve cell that transmits messages throughout the body Neurotransmitter Chemical substance released by the axon of the sending neuron and involved in the transmission of neural impulses to the dendrite of the receiving neuron Obesity A body mass index of greater than 30 Observational learning theory Theory that suggests that an individual can acquire new behaviors by watching other people perform them Obsession Intrusive, repetitive thought or image that produces anxiety Obsessive-compulsive disorder (OCD) A disorder characterized by obsessions or compulsions Obsessive-compulsive personality disorder A personality disorder characterized by perfectionism, a tendency to be interpersonally controlling, devotion to details, and rigidity Operant behavior A voluntary and controllable behavior, such as walking or thinking, that “operates” on an individual’s environment Operant conditioning A theory of learning that holds that behaviors are controlled by the consequences that follow them Operational definitions Concrete definitions of the variables that are being studied Oppositional defiant disorder (ODD) A childhood disorder characterized by a

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pattern of negativistic, argumentative, and hostile behavior in which the child often loses his or her temper, argues with adults, and defies or refuses adult requests; refusal to take responsibility for actions, anger, resentment, blaming others, and spiteful and vindictive behavior are common, but serious violations of other’s rights are not Orgasmic disorder An inability to achieve an orgasm after entering the excitement phase and receiving adequate sexual stimulation. Pain disorder A disorder characterized by reports of severe pain that appear to have no physiological or neurological basis, that are in excess of what would be expected from an existing physical condition, or that linger long after a physical injury has healed Panic attack Intense fear accompanied by symptoms such as a pounding heart, trembling, shortness of breath, or fear of losing control or dying Panic disorder Recurrent unexpected panic attacks and at least one month of apprehension over having another attack or worrying about the consequences of an attack Paranoid personality disorder A personality disorder characterized by unwarranted suspiciousness, hypersensitivity, and a reluctance to trust others Paranoid schizophrenia A schizophrenic subtype characterized by one or more systematized delusions or auditory hallucinations and by the absence of such symptoms as disorganized speech and behavior or flat affect Paraphilia Sexual disorder of at least six months’ duration in which the person has either acted on or is severely distressed by recurrent urges or fantasies involving nonhuman objects, nonconsenting persons, or suffering or humiliation Parkinson’s disease A progressively worsening disorder characterized by four primary symptoms: tremor, or trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination Pathological gambling An impulse control disorder in which the essential feature is a chronic and progressive failure to resist impulses to gamble Pedophilia Disorder in which an adult obtains erotic gratification through urges, acts, or fantasies involving sexual contact with a prepubescent child

Personality disorder A disorder characterized by inflexible, long-standing, and maladaptive personality traits that cause significant functional impairment, subjective distress, or a combination of both for the individual Pervasive developmental disorder A disorder involving severe childhood impairment in areas such as social interaction and communication skills and the display of stereotyped interests and behaviors; includes autistic disorder, Rett syndrome, childhood disintegrative disorder, Asperger’s syndrome, and pervasive developmental disorders not otherwise specified Phenotype Observable physical and behavioral characteristics caused by the interaction between the genotype and the environment Phobia A strong, persistent, and unwarranted fear of some specific object or situation Pleasure principle The impulsive, pleasureseeking aspect of our being from which the id operates Polysubstance dependence Substance dependence in which dependency is not based on the use of any single substance but on the repeated use of at least three substances (not including caffeine and nicotine) for a period of twelve months Positive symptom A symptom of schizophrenia that involves unusual thoughts or perceptions such as delusions, hallucinations, thought disorder (shifting and unrelated ideas that produce incoherent communication), and bizarre behavior Positron emission tomography (PET) A technique for assessing brain damage in which the patient is injected with radioactive glucose and the metabolism of the glucose in the brain is monitored Posttraumatic stress disorder (PTSD) Disorder characterized by anxiety, dissociative, and other symptoms that last for more than one month and that occur as a result of exposure to extreme trauma Premature ejaculation Ejaculation with minimal sexual stimulation before, during, or shortly after penetration Prevalence The percentage of people in a population who suffer from a disorder at a given point in time Privileged communication A therapist’s legal obligation to protect a client’s privacy and to prevent the disclosure of confidential communications without a client’s permission Prognosis A prediction of the future course of a particular disorder

Projective personality test Test in which the test taker is presented with ambiguous stimuli, such as inkblots, pictures, or incomplete sentences, and asked to respond to them in some way Prospective study A long-term study of a group of people that begins before the onset of a disorder to allow investigators to see how the disorder develops Psychoanalysis Therapy whose goals are to uncover repressed material, to help clients achieve insight into inner motivations and desires, and to resolve childhood conflicts that affect current relationships Psychodiagnosis An attempt to describe, assess, and systematically draw inferences about an individual’s psychological disorder Psychodynamic model Model that views disorders as the result of childhood trauma or anxieties and that holds that many of these childhood-based anxieties operate unconsciously Psychological autopsy The systematic examination of existing information for the purpose of understanding and explaining a person’s behavior before his or her death Psychological tests and inventories Instruments used to assess personality, maladaptive behavior, development of social skills, intellectual abilities, vocational interests, and cognitive impairment Psychological view The belief that mental disorders are caused by psychological and emotional factors rather than organic or biological ones Psychometrics Mental measurement, including its study and techniques Psychopathology A term clinical psychologists use as a synonym for abnormal behavior Psychophysiological disorder Any physical disorder that has a strong psychological basis or component Psychosexual stages In psychodynamic theory, the sequence of stages—oral, anal, phallic, latency, and genital—through which human personality develops Pyromania An impulse control disorder having as its main feature deliberate and purposeful fire setting on more than one occasion Rape A form of sexual aggression that refers to sexual activity (oral-genital sex, anal intercourse, and vaginal intercourse) performed against a person’s will through the use of force, argument, pressure, alcohol or drugs, or authority

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Rape trauma syndrome A two-phase syndrome that rape victims may experience, including such emotional reactions as psychological distress, phobic reactions, and sexual dysfunction Reactivity A change in the way a person usually responds, triggered by the person’s knowledge that he or she is being observed or assessed Reality principle An awareness of the demands of the environment and of the need to adjust behavior to meet these demands from which the ego operates Reinforcing abstinence (contingency management) Treatment technique in which the individual is given behavioral reinforcements for abstinence from substance use Relaxation training Therapeutic technique in which a person acquires the ability to relax the muscles of the body in almost any circumstance Reliability The degree to which a procedure or test—such as an evaluation tool or classification scheme—will yield the same results repeatedly under the same circumstances Residual schizophrenia A subtype of schizophrenic disorder reserved for people who have had at least one previous schizophrenic episode but are now showing an absence of prominent psychotic features; there is continuing evidence of two or more symptoms, such as marked social isolation, peculiar behaviors, blunted affect, odd beliefs, or unusual perceptual experiences Resistance During psychoanalysis, a process in which the patient unconsciously attempts to impede the analysis by preventing the exposure of repressed material Right to treatment The concept that mental patients who have been involuntarily committed have a right to receive therapy that would improve their emotional state Risk factors Variables related to, or etiologically significant in, the development of a disorder Sadism Form of paraphilia in which sexually arousing urges, fantasies, or acts are associated with inflicting physical or psychological suffering on others Scientific method A method of inquiry that provides for the systematic collection of data, controlled observation, and the testing of hypotheses Schema A cognitive framework that helps organize and interpret information; a set

of underlying assumptions heavily influenced by a person’s experiences, values, and perceived capabilities Schizoaffective disorder A disorder characterized by both a mood disorder (major depression or bipolar disorder) and the presence of psychotic symptoms “for at least two weeks in the absence of prominent mood symptoms” Schizoid personality disorder A personality disorder characterized by social isolation, emotional coldness, and indifference to others Schizophrenia A group of disorders characterized by severely impaired cognitive processes, personality disintegration, affective disturbances, and social withdrawal Schizophreniform disorder Psychotic disorder that lasts more than one month but less than six months Schizotypal personality disorder A personality disorder characterized by peculiar thoughts and behaviors and by poor interpersonal relationships Selective amnesia An inability to remember certain details of an incident Self-actualization An inherent tendency to strive toward the realization of one’s full potential Self-concept An individual’s assessment of his or her own value and worth Self-report inventories An assessment tool that requires test takers to answer specific written questions or to select specific responses from a list of alternatives Sexual addiction A popular term referring to a person’s desire and need to engage in constant and frequent sexual behavior (frequently labeled compulsive sexual behavior) Sexual arousal disorder Disorder characterized by problems occurring during the excitement phase of the sexual response cycle and relating to difficulties with feelings of sexual pleasure or with the physiological changes associated with sexual excitement Sexual desire disorder Sexual dysfunction that is related to the appetitive phase of the sexual response cycle and is characterized by a lack of sexual desire Sexual dysfunction A disruption of any part of the normal sexual response cycle that affects sexual desire, arousal, and response Shared psychotic disorder Disorder in which a person who has a close relationship with an individual with delusional or psychotic beliefs comes to share those beliefs

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Single-participant experiment An experiment performed on a single individual in which some aspect of the person’s own behavior is used as a control or baseline for comparison with future behaviors Skills training Teaching skills for resisting peer pressures or temptations, resolving emotional conflicts or problems, or for more effective communication Social phobia An intense, excessive fear of being scrutinized in one or more social or performance situations Somatization disorder A disorder involving chronic complaints of specific bodily symptoms that have no physical basis Somatoform disorder A disorder involving physical symptoms or complaints that have no physiological basis, believed to occur due to an underlying psychological conflict or need Specific phobia An extreme fear of a specific object (such as snakes) or situation (such as being in an enclosed place) Standardization In test administration, the use of identical procedures in the administration of tests; (in samples) the establishment of a norm or comparison group to which an individual’s test performance can be compared Stimulant Substance that is a central nervous system energizer, inducing elation, grandiosity, hyperactivity, agitation, and appetite suppression Stress An internal psychological or physiological response to a stressor Stressor An external event or situation that places a physical or psychological demand on a person Stroke (cerebrovascular accident) A sudden stoppage of blood flow to a portion of the brain, leading to a loss of brain function Substance abuse Maladaptive pattern of recurrent use that extends over a period of twelve months; leads to notable impairment or distress; and continues despite social, occupational, psychological, physical, or safety problems Substance dependence Maladaptive pattern of use extending over a twelve-month period and characterized by unsuccessful efforts to control use despite knowledge of harmful effects; taking more of substance than intended; tolerance; and/ or withdrawal Substance-related disorder Ailment arising from the use of psychoactive substances that affect the central nervous system, causing significant social, occupational, psychological, or physical problems, and that sometimes result in abuse or dependence

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Suicidal ideation Thoughts about suicide Suicide The intentional, direct, and conscious taking of one’s own life Synapse Minute gap that exists between the axon of the sending neuron and the dendrites of the receiving neuron Syndromes Certain symptoms that tend to occur regularly in clusters Systematic desensitization Exposure strategy that uses muscle relaxation to reduce the anxiety associated with specific and social phobias Systematized amnesia The loss of memory for certain categories of information Tarasoff ruling often referred to as the “duty-to-warn” principle; obligates mental health professionals to break confidentiality when their clients pose clear and imminent danger to another person Tension headache Produced by prolonged contraction of the scalp and neck muscles, resulting in vascular constriction and steady pain Theory A group of principles and hypotheses that together explain some aspect of a particular area of inquiry Therapy A program of systematic intervention whose purpose is to modify a client’s behavioral, affective (emotional), and/or cognitive state Tolerance Condition in which increased doses of a substance are necessary to achieve the desired effect

Transference Process by which a patient reenacts early conflicts by carrying over and applying to the analyst feelings and attitudes that the patient had toward significant others in the past Transvestic fetishism Intense sexual arousal obtained through cross-dressing (wearing clothes appropriate to the opposite gender); not to be confused with transsexualism Traumatic brain injury A physical wound or injury to the brain Trephining A surgical method from the Stone Age in which part of the skull was chipped away to provide an opening through which an evil spirit could escape Trichotillomania An impulse control disorder characterized by an inability to resist impulses to pull out one’s own hair Unconditioned response (UCR) In classical conditioning, the unlearned response made to an unconditioned stimulus Unconditioned stimulus (UCS) In classical conditioning, the stimulus that elicits an unconditioned response Undifferentiated schizophrenia A schizophrenic subtype in which the person’s behavior shows prominent psychotic symptoms that do not meet the criteria for paranoid, disorganized, or catatonic schizophrenia

Undifferentiated somatoform disorder The diagnosis given an individual who does not fully meet the criteria for somatization disorder but who has at least one physical complaint of six months’ duration Unipolar depression A mood disorder in which only depression occurs and that is characterized by intense sadness, feelings of futility and worthlessness, and withdrawal from others Vaginismus Involuntary spasm of the outer third of the vaginal wall, preventing or interfering with sexual intercourse Validity The extent to which a test or procedure actually performs the function it was designed to perform Vascular dementia Dementia characterized by uneven deterioration of intellectual abilities and resulting from a number of cerebral infarctions Voyeurism Urges, acts, or fantasies involving observation of an unsuspecting person disrobing or engaging in sexual activity Withdrawal Condition characterized by distress or impairment in social, occupational, or other areas of functioning or by physical or emotional symptoms such as shaking, irritability, and inability to concentrate after reducing or ceasing intake of a substance

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Text Credits Chapter 3: p. 79 Figure 3.3 Bender, L. (1938). A visual motor gestalt test and its clinical use. Research Monograph of the American Orthopsychiatric Association, 3(11), 176. Reprinted by permission of American Orthopsychiatric Association. p. 83 Table 3.3 Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association. p. 88 Figure 3.4 Adapted from Kessler, R.C., et al (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV Disorders in the National Comorbidity Survey replication. Archives of General Psychiatry, 62, 593–602. Reprinted by permission of American Medical Association. Chapter 4: p. 110 Figure 4.3 The Impact of Social-Behavioral Learning Strategy Training on the Social Interaction Skills of Four Students with Asperger Syndrome by Marjorie A. Bock. Focus on Autism and Other Developmental Disabilities. Austin: Summer 2007, Vol. 22, #2, p. 92. Reprinted by permission of Sage Publications via Copyright Clearance Center. Chapter 5: p. 125 Table 5.3 “Thoughts Reported by Patients with Social Phobia During Social Situations” from Wells & Papageorgiou, © 2001, Social Phobic Interoception: Effects of bodily information on anxiety, beliefs and selfprocessing. Reprinted by permission of Elsevier. Chapter 7: p. 178 Table 7.1 From Ballenger, J. C., Davidson, J. R. T., Lecrubier, Y., and Nutt, D. J. (2002). Consensus statement on generalized anxiety disorder from the International Consensus Group on depression and anxiety. Journal of Clinical Psychiatry, 62, 53–58. p. 184 Figure 7.2 Ventricular Defibrillation in Sudden Unexplained Death, Figure “Circulation” from Nademanee, K., et al, “Arrhythmogenic Marker for Sudden Unexplained Death Syndrome in Thai Men” in Circulation, 96 (October 21, 1997), p. 2598. Reprinted by permission of Wolters Kluwer Health. p. 188 Figure 7.5 “Anatomy of an Asthma Attack” from Cowley and Underwood, Newsweek, May 25, 1997, p. 61. Reprinted by permission of Newsweek. p. 189 Figure 7.6 National Center for Health Statistics. (2007). Asthma prevalence, health care use and mortality: United States, 2003–2005. From www.cdc.gov Chapter 9: pp. 234 and 237 Figures 9.1 and 9.2 SAMHSA (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD Chapter 10: p. 269 Figure 10.2 From Crooks/ Baur. Our Sexuality, 5e. © 1993 Wadsworth, a part of Cengage Learning, Inc. Reproduced

by permission. www.cengage.com/permissions. p. 271 Table 10.1 From UNDERSTANDING SEXUALITY by Kurt Haas and Adelaide Haas. Copyright © 1993. Reprinted by permission of the author. p. 273 Table 10.3 From UNDERSTANDING SEXUALITY by Kurt Haas and Adelaide Haas. Copyright © 1993. Reprinted by permission of the author. p. 276 Table 10.4 From UNDERSTANDING SEXUALITY by Kurt Haas and Adelaide Haas. Copyright © 1993. Reprinted by permission of the author. p. 286 Figure 10.5 Data from Diokno, A. C., Brown, M. B., & Herzog, A. R. (1990). Sexual function in the elderly. Archives of Internal Medicine, 150, 197–200. Reprinted by permission of American Medical Association. p. 297 Table 10.8 Source: San Francisco Women Against Rape, 3543 18th Street, San Francisco, CA 94110 (415/861-2024) Chapter 11: p. 307 Table 11.3 Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association. p. 328 Table 11.5 Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association. Chapter 12: p. 338 Table 12.2 Source: Definition of Suicide, E. Shneidman, 1985. New York: John Wiley & Sons. Figure 12.2 Luoma, J. B., Pearson, J. L. Suicide and marital status in the United States, 1991–1996: Is widowhood a risk factor? American Journal of Public Health. 2002; 92:1518–1522. (Figures 1–3). Reprinted with permission from the American Public Health Association. p. 342 Figure 12.3 Source: Adapted from www.suicidology.org. Reprinted by permission. Chapter 13: p. 360 Table 13.1 Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association. p. 362 Figure 13.1 “Schizophrenic Patients’ Lack of Awareness of Psychotic Symptoms” in Amador, X. F., et al. (1994) “Awareness of illness in schizophrenia and schizoaffective and mood disorders.” Archives of General Psychiatry, Vol. 51, p. 830. Reprinted by permission of American Medical Association. p. 367 Figure 13.2 Adapted with permission from SLACK Incorporated: Cornic, F., Consoli, A., & Cohen, D. (2007). Catatonia in children and adolescents. Psychiatric Annals, 37, 19–26. p. 379 Table 13.4 Source: From Rector, N.A., Beck, A.T., & Stolar, N. (2005). The negative symptons of schizophrenia: A cognitive perspective. Canadian Journal of Psychiatry, 50, 247–257. p. 382 Table 13.5 From McCabe, R., & Priebe, S. (2004). Explanatory models of

illness in schizophrenia: Comparison of four ethnic groups. British Journal of Psychiatry, 185, 25–30. Reprinted by permission of The Royal College of Psychiatrists. Chapter 15: p. 432 Figures 15.3 and 15.4 Child Welfare Information Gateway. (2006). Child abuse and neglect fatalities: Statistics and interventions. From www.childwelfare.gov Chapter 16: p. 444 Table 16.1 Data from national survey of 6,728 adolescents NeumarkSztainer, D., Hannan, P. J., & Stat, M. (2002). Weight-related behaviors among adolescent girls and boys. Archives of Pediatric Adolescent Medicine, 154, 569–577. Reprinted by permission of American Medical Association. p. 452 Figure 16.1 “Binge Eating Disorder” from Pike, K.M., et al in “A Comparison of Black and White Women on Binge Eating Disorder” from American Journal of Psychiatry, Vol. 158, 2001, pp. 1455–1461. Adapted with permission from the American Journal of Psychiatry, Copyright (1995, 2001). American Psychiatric Association. p. 458 Table 16.4 Ogden, C.L., et al. (2004). Mean body weight, height, and body mass index, United States 1960–2002. Advance data from vital and health statistics (no. 347). Hyattsville, MD: National Center for Health Statistics. p. 460 Figure 16.4 “Female Body Drawings” from S. Kety, et al. in The Genetics of Neurological and Psychiatric Disorders (NY: Raven Press, 1983). Reprinted by permission of Lippincott Williams & Wilkins, Wolters Kluwer Health.

Photo, Cartoon, and Advertisement Credits Chapter 1: p. 2 AP Photo/Jim Cole p. 3 © HO/ Reuters/Corbis p. 5 David Harry Stewart/TSI/ Getty Images p. 8 AP Images/Richmond TimesDispatch/Dean Hoffmeyer p. 10 AP Images/ James A Finley p. 11 (left) Sylvain Grandadam/ TSI/Getty Images p. 11 (right) © Mohsen Shandiz/Corbis p. 13 Reuters/Corbis p. 14 James Leynse/Corbis p. 16 Neg#312263 photo by Julius Krishner, 1928/Courtesy Dept. of Library Services, American Museum of Natural History. p. 18 © Christel Gerstenberg/CORBIS p. 20 Archives of the History of American Psychology—The University of Akron p. 22 Stock Montage p. 23 Science Photo Library/ Photo Researchers, Inc. p. 27 AP Images/ Gurinder Osan Chapter 2: p. 30 Stephen Simpson/Getty Images p. 45 Library of Congress/Woodfin Camp & Associates p. 46 (left) Roseanne Olson/TSI/ Getty p. 46 (right) Laura Dwight/Peter Arnold, Inc. p. 48 The Granger Collection p. 49 (top) Steve Warnowski/The Image Works p. 49 (right) AP Images p. 51 Bob Daemmrich/Stock Boston p. 55 Roger Ressmeyer/CORBIS p. 58 Hill Street Studios/Getty Images p. 59 (left) TSI/Getty Images p. 59 (right) AP Images/Nati Harnik, file

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Chapter 3: p. 66 © Science and Society Picture Library/The Image Works p. 70 (left) Bill Aron/ PhotoEdit, Inc. p. 70 (right) Spencer Grant/ PhotoEdit, Inc. p. 72 Rorschach H. Diagnostics p. 73 Reprinted by permission of the publishers from Henry A. Murray. THEMATIC APPERCEPTION TEST, Card 12F, Cambridge, Mass.: Harvard University Press, Copyright 1943 by the President & Fellows of Harvard College, Copyright © 1971 by Henry A. Murray. p. 78 Mike Siluk/The Image Works p. 80 (all photos) Dan McCoy/Rainbow p. 81 Dan McCoy/Rainbow p. 89 AP Images/Donna McWilliam Chapter 4: p. 93 The Eng Koon/Getty Images p. 98 AP Images p. 103 Christopher Morrow/ Stock Boston p. 106 Courtesy of David Sue p. 107 © ROB & SAS/Corbis p. 108 James Robert Fuller/Corbis p. 111 Jean-Christian Bourcart/Getty Images p. 114 AP Images/ Yonhap, Choi Byung-kil Chapter 5: p. 117 Marco Di Lauro/Getty Images p. 123 Ellen Senisi/The Image Works p. 126 (left) Topham/The Image Works p. 126 (right) AP Images/Jennifer Graylock p. 131 David Ulmer/Stock Boston p. 133 Jeff Greenberg/ PhotoEdit, Inc. p. 134 Munch, Edvard (1863–1944) © ARS, NY. The Scream. National Gallery, Oslo, Norway. Phot Credit: Scala/Art Resource. © 2008 The Munch Museum/The Munch-Ellingsen Group/Artists Rights Society (ARS), NY p. 143 Thomas R. Fletcher/Stock Boston Chapter 6: p. 149 Reproductions Ltd./Getty Images p. 150 David McNew/Getty Images p. 153 AP Images/John Froschauer p. 154 The Subway, 1950 Egg tempera on composition board, Sight: 18 1/8 x 36 1/8 in. (46.04 x 91.76 cm) Frame 26 x 44 in./Whitney Museum of American Art, New York; Purchase, with funds from the Juliana Force Purchase Award 50.23 p. 155 Gordon M. Grant Photography p. 159 Thony Belizaire/AFP/Getty Images p. 161 Debra Ley/Getty Images p. 166 Steve Smith p. 171 The Granger Collection Chapter 7: p. 175 AP Photo/The Columbus Republic/Mike Dickbernd p. 177 AP Images/ Marcio Jose Sanchez p. 180 AP Images p. 182 Cayton Photography/The Image Works p. 185 Spencer Platt/Getty Images p. 186 AP Images/Darren Hauck p. 190 NIBSC/Science Photo Library/Photo Researchers, Inc. p. 195 AP Images/The Grand Island Independent. Scott Kingsley p. 197 David Sacks/TSI/Getty Images p. 199 Michael A. Keller/Corbis Chapter 8: p. 201 Mika/zefa/Corbis p. 208 AP Images/Elaine Thompson p. 211 (left) Paramount Pictures/Getty Images p. 211 (right)

Anthony Neste/Getty Images p. 212 Michael Newman/PhotoEdit Inc. p. 213 Chris Leslie Smith/PhotoEdit Inc. p. 217 Topham/The Image Works p. 220 Sony Pictures/Everett Collection p. 223 Ross Woodhall/Getty Images p. 230 Mary Kate Denny/PhotoEdit Chapter 9: p. 232 ©image100/Corbis p. 238 Vizion/The Image Works p. 239 (top) Christobal Corral Vega/HBO Films/Zuma/ Corbis p. 239 (right) © Zinn Arthur/The Image Works p. 240 Tom Prettyman/PhotoEdit, Inc. p. 243 (top photos) © Nancy Kaszerman/ ZUMA/Corbis p. 243 (bottom) John Griffin/ The Image Works p. 245 Gerry Gropp/Sipa p. 248 Kurt Kreiger/Corbis p. 252 Getty Images p. 254 LOOK Die Bildagentur der Fotografen GmbH/Alamy p. 256 AP Images/The Times, Jon L. Hendricks p. 257 Rob Crandall/Rainbow p. 258 Press Association via AP Images p. 260 Reprinted with permission of Recovery Is Everywhere Chapter 10: p. 264 Lisa B. Corbis p. 266 (left) Jeff Greenberg/PhotoEdit, Inc. p. 266 (right) Glowimages/Getty Images p. 268 © Dennis Brack/Black Star Picture Collection Inc. DBA stockphoto.com p. 271 © Ira Wyman/CORBIS SYGMA p. 282 Larry Mulvehill/The Image Works p. 284 © Noah K. Murray/Star Ledger/ Corbis p. 285 David Young-Wolff/PhotoEdit, Inc. p. 287 Images provided courtesy of Ben Barres p. 291 AP Images p. 292 Bettmann/ CORBIS p. 293 Copyright 2008 Custom Medical Stock Photos p. 298 © Kim Ludbrook/ epa/Corbis Chapter 11: p. 303 © Rick Gomez/Corbis p. 306 © Bettmann/CORBIS p. 308 Getty Images p. 309 Science and Society Picture Library/The Image Works p. 313 (top) Will & Deni McIntyre/Photo Researchers, Inc. p. 313 (right) Harlow Primate Laboratory/University of Wisconsin p. 314 AP Images/Karim Kadim p. 315 Dennis MacDonald/PhotoEdit, Inc. p. 317 Michael Grecco/Stock Boston p. 319 AP Images/Mark Lennihan p. 320 Barbara Alper/ Stock Boston p. 322 Steve Leonard Photography p. 331 (left) Lisa O’Connor/ZUMA/Corbis p. 331 (right) Frank Trapper/Corbis Chapter 12: p. 333 AP Photo/Pioneer, Molly Miron p. 337 Issac Baldizon/NBAE via Getty Images p. 341 (left) Bob Daemmrich/The Image Works p. 341 (right) Copyright © Shepard Sherbell/Corbis p. 342 William F. Campbell/Time Magazine/Getty Images p. 346 © Bettmann/CORBIS p. 347 © Stringer/Iraq/ Reuters/Corbis p. 348 AP Images/Susan Sterner p. 349 Christiana Dittmann/Rainbow p. 353 Geri Engberg Photography/The Image Works p. 356 © Carlos Osorio/epa/Corbis

Chapter 13: p. 359 Grunnintus Studio/Photo Researchers, Inc p. 361 Image courtesy of Elyn Saks. Photo copyright Will Vinet. p. 363 AP Images p. 365 © Coco/Cartoonists & Writers Syndicate p. 366 (both) Prinzhorn Sammlung/ Psychiatric Hospital in Heidelberg p. 370 (left) Mary Ellen Mark p. 370 (right) Grunnitus Studio/Photo Researchers, Inc. p. 376 Reprinted with permission of Dr. Paul Thompson, UCLA Laboratory of Neuro Imaging p. 377 Dr. Wouter G. Staal, PhD, Dept. of Psychiatry University Hospital, Utrecht, Netherlands p. 381 © SHANNON STAPLETON/Reuters/Corbis p. 387 Bruce Ayers/Getty Images p. 388 AP Images/Paul Sakuma Chapter 14: p. 390 China Photos/Getty Images p. 392 © Bettmann/CORBIS p. 393 Will & Deni McIntyre/Photo Researchers, Inc. p. 397 John Boykin/PhotoEdit, Inc. p. 399 Courtesy of Indiana University. p. 398 Zephyr/Photo Researchers, Inc. p. 401 AP Images/Gautam Singh p. 403 (top) Jeff T. Green/Getty Images p. 403 (bottom) Alfred Pasieka/Photo Researchers, Inc. p. 404 Kevin Mazur/Getty Images p. 405 (left) Dr. David Chase/CNRI/ Phototake p. 405 (right) A.B. Dowsett/Science Photo Library/Photo Researchers, Inc. p. 406 © Mark Peterson/Corbis p. 407 (top) CNRI/ Phototake p. 407 (bottom) Gogh, Vincent van (1853–1890) Self-portrait with Bandaged Ear. Photo Credit: ridgeman-Giraudon/Art Resource p. 409 David Young-Wolff/PhotoEdit, Inc. Chapter 15: p. 412 Ron Neubauer/PhotoEdit, Inc. p. 416 Tony Freeman/PhotoEdit, Inc. p. 417 Will & Deni McIntyre/Photo Researchers, Inc. p. 420 Cary Wolinsky/Aurora Photos p. 424 AP Images/George Widman p. 426 Brendan Smialowski/Getty Images p. 427 Bill Aron/PhotoEdit, Inc. p. 430 AP Images/William Bretzger p. 440 W.B. Saunders & Co./Harcourt Brace & Company p. 441 Mika/zefa/Corbis Chapter 16: p. 443 © Bob Daemmrich/The Image Works p. 447 © L’Equipe Agence/ Handout/Reuters/Corbis p. 448 Anorexic Nation p. 456 (top) Myrleen Ferguson Cate/ PhotoEdit, Inc. p. 456 (bottom) AP Images p. 459 (both) AP Images/Alberto Pellaschiar p. 461 Bryan Bedder/Getty Images p. 463 © Mango Productions/Corbis p. 467 AP Images/ Matt Slocum Chapter 17: p. 474 JUPITER IMAGES/Brand X/Alamy p. 476 AP Images/Greg Gilbert, Pool p. 478 AP Images p. 481 © Bettmann/CORBIS p. 485 © Reuters/Corbis p. 490 AP Images/ Shiho Fukada p. 491 © Gideon Mendel/Corbis p. 493 (both) AP Images p. 495 Matthew H. Starling Photography

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page numbers followed by f refer to figures page numbers followed by t refer to tables AAIDD, see American Association on Intellectual and Developmental Disabilities (AAIDD) Abby, S. L., 427 Abe, J., 82 Abeles, N., 74, 392 Aboa-Eboule, C., 184 Abramowitz, J. S., 146, 167, 220 Abrams, R. C., 203 Abramson, L. Y., 317 Ackard, D. M., 444 Adams, G., 156 Adams, P., 191 Adams-Curtis, L. E., 460 Adamson, J., 471 Addington-Hall, J., 356 Adelman, H. S., 429 Adkins, J., 356 Adler, J., 186 Administration on Aging, 398 Agras, W. S., 452, 466 Ahern, D. K., 173 ak Suut, D., 156 Alao, A. O., 163 Albee, G. W., 24 Alcantara, C., 346, 348 Alcoholics Anonymous (AA), 250, 258–259 Alder, A., 47t Aldridge-Morris, R., 160 Alex, P., 443 Alexander, F. G., 16, 19 Alexander, J. F., 57, 255 Alexander, J. R., 110 Alford, G. S., 259, 296 Ali, M., 392 Ali, N., 481 Allanson, J., 170 Allen, L. A., 164, 173, 404 Allgulander, C., 140 Alligeier, A. R., 289t Alligeier, E. R., 289t Allman, C. J., 344 Alloy, L. B., 317 Altemus, M., 145 Alvarenga, M., 184 Amador, S. F., 362, 362f American Association of Retired Persons (AARP), 285 American Association of Therapeutic Humor, 191 American Association on Intellectual and Developmental Disabilities (AAIDD), 435, 436–437, 441 American Bar Association (ABA), 481 American Cancer Society, 242

American Dietetic Association, 450, 465 American Heart Association, 183, 185, 185f American Heritage Dictonary, 250 American Law Institute (ALI), 480 American Medical Association (AMA), 89, 250, 481 American Psychiatric Association (APA), 7, 11, 12, 26, 27, 83t, 84, 117, 125, 134, 139, 146, 151, 151t, 153, 156, 157, 163t, 164, 168, 177, 182, 202, 203, 205, 206t, 208, 209, 211, 216, 217, 221, 226, 228, 239, 241, 242, 265, 271, 272t, 274, 283, 288, 289t, 305t, 307t, 311, 319, 327, 328t, 329, 359, 360t, 368, 368t, 372, 374, 384, 390, 391, 415, 416, 418t, 419, 423, 423t, 424, 426, 427, 431, 435t, 436, 436t, 437t, 438t, 445t, 446, 447, 448, 449, 450, 451, 453, 453t, 465, 466, 476, 477, 481, 495 American Psychological Association (APA), 26, 90, 113–114, 116, 250, 429, 494–495 American Psychological Association Task Force on Socioeconomic Status, 59 American Society for Aesthetic Plastic Surgery, 450 American Society of Suicidology, 342f Ames, M. A., 287 Amodio, D. M., 394 Amundsen, A., 344 Anastasi, A., 73, 77, 79 Anda, R. F., 193, 378 Andersen, A. E., 444, 446, 453 Andersen, B. L., 266 Anderson, B., 98 Anderson, J., 123 Anderson, K. W., 132 Anderson, M. S., 100 Anderson, T., 100 Anderson-Fye, E. P., 463 Andersson, G., 198 Andreasen, N. C., 38, 40, 41, 80 Andreski, P., 180 Andrews, B., 123, 180 Angermayr, L., 437 Angermeyer, M. C., 15 Anna O., 171 Annus, A. M., 457 Anonymous 5, 443 Anton, R. F., 248, 256 Antonuccio, D. O., 102 Antony, M. M., 127 Anxiety Disorders Association of America (ADAA), 118 Aoki, H., 183

APA, see American Psychiatric Association (APA); American Psychological Association (APA) APA Task Force on the Sexualization of Girls, 458 Aplin, A., 167 Applebaum, P. S., 491 Arackal, B. S., 278 Armstrong, S., 251 Arndt, W. B., Jr., 266, 288, 291, 295 Arnold, I. A., 162 Arnold, L. M., 228 Aronson, J., 77 Aronson, S. G., 251 Arrendondo, P., 27 Ashcroft, J., 355 Asian American Federation of New York, 11 Asmundson, G. J. G., 134, 172 Associated Press, 96, 102, 149, 160, 470 Asthma and Allergy Foundation of America, 188, 189 Astin, M. C., 178 Atkins, M., 296 Auerbach, C. F., 115 Auerbach, J. G., 121 Auerbach, R., 275 Auerbach, S. M., 197 Austin, L. S., 169 Ausubel, D. P., 249 Autism Society of America, 108 Avia, M. D., 167, 171 Ayers, C. R., 141 Aziz, N., 380 Bagby, R. M., 74, 76 Bailey, C. M., 189 Bailey, D. S., 338 Bak, M., 364 Baker, B. L., 422 Baker, J. L., 468 Baker, L. A., 40 Baker, T. B., 249 Bakker, A., 136, 138 Ball, J. D., 72 Ballenger, J. C., 178t Ballew, L., 152 Balon, R., 265, 266, 271 Bandura, A., 50 Banerjee, G., 382 Banerjee, T. D., 424 Bansal, S., 301 Barbaree, H. E., 300 Barber, J. P., 129, 220, 325, 326 Bardone-Cone, A. M., 448, 455 Barkley, R. A., 426 Barlow, D. H., 86, 123, 124, 127, 137, 145, 291 Baron, L., 299 Baron, M., 110 Baron, R. M., 402

Baron-Cohen, S., 421 Barraclough, B., 344 Barraclough, B. M., 354 Barres, B., 287 Barrett, G. V., 78 Barrymore, D., 248 Barsky, A. J., 167, 169, 171, 173 Barth, N., 372 Bartholow, B. D., 252, 253 Barton, J., 192 Basoglu, M., 181 Bass, C., 164, 170 Bauer, G. R., 460 Bauer, L., 222 Baumeister, R. F., 293 Bauserman, R., 98 Baxter, L. R., Jr., 44 Bazelon, D., 480 BBC News, 96 Beail, N., 439 Bearman, S. K., 457 Beck, A. T., 51–52, 53, 75, 140, 214, 218, 220, 224, 229, 315, 317, 325, 344, 364, 366, 378, 379t Becker, A. E., 454, 462, 463 Becker, E. S., 122 Becker, J. V., 292 Bedell-Smith, S., 213 Bednar, R. L., 482, 493 Beers, C., 20–21 Beers, M. H., 286, 290, 297, 345 Beiger, J., 149 Bellack, A. S., 361, 380, 383 Bellock, A., 142 Bellodi, L., 449 Belushi, J., 240 Bender, L., 78, 79f Benedict, J. G., 160 Benedict, R., 226 Benegal, V., 278, 378 Benjamin, L. S., 204, 214, 215, 225 Bennett, D. A., 404 Bennett, M. P., 191 Bentall, R. P., 369 Bentler, P. M., 251, 402 Benton, S. A., 494 Ben-Tovim, D. I., 448, 451 Beratis, S., 368t Berenbaum, H., 90 Berenson, A., 323, 324 Bergemann, N., 381 Berglund, P., 12, 88f, 118, 123, 126, 127, 139, 177 Bergstrom, R. L., 455, 460 Berkman, L. F., 56 Berkow, R., 286, 290, 297, 345 Berman, A. L., 335, 337, 344, 347, 351 Bernal, G., 346, 347 Bernard, J., 321 Bernheim, H.-M., 22 Berrios, G. E., 141 Berry, A. C., 330

I-1

I -2

N A ME IN DE X

Berry, J. W., 10 Bersoff, D. N., 81 Bertschy, G., 169 Best, S. R., 123, 180 Bettelheim, B., 336, 345 Beutler, L. E., 280 Beydoun, M. A., 444, 468 Bhadrinath, B. R., 462 Bhatti, R., 462 Bianchi, K., 480 Bickel, W. K., 257 Biederman, J., 424 Bienenfeld, D., 204, 214 Bigler, E. D., 79 Binder, R. L., 484 Bin Laden, O., 149, 336 Binzer, M., 166 Biondi, M., 137, 138 Birch, H. G., 193 Birchler, G. R., 171 Bird, C. E., 321 Bishop, G. E., 185 Bishop, J., 229 Biskupic, J., 401 Bitter, J. R., 57 Black, S. T., 335 Blais, M. A., 311 Blalock, S. J., 317 Blanchard, J. J., 209 Blanchard, R., 291 Blandon-Gitlin, I., 152 Bleichhardt, G., 167 Blier, P., 144 Block, J., 253 Block, J. J., 385 Bloomberg, D., 160 Bloomberg, G. R., 190 Bloomfield, K., 254 Blouin, A., 456 Blue, H. C., 82 Bock, M. A., 109, 110f Boehmer, U., 460 Bohac, D. L., 395 Bohne, A., 169 Boldrini, M., 343 Boll, T. J., 79 Bond, A. J., 131 Bondolfi, G., 169 Bongar, B., 337, 343, 357 Bonk, C., 198 Boon, S., 158 Booth, R., 131, 132 Borch-Jacobsen, M., 160 Borda, T., 168, 169, 171, 377 Bordnick, P. S., 258 Borkovec, T. D., 141 Bornstein, R. F., 203, 205, 218, 219 Borowiecki, J. J., III, 445 Boucher, J., 421 Boudreau, D., 312 Bourne, D., 123 Bourque, L. B., 348 Boustani, M., 394, 400, 403, 404, 408 Bouvard, M. A., 146 Bowen, D. J., 460 Bowers, W. A., 453 Bowley, L., 130 Boyce, W. T., 59 Boyd, J. L., 386 Braaten, E. B., 424 Bradley, B. P., 125 Bradley, S. J., 288 Brady, K. T., 169 Braff, D. L., 361, 376 Brambilla, P., 222

Brando, M., 211 Brandsma, J., 259 Branningan, G. G., 78 Braucht, G., 252 Braun, B., 160 Braun, P., 492 Brawman-Mintzer, O., 139 Bray, J. H., 252 Breakey, W. R., 491 Breier, A., 380, 384 Bremner, J. D., 180 Brent, D. A., 343, 344 Breslau, N., 180 Breuer, J., 23, 170, 171 Brewin, C. R., 123, 180 Brewslow, N., 294t Bride, B. E., 178 Briere, J., 98 Briggs, B., 277 Brislin, R., 82 Bristol, M. M., 415 Bromberg, C. E., 203 Brooks-Harris, J. E., 33, 64 Brower, V., 241, 243, 247, 248 Brown, D., 433, 492 Brown, E. C., 260 Brown, G., 318 Brown, G. L., 343 Brown, G. R., 98 Brown, G. W., 318 Brown, J., 166 Brown, L. S., 283 Brown, M. B., 285, 286f Brown, R., 257 Brown, R. T., 436 Brown, R. W., 57 Brown, S. A., 251 Brown, S. M., 311 Brown, T. A., 86–87, 118, 127, 134 Brownell, K. D., 291 Bruce, K. R., 454, 462 Bruch, H., 447, 456 Bruch, M. A., 125, 126 Brunnhuber, S., 167, 173 Bruss, M. B., 463, 471 Bryan, C. J., 334, 335, 337, 344, 350, 350t, 351, 352 Bryant, K., 296, 300, 447, 464 Buchanan, A., 5, 484 Buchanan, R. W., 384 Buchwald, A., 15 Budd, G., 449, 455, 457 Bukstel, L., 296 Bulik, C. M., 447, 449, 454, 468 Bullock, S., 252 Bunce, D., 404 Bunney, W. E., 311 Burge, D., 215 Burgess, A. W., 279, 299 Burgess, P., 160 Burgus, P., 99 Burgy, M., 145 Burke, W. J., 395 Burkhart, B. R., 297 Burman, B., 379 Burnette, M. M., 271, 275, 278, 286, 293, 296, 300 Burns, D. D., 102 Burruss, J. W., 399 Burt, V. L., 185f Buschbaum, Y., 264, 265 Bush, A., 439 Bush, D. E., 120 Butcher, J. N., 73, 74 Butera, F., 318 Butler, L. D., 158

Butzlaff, R. L., 380 Buzan, R., 317, 325, 329, 330 Caccavale, J., 24 Cade, J. F. J., 23 Cadoret, R. J., 222, 247 Cafri, G., 460 Cain, C., 222 California Birth Defects Monitoring Program, 439, 439t Callahan, L. A., 481 Callanan, P., 483 Calugi, S., 446, 453 Calvin, J. E., III, 471 Calvin, J. E., Jr., 471 Camara, W. J., 71, 79, 81 Camargo, C. A., 460 Camargo, E. E., 144 Cameron, R. P., 461 Campbell, R. J., 324 Campo, J. A., 373 Canapary, D., 337, 345, 351 Canas, F., 378, 383 Cannon, T. D., 378 Cantor-Graae, E., 381, 382 Caplan, P. J., 320 Cardemil, E., 325, 326 Cardena, E., 156 Carels, R. A., 193t Carey, B., 38 Carey, G., 40 Carey, K. B., 50, 242 Carey, M. P., 50, 271, 272t, 275, 289t Carlat, D. J., 460 Carlin, A. S., 132 Carlisle, J. M., 295 Carlson, C. L., 423t, 424 Carlson, E. B., 177 Carnes, P., 267 Carney, R. M., 194 Caroff, S. N., 370 Carpenter, W. T., 383–384 Carroll, K. M., 257, 258, 262 Carson, C. C., 280 Carter, C. S., 326 Carter, K., 140 Casas, J. M., 64 Casey, D. E., 384 Cash, J., 239 Cash, R., 133 Cash, T. F., 134 Caspi, A., 43, 318 Cass, K. M., 448, 455 Castelli, J., 154, 155 Castelloe, P., 415f Castro-Blanco, D. R., 94 Catapano, F., 141 Cather, C., 387 Cauffman, E., 459 Cautela, J. R., 257 Ceci, S. J., 437, 441 Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting System, 335t, 337, 339, 343, 344, 346, 347, 349 Center for Male Reproductive Medicine and Microsurgery, 280 Centers for Disease Control and Prevention (CDC), 183, 185, 236, 239, 337, 347, 373, 396, 397f, 407, 408, 415, 439, 468, 468f, 469

Cerda, G. M., 395 Chadwick, P., 364 Chadwick, P. D. J., 364 Chamberlain, S. R., 144 Chambless, D. L., 132, 143t, 146 Chambless, D. M., 25 Chandra, A., 266 Chang, G., 24 Chang, S. Y., 262 Chapman, J. P., 73 Chapman, L. J., 73 Charcot, J.-M., 22 Charman, I., 420 Charwarska, K., 417 Chassin, L. C., 252, 253 Chatkoff, D. K., 167 Checker, C., 457 Chen, C., 320 Chen, E., 59, 190 Cherin, E. A., 309 Chess, S., 193 Chevron, E. S., 325 Child Welfare Information Gateway, 432, 432f, 433 Chinese Psychological Association, 283 Chirac, J., 354 Chiu, W. T., 12, 86, 88f, 118, 126, 133, 134, 139, 140, 142, 228 Cho, S. H., 2, 3, 3f, 4–5, 7, 9, 14, 487, 488 Chobanian, A. V., 185 Chodoff, P., 160 Choi, P. Y. L., 169 Chollar, S., 425 Chorpita, B. F., 123 Chorpita, B. R., 86 Choudry, I. Y., 462 Christakis, N. A., 471 Christensen, K., 311 Christensen, L., 305 Christiansen, S. C., 189 Chung, C., 163 Chung, R., 320 Chung, Y. B., 283 Church, D., 238 Cinciripini, P. M., 257 Cirincione, C., 481 Clar, C., 437 Claridge, G., 100, 101f Clark, D. M., 125 Clark, L. A., 89 Clark, M., 401 Clark, R., 40, 196 Clarke, J. C., 131 Clarkin, J. F., 72, 74, 79, 215, 398 Clavan, M., 142, 143 Clawson, E. P., 170 Clay, R. A., 246, 260, 355, 357 Clayton, A., 265 Cleary, C. P., 91 Cleary, K. M., 337 Cleckley, H. M., 155 Cleckley, J., 210, 211 Cleopatra, 337 Clinton, B., 296 Cloninger, C. R., 40 Clowes-Hollins, V., 130 Clum, G. A., 344 Coates, S., 288 Coates, T. J., 319 Cobain, K., 336, 337, 348 Coen, R., 330 Coffman, J. A., 80 Cohane, G. H., 445 Cohen, D., 367f

N A ME I NDEX Cohen, S., 190, 196 Coker, L. A., 204 Cole, D. A., 89, 317 Collaris, R., 127 Colt, G. H., 38 Coltheart, M., 364, 378 Combs, D. R., 386 Comings, D. E., 95 Compton, M. T., 378 Comtois, K. A., 334, 337, 350 Conklin, C. A., 250 Conley, R. R., 384 Connell, M. A., 476 Conner, B. T., 248 Conners, M. E., 99, 456 Consoli, A., 367f Conwell, Y., 212 Cook, E. W., III, 50 Cooke, D. J., 211 Coombs, D. W., 354 Cooney, N. L., 251 Coons, M. J., 172 Coons, P. M., 111, 156, 158, 162 Cooper, A. J., 279 Cooper, A. M., 216 Cooper, M. L., 251, 258 Copolov, D. L., 365 Corbitt, E. M., 206t, 215, 218 Cordova, M. J., 199 Corey, G., 47, 50, 53, 56, 57, 64, 356, 483, 492, 494 Corey, M. S., 483 Cormier, J. F., 155 Cormier, L. S., 50 Cormier, W. H., 50 Corn, K. J., 136 Cornic, F., 367f Corrigan, P. W., 9, 14 Cortina, L. M., 181 Cosand, B. J., 348 Cosby, A., 337 Costa, P. T., Jr., 204, 205 Costello, E. J., 426 Cottone, R. R., 36 Cottraux, J., 146 Cougnard, A., 375 Council on Scientific Affairs, 111 Cousins, N., 191 Cowen, P. J., 312 Cowley, G., 188f Cox, D., 128 Cox, D. J., 291 Cox, W. M., 258 Coyne, J. C., 192 Crabbe, J., 110 Crago, M., 449 Craig, M. E., 297 Cramer, V., 204 Craske, M. G., 135, 136f, 139 Creer, T. L., 189 Crimlisk, H. L., 166 Crippa, J. A. S., 156 Cristol, A. H., 47 Cromwell, R. L., 315 Cronkite, R. C., 319 Croteau, J. M., 283 Crow, S. J., 168, 451 Crowson, J. J., 315 Cruess, D. G., 199 Cruz, I. Y., 261 Csipke, E., 448 Cummings, J. L., 409 Cummings, N. A., 24 Cumsille, P. E., 252 Cunningham, M. D., 476 Curran, P. J., 253

Curry, V., 176 Curtain-Telegdi, N., 271 Cuthbert, B. N., 386 Cutrona, C. E., 319 Cutting, L. P., 380 Cynkar, A., 228 Cyranowski, J. M., 266 Dahlstrom, W. G., 75f Dahmer, J. L., 485, 486, 487 Daigneault, S. D., 464 Daley, S. E., 215 Dalle Grave, R., 446, 453 Dalman, C., 381 Daly, B. P., 426 Dammeyer, M. D., 99 Dana, R. H., 87 Dance, A., 343 D’Andrea, M., 60 Daniluk, J. C., 292 Dannison, L., 463 Danton, W. G., 102 Dar, R., 146 Dardick, H., 160 Darrach, D., 305 Davenport, R., 141 Davey, G. C. L., 129 Davidson, D., 260 Davidson, H., 72 Davidson, J. R. T., 131, 140, 181 Davidson, R. J., 312, 330 Davies, P. G., 91 Davilla, J., 318 Davis, C., 182 Davis, G. C., 180 Davis, K. L., 377 Davis, M. C., 196 Davis, P. J., 369 Davis, T. L., 451 Davison, G. C., 90 Dawson, G., 415f DeAngelis, T., 229 de Chateau, P., 417 DeChavez, G. M., 378 Deckel, A. W., 222 Decker, S. L., 78 De Coteau, T., 123 DeFries, J. C., 424 De Geus, E. J. C., 185, 193 Deguang, H., 172 de Jong, P. J., 129, 132 Delahanty, D. L., 177 Delaney, H. D., 257 Delay, J., 23 Delgado, P. L., 323, 330 DeLisi, L. E., 107 Dell, P. F., 159 Demaray, M. K., 428 Demler, O., 86, 228 Demming, B., 251 den Heijer, T., 402 Deniker, P., 23 Denisoff, E., 450 Denov, M. S., 432 Dent, C. W., 261 Department of Health and Human Services (DHHS), see U.S. Department of Health and Human Services (DHHS) Depinet, R. L., 78 DeRubeis, R. J., 326 de Sade, M., 293 de Simone, V., 394 Deutsch, A., 19 DeVault, C., 283

DeVellis, B. M., 317 Devinsky, O., 408 DeVita-Raeburn, E., 373 Devlin, M. J., 445t, 446, 451, 455, 465 DeVoe, J. F., 429 DeVries, R., 100 DeWaal, M. W. M., 162 de Wilde, E. J., 337 DHHS, see U.S. Department of Health and Human Services (DHHS) Diamond, S. S., 99 Diana (England), 213 Diaz-Asper, C. M., 78 Dick, D. M., 25 Dickerson, S. S., 196 Diekstra, R. F., 337 Difede, J., 123 DiFranza, J. R., 242 DiLalla, D. L., 40 Dimidjian, S., 325 Dinwiddie, S. H., 98 Diokno, A. C., 285, 286f Dion, S. C., 444, 458, 459 Dirmann, T., 449 Dishion, T. J., 430 Dix, D., 20 Dobkin, R. D., 404, 409, 410 Docherty, N. M., 380 Dogden, D., 433 Dollinger, S. J., 161 Donaldson, D. W., 160 Donaldson, K., 488 Donenberg, G., 422 Dong, Q., 126, 320 Dowben, J. S., 177, 178, 193t Drabant, E. M., 121 Draijer, N., 158 Drake, R. E., 385 Drane, J., 355 Drezezga, A., 402 Duarte-Velez, Y. M., 346, 347 Dube, S. R., 378 Duberstein, P. R., 212 Dubovsky, S. L., 317, 325, 329, 330 Dugas, M. J., 141 Duncan, E. M., 318 Duncan, K., 305 Dunn, M. E., 261 Durex, 266, 267, 279 Durkheim, E., 346 Dworkin, S., 170 Dyer, O., 97 Dykens, E. M., 441 Dzokoto, A. A., 156 Eaker, E. D., 196 Eastman, C. I., 309 Eaton, D. K., 344 Eddy, J. M., 431 Eddy, K. T., 446, 468, 471 Edelmann, R. J., 125 Edlund, A., 395 Edman, G., 343 Egeland, J. A., 322 Eggleston, P., 189 Ehlers, A., 125 Ehringer, M. A., 139 Ehrlich, J., 385 Eifert, G. H., 128 Eigenmann, P., 96 Einstein, A., 421 Eisen, A. R., 139, 141 Eisenhower, J. W., 159

I-3

Eisenmann, M., 166 Ekerwald, H., 388 Elder, S., 198 Eleonora, G., 130 Eley, T. C., 222 El-Guebaly, N., 251 El-Hage, W., 149 Elkin, I., 42, 325 Ellason, J. W., 162 Ellicott, A., 318 Elliott, C., 222 Ellis, A., 51–52, 125, 315 Ellis, L., 287, 300 Ely, D. L., 185 Emery, G., 325, 344 Emmelkamp, P. M., 214, 248, 259, 315 Endler, N., 331 Endler, N. S., 450 Eng, M. Y., 254 Epstein, L. H., 455, 469, 470 Erdely, S. R., 450 Erikson, E., 47t Eriksson, A. S., 417 Eronen, M., 15 Evans, L., 294t Eve, see Sizemore, C. Everaerd, W., 190 Ewing, C. P., 99 Exner, J. E., 72 Fabbri, S., 162 Fagan, P. J., 290 Fairburn, C. G., 446, 451, 452, 453 Fallon, M., 125 Falloon, I. R. J., 386 Fals-Stewart, W., 260 Falwell, J., 283 Fang, C. Y., 196 Farach, F. J., 140 Faraone, S. V., 330, 424 Farberow, N. L., 353 Farley, F., 223, 229 Farmer, E. M. Z., 422 Farquhar, J. C., 444, 445 Farrell, A. D., 82, 253 Farrugia, D., 424 Fauman, M. A., 90 Fava, G. A., 137, 162, 167, 169 Fawcett, J., 326 Federal Bureau of Investigation (FBI), 296 Federal Interagency on AgingRelated Statistics, 400f Feingold, B. F., 425 Feinstein, J. S., 120 Felce, D., 441 Feldman, H. A., 274 Feldman, H. M., 424 Feldman, J., 160 Feldman-Summers, S., 152 Felitti, V. J., 378 Fellenius, J., 127 Fenichel, O., 224 Fenton, W. S., 367 Fergusson, D. M., 422 Ferster, C. B., 84 Fichner-Rathus, L., 266, 295 Fichter, M. M., 167 Fiebelkorn, I. C., 468 Fields, R., 236 Figueroa-Garcia, A., 123 Filmer, R. B., 434 Finkelhor, D., 292, 293, 432 Finkelstein, E. A., 468

I -4

N A ME IN DE X

Fischer, P. J., 491 Fitzgerald, F. S., 329 Flaherty, M. L., 165 Flavin, D. K., 345 Fleet, R. P., 133 Flegal, K. M., 470 Fleming, I., 185 Foa, E. B., 141, 142f, 146, 181 Fogg, L. F., 309 Follette, W. C., 89 Fombonne, E., 418t Fontenelle, L. F., 168 Food Standards Agency (Britain), 425 Foote, B., 155, 158 Forbes, G. B., 460, 460f Forsyth, J. P., 128 Foster-Scott, L., 471 Fowler, D., 365 Fowler, J. H., 471 Fowler, K. A., 74 Fowler, K. B., 364 Fox, M. J., 404 Fox, N. A., 115, 121–122, 147 Fox, R. E., 24 Foxhall, K., 24 Foxx, R., 257 Fraley, C. R., 308 Frances, R. J., 241, 247, 252, 256, 345 Frankle, W. G., 222 Franklin, B., 22 Franklin, D., 89 Franklin, J. E., 241, 247, 252, 256, 345 Franklin, M. E., 146, 147 Franks, R., 330 Frederick, T., 435 Freedland, K. E., 194 Freedman, R., 376 Freeman, D., 363, 364, 369 Freeston, M. H., 141, 142 Freiberg, P., 347, 349 Freinkel, A., 156 Freud, A., 47t Freud, S., 6t, 23, 45–46, 47t, 53, 65, 129, 145, 170, 171, 313–314, 431 Frick, P. J., 424 Friedman, J., 183 Friedman, M. A., 326 Friedman, M. J., 180 Friedman, R. A., 335 Friedrich, W. N., 99 Fritz, G. K., 190 Froehlich, T. E., 423t, 424 Froese, A., 348 Fulero, S. M., 493 Fulkerson, J. A., 444, 471 Fulton, J. P., 481 Furer, P., 167, 171 Furr, S. R., 310, 337, 338 Gabay, M., 131 Gabbard, G. O., 147, 325 Gabbay, P., 152 Gabriel, J., 368t Gage, P., 396 Gagnon, J. H., 267, 273, 280 Gale, E., 160 Galea, S., 180, 181 Galen, 17 Gallant, D., 255 Gallaper, D., 311 Gallardo-Cooper, M., 27 Gallup Organization, 347

Gamble, E., 198 Gandolfini, J., 211 Gangadhar, B., 324 Ganguli, M., 400 Garb, H. N., 74 Garcia-Preto, N., 10 Garcia-Soriano, G., 142 Gardner, C. O., 318 Garety, P. A., 369, 378 Garfinkel, B. D., 344, 348 Garrett, M., 365 Garry, M., 160 Gass, C. S., 78 Gatz, M., 40, 139, 390, 394, 396, 400, 401, 403, 404, 409 Gaub, M., 423t, 424 Gaulin, S. J. C., 462 Gawin, F. H., 244 Gearing, M., 296 Gebhard, P. H., 266 Gejman, P. V., 378 Gelenberg, A. J., 323, 330 Gelernter, J., 95 George, M. S., 142 George, W. H., 251 Gere, R., 478 Ghaziuddin, M., 419 Giancola, P. R., 250–251 Gibb, R., 36 Gibbons, R. D., 324 Gibson, M. G., 369 Gidycz, C. A., 298 Gierhart, B. S., 266 Gilbert, S. C., 444, 461, 462 Gilbertson, M. W., 179–180 Gilger, J. W., 424 Gillespie, C. F., 312 Gillett, G., 222 Gillham, J., 317 Gilliland, B. E., 50 Gillis, J. J., 424 Giordano, J., 10 Girgus, J. S., 316 Gitlin, M., 318 Glaser, R., 190 Glass, C. R., 132 Glassgold, J. M., 283 Glaus, K. D., 59 Gleaves, D. H., 158 Glei, D. A., 409 Glynn, S. M., 361, 383, 388 Goetsch, V. L., 134, 136 Goetz, K. L., 406 Goff, D. C., 154, 155f, 159, 160–161 Gold, L. H., 476 Goldapple, K., 326 Goldberg, D., 139, 310, 311, 321 Goldberg, J. F., 330 Goldberg, T. E., 384 Golden, C. J., 79 Golden, J., 271 Golden, R. N., 309 Goldfein, J. A., 451, 457, 467 Goldfried, M. R., 90 Golding, J. M., 146 Goldman, H. H., 324 Goldsmith, H. H., 222 Goldstein, A., 489 Goldstein, I., 274 Goldstein, M., 380 Goldwater, B., 12 Goleman, D., 299 Golier, J. A., 215 Golumbek, H., 344 Goma, M., 223

Gone, J. P., 346, 348 Gonzalez, C. A., 82 Goodman, M., 209, 212, 214, 222 Goodwin, D. W., 247, 311, 312, 320, 329 Goodwin, R. D., 191, 309 Gooren, L. J. G., 287 Gordis, E. B., 432 Gordon, A., 450 Gordon, B., 23, 24, 38, 39 Gordon, T., 123 Gore, A., 15 Gore, T., 15 Gorman, J. M., 120, 137, 139, 140 Gorski, P. A., 434 Gorsuch, R. L., 76 Gotestam, K. G., 146 Gotlib, I. H., 309, 321 Gottesman, I. I., 44, 110, 222, 375, 376, 376f Gould, M. S., 348 Gould, T. D., 44, 110 Grabe, S., 460, 462 Graham, J. R., 73, 74 Graham, J. W., 252 Gramling, S. E., 170, 197 Grann, M., 14 Grant, B. F., 204, 206t, 208, 211, 215, 216, 218, 220, 309 Grant, I., 405 Grant, J. E., 168 Gray, J., 462 Gray, K. F., 394 Green, M. F., 384 Green, R., 287 Green, R. J., 283 Greenan, D. E., 283 Greenbaum, C. W., 436 Greenberg, B. D., 145 Greenberg, R. L., 344 Greenberg, S. A., 476, 480 Greenberger, E., 320 Greene, R. L., 73 Greeno, C. G., 452 Gregory, R. J., 165, 173 Gregus, A., 312 Griesinger, W., 21 Griffith, E. E., 82 Grigoriadis, S., 381 Groopman, L. C., 216 Grossberg, G. T., 384 Grossman, S., 202 Groth, A. N., 299 Grounds, A., 203, 211 Gulliver, S. B., 260 Gunderson, J. G., 202, 214, 215, 218, 220, 225, 229 Gunnell, D., 381 Gur, R. E., 366, 376 Gureje, O., 164 Gustafson, R., 459 Gutierrez, P. M., 24 Guze, S. B., 311, 312, 320, 329 Haaga, D. A., 259 Haas, A., 271t, 273t, 276t Haas, K., 271t, 273t, 276t Haenen, M. A., 167, 171 Haenggeli, C., 96 Hafner, H., 381 Hag, N., 476 Hagen, B., 470 Hagen, D. P., 76 Hagen, M. A., 96 Haggard-Grann, U., 9 Halderman, D. C., 283

Haley, J., 57, 150, 260 Hall, G. C., 297, 298 Hall, J. E., 24 Hallak, J. E. C., 156 Halmi, K. A., 447, 456 Halstead, W. C., 79 Halvorsen, I., 465 Hamelsky, S. W., 187 Hammen, C., 215, 316, 317, 318 Hammond, D. C., 279 Hanback, J. W., 170 Hankin, B. L., 308 Hannan, P. J., 444 Hansen, L., 386, 387 Hare, R. D., 222 Harenstam, A., 184 Hariri, A. R., 121, 311 Harlow, H. F., 313 Harlow, J. M., 396 Harlow, M., 313 Harnack, L., 444 Harnden-Fischer, J., 449 Harrington, P., 168, 169 Harris, E., 2, 486 Harris, E. C., 344 Harris, G., 449 Harris, G. J., 144 Harris, J. and S., 284 Harris, J. C., 134, 437, 442 Harris, S. M., 461 Harris, T. O., 318 Harrison, K., 458 Harrow, M., 363, 374 Hartman-Stein, P., 404 Harvey, A. G., 125, 132 Harvey, P. D., 367, 376 Hasin, D. S., 309, 309f Haslam, N., 205 Hastings, J. D., 335 Hathaway, S. R., 73 Hatzichristou, D. G., 274 Haugaard, J. J., 98 Haug Schnabel, G., 433 Hausman, K., 288 Hautzinger, M., 314 Hawkins, R., 486 Hayes, S. C., 24, 291 Hayley, M., 448 Haynes, S. N., 68 Hays, R. B., 319 Hayward, P., 41 Heard-Davison, A., 277 Heath, A. C., 236 Hebert, L. E., 394 Hedlund, S., 316 Heffernan, K., 460 Heiby, E. M., 330 Heiman, J. R., 276, 277 Heimberg, R. G., 125, 126 Heinrichs, R. W., 361 Heinssen, R. K., 386 Hellmich, N., 448 Hellstrom, K., 127, 132 Helms, J. E., 78 Hemel, D., 179 Hemingway, E., 15, 329, 337 Hemlock Society, 355 Hen, R., 44, 121, 310, 312, 334 Hendin, H., 356 Hendrie, H. C., 402 Henningsson, S., 287 Henry, G. W., 16, 19 Herbert, T. B., 190 Herlicky, B., 492 Herman, C. P., 459 Herman, J., 293

N A ME I NDEX Hermes, G. L., 195 Hernandez, A., 172 Hernandez, J., 167 Hernandez, P., 27 Heron, J., 431 Herrnstein, R. J., 77 Herschell, A. D., 430, 433 Herzog, A. R., 285, 286f Herzog, D. B., 460 Herzog, W., 457 Hesselbrock, V. M., 222 Hessl, D., 438 Hester, R. K., 257 Heston, C., 400 Hettema, J. M., 128, 318 Heyerdahl, S., 465 Hick, K., 446 Hicks, T. V., 136, 137 Higgitt, A., 41 Hilbert, A., 452 Hildebrand, D. K., 76 Hill, A. J., 462 Hill, C. E., 71 Hiller, W., 162, 167, 173 Hilsenroth, M. J., 216 Hilty, D. M., 395 Hinckley, J., Jr., 478–479, 481 Hingson, R. W., 236 Hippocrates, 16, 17, 29, 90, 171 Hirdes, J. P., 271 Hiripi, E., 445t, 446, 450, 451 Hirose, S., 385 Hirschman, L., 293 Hitler, A., 213, 239, 337 Hjern, A., 381 Hjorthoj, C., 379 Ho, D. D., 194 Ho, D. Y. F., 416 Ho, E. D. F., 416 Hoberman, H. M., 314, 318 Hochron, S., 190 Hodapp, R. M., 441 Hodes, R. L., 50 Hodgins, D. C., 251 Hodgins, S., 484 Hodgson, R., 143t Hoehn-Saric, R., 138, 144 Hoek, H. W., 450 Hof, A., 184 Hoff, A. L., 381 Hoffman, B. M., 136, 137, 167 Hoffman, H. G., 132 Hoffman, K. B., 317 Hoffman, L., 452, 454 Hoffman, P. L., 248 Hofman, M. A., 287 Hofmann, S. G., 124, 132 Hoge, C. W., 176, 180 Hogue, L., 475, 476, 478, 482, 484 Hoidas, S., 368t Hokanson, J. E., 318 Holahan, C., 447 Holahan, C. J., 318 Holcomb, H. H., 80 Hollender, M. H., 171 Hollister, A., 38 Hollon, S. D., 25, 325, 326, 329, 330, 331 Holloway, J. D., 25, 267 Holmbeck, G., 68 Holmstrom, L. L., 279 Holroyd, K. A., 198 Holroyd, S., 421 Holstrom, L., 299 Holtzaorth-Munroe, A., 57 Holzman, P. S., 365

Honda, K., 191 Hood, J., 348 Hook, J. N., 346 Hooley, J. M., 143, 380 Hoon, E. F., 278 Hoon, P. W., 278 Hooper, J., 272t, 273, 274, 278, 282 Hope, D., 123 Hope, D. A., 69 Hornbacher, M., 446 Horne, O., 448 Horney, K., 47t Horowitz, M. J., 216 Horwath, E., 140 Horwood, L. J., 422 Hossain, A., 217, 363, 372 Hostetter, A. M., 322 House, J. S., 56 Houts, A. C., 89 Hovanitz, C. A., 198 Howard, R., 10, 381 Hoyer, J., 140 Hu, S., 283 Hudson, J. I., 99, 169, 177, 445, 445t, 446, 450, 451, 456 Hugdahl, K., 130 Hultman, C. M., 378, 388 Humbert, V., 354–355 Humphrey, D., 355 Hunfeld, J., 167 Hunsley, J., 96 Hunt, H., 220 Hunter, R., 16 Huntjens, R. J. C., 155 Huppert, J. D., 146 Hurley, R. A., 144 Hurt, S. W., 72 Hussong, A. M., 254 Hutchinson, K. E., 255 Huttunen, M. O., 378 Hyde, J. S., 277, 278 Hyde, S., 460, 462 Illinois Department of Professional Regulation, 160 Ingersoll, R. E., 434 Ingram, J., 153 Ingvar, M., 44 Innocent VIII (pope), 19 Institute of Medicine, 58 International Society for the Study of Dissociation, 158, 160, 162 Irani, F., 374 Irizzarry, L., 448 Irving, L. M., 457 Irwin, H. J., 158 Isenberg, S. A., 190 Issenman, R. M., 434 Ivey, A. E., 60, 226, 227 Ivey, M. B., 60 Jaberg, P., 460 Jablensky, A. V., 378 Jackson, B., 424 Jackson, G., 190 Jackson, M., 100, 101f Jackson, R. J., 122 Jackson, T., 149 Jacobs, D., 335 Jacobs, D. R., Jr., 190 Jacobsen, P. B., 130 Jacobson, E., 198 Jacobson, L., 91 Jacobson, S., 443 Jaffee, D., 299

James, R. K., 50 James, W., 21 Jameson, P., 57 Janssen, K., 198 Janus, C. L., 268, 273, 285, 286, 294 Janus, S. S., 268, 273, 285, 286, 294 Japanese Society of Psychiatry and Neurology, 367 Jason, L. A., 261 Jawed, S. Y., 172 Jaycox, L., 317 Jelicic, M., 158 Jellinek, E. M., 238 Jenike, M. A., 141, 143t, 146 Jenkins, J. M., 310 Jenner, F. A., 329 Jennings, C., 354 Jennings, T., 182 Jensen, A. R., 77 Jensen, P. S., 417 Jeste, D. V., 384 Jilek, W. G., 367 Jimenez, T., 336, 346 Jindal, S., 165, 173 Jobes, D. A., 334, 344, 345, 346 Johnson, C. P., 418t, 421 Johnson, D. L., 388 Johnson, D. W., 56 Johnson, F., 487 Johnson, F. P., 56 Johnson, J. G., 104 Johnson, S. L., 330 Johnson, V. E., 268, 268f, 269f, 271, 273, 274, 275, 276, 279, 282, 283, 286, 292 Johnston, L. D., 245 Johnston, P., 300 Johren, P., 101 Joiner, T. E., 306, 317, 334 Joinson, C., 431, 433 Jones, C., 449, 456 Jones, D. R., 196 Jones, J., 266, 337 Jones, J. M., 446, 455 Jones, R., 300 Jongsma, A. E., 334, 350 Joormann, J., 316 Joplin, J., 240 Joraschky, P., 166 Jorm, A. F., 404 Joseph, E., 46 Josephs, R. A., 250, 345 Jung, C., 47t Junginger, J., 484 Kabot, S., 415 Kaczynski, T., 208 Kahler, C. W., 262 Kahn, A. S., 461 Kahn, A. U., 198 Kahn, R. S., 377, 381, 382 Kaijser, L., 184 Kalarchian, M. A., 444 Kalivas, P. W., 247 Kalso, E., 44 Kalyanasundaram, S., 324 Kalynchuk, L. E., 312, 317 Kamarck, T. W., 184 Kamphaus, R. W., 78 Kamphuis, J. H., 132 Kanas, N., 247, 259 Kanaya, T., 437, 441 Kanayama, G., 445 Kane, J. M., 167

I-5

Kanfer, F. H., 84 Kanner, L., 415, 421 Kantrowitz, B., 162, 415 Kaplan, H. S., 268, 282, 283 Kaplan, M., 89 Kapur, R., 324 Karch, D., 337 Kardiner, A., 226 Karlsson, H., 378 Karno, M., 146, 380 Karpiak, C. P., 204, 214 Kasch, K. L., 318 Kaslow, N. J., 351 Kastelan, A., 371, 373 Kato, T., 310, 329 Katon, W. J., 131 Kattan, M., 189 Katzman, D. K., 446 Kaufman, A. S., 78 Kaufman, N. L., 78 Kavanagh, D. J., 380 Kazdin, A. E., 430 Keefe, R. S. E., 367 Keel, P. K., 451 Keith, C. R., 287 Keith-Spiegel, P., 494 Keller, J., 41 Kellner, R., 167, 169, 170 Keltner, N. G., 177, 178, 193t Kemeny, M. E., 196 Kendall, P. C., 68 Kendall-Tackett, K. A., 432 Kendler, K. S., 110, 128, 134, 139, 209, 248, 318, 447, 449, 454 Kennedy, R., 178 Kenny, D. A., 402 Kerlitz, I., 481 Kernberg, O., 47t, 214, 216 Kerns, R. D., 167 Kervorkian, J., 355, 356 Keski-Rahkonen, A., 448 Kessler, R. C., 12, 13, 86, 88f, 118, 123, 126, 127, 133, 134, 139, 140, 142, 177, 228, 236, 309, 309f, 318, 320, 329, 445t, 446, 450, 451 Kiani, R., 397 Kiecolt-Glaser, J. K., 190, 196 Kienhorst, C. W. M., 337 Kienhorst, I. C., 344 Kiesler, C. A., 491 Kiesler, D. J., 225 Killen, J. D., 253 Kilmann, P., 296 Kilmann, P. R., 275 Kim, J.-J., 376 Kim, S. W., 168 Kim, U., 10 Kinderman, P., 369 King, D. W., 123 King, N. J., 130, 133 King, R. A., 96 King, S. M., 248 Kingdon, D., 386 Kinsey, A. C., 266, 268, 272t, 289t, 294 Kirkpatrick, B., 366 Kiss, J. E., 196 Kitamura, T., 367 Kivipelto, M., 404 Klages, T., 431, 434 Klebold, D., 2, 486 Klein, D. N., 307, 318 Klein, E., 179 Klein, M. E., 335 Kleinman, A., 319, 320

I -6

N A ME IN DE X

Klerman, G. L., 42, 325, 344 Klin, A., 417 Kline, T. J., 67, 69, 76, 81 Klinger, E., 258 Klopfer, B., 72 Klott, J., 334, 350 Kluft, R. P., 158, 159f Kluger, J., 414 Klump, K. L., 454 Knopf, I. J., 424 Knowlton, A. R., 319 Ko, G., 377 Koenigsburg, H. W., 484 Kohler, J., 96 Kohn, S. W., 82 Kohon, G., 290 Kohut, H., 47t Kolata, G., 273 Kolb, B., 36, 41 Kolko, D. J., 430 Kolodny, R. C., 292 Kondratas, A., 491 Koopman, C., 156 Kopelman, M. D., 153, 161 Kopelowicz, A., 383 Koppelman, J., 413 Koran, L., 141 Koren, D., 179 Kornman, L., 438 Koss, M. P., 298 Kotses, H., 189 Kottler, J. A., 47, 57 Kournikova, A., 372 Kozak, M. J., 141, 142f Kraepelin, E., 21, 22, 83, 84 Krafft-Ebing, R. von, 22 Krane, R. J., 274 Krantz, S. E., 318 Kranzler, H., 95, 248 Krasner, L., 84, 225 Kraus, J. F., 348 Kremen, W. S., 330 Kresin, D., 278 Kringlen, E., 204 Kroenke, K., 162, 169 Krueger, K. R., 396 Krueger. R. F., 86 Krystal, A. D., 324 Kubany, E. S., 181 Kubiak, S. P., 181 Kubiszyn, T. W., 79 Kubzansky, L. D., 190 Kugler, K. E., 482 Kuhn, B., 434 Kullgren, G., 166 Kumar, S., 468 Kumari, V., 120 Kumperscak, H. G., 369 Kunkel, M. A., 344 Kuring, J. K., 444, 458 Kurth, J. H., 404 Kurth, M. C., 404 Kusek, K., 127 Lader, M., 131 Ladouceur, R., 140, 141, 142 La Greca, A. M., 76, 140, 178 Lahey, B., 226 Lahey, B. B., 308, 424 Lai, J. Y., 185 Laird, J., 283 Lakkis, J., 455 Lam, R. W., 451 Lamb, H. R., 491 Lambert, E. W., 153, 428 Lambert, M. J., 71, 326

Lambley, P., 290 Landis, K. R., 56 Laney, C., 152 Lang, P. J., 50 Langdon, R., 364, 378 Langer, E. J., 195 Langley, J., 294t Langstrom, N., 14, 288 Lara, M. E., 318 Laraia, M. T., 136 Lark, J. S., 283 Larkin, K. T., 132, 198–199 Larsen, J. E., 146 Larson, C. A., 242 Larson, E. B., 400 Larsson, G., 146 Lassek, W. D., 462 Latané, B., 224 Latkin, C. A., 319 Latner, J. D., 470 Laumann, E. O., 267, 272t, 273, 274, 275, 278, 287 Lawrie, S. M., 376 Lazarus, P., 429 Leach, M. M., 337, 343, 346, 347 Leahy, R. L., 329 Leary, P. M., 149, 166 Leary, W. E., 274 Leavy, J. M., 348 Lebow, J., 259 Leckman, J. F., 96 LeCrone, H., 467 LeDoux, J. E., 120 Lee, A. S., 166 Lee, H.-Y., 444 Lee, M., 183 Lee, S., 249 Lee, T. M. C., 309 Leenaars, A. A., 334, 335, 345 Leeper, J. D., 354 Leff, J., 386 Lehman, A. F., 379, 385 Lehman, C. L., 124 Lehmann, H. E., 309 Lehrer, P. M., 190, 198 Leibbrand, R., 167 Leiblum, S. R., 271 Leitao, M., 373 Leland, J., 282 Lemay, E. P., 196 Lemonick, M. D., 236 Lengacher, C. A., 191 Lenzenweger, M. F., 202, 209, 213 Leonardo, E. D., 44, 121, 310, 312, 334 Leong, F. T., 343, 346, 347 Lerer, B., 110 LeResche, L., 170 Lerew, D. R., 122, 136 Leserman, J., 56 Leshner, A. I., 250 Leskin, G. A., 136 Leslie, R., 492 Lesser, L. I., 415 Lester, D., 337, 343, 344, 354 Lester, R., 455, 462 Leuchter, A., 44 Leung, N., 449 Levant, R. F., 25, 42, 115 Levine, D., 466 Levine, I. S., 491 Levinson, D. F., 311 Levinthal, C. F., 41 Levitt, E. E., 293 Levy, D. L., 365 Levy, K. N., 398

Lewinsohn, P. M., 306, 314–315, 317, 318 Lewis, G., 381 Lewis, J. L., 292 Lewis, M. A., 460 Lewis, R. W., 270, 273 Lewis, Y., 421 Lewiston, N. J., 190 Liberini, P., 165 Liberman, R., 260 Liberman, R. P., 383 Lichtenberg, J. W., 25 Lichtenstein, P., 222 Lickey, M. E., 23, 24, 38, 39 Lidderdale, M. A., 283 Liébeault, A.-A., 22 Lieberman, J. A., 384 Lieblum, S. R., 275, 279, 280 Lifschitz, M., 330 Lilienfeld, S. O., 74, 159 Lincoln, A., 15 Lindau, S. T., 284, 285 Linden, W., 185 Linehan, M. M., 212, 214–215, 334, 337, 350 Links, P. S., 214 Linn, V., 186 Lippmann, S., 152 Lipsey, T. L., 123, 180 Lipsitt, D., 171, 173 Lipsitz, J. D., 125, 131 Lipton, R. B., 187 Listernick, R., 165 Liu, W. M., 59 Livanou, M. L., 181 Loar, L. L., 430 Lock, J., 444 Loe, I. M., 424 Loeber, R., 225 Loening-Baucke, V., 434 Loesch, D. Z., 438 Loew, T. H., 166 Loewenstein, R., 159f Loftus, E. F., 152, 160 Lohr, J. M., 74 Lombardo, I., 222 Longstaffe, S., 433 Lonnqvist, J., 345 Lopater, S., 278 Lopez, S. R., 27, 380 LoPiccolo, J., 271, 272t, 274, 279, 282, 283 Lott, T., 283 Lovaas, O. I., 422 Lovallo, W. R., 247 Love, C., 336 Lovejoy, M., 461, 462 Lovell, M. R., 406 Lowe, C. F., 364 Luborsky, L., 105, 129 Lucas, J. A., 134 Lucchelli, J. P., 169 Luchian, S. A., 143 Luczak, S. E., 254 Luedeckde, J., 297 Luoma, J. B., 339, 340f Luther, M., 18 Lydiard, R. B., 169 Lyke, M. L., 177 Lykken, D. T., 223 Lynskey, M. T., 422 Macalpine, I., 16 MacDonald, H., 456 Mace, C. J., 166 Machlin, S. R., 144

Machon, R. A., 378 Machover, K., 73 Mackenzie, T. B., 344 Mackinnon, A., 365 MacMillan, P. D., 466, 467 Maddi, S. R., 175, 194 Madsen, D. H., 78 Maher, B. A., 16 Maher, W. B., 16 Mahgoub, N., 217, 363, 372 Mahoney, D. M., 136 Malamud, M., 301 Malamuth, N. M., 297 Malaspina, D., 381 Malecki, C. K., 428 Malenka, R. C., 249, 250 Mallinckrodt, B., 98 Maltsberger, J. T., 219, 220 Maltzman, I. M., 259 Malvo, L. B., 149, 487 Mancuso, C. E., 131 Manderschied, R. W., 24 Mann, J. J., 312 Mann, T., 471 Maramba, G. C., 297 Marantz, S., 288 Marchesi, C., 371 Marciano, P. L., 430 Marcus, B., 434 Marcus, J., 379 Marcus, M. D., 444 Marcus, S. M., 137 Margolin, G., 432 Margraf, J., 103, 137 Maris, R. W., 335, 344, 347 Markowitz, J. C., 25 Marks, I. M., 143t Marlatt, G. A., 238, 251, 252, 259, 260 Marmar, C. R., 206t, 208, 216, 218, 219 Marmot, M. G., 196 Marquardt, W. H., 187 Marr, A. J., 197 Marris, E., 373 Marsa, L., 414 Marsella, A. J., 10 Marsh, D. T., 388 Marsh, H. W., 462, 463 Marsh, J. C., 296 Marshall, J., 446 Marshall, R. D., 176, 178 Marshall, W. L., 132, 300 Martin, C. E., 266, 268 Martin, J. M., 317 Martin, K. E., 258 Martin, L., 271 Martin, P. R., 186, 188 Martinez-Mallen, E., 466 Martinez-Taboas, A., 93 Martinson, B. C., 100 Marziali, E., 215 Masi, W., 415 Mask, A., 470 Maslow, A. H., 54 Masserman, J., 249 Masterman, D. L., 409 Masters, W. H., 268, 268f, 269f, 271, 273, 274, 275, 276, 279, 282, 283, 286, 292, 293 Masterson, J. F., 216 Mataix-Cols, D., 144 Materka, P. R., 401 Mather, M., 400 Mathews, K. A., 59, 196 Mattay, V. S., 121

N A ME I NDEX Matthews, K. A., 195 Mattis, S., 72 May, J. H., 345 May, R., 53 Mazure, C. M., 318 McAbee, R., 312 McAdams, D. P., 73 McAnulty, R. D., 271, 275, 278, 286, 293, 296, 300 McArthur, J., 405 McCabe, M. P., 444, 457 McCabe, R., 382, 382t McCann, D., 425 McCann, J., 191 McCarron, R. M., 162 McCarthy, K., 190 McConnell, G. N., 310 McCord, J, 430 McCoy, M. L., 99 McCracken, L. M., 132 McCrady. B. S., 259 McCrae, R. R., 204, 205 McCreary, B. A., 98 McCrindle, B. W., 446 McCullough, L., 82 McCullough, P. K., 219, 220 McDonald, M. K., 170 McDowell, E. E., 345 McElroy, S. L., 228 McFarlane, A. C., 180 McGarvey, S. T., 197 McGill, C. W., 386 McGilley, B. M., 450 McGlashan, T. H., 385 McGoldrick, M., 10 McGonagle, K. A., 318 McGrath, M., 360 McGue, M., 248, 311 McGuffin, P., 37, 38, 43 McGuire, L., 363 McGuire, R. J., 295 McHugh, M. D., 464 McIntosh, J. L., 56, 339, 349 McKay, R., 364, 378 McKinlay, J. B., 274 McKinley, J. C., 73 McLaughlin, K. A., 140 McLean, P. H., 132 McMahon, B., 291 McNally, R. J., 122, 143, 152, 160 McNamee, H. B., 250 McNeil, C. B., 430 McNeil, D. W., 430 McNiel, D. E., 484 McWilliams, N., 84, 90 Mead, M., 226 Meaden, P. M., 309 Meagher, S., 202 Mease, A. L., 255 Mecan, S., 372 Mednick, S. A., 378 Meehl, P. E., 36, 43 Meeks, J., 186, 188 Mehler, P. S., 450 Meilahn, E. N., 196 Meissner, W. W., 207 Melamed, B., 171 Melchert, T. P., 97, 114 Mello, N. K., 250 Meloy, J. R., 211, 212, 229 Meltzer, H. Y., 384 Mendelson, J. H., 250 Mendlowicz, M. V., 151 Mennin, D. S., 140 Menza, M., 404 Menzies, R. G., 131

Merckelbach, H., 127, 129, 132, 142, 143, 146 Meredith, L. S., 314 Merikangas, K. R., 309f, 329 Merkelbach, H., 158 Merluzzi, N., 128 Merrill, M. A., 76 Merritt, M. M., 196 Merryman, K., 152, 153 Merskey, H., 111, 155, 160 Merten, J., 167, 173 Mesmer, F. A., 22, 23, 165 Messer, S. B., 26 Metalsky, G. I., 317 Meyer, G. J., 71, 81 Meyer, R. G., 227 Meyer, W. S., 287 Meyers, R. J., 257 Meyers, W. A., 287 Michael, R. T., 267, 273 Michaels, S., 267 Michelangelo, 329 Michie, C., 211 Mick, E., 424 Middleton, F., 424 Miklowitz, D. J., 331, 380, 381 Mikton, C., 203, 211 Mileno, M. D., 165 Milk, H., 480 Miller, D. J., 492 Miller, G. A., 41 Miller, G. E., 190, 194 Miller, H. L., 354 Miller, J. N., 419 Miller, K. B., 451 Miller, M., 162 Miller, M. N., 462 Miller, S. B., 195 Miller, W. R., 257 Milliery, M., 146 Millon, C., 202 Millon, T., 202, 203, 204, 205, 213, 214, 216, 217, 221, 222, 224, 225, 226, 227 Milrod, B., 122, 135 Milstein, V., 222 Milstone, C., 155 Mineka, S., 117, 119, 128, 175, 316 Mintz, J., 380 Mintz, L., 380 Mintz, L. B., 462 Minuchin, S., 57 Mishna, F., 466 Mitchell, A., 283 Mitchell, J. E., 451 Miura, Y., 27 M’Naghten, D., 479 Modestin, J., 155 Moffatt, M. E., 433 Moffitt, T. E., 222 Mogg, K., 125 Mohr, D. C., 128, 280 Mohr, P., 198 Mommerstegg, P. M. G., 197 Monahan, J., 484 Money, J., 267, 294 Monk, C. S., 139 Monopoli, J., 173 Monroe, M., 213, 239, 337, 348 Monroe, S. M., 312 Monti, P. M., 255, 258 Moore, E. L., 167 Moore, R., 130 Moore, T. H. M., 379 Moorey, S., 193

Moorman, J. E., 189 Moos, B. S., 259, 319 Moos, R. H., 259, 318, 319 Morales, A. T., 58 Moreno, C. S., 239 Morenz, B., 292 Morey, L. C., 205, 215 Morgan, D. L., 109 Morgan, H., 72 Morgan, R. K., 109 Morgan, W. J., 189 Morgan, Y., 152 Morganstern, J., 259 Morihisa, J. M., 80 Morillo, C., 142 Morin, C., 296 Morris, C. D., 331 Morris, J., 463 Morrison, J., 240 Morse, W., 99, 456 Moscone, G, 480 Moser, C., 293 Moser, G., 163 Mosher, W. D., 266, 283 Mosholder, A., 97 Moss, J. R., 354 Moss, K., 448 Mostardi, R. A., 185 Mountain-Kimchi, K., 419 Mueser, K. T., 388 Muhammad, J. A., 487 Muhlberger, A., 128 Mukai, T., 457 Mulder, R. T., 227 Mulholland, A. M., 462 Mulkens, S. A. N., 129, 131 Mullendore, K. B., 476 Muller, R. J., 369, 372 Mullins-Sweatt, S. N., 214 Mumford, D. B., 462 Munch, E., 134 Munoz, R. F., 261, 309, 326 Munroe-Blum, H., 215 Muris, P., 127, 130, 132, 142, 143, 146 Murphy, D. L., 145, 146 Murphy, M., 164 Murray, C., 77 Murray, H. A., 72 Murray, R., 96 Mutsatsa, S. H., 362, 366 Myers, H. F., 196 Myers, S. M., 421, 422 Nacasch, N., 181 Nademanee, K., 184 Nagin, D. S., 431 Naglieri, J. A., 82 Nakamura, C. Y., 254 Nakao, M., 198 Naqvi, N. H., 249 Narcotics Anonymous, 259 Nash, J., 363 Nash, J. M., 409 Nathan, J. S., 71 Nathan, P. E., 25, 89, 250, 252 National Academy of Engineering, 58 National Academy of Sciences, 58 National Association of Anorexia Nervosa and Associated Disorders, 462 National Association of Social Workers (NASW), 250, 429 National Center for Children Exposed to Violence, 429

I-7

National Center for Complementary and Alternative Medicine, 322 National Center for Health Statistics, 189, 189f National Comorbidity Survey Replication Study (NCS-R), 12 National Council on Aging, 286 National Dissemination Center for Children with Disabilities, 441 National Institute of Mental Health (NIMH), 12, 24, 100, 125, 126, 127, 133, 138, 140, 176, 177, 181, 330, 360, 367, 416, 418t, 419, 420, 425, 446, 447, 450 National Institute of Neurological Disorders and Stroke (NINDS), 186, 404 NCS-R, see National Comorbidity Survey Replication Study (NCS-R) Neale, M. C., 454 Nearing, K. I., 130 Neerakal, I., 136 Neighbors, C., 455, 460 Neighbors, L., 459 Nelson, C. B., 236 Nelson, P., 134 Nelson-Gray, R. O., 89 Nemeroff, C., 458 Nemeroff, C. B., 23, 312 Neng, T., 367 Nestler, E. J., 249, 250 Netting, J., 41 Neugebauer, R., 16 Neumark-Sztainer, D., 444, 444t, 461, 471 Neumeister, A., 134 Nevid, J. S., 266, 295, 298 New, A. S., 222 Newcomb, M. D., 251 Newman, C. F., 64 Newman, D., 126 Newman, J. P., 223 Newmark, C. S., 74 Newschaffer, C. J., 415, 418t, 419, 420, 421 Neziroglu, Y., 173 Niaura, R. S., 258 Nichols, M. P., 57 Nicholson, J., 220, 249 Nicholson, R. A., 482 Niendam, T. A., 385 Nigg, J. T., 212 Nightingale, N. N., 99 NIMH, see National Institute of Mental Health (NIMH) NINDS, see National Institute of Neurological Disorders and Stroke (NINDS) Nisbett, R. E., 77 Nitschke, J. B., 312 Nitzkin, J., 236, 261, 310 Noble, E. P., 248 Nolen-Hoeksema, S., 123, 316, 321–322 Norcross, J. C., 25, 44, 64 Nordentoft, M., 379 Norfleet, M. A., 23 Norre, J., 456 North, C. S., 180 Norton, G. R., 134 Norton, P. J., 69 Noveck, J., 315

I -8

N A ME IN DE X

Noyes, R., Jr., 162, 164, 169, 171, 172 Nussbaum, N. L., 79 Nutt, D. J., 140 Nystul, M. S., 46 Obesity Action Coalition, 470 O’Brien, C. P., 443, 467, 468, 469 O’Brien, M. P., 378, 379 Ochoa, E. S., 205 O’Connell, K. A., 257 O’Connor, J., 403 O’Connor, S. D., 401, 403 Odejide, O. A., 172 O’Donnell, R., 15 O’Donohue, W. T., 176 O’Farrell, T. J., 260 Ofshe, R. J., 111, 156, 160 Ogden, C. L., 458t, 462 Ogles, B. M., 326 Ohaeri, J. U., 172 O’Hara, M. W., 308 Ohl, L. E., 268, 276 Ohman, A., 128, 378 Okazaki, S., 123, 126, 127, 320 Olarte, S. W., 494 Oldham, J. M., 213, 214 Olivardia, R., 169, 445 Olkin, R., 10 Ollendick, T. H., 126, 130, 133 Olsen, L. W., 468 Olsen, M.-K., 448 Olsson, A., 130 Onken, L. S., 257, 258, 262 Operskalski, B., 324 O’Reilly, B., 296 Oren, D. A., 309 Orne, M., 480 Orosan, P., 173 Orr, S. P., 178, 180 Ortega, A. N., 189 Orum, A., 182 Osborne, Y. V. H., 227 Osbourne, L., 156 Öst, L.-G., 127, 127f, 130, 132 Othmer, E., 71 Othmer, S. C., 71 Otto, M. W., 137, 330 Otto, R. K., 480 Owen, M. J., 38 Ozer, E. J., 123, 180 Ozonoff, S., 415, 415f, 416, 419, 422 Paik, A., 272t, 275, 278 Pallack, M., 91 Palmer, S. C., 192 Palmieri, P. A., 123 Panagiotopoulos, C., 446 Papageorgiou, C., 125t Papas, R. K., 167 Pappenheim, B., see Anna O. Paquette, M., 373 Paquette, V., 44 Parents Television Council, 104 Parrish, G., 183 Parrott, C., 466 Parry, C. D. H., 483, 490, 491 Parsons, R. D., 58 Pasteur, L., 21–22 Pathak, D., 167 Pattatucci, A. M. L., 283 Patterson, C. L. L., 283 Patterson, G. R., 430 Paulus, M. P., 120, 249 Pavlov, I., 48

Paykel, E. S., 56, 314, 318 Pazda, S. L., 449 Pearlson, G. D., 78, 144 Pearson, J. L., 339, 340f Pearson, M. A., 339, 340f Peel, R., 479 Peled, A., 367 Pelletier, L. G., 444, 458, 459 Penava, S. J., 137 Pendery, M. L., 259 Penn, D. L., 388 Pennington, B. F., 424 Penninx, B. W. J. H., 184 Peralta, R. L., 471 Perez, J., 223 Perez, J. E., 97 Perkins, K. A., 250 Perlman, C. M., 271, 274 Perner, L. E., 421 Perper, J. A., 344 Perrot-Sinal, T. S., 312 Perry, J., 441 Perry, J. C., 219 Perse, T. L., 145 Pert, A., 311 Pert, C. B., 311 Petersen, L., 433 Peterson, C., 317 Peterson, K. M., 44 Peterson, R. A., 102 Petrie, K. J., 194 Petrie, T. A., 449, 455, 456, 462 Petrovic, P., 44 Petry, N. M., 260 Pett, M. A., 279 Pettersson, R., 198 Pettit, J. W., 306 Peveler, R., 163 Pezawas, L., 121, 122 Pezdek, K., 152 Pflueger, M. O., 367 Pfuhlmann, B ., 368t Phelps, B. J., 155 Phelps, E. A., 130 Phelps, L., 436 Philippot, P., 125 Phillips, A., 292 Phillips, D. P., 100, 348 Phillips, J. S., 84 Phillips, K. A., 163t, 168f, 169, 172, 202, 215, 218, 220, 225, 229 Phoenix, R., 240 Piasecki, T. M., 247 Picasso, P., 15 Pickar, D., 380 Pickens, R. W., 248 Pigott, T. A., 146 Pike, J. L., 196 Pike, K. M., 452, 452f, 462 Pinel, P., 20 Pitner, S., 434 Pitts, R. K., 347 Pizzagalli, D., 312 Pizzaro, J., 180 Plato, 17 Plomin, R., 37, 38, 40, 43, 110 Poddar, P., 476, 493 Poe, E. A., 15 Polaschek, D. L. L., 299 Polivy, J., 459 Pollack, M. H., 137 Pollard, C. A., 136 Pollard, H. J., 136 Pomeroy, W. B., 266, 268 Ponder, J., 96

Ponterotto, J. G., 58, 64 Ponticas, Y., 290 Pope, H. G., Jr., 98, 99, 152, 154–155, 169, 444, 445, 445t, 446, 450, 451, 453, 456, 460 Pope, K. S., 152, 494 Popkin, M. K., 344 Popovich, M., 459 Popper, C., 436, 437, 440 Population Reference Bureau, 399, 409 Poulin, F., 430 Poulton, R., 127, 128 Pound, E., 305, 306 Pound, E. J., 440 Powell, A. D., 461 Powell, L. H., 471 Power, T. J., 436 Powers, M. B., 330 Prause, J., 180 Prescott, C. A., 318 President’s New Freedom Commission on Mental Health, 13, 14, 235, 310, 325 Presley, E., 239 Previts, S. B., 434 Pribor, E. F., 98 Price, T. R. P., 406 Prichard, J. C., 210 Priebe, S., 382, 382t Priester, M. J., 344 Prinze, F., Sr., 337 Prisciandaro, J. J., 307 Prochaska, J. O., 44 Pryor, T. L., 450 Przybeck, T., 211 Puente, A. E., 71 Puhl, R. M., 470 Pumariega, A. J., 462 Purdon, C., 140 Putnam, K., 312 Rabinowitz, J., 374, 381 Racansky, I. G., 291 Rachman, S., 131, 132, 143t, 295 Rade, B., 460 Raikkonen, K., 195 Raine, A., 209 Rajab, M. H., 334 Ramnath, R., 202 Rapaport, K., 297 Rapee, R. M., 125 Rapp, M. A., 402 Rappaport, J., 91 Raps, C. S., 317 Rasmussen, S. A., 169, 172 Rassin, E., 146 Rathus, S. A., 266, 267, 295 Ratican, K. L., 98 Rauch, S. L., 121, 128, 144, 178 Rausch, S. M., 197 Ray, S., 401 Raymond, F. L., 438 Rayner, R., 48, 130 Read, J. P., 262 Reading, C., 198 Reagan, R., 400, 479, 481 Rechlin, T., 166 Recovered Memory Project, 99 Rector, N. A., 364, 366, 378, 379t Reichborn-Kjennerud, T., 468 Reichenberg, A., 367, 376 Reid, J., 251 Reid, J. B., 431 Reid, W. H., 476 Reigier, D. A., 13, 13f

Reilly, D., 260 Reinders, A. A. T. S., 157 Reinhard, K. E., 317 Reiser, D. E., 70 Reiss, S., 122, 134 Reitan, R. M.,79 Reiter, J., 173 Reivich, K., 317 Remschmidt, H., 372 Resnick, M., 347 Resnick, R. J., 422 Reston, A. C., 447 Rettew, D. C., 217 Reus, V. I., 307, 312 Revelle, W., 170 Reynolds, C. R., 78 Rhee, S. H., 424 Rhodes, L., 189 Ricca, V., 466 Ricciardelli, L. A., 444, 449, 455 Richards, J. C., 184, 195 Richardson, L. F., 158 Richie, N., 448 Richwine, L., 97 Ridgway, A. R., 426 Ridley, C. R., 27, 60 Rieber, R. W., 160 Rief, W., 162, 167 Rieker, P. P., 321 Riemann, B. C., 147 Rietveld, S., 190 Rinck, M., 122 Rind, B., 98 Riolo, S. A., 202, 203, 216, 217 Riskind, J. H., 130, 140 Rivas-Vazquez, R. A., 311, 400 Rivera, R. P., 168, 169, 171 Rizvi, S., 331 Robbennolt, J. K., 335 Roberts, J. E., 307 Roberts, L. W., 97 Roberts, W., 335 Robertson, A. K., 98 Robertson, P., 283 Robins, L. N., 13f, 211, 226 Robinson, J. P., 67 Robinson, M. E., 171 Robinson, R. G., 399 Robinson, T. E., 36 Roder, V., 388 Rodin, J., 195 Rog, D. J., 491 Rogers, A., 186 Rogers, C. R., 54–55, 479, 481, 482 Rogers, J. R., 337, 345 Rogers, R. L., 449 Rogers, S. J., 415, 415f, 416, 422 Rohde, P., 317 Rohsenow, D. J., 255, 258 Rollins, A., 195 Romeo, N., 488 Root, M. P., 61 Root, R. W., 422 Rorschach, H., 72 Rose, R. J., 25 Rosen, J. C., 173 Rosen, L. A., 424 Rosen, R. C., 271, 275, 279, 280 Rosenbaum, M., 318 Rosenberg, L., 191 Rosenberg, S. D., 180 Rosenblatt, J., 311 Rosenfarb, I. S., 379, 380 Rosenfeld, B., 334, 344, 349, 355, 356

N A ME I NDEX Rosenfield, A. H., 290 Rosenhan, D. L., 91 Rosenstreich, D. L., 189 Rosenthal, B. L., 78 Rosenthal, D., 36, 43 Rosenthal, J., 91 Rosenthal, N. E., 309 Ross, C. A., 159, 162 Rosser-Hogan, R., 177 Rossler, W., 365 Rossow, I., 344 Roth, R. M., 361 Rothbaum, B. O., 132 Rother, L., 447 Rothschild, L., 214 Rottnek, F., 427 Rounsavelle, B. J., 325 Roy, A., 343 Roy, S., 382 Roy-Byrne, P. P., 135, 136f, 137 Rubenstein, S., 190 Rudd, D., 334, 335, 337, 344, 350, 350t, 351, 352 Rudd, M. D., 334, 345, 347, 350, 357 Rude, S. S., 316 Rueger, D., 260 Ruiz, J. M., 185 Ruiz, M. A., 167, 171 Rumbaut, R. G., 320 Ruscio, A. M., 89, 141 Ruscio, J., 89 Rush, A., 325 Rush, A. J., 326 Rush, B., 20 Rushton, J. P., 77 Russell, M., 251 Ruth, T. E., 100, 348 Rutter, M., 456 Rutter, M. L., 222 Sabalis, R., 296 Sabatino, S. A., 137 Sable, P., 214 Sacher-Masoch, L. von, 293 Sachs-Ericsson, N., 172 Sacktor, H., 405 Sadovsky, R., 152 Safarinejad, M. R., 279 Sakamoto, S., 367 Saklofske, D. H., 76 Saks, E. R., 359, 361, 362, 363 Salcioglu, E., 181 Saldano, D. D., 433 Salgado-Pineda, P., 376 Salkovskis, P. M., 129 Salmon, P., 198 Salomon, K., 195 Salthouse, T. A., 400 SAMHSA, see Substance Abuse and Mental Health Services Administration (SAMHSA) Sammons, M. T., 24 Samuel, D. B., 89 Samuels, J., 144, 145 Sanchez, H. G., 344 Sanders, A. R., 378 Sanders, J., 99 Sands, S. H., 456, 464 San Francisco Women Against Rape, 297t Santiago-Rivera, A. L., 27 Santisteban, D. A., 214 Sarbin, T. R., 87, 89 Sargent, J., 448 Sartory, G., 101

Satir, V. M., 57 Satow, R., 171 Sattler, J. M., 76 Satz, P., 398 Saudino, K. J., 230 Saul (King), 337 Saulny, S., 343 Savarino, J., 324 Saxena, S., 142, 144 Sayer, A. G., 252 Scelfo, J., 415 Schacht, T. E., 89 Schachter, S., 224, 242 Schafer, J., 251 Schaudinn, F., 22, 38 Scherr, P. A., 409 Schiavi, R. C., 278 Schlesinger, L., 487 Schmauk, F. J., 225, 225f Schmidt, C. W., 290 Schmidt, H., 146 Schmidt, N. B., 122, 136, 168, 169 Schmitt, W. A., 223 Schneider, J. A., 402 Schneider, M. S., 283 Schneier, F. R., 126, 132 Schnurr, P. P., 180 Schoneneman, T. J., 19 Schonfeldt-Lecuona, C., 166 Schork, N. J., 376 Schreiber, F. R., 158 Schreiber, J. L., 380 Schretlen, D. J., 78 Schrut, A., 295 Schuckit, M. A., 248, 249, 345 Schuen, L., 296 Schulman, S. L., 433 Schulze, B., 15 Schwartz, B. S., 188 Schwartz, L., 170–171 Schwartz, L. M., 470 Schwartz, R. C., 57 Schwartzman, J. B., 59 Schwenk, F., 468 Schwitzer, A. M., 455 Scorcia, D., 82 Scott, M. J., 178 Scott, W., 388 Scovern, A., 296 Scribner, C. M., 25 Scroppo, J. C., 158 Scullin, M. H., 437, 441 Seale, C., 356 Searight, H. R., 427, 428 Seay, S., 146 Seeley, J. R., 306 Seeman, M. V., 381 Segal, M., 415 Segall, R., 449 Segerstrom, S. C., 194 Segraves, R. T., 265, 278 Segrin, C., 56 Seidel, L., 140 Seidell, J., 450 Seitz, V., 458 Selesnick, S. T., 16, 19 Seligman, M. E. P., 25, 42, 103, 128, 316, 317, 326 Selten, J.-P., 381, 382 Seltzer, B., 394 Selvin, I. P., 286 Selye, H., 194 Seneviratne, H. M., 186, 188 Seroczynski, A. D., 317 Severeijns, R., 171 Sewall, B., 157

Sexton, T. L., 255 Shadlen, M. N., 397 Shafran, R., 131, 465, 466 Shahidi, S., 198 Shalev, A. Y., 177 Shapiro, D. L., 479, 481, 484, 489 Sharpe, M., 162, 169 Shaver, P. R., 67 Shaw, B., 325 Shaw, H., 458, 464 Shaw, P., 425 Shea, S. C., 335, 337, 345 Shea, T., 205 Sheafor, B. W., 58 Shear, M. K., 137 Shedler, J., 253 Sheehan, W., 157, 158 Sheeley, V. L., 492 Sheikh, J. I., 136 Shelley-Ummenhofer, J., 466, 467 Sher, K. J., 252, 253 Sherbourne, C. D., 314 Sherwood, N. E., 444, 452 Shiffman, S., 252, 257, 452 Shin, E., 493 Shin, L. M., 121, 178 Shinohara, M., 455 Shisslak, C. M., 449 Shneidman, E. S., 337, 338t, 345, 353 Shore, M. F., 89, 90 Shore, S., 108–109 Shreve, B. W., 344 Shulman, C., 436 Shuman, D. W., 476, 480 Siegel, J. M., 297 Siegel, M., 493 Siegel, R. A., 225 Siegel, S., 40 Siegel, S. J., 374 Siegle, G. J., 326 Sigler, J.-L., 461 Silagy, C., 256–257 Silberg, J., 43 Silberg, J. L., 110 Silberstein, S. D., 186, 187, 187f, 188 Silk, K. R., 24 Silva, R., 365 Silver, E., 481, 482 Silver, R. C., 180 Silverman, J. M., 384 Silverman, M. M., 335 Silverman, W. K., 139, 140, 141, 178 Silverstein, L. B., 115 Sim, K., 376 Sim, L. A., 457, 465 Simek-Morgan, L., 60 Simeon, D., 153 Simmons, A. M., 462 Simmons, A. N., 120 Simms, C. A., 154, 155f, 159, 160 Simon, G. E., 164, 170, 324 Simon, L. M. J., 227 Simon, R. I., 476 Simon, T., 337 Simons, A. D., 312 Simons, J., 244 Singh, B. S., 164 Singh, S. P., 166 Singhal, V., 468 Sirri, L., 162 Sizemore, C., 155, 161, 162 Skinner, B. F., 49, 50, 53 Slater, M. A., 171

I-9

Sloane, R. B., 47 Slovenko, R., 481 Slutske, W. S., 222 Smeets, T., 158 Smith, B., 361, 378 Smith, C., 165 Smith, C. S., 355 Smith, E. M., 180 Smith, G. C., 162, 170, 171, 172 Smith, J. E., 253, 257 Smith, K., 435 Smith, L., 59 Smith, S. A., 236, 261, 310 Smith, T. W., 185 Smits, J. A. J., 330 Snowden, L. R., 142, 146 Snyder, S., 39 Sobal, J., 459 Sobell, L. C., 253 Sobell, M. B., 253 Society for Personality Assessment, 74 Solano, J., Jr., 378 Sommers-Flanagan, J., 50, 64 Sommers-Flanagan, R., 50, 64 Sonnenschein, M. A., 24 Sontag, D., 338 Sorenson, S. B., 297 Sorenson, T. I. A., 468 Sorkin, A., 367 Sotres-Bayon, F., 120 Southwick, S. M., 96 Spanos, N. P., 16, 19, 159 Spector, I. P., 271, 272t, 275, 289t Speer, D. C., 354 Spencer, S. J., 91 Spencer, S. L., 279 Spencer, T. J., 424, 425 Spiegel, D., 156, 157 Spiegel, H., 160 Spielberger, C. D., 74 Spitzer, R. L., 207, 209, 245, 394, 451 Spitznagel, E. L., 180 Spotnitz, H., 47t Spradlin, L. K., 58 Springen, K., 448 Srebalus, D. J., 492 Srinivasan, K., 136 Staal, W. G., 376, 377 Staats, A. W., 330 Stack, S., 348 Stacy, A. W., 251 Stader, S. R., 318 Staerk, M., 198 Stahl, S. M., 375, 378 Stalberg, G., 388 Stambor, Z., 196 Stanley, M. A., 141, 146 Staples, F. R., 47 Starcevic, V., 162, 167, 169, 170, 171, 173 Stark, E., 293 Stark, J., 362 Stark, M. J., 261 Startup, H., 369 Stat, M., 444 Stathopoulou, G., 330 Steadman, H. J., 481, 482 Steege, J. F., 280 Steele, C. M., 91, 250, 345 Steele, M. S., 197 Stefanek, M., 192 Stefanidis, E., 361 Steffen, J. J., 250 Steiger, H., 454, 462

I -1 0

N A ME IN DE X

Stein, D. J., 138, 139 Stein, M. B., 120, 126, 135, 136f Steinberg, J. S., 182 Steinberg, L., 459 Steiner, B. W., 291 Steinwachs, D. M., 379, 385 Steketee, G., 143t, 145, 146 Stenard, P., 346 Sterin-Borda, L., 377 Stern, J., 164 Sternberg, R. J., 77–78 Stevenson, J. F., 262 Stewart, C. A., 299 Stewart, M. O., 325, 329 Stewart, W. F., 187 Stice, E., 253, 457, 458, 458f, 464 Stiles-Camplair, P., 82 Stiller, B., 331 Stillion, M. J., 345 Stinson, F. S., 309 Stober, G., 365, 368t, 369 Stock, W. E., 274, 279, 282, 283 Stolar, N., 366, 378, 379t Stone, A. A., 193, 199 Stone, M. H., 209 Stoolmiller, M., 431 Story, M., 444, 461 Stout, A. L., 280 Stout, C., 189 Stradling, S. G., 178 Straus, M. A., 299 Streep, M., 217 Strickland, B. R., 309, 320, 321 Striegel-Moore, R. H., 462 Stringer, S. A., 76 Strobeck, C., 141 Strober, M., 454 Stroebe, M., 314 Stroebe, W., 314 Strohman, R., 36, 43 Strom, L., 198 Strong, B., 283 Strong, J. E., 82 Strong, S. M., 460 Strous, R. D., 384 Strunk, D., 325, 329 Strupp, H. H., 100 Stuart, F. M., 279 Stuart, S., 171 Sturm, R., 314 Sturnick, D., 430 Subich, L. M., 454, 458 Substance Abuse and Mental Health Services Administration (SAMHSA), 234f, 236, 237, 239, 241, 242, 243, 244, 253, 254, 428, 430 Suchday, S., 134 Sue, D., 10, 11, 26, 27, 57, 58, 59, 60, 102, 172, 180, 183, 203, 218, 226, 227, 280, 494, 495 Sue, D. M., 102 Sue, D. W., 10, 11, 26, 27, 57, 58, 59, 60, 172, 180, 183, 203, 218, 226, 227, 280, 494, 495 Sue, S., 82, 254 Sugiura, T., 367 Sui, X., 471 Sullivan, H. S., 47t Sullivan, L., 481 Sullivan, P. F., 454 Sulser, F., 311 Sun, P., 261 Sundberg, N. D., 69 Sundel, M., 131 Sundel, S. S., 131

Sundstrom, E., 360 Suokas, J., 345 Sussman, S., 253, 261 Sutherland, S. M., 218 Sutton, S. K., 316 Suzuki, K., 127 Suzuki, L., 77 Svikis, D. S., 248 Swaab, D. F., 287 Swanson, J., 484 Swanson, J. W., 15 Swartz, M., 163t, 164 Swedo, S. E., 142, 143, 143t Sweillam, A., 484 Swindler, J., 338, 348 Sybil, 155, 158, 160, 162 Sykes, R., 162, 163, 169 Syme, S. L., 56, 196 Szasz, T. S., 12, 250, 355 Tabachnick, B. G., 494 Tabakoff, B., 248 Taber, K. H., 144 Tabert, M. H., 395 Takeuchi, J., 382 Talleyrand, R. M., 444, 455 Tally, S. R., 320 Tamminga, C. A., 384 Tan, H.-Y., 377, 378 Tanaka, E., 367 Tanzi, M. G., 131 Tapert, S. F., 249 Taplin, J. R., 69 Tarasoff, T., 476, 493 Tardiff, K., 484 Tarkan, C. L., 447 Tárraga, L., 409 Task Force on Promotion and Dissemination of Psychological Procedures, 25 Tatman, S. M., 24 Taylor, E. H., 77, 78 Taylor, H. A., 250 Taylor, J., 449 Taylor, J. B., 399 Taylor, L., 429 Taylor, S., 132, 137, 172, 181 Taylor, S. E., 195 Tchaikovsky, P. I., 329 Teasdale, J. D., 317 Teicher, M., 157 Teicher, M. H., 432 Telch, M. J., 132, 134 Teri, L., 314 Terman, L. M., 76 Terr, L. C., 98 Tessner, K., 379 Thanos, P. K., 470 Tharp, B. R., 415f Thase, M. E., 25, 312, 326 Thelen, M. H., 155, 492 Theorell, T., 184 Thiedke, C. C., 433 Thienemann, M., 141 Thigpen, C. H., 155 Thirthalli, J., 378 Thom, A., 101, 102, 103 Thomas, A., 193 Thomas, C., 296 Thomas, D., 186 Thomas, P., 365 Thompson, J. K., 458 Thompson, P. M., 376 Thompson, R. N., 128 Thompson, T., 315 Thomsen, S., 459

Thorndike, E., 49 Thorndike, R. L., 76 Thorup, A., 381 Thrope, S. J., 129 Thurber, S., 157 Thurmond, A., 312 Tienari, P., 379 Tierney, J., 184 Tiggemann, M., 444, 458 Tikhonova, I. V., 150 Timmer, B., 167 Tipp, J., 211 Titone, D., 365 Tobin, J. J., 183 Tolan, P. H., 225 Tolin, D. F., 129, 181 Tollefson, G. D., 145 Tolman, A. O., 476 Tomada, A., 367 Tooker, G., 154 Torgersen, S., 169, 204, 218 Toro, P. A., 491 Torrubia, R., 223 Townsend, M., 179 Trakowski, J. H., 136 Tram, J., 317 Trauer, T., 365 Travella, J. I., 399 Treasure, J. L., 455 Tregellas, J. R., 376 Tremblay, R. E., 431 Trimble, M. R., 166 Tripp, M. M., 456 Tromovitch, P., 98 Trottier, K., 459 Troxel, W. M., 196 Trull, T. J., 214, 252 Tsai, G., 462 Tsai, G. E., 157 Tsang, A. K. T., 416 Tsoi, W. F., 289t Tsuang, M. T., 330 Tucker, E., 150 Tuke, W., 20 Tuller, D., 282 Tunnell, G., 283 Tuomisto, M. T., 185, 193 Turetsky, B. I., 376 Turkheimer, E., 483, 490, 491 Turkington, D., 386 Turner, E. H., 97 Turner, H., 319 Turner, S. M., 146 Turner, W. J., 283 Tuschen-Caffier, B., 452 Tutkun, H., 155 Tyler, L. E., 69 Tylka, T. L., 454, 458 Tyre, P., 197 Tyson, M., 296, 300 Uchino, B. N., 185 Ucok, A., 367 Ullmann, L., 225 Ullmann, L. P., 84 Ulloa, R.-E., 146 Umberson, D., 56 Underwood, A., 176, 184, 188f, 194, 297 U.S. Census Bureau, 26, 60 U.S. Department of Education, 429 U.S. Department of Health and Human Services (DHHS), 13, 14, 15, 25, 36, 39, 41, 404, 408, 426, 432, 440, 491

U.S. Food and Drug Administration (FDA), 97, 324, 420 United States Public Health Service, 348 U.S. Surgeon General, 241, 253, 309, 322, 323, 324, 425, 440 Utsey, S. O., 346, 347 Vaillant, G. E., 208, 216 Valderhaug, R., 146 Valenstein, M., 384 Valentine, J. D., 123, 180 Valentiner, D. P., 178 van Beest, I., 190 Van den Hout, M. A., 129 Vandereycken, W., 456 Van der Gaag, M., 374 Vanderlinden, J., 456 Van Evra, J. P., 229 Van Gestel, S., 121 Van Gogh, V., 15, 329, 407 van Goozen, S. H., 428 Van Hoeken, D., 450 Van Praag, H. M., 343 Van Voorhees, C. A., 100, 348 Vaughan, S., 365 Vazquez-Nuttall, E., 78 Vega, W., 320 Veith, R. C., 194 Veling, W, 382 Verduin, T., 68 Vermetten, E., 157–158 Victor, T., 392 Vidmar, N., 99 Vincent, M. A., 457 Virginia Tech Review Panel, 2 Vogel, F., 312 Vogel, G., 312 Volavka, J., 343 Volkmar, F., 417 Volkow, N. D., 247, 443, 467, 468, 469 von Gontard, A., 431 VonKorff, M., 170 Vorage, I., 129 Vossekuil, G., 429 Wade, D. T., 170 Wade, N., 44 Wade, T. D., 444, 452, 453, 454, 455 Wadia, R. S., 405 Waehler, C. A., 25 Wagner, A. K., 140 Wagner, D., 397 Wahlin, A., 404 Waldman, I. D., 308 Waldrop, D., 195 Walker, E., 379 Walker, J. R., 167, 171 Walkup, J., 364 Walkup, J. T., 140 Wall, D. D., 491 Wall, T. L., 248, 254 Wallace, M., 15 Waller, G., 455 Walling, A. D., 275 Wallis, C., 425 Walsh, B. T., 445t, 446, 455, 465 Walter, H. J., 246, 251 Walters, E. E., 86, 228 Wampold, B. E., 25 Wander, M. R., 198 Wang, G. J., 469 Wang, P. S., 324

NA M E I NDEX Wang, Y., 444, 468 Ward, M. J., 21 Ward, T., 299, 300 Wardie, J., 41 Wardle, J., 457 Warman, D. M., 363 Warner, T. D., 97 Wartik, N., 165 Wasylkiw, L., 444, 445 Watkins, C., 96 Watson, A. C., 9, 14 Watson, D., 89 Watson, J. B., 48–49, 50, 53, 130 Watson, T., 453 Watts, S., 123 Waxmonsky, J. A., 331 Weathers, F. W., 123 Webdale, K., 489 Wechsler, D., 76 Wedding, D., 24 Weems, C. F., 123, 136, 180 Weghorst, S., 132 Wehmeier, P. M., 372 Weiden, P. J., 385 Weiner, I. B., 74, 81 Weiner, I. W., 354 Weiner, L. A., 156 Weiner, R. D., 324 Weinman, J., 194 Weinshall, D., 367 Weiser, B., 149 Weishaar, M. E., 53, 344 Weisler, R., 179 Weisman, A. G., 379 Weiss, D. S., 72, 123, 180 Weiss, H., 371 Weissberg, M., 160 Weissman, M. M., 140, 202, 206t, 325 Weisz, J. R., 414 Welch, S. S., 212 Wells, A., 125t, 140 Wells, K. B., 314 Welsh, G. S., 75f Werner, S., 381 Werth, J. L., 357 Wertheim, E. H., 459

Wesner, R. B., 247 West, A. E., 126 West, L. J., 259 West, S. A., 436, 437, 440 Westefeld, J. S., 310 Westen, C. G., 217 Westen, D., 449 Westermeyer, J., 491 Westheimer, R. K., 278 Weston, C. G., 202, 203, 216 Weston, R., Jr., 474–475, 476, 481, 488 Wetherell, J. L., 139 Wexler, N., 406 Weyer, J., 20 Whalen, J. C., 433 Whelan, J. P., 248 Whipple, K., 47 Whitaker, A. H., 440 White, D., 480 White, G. M., 172 White, J. W., 425 White, K. S., 253 White, P. D., 193 Whitehouse, A. M., 462 Whiteside, S. P., 220 Whitfield, C. L., 378 Whitley, M., 430 Whitman, W., 329 Whittal, M. L., 134, 136 Wickramasekera, I., 296 Wicks, S., 381 Widiger, T. A., 89, 204, 204t, 205, 206t, 207, 214, 215, 218, 230 Widom, C. S., 212 Wiens, A. N., 71 Wiersma, D., 374, 374f Wiesel, F.-A., 384 Wilbur, C., 160 Wilfley, D. E., 452 Williams, J. B., 84 Williams, J. D. (J. Roberts), 153 Williams, K. E., 143t, 146 Williams, L. M., 293, 432 Williams, R., 331 Williams, R. J., 262, 449, 455 Williamson, D., 171

Williamson, P., 375 Willis, S. L., 409 Wilson, D. B., 425 Wilson, G. T., 452, 465, 466 Wilson, J. L., 448, 449 Wilson, O., 337 Wilson, R. S., 396, 402, 404, 409 Wilson, S., 191 Wilson, W., 12 Wincze, J. P., 278, 301 Windle, M., 253 Windle, R. C., 253 Windover, A. K., 297 Wing, R. R., 452 Winton, E. C., 125 Wise, M. G., 394, 395, 398 Wise, R. A., 241 Wise, T. N., 162, 167, 290 Wiseman, F., 21 Wisniewski, N., 298 Witkiewitz, K., 238, 252 Wittchen, H.-U., 136, 140 Wittstein, I. S., 175 Woike, B. A., 73 Woliver, R., 154 Wollschlaeger, B., 250 Woloshin, S., 470 Wolpe, J., 132 Wolraich, M. L., 425 Wonderlich, S. A., 215, 451, 467 WonPat-Borja, A. J., 11, 27 Wood, M. D., 252, 253 Woods, S. W., 137 Woody, S. R., 132 Woolf, V., 337 Wootton, J. M., 222 Work Group on ObsessiveCompulsive Disorder, 142, 146 World Health Organization, 312 Wright, C. I., 121, 178 Wrightsman, L. S., 67 Wrosch, C., 194 Wu, E. Q., 360 Wyatt, S., 196 Wyatt, W. J., 250 Wyshak, G., 169

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Xiong, V., 183 Yalom, I. D., 57 Yang, B., 126 Yang, L. H., 11, 27 Yanovski, S. Z., 452 Yaryura-Tobias, J. A., 173 Yassa, R., 384 Yates, A., 308, 474, 476 Yehnuda, R., 347 Yehuda, R., 179, 180 Yen, S., 202, 212, 217 Yeung, A., 172 Yirmiya, N., 436 Yorkston, N. J., 47 Youk, T., 356 Young, A. S., 383 Young, B. G., 295 Young, M. A., 309 Youngren, M. A., 314–315 Youngstrom, N., 487 Yu-Fen, H., 367 Yum, K., 249 Zamichow, N., 494 Zanarini, M. C., 213, 215, 217 Zaretsky, A. E., 331 Zayas, E. M., 384 Zayfert, C., 199 Zeichner, A., 250–251 Zeiss, A. M., 279, 318 Zeller, J. M., 191 Zhang, A. Y., 142, 146 Zhang, Y., 141 Zhou, E. S., 190 Zhou, J. N., 287 Zigler, E., 438 Zilboorg, G., 16, 19 Zimmerman, G., 386 Zinbarg, R., 117, 119, 175 Zito, J. M., 414 Zohar, J., 145 Zoroya, G., 398 Zuardi, A. W., 156 Zucker, K. J., 288 Zuckerman, M., 223 Zywicki, T. J., 471

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sub ject in d ex

page numbers followed by f refer to figures page numbers followed by t refer to tables AA, see Alcoholics Anonymous (AA) A-B-C theory of personality, 52 Aberrant behavior, culture-bound, 83t Abnormal behavior assessment of, 68–82 classification of, 83–91 controlling, 5–7 crime and, 476 dimensions leading to particular disorders, 36f DSM definition of, 7–8 explanations of, 4 four dimensions of, 34–36, 35f historical perspectives on, 16–21 humanistic perspective on, 54 incidence of, 15 limitations in defining, 9–11 models of, 30–64 predicting, 4–5 predisposition to develop illness, 43 See also specific models Abnormal psychology, 3–7 defined, 3 legal and ethical issues in, 474–496 trends in, 23–27 Abstinence violation effect, 252 Abuse polysubstance, 240–241 PTSD and, 180 substance, 234, 248 See also Child abuse; Substance abuse disorders Acculturation, anxiety disorders and, 123 Acetaldehyde, alcoholism and, 254 Acetylcholine (ACH), 39, 41t Achieving the Promise: Transforming Mental Health Care in America, 13 Acting-out behaviors, culture and, 11 Active phase, of schizophrenia, 373 Actors, fears or phobias of, 127 Actualization, 54 Acute stress, 318 Acute stress disorder (ASD), 176 defined, 176 diagnosis of, 176–177 etiology of, 177–181 treatment of, 181 AD, see Alzheimer’s disease (AD) Adaptive responses, to short-term stress, 193t Adaptive skills, for mentally retarded people, 437

Addiction cocaine, 243 cognitive-behavioral treatments of, 257–258 compulsive behaviors and, 247 compulsive sexual behavior as, 267 to food, 468 Internet, 228–229 sexual, 266, 267 See also Substance-use disorders Addington v. Texas, 485–486 Additives, ADHD and, 425 ADHD, see Attention deficit/ hyperactivity disorder (ADHD) Adjustment disorders, 87t Adolescents cyberbullying by, 428 dieting by, 459 disorders in, 86t, 412–414 drinking patterns of, 253–254 gray matter loss in schizophrenics, 376 social phobias in, 126 suicide among, 347–348 See also College students Adoptive families, mood disorders in, 310–311 Affect flattening, 366, 379t Affective disorders, eating disorders and, 455–456 Affective symptoms of bipolar disorders, 327 of depression and mania, 306t of unipolar depression, 304 African Americans beauty standards of, 463 body image and weight concerns of, 460–461, 461t eating disorders among, 455 hypertension in, 185, 186, 196 IQ scores and, 78 with OCD, 146 suicides among, 346, 347 Age autistic disorder diagnosis and, 417 mental disorders and, 13 of phobia onset, 127f Age bias, in diagnoses, 27 Aggression alcohol addiction and, 251 Freud on, 45 management of, 430–431 Aging cognitive disorders associated with, 398–400 sexual activity, sexual dysfunctions, and, 284–286 sexual activity by men and women over 60, 286f suicide and, 349 See also Elderly Agnosia, 393

Agoraphobia, 119t, 131–132 defined, 134 etiology of, 134–136 panic disorder and, 134–137 AIDS dementia complex (ADC), 404–405 Akathesis, 384 Alarm stage, of GAS, 194 Alcohol car accidents and, 238 characteristics of, 237t consumption in U.S., 236 effects of, 237–238 ethnic differences in consumption patterns, 237f snorting of, 251 substance-use disorders and, 235 suicide and, 345 Alcoholics, defined, 236 Alcoholics Anonymous (AA), 258–259 Alcoholism defined, 236 environment in, 248 heredity in, 40, 248 risk factors in, 248 Alleles, 43 Alogia, 366, 379t Alternative community programs, for mentally ill, 491–492 Altruistic suicide, 346 Alzheimer’s disease (AD), 394, 400–404 brain and, 401–402, 403 etiology of, 402–404 iatrogenic effects in, 111 isolation as risk for, 396 smell in, 402 American Association on Intellectual and Developmental Disabilities (AAIDD), 436–437 American Law Institute (ALI), Model Penal Code of, 480 American Medical Association, on addiction as disease, 250 American Psychiatric Association, 84 on homosexuality, 283 See also Diagnostic and Statistical Manual of Mental Disorders, The (DSM-IV-TR) American Psychological Association (APA) code of conduct, 477–478 ethical guidelines of, 113–114 Ethical Principles of Psychologists and Code of Conduct, 494–495 “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists,” 495 on school violence, 429

on stereotypes, 90 on working with culturally diverse populations, 114 Amish, depression in, 322 Amnesia continuous, 152 dissociative, 150–151, 151t generalized, 152 localized, 151 selective, 151–152 systematized, 152 See also Dissociative disorders Amnestic disorders, 86t, 391t, 395 dementia, delirium, and, 395f Amniocentesis defined, 439 Down syndrome and, 439 Amphetamines, 241–242 characteristics of, 237t defined, 241 in schizophrenia, 377 treatment for use of, 260 Amygdala, 120, 312 Amytal, 237t Analogue observations, 68 Analogue study, defined, 106 Anal stage, 45, 46 Anger management, 198–199 Anger rapist, 299 Animal research, 98 Animals, fear of, 129 Anorexia nervosa, 445t, 446–449 associated characteristics of, 449 course of, 448 defined, 446 physical complications from, 447–449 subtypes of, 447 tips for, 448 treatment of, 448, 464–466 See also Eating disorders Anorexic Nation Web site, 448 Antabuse, 255, 259 Antianxiety drugs (minor tranquilizers), 41–42 See also Drug(s); Medication Anticonvulsant drugs, for bipolar disorders, 331 Antidepressant drugs, 41, 42 for bulimia nervosa, 466 for cognitive disorders, 408–409 for depressive disorders, 323 for OCD, 145, 146 for somatoform disorders, 172 for stress disorders, 181 Anti-inflammatory medications, for cognitive disorders, 408–409 Antimanic drugs, 41 Antipsychotic drugs, 39, 41, 383–384 for schizophrenia, 386 Antisocial behaviors, 427 father’s influence on, 225 model of, 430 treatment of, 230

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Antisocial personality disorder (APD), 202, 206t, 210–212 biological dimension of, 221–224 crime bosses and, 211 defined, 210 incidence in U.S., 211 multipath analysis of, 221–227, 221f treatment of, 227 Anxiety alcohol for reducing, 249–251 defined, 117 depression and, 305 drug use and, 250–251 genetic predisposition to lack of, 223 Anxiety disorders, 86t, 117–147 biological dimension of, 119–122 defined, 117 groups of, 118, 119t lifetime and 12-month prevalence of, 88f multipath perspective on, 119–123, 120f neuroanatomical basis for, 121f obsessive-compulsive disorder, 141–147 panic attacks, 117, 133 panic disorder and agoraphobia, 133–137 phobias as, 124–133 prevalence in U.S., 118f psychological dimension of, 122–123 social and sociocultural dimensions of, 123 See also specific disorders Anxiety sensitivity, 122 Anxiety Sensitivity Inventory (ASI), 134 Anxious behaviors, personality disorders characterized by, 217–220 A1 allele, of D2 dopamine receptor, 248 APA, see American Psychological Association (APA) APD, see Antisocial personality disorder (APD) Aphasia, 390, 393 Aphrodisiacs, 267 ApoE-e2 allele, 404 Appetitive phase, of sexual response cycle, 268 Apraxia, 393 Arbitrary inference, depression and, 315 Arousal, APD and, 223–224 Arousal phase, of sexual response cycle, 268 Arrhythmia, 184 Art, communicating through, 420 ASD, see Acute stress disorder (ASD) As Good As It Gets (movie), OCPD in, 220 Asia APD and, 227 cultural values in, 11 Asian Americans eating disorders among, 444 suicides among, 346, 349

Asians, alcohol consumption by, 254 Asperger’s syndrome, 415, 417–419, 418t training program for, 109 Assessment, 66–82, 83 computer, 81–82 ethics of, 81–82 interviews in, 69–71 of members of different cultural groups, 82 neurological tests and, 80–81 observations in, 68–69 psychological tests and inventories in, 69t, 71–79 reliability and validity in, 67–68 See also Psychological tests and inventories Assisted treatment, court-ordered, 489 Associative learning, classical conditioning as, 48 Asthma, 188–190 bronchiole network and, 188f defined, 188 percent of current prevalence in U.S., 189f Ataque de nervios, 83t, 123, 156 Attention deficit/hyperactivity disorder (ADHD), 412, 414, 422–426, 423t combined type, 424 defined, 423 etiology of, 424–425 predominantly hyperactiveimpulsive type, 423 predominantly inattentive type, 423–424 treatment of, 426 types of, 423–424 Attitudes, behavior disorders and, 11 Auditory hallucinations, 364 Autism spectrum disorders, 414 Autistic disorder, 412, 414, 415–417, 418t defined, 415 diagnosis of, 417 impairments in, 416 psychological dimension of, 420–421 social dimension of, 421 sociocultural dimension of, 421 symptoms of, 416 Autonomic nervous system (ANS) abnormalities in APD, 223 reactivity inherited by, 40 Autonomic response specificity, 193 Autopsy, psychological, 335 Aversion therapy, defined, 257 Aversive behavior rehearsal (ABR) program, 296 Avoidance learning, 225 Avoidant personality disorder, 206t, 217–218 defined, 217 Avolition, 366, 379t Axes (DSM), 84–85 Axis I disorders, personality disorders and, 213, 218 Axis II disorders, categorical weaknesses of, 204t Axon, defined, 38 Axon terminals, 39

Bacterial meningitis, 405 Barbiturates, 239–241 celebrity users of, 239 characteristics of, 237t defined, 239 Base rates, 99–100 defined, 99 B-cells, 190 BDD, see Body dysmorphic disorder (BDD) Beautiful Mind, A (movie), 363 Beauty, western standards of, 463 Beck Depression Inventory (BDI), 75 Behavior ADHD and, 424 context, diagnosis, and, 212 personality disorders characterized by odd or eccentric, 205–209 Behavioral approaches to cognitive disorders, 409 to substance-use treatment, 257–258 to treating enuresis, 433 Behavioral classification scheme, 89 Behavioral models, 32–33, 47–50, 62t cognitive models and, 53 criticisms of, 51 defined, 47 Behavioral perspectives on APD, 223 on OCD, 145–146 on phobias, 130 Behavioral symptoms of bipolar disorders, 327–328 of depression and mania, 306t of unipolar depression, 305–306 Behavioral treatment for depressive disorders, 324–326 for OCD, 146–147 of panic disorder, 137 for phobias, 131 Behaviorism, 23 Belief modification, for delusions, 363–364 Bell curve, 77, 77f Bell Curve, The (Herrnstein and Murray), 77 Belonging, as value, 60 Bender-Gestalt Visual-Motor Test, 78–79, 79f Benzedrine, 237t Benzodiazepines, 41, 241 characteristics of, 237t as GAD treatment, 140 for OCD, 145 Beyond a reasonable doubt, 487 Bias age, 27 in diagnosis, 27, 207 in DSM, 89 multicultural model and, 61 against poor, 59 Binge-eating disorder, 445t, 451–453 course and outcome of, 452–453 defined, 451 treatment of, 466–467 See also Eating disorders Binge-eating/purging type, of anorexia, 447, 449 Biochemical theories, 38–40 Biochemical treatment of panic disorder, 137 for phobias, 131

Biofeedback training, defined, 198 Biological challenge tests, 111–112 Biological dimensions of ADHD, 424–425 of anxiety disorders, 119–122 of APD, 221–224 of conduct disorders, 428f of dissociative disorders, 157–158 of eating disorders, 454–455, 454f of enuresis, 433 of GAD, 139, 139f of gender identity disorder, 287 of mental retardation, 439–440 of obesity, 469–470, 469f of OCD, 144–145 of panic disorder and agoraphobia, 134–135 of pervasive developmental disorders, 419–420 of phobias, 128 of psychophysiological disorders, 192–194 of PTSD, 178–179 of schizophrenia, 375–378 in sexual disorders, 295 of sexual dysfunction, 278 of somatoform disorders, 169–170, 170f of substance-use disorders, 247–249, 247f of suicide, 343–344 of unipolar depression, 310–313, 310f Biological interventions, for sexual dysfunctions, 280–282 Biological models, 62t biochemical theories and, 38–40 biological-sociological correlates of psychopathology, 37 biology-based treatment techniques and, 41–43 brain and, 37 genetic explanations and, 40–41 of mental disorders, 21–22, 32, 36–44 multipath model for, 34, 35f Biological research, 110–112 Biological treatment for OCD, 146 for somatoform disorders, 172 Biology, and gender differences in depression, 321 Biomedical treatments, for depressive disorders, 323–324 Biopsychosocial models, defined, 14 Bipolar disorders, 327–331 bipolar I disorder, 328, 328t bipolar II disorder, 305t, 328, 328t classification of, 328–329 defined, 304 depressive disorders compared with, 329 drugs for, 42 etiology of, 329–330 prevalence of, 329 symptoms and characteristics of, 327–328 treatment for, 330–331 twelve-month and lifetime prevalence of, 309f Biracial persons, 61 Bisexuality, 283 Blind design, 102–103

S UB JEC T I NDEX Blood cells, stress, immune system, and, 190 Blood phobias, 127, 132 BMI, see Body mass index (BMI) Body consciousness, eating disorders and, 456 Body dissatisfaction among ethnic minority women, 460–461 by gender, 444–445 socialization and, 457 Body dysmorphic disorder (BDD), 162, 163t, 168–169 defined, 168 imagined defects in, 168f Body image in African American and white females, 461t childbearing and, 462 of men, 456, 460 society and, 462 thinness and, 457, 458 Body mass index (BMI), 467–468 appropriateness of standards, 470 defined, 467 Borderline personality disorder, 206t, 212–215 bulimia and, 451 defined, 212 Boys with ADHD, 424 bullying by, 428 See also Men Bradycardia, 184 Brain, 37 in ADHD, 425 Alzheimer’s disease and, 401–402 cognitive disorders and, 392–393, 402 dementia and, 394 diseases and infections of, 404–406 disorder specific chemical imbalances and, 39 in dissociative disorders, 157–158 eating behaviors and, 454–455 electrical stimulation of, 38 environment and, 44 mood disorders and, 312 normal vs. Alzheimer’s, 403 PTSD and, 179 in schizophrenia, 376–377 smoking damage to, 249 stroke results on, 398 traumatic injury to, 396–397 Brain-behavior relationships, 25 Brain fag, 156 Brain pathology, 17 Brain structure, 38f in anxiety disorders, 120 Brain trauma, 394 Brief psychotic disorder defined, 371 schizophreniform disorders, schizophrenia, and, 371t Bulimia nervosa, 445t, 449–451 course and outcome of, 451 defined, 449 treatment of, 466 See also Eating disorders Bullying, 428 resisting, 430

Buspirone, for GAD treatment, 140 B vitamins, memory and, 404 Caffeine, 236, 242 characteristics of, 237t Campral, 255–256 Cancer, stress and, 191–192 Cannibalism, by Dahmer, 486 Caregivers for cognitive disorders, 410 for mentally retarded, 441–442 Case formulation, research in, 95–96 Case study, 108–109 defined, 108 Castration, for treating sexual offenders, 300–301 Catatonia, 308 symptoms in, 367f Catatonic schizophrenia, 368t defined, 369–370 Catecholamines, in ADHD, 425 Cathartic method, 23 Causal attributions, learned helplessness and, 316 Center Cannot Hold, The: My Journey Through Madness (Saks), 359 Center for Attention and Related Disorders, camp of, 426 Central nervous system abnormality in APD, 222–223 ADHD and, 424–425 Cerebral blood flow measurement, defined, 392 Cerebral cortex, 37 Cerebral infarction, defined, 399 Cerebral tumors, 407 defined, 406 Cerebrovascular accidents, see Strokes Cerebrovascular disease, 394 Cerebrum, 37 Chemical actions, in body, 38 Chemical imbalances, disorder specific, 39 Chemicals, in ADHD, 425 Chemical therapy, for treating sexual offenders, 301 Child abuse, elimination disorders and, 432–433 Childbearing, body type and, 462 Child custody, evaluations in divorce proceedings, 477t Childhood disorders of, 86t, 412–414 lifetime and 12-month prevalence of disorders in, 88f Childhood behaviors, in Thailand, 414 Childhood disintegrative disorder, 415, 418t, 419 Child protection, psychological evaluations for, 477t Children DSM classifications and, 89 elimination disorders in, 431–434 learning disorders in, 434–435 medication for, 414 mental retardation in, 435–442 obesity in, 467 with OCD, 146 pervasive developmental disorders in, 414–422

self-control, mastery, and, 123 suicide among, 347–348 unipolar depression in, 306 Child Welfare Information Gateway, 432–433 China children in, 59 delusions in, 367 eating disorders in, 463 Chlorpromazine, 42, 383 Christianity abnormal behavior and, 17 exorcism in, 18 witchcraft and, 18–19 Chronicity, of stress, 318 Cialis, 282 Cigarette smoking, 236 See also Nicotine Civil commitment, 482–485 criteria for, 483–484 defined, 482 determination of, 477t factors in, 483f involuntary, 484–485 level of proof for, 485–486 procedures in, 484–485 Class body image and, 457 obesity by, 471 socioeconomic, 59 Classical conditioning basic process of, 48f defined, 48 vs. operant conditioning, 49 Pavlovian, 48 perspectives on phobias, 130 Watson on, 48–49 Classification of abnormal behavior, 83–91 behavioral scheme for, 89 objections to, 90–91 Classification system defined, 83 in DSM, 83–90 Claustrophobia, 126 Clear and convincing evidence, 487 Clinical observations, 68–69 Clinical psychology, 6t Clinical research, 96–100 base rates in, 100 concerns in, 102–103 Clinical risk factors, for rape, 299 Clinical significance, vs. statistical significance, 100 Clinical syndromes, in DSM Axis I, 84 Clomipramine, for OCD, 145, 146 Clonidine, 256 Closed-head injuries, 397 Clozapine, 383 Clozaril, 383 Club drugs, 241 Cluster headaches, 188 Cocaine, 235t, 242–244 characteristics of, 237t defined, 242 Codeine, 237t Codes of conduct, 477–478 Coffee, see Caffeine Cognition, in panic attacks, 136 Cognitive approaches to cognitive disorders, 409 to substance-use treatment, 257–258 to therapy, 53, 198–199

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Cognitive-behavioral interventions, for psychophysiological disorders, 198–199 Cognitive-behavioral perspective on GAD, 140 on panic disorder and agoraphobia, 135–136 on phobias, 130–131 on somatoform disorders, 170–171, 172–173 Cognitive-behavioral theories, anxiety disorders and, 122 Cognitive-behavioral therapy (CBT) for binge eating, 467 for bulimia nervosa, 466 for depressive disorders, 325–326 as GAD treatment, 141 for panic disorder, 138 for schizophrenia, 386–388 for somatization disorder, 173 Cognitive disorders, 86t, 390–392 aging and, 398–400 amnestic disorders as, 86t, 391t, 394–395 brain anomalies and, 402 causes of, 392, 395–396, 396t cognitive disorders not otherwise specified as, 391t defined, 390 delirium as, 86t, 391t, 394–395 dementia as, 86t, 391t, 393–394 etiological factors or types, 391t etiology of, 395–400 treatment and prevention of, 408–410 types of, 393–395 See also Elderly Cognitive factors in addiction, 251–252 in binge-eating disorder, 466–467 in PTSD symptoms, 181 Cognitive functioning, age-related declines in, 400 Cognitive impairment, tests for, 78–79 Cognitive-learning approaches, to depression, 316–317 Cognitive models, 51–53, 62t criticisms of, 53 defined, 51 Cognitive-oriented approaches, to borderline personality disorder, 214 Cognitive perspectives on APD, 224 on depression, 315–316 on OCD, 145–146 Cognitive restructuring, 131, 132 Cognitive symptoms of bipolar disorders, 327 of depression and mania, 306t of Parkinson’s disease, 392 of schizophrenia, 367 of unipolar depression, 305 Cognitive therapy for psychogenic disorder, 95 for schizophrenia, 388 Collectivity, as value, 60, 61 College students alcohol-related injuries among, 236 depression among, 310 as samples, 102 suicide among, 338

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Columbine High School killings, 486 Comatose patients, brain injuries in, 397 Commitment, see Civil commitment Communication by schizophrenics, 386 in social-relational treatment, 57 of suicide intent, 342 Communication patterns, in schizophrenia, 379–380 Community programs, for mentally ill, 491–492 Comorbid disorders, 138–139 Comorbidity, defined, 86 Competency to stand trial, 477t, 481–482 defined, 481 Comprehensive programs, for children with pervasive developmental disorders, 422 Compulsions, 142f clinical examples of, 143t defined, 141 Compulsive behaviors, addiction and, 247 Compulsive sexual behavior (CSB) as addiction, 267 defined, 266 Computerized axial tomography (CT) defined, 392 scan, 80 Computers, in assessment, 81–82 Concordance rate, in schizophrenia, 378 Concussion, 396 Conditioned response (CR), defined, 48 Conditioned stimulus (CS), defined, 48 Conditioning classical, 48 and fetishism, 295 in phobias, 130 social, 26 Conduct disorders, 423t, 427–428 biological dimension of, 428f defined, 427 etiology of, 428–430 multipath model for, 428f psychological dimension of, 428f social dimension of, 428f sociolocultural dimension of, 428f treatment of, 430 Confidentiality of client records, 81 in therapist-client relationship, 492 Conjoint family therapeutic approach, 57 Conscience, 45 Conscientiousness, 230 Conservatives (political), flexibility of, 394 Constipation, encopresis and, 434 Construct validity, 68 Contamination obsession, 143 Content validity, 68 Contingency management, defined, 257 Continuous amnesia, 152 Control anxiety disorders and, 122–123

delusions of, 362 in psychophysiological disorders, 194–195 stress and, 194–195 Control group, 101–102 Controlled (analogue) observations, 68 Controlled drinking, 259 Controlled observations, 70, 98 Contusion, 396 Conversion disorder, 162, 163t, 164–167, 166 in Anna O., 171 defined, 164 Copycat suicides, 348–349 Coronary heart disease (CHD), 183–184 and fibrinogen, 196 among Japanese people, 196, 197 Correlation coefficient, 103 Correlations, 103–105, 106 defined, 103 Corticosteroids, 190 Cortisol, abnormal levels in mood disorders, 312 Coulrophobia, 126 Counseling psychology, 6t Couples therapy, defined, 57 Courts on rights of mental patients, 485–490 treatment ordered by, 487–488, 489 Covert sensitization, defined, 257 Crack cocaine, 244 characteristics of, 237t Cretinism, 439 Crime insanity defense for, 476 insanity during, 474–476 M’Naghten Rule for, 479 Criminal commitment, 478–482 defined, 478 Criminal conduct, as predictor of dangerousness, 484 Criminals, profiling of, 477t Criminogenic risk factors, for rape, 299 Crisis intervention, for suicide prevention, 351–352, 353–354 Criterion-related validity, 68 Critical development periods, 43 Cross-cultural assessment, in DSM-IV-TR, 87, 89 Cross-cultural factors in dissociative disorders, 159 in psychopathology, 382–383 Cross-cultural studies on eating disorders, 462–464 of mood disorders, 320 CT scan, see Computerized axial tomography (CT) Cue exposure, for bulimia nervosa, 466 Cultural bias, in DSM, 89 Cultural competence, mental health profession and, 494–495 Cultural dimensions, of OCD, 146 Cultural diversity, APA guidelines for working with, 114 Cultural groups, assessing status of, 82 Cultural issues, in schizophrenia, 367–368

Cultural relativism, defined, 10–11 Cultural universality, defined, 10 Culture alcohol consumption by, 254 APD and, 227 defined, 9–10 defining abnormality and, 9–11 in diagnosis and treatment, 495 disorders viewed by, 382 drinking patterns and, 254 health and, 196 panic disorder and, 136 psychogenic disorders and, 94 in schizophrenia, 380, 381–383 sexuality and, 266 somatoform and dissociative disorders and, 156 suicide among elderly and, 349 in unipolar depression symptoms and treatment, 319–322 Culture-bound syndromes, 83t, 156 Cures, myths about, 14–15 Cyclothymic disorder, 305t, 329 Danger, from mentally disturbed people, 15 Dangerousness assessing, 477t defined, 484 predicting, 9, 484–485, 486 Dark Ages, behavior explained during, 17–18 Date rape, 297 Date-rape drug, Rohypnol as, 242 Deaths from anorexia, 447 from asthma, 189 from obesity, 468 See also Suicide Defendants, legal standards on mental state of, 479f Defense mechanism, defined, 44 Deficit, mental illness as, 15 Deficit model, defined, 60 Deinstitutionalization, 490–492 defined, 490 downside of, 491 drug therapies and, 24 Delinquent youths, 430 Delirium, 86t, 391t, 392, 394–395 defined, 394 dementia, amnestic disorders, and, 395f risk for, 395 Delusion(s), 8 challenges to, 363–364 culture and, 367 of grandeur, 8 of persecution, 8 in schizophrenia, 361–364 Delusional disorder, defined, 372 Delusional parasitosis, vs. physical disease, 373 Dementia, 86t, 391t, 393–394 AIDS dementia complex and, 404–405 auto-driving competency and, 394 defined, 393 delirium, amnestic disorders, and, 395f and Down syndrome, 439 heredity in, 396 interactions with others and, 396

vascular, 399 See also Alzheimer’s disease (AD) Demonic possession, 18 Dendrite, defined, 38 Dependence on cocaine, 244 on opiates, 239 polysubstance, 241 progression toward, 247f substance, 234 Dependency, as stressor, 318 Dependent personality disorder, 206t, 218–219 defined, 218 Dependent variable, defined, 100 Depersonalization disorder, 150, 151t, 154–156 defined, 153, 154 treatment of, 161 Depo-Provera, 301 Depressants, 235t, 236–241, 237t characteristics of, 237t defined, 236 Depression and Alzheimer’s disease, 402 anxiety and, 305 bulimia and, 451 characteristics of, 308 cognitive explanations of, 315–316 combined medicationpsychotherapy treatments for, 326 culture and, 319–322 drugs for, 39, 40, 42 eating disorders and, 455–456 gender and, 320–322, 321t heredity in, 40 homelessness, suicide, and, 344–345 learned helplessness and, 316–317 Lewinsohn’s model of, 314–315 loss as source of, 314 medications for, 323, 324 in Parkinson’s disease, 409 in psychophysiological disorders, 194 PTSD and, 180 recognition of, 90 responses to, 322 separation as cause of, 313 stress and, 317–319 suicide and, 349 symptoms of, 306t unipolar, 304 See also Bipolar disorders; Depressive disorders; Unipolar depression; Unipolar disorders Depressive disorders behavioral treatments for, 324–326 biomedical treatments for, 323–324 bipolar disorders compared with, 329 defined, 307 diagnosis and classification of, 307–309 major depressive disorder, 305t, 307, 307t psychotherapy for, 324–326 specifiers of, 307–309 symptoms of, 307–309 See also Depression

S UB JEC T I NDEX Detoxification, defined, 255 Developing countries, eating disorders in, 463–464 Deviance, 8 recognizing mental disturbance by, 14 societal norms and, 8 Devil Wears Prada, The (movie), narcissistic behavior in, 217 Dexedrine, 237t Dhat (hypochondriacal concerns, India), 156 Diagnosis of autism, 416–417 bias in, 27 of mental retardation, 436–437 See also Assessment; Classification system; specific disorders Diagnostic and Statistical Manual of Mental Disorders, The (DSM-IV-TR), 7, 21 acute stress disorder in, 177 antisocial personality order in, 211 Axes in, 84–85 binge-eating disorder and, 451 borderline personality disorder in, 213 classification system of, 83–90 criminal commitment and, 476 criticisms of, 89–90 culture-bound syndromes and, 26–27 dementia in, 394 diagnosing Axis II personality disorders and, 204t eating disorders and, 443 evaluation of system, 86–90 gender identity disorder in, 288 major depressive disorder in, 307t mental disorders in, 85–86, 86t–87t mental retardation in, 436 on multicultural influences, 495 obesity and, 467–468 OCPD in, 220 oppositional defiant disorder in, 426–427 panic disorder in, 133 personality disorders in, 203 phobias in, 124–125 posttraumatic stress disorder in, 177 psychophysiological disorders in, 182 sadomasochism in, 294 schizophrenia in, 359–360, 361 sexual dysfunction in, 271 somatization disorder in, 133 suicide in, 335 Dialectical behavior therapy, 214–215 Diathesis-stress process, 317 Diathesis-stress theory, defined, 43 DID, see Dissociative identity disorder (DID) (multiple personality disorder) Diet, for ADHD, 425 Dieting, 471 See also Eating disorders; Weight Diminished capacity, 480 Disasters, anxiety disorders and, 123

Disconfirmatory bias, in OCD, 146 Disease drug addiction as, 250 exposure to stress and, 190 hereditary, 40–41 impact of laughter on, 191 from obesity, 468 See also Physical disease Disgust, vs. fear, 129 Disorders lifetime and 12-month prevalence of, 88f See also specific types Disorders of Sexual Desire (Kaplan), 268 Disorganized motor disturbances, in schizophrenia, 365–366 Disorganized schizophrenia, 368t defined, 369 Disorientation, 8 Dispositional risk factors, for rape, 299 Disruptive behavior disorders, 414 Dissociative amnesia, 150–151, 151t defined, 150 treatment of, 161 Dissociative disorders, 87t, 149–162, 151t biological dimension of, 157–158 culture and, 156 defined, 149 etiology of, 157–161 multipath model for, 157f psychological dimension of, 158–159 social and sociocultural dimension of, 159–161 treatment of, 161–162 Dissociative fugue, 150, 151t defined, 153 treatment of, 161 Dissociative identity disorder (DID) (multiple personality disorder), 150, 151t, 154–155 comparison of reported cases of, 155f defined, 154 diagnostic controversy over, 155–156 Hillside Strangler and, 480 “suspect” techniques in treating, 160 treatment of, 161 Distress, 8 drug use and, 253 Disturbed eating patterns, 443 Dittrick v. Brown County, 266 Dixon v. Weinberger, 486 DNA, Human Genome Project and, 40–41, 110, 111 Dopamine, 39, 41t, 311 in ADHD, 425 eating disorders and, 454–455, 469–470 Dopamine hypothesis, in schizophrenia, 377–378 Dopaminergic receptor blocks, 383 Double-blind design, 102–103 Downers, see Barbiturates Down syndrome, 438–439 defined, 438 rate of births to mothers in California, 439t trisomy of, 440 work environment and, 441

Dramatic behavior, disorders characterized by, 210–216 Draw-a-person test, 73 Dream analysis, 45 Drinking controlled, 259 See also Alcohol; Substance-use disorders Drug(s) for bipolar disorder, 330–331 caffeine as, 236 for children, 414 club drugs, 241 for cognitive disorders, 408–409 and dopamine hypothesis in schizophrenia, 377–378 for obesity, 472 prescription privileges for, 24 psychoactive, 39–40 psychopharmacology and, 41–42 therapeutic drug intoxication from, 399–400 as triggers for schizophrenia, 378 Drug addiction, 249 as disease, 250 Drug manufacturers, scientific integrity at, 97 Drug overdose, suicide by, 348 Drug revolution, in psychiatry, 23–24 Drug treatment, 41 for depression, 323, 324 Drug use as indicator of disturbance, 253 progression toward, 247f See also Substance-use disorders Drug-use disorders, see Substanceuse disorders Dry cultures, 254 DSM, see Diagnostic and Statistical Manual of Mental Disorders, The (DSM-IV-TR) Due process, defined, 482 Durham standard, defined, 480 Durham v. United States, 480 Duty-to-warn principle, 476, 493 Dynamic functional MRI, 393 Dyscalculia, 435t Dysfunction, 8–9 Dysgraphia, 435t Dyslexia, 435t Dyspareunia, 272t defined, 275 possible causes of, 276t Dysthymic disorder (dysthymia), 305t, 329 defined, 307 Dystonia, 384 Early childhood experiences, 44 Early intervention, for mental retardation, 440–441 Eating disorders, 443, 444–453, 445t anorexia nervosa, 445t, 446–449 binge-eating disorder, 445t, 451–453 biological dimension of, 454–455, 454f bulimia nervosa, 445t, 449–451 cross-cultural studies on, 462–464 ethnicity and, 460–462 etiology of, 454–464 gender and, 464

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mood disorders and, 456 psychological dimension of, 454f, 455–456 route to, 458f social dimension of, 454f, 456–457 society and, 462 sociocultural dimension of, 454f, 457–464 treatment of, 464–467 Eating disorders not otherwise specified (NOS), 443, 453 among African Americans women, 461–462 defined, 453 See also Eating disorders Ecstasy, 241 ECT, see Electroconvulsive therapy (ECT) ED, see Male erectile disorder (ED) Education interventions for schizophrenia and, 388–389 somatic complaints and, 172 and somatization disorder, 164 EE, see Expressed emotion (EE) EEG, see Electroencephalograph (EEG) Ego, 45 Ego autonomy, 47t Ego ideal, 45 Elderly memory loss in, 399–400 neuroleptic side effects of medication in, 384 suicides among, 349 See also Aging Electroconvulsive therapy (ECT), 42, 324 Electroencephalograph (EEG), 80 defined, 392 Elimination disorders, 431–434 and child abuse, 432–433 Ellis’s A-B-C theory of personality, 52, 52f Embryonic development, in mental retardation, 438t Emotion(s) bulimia and, 450 from delusions, 362–363 Emotional behavior, disorders characterized by, 210–216 Emotional disturbances, taxonomy of, 90 Employment programs, for mentally retarded, 441 Empty-chair technique, 95 Encephalitis, 405–406 defined, 405 Encopresis, 433–434 defined, 433 Endophenotypes, 110–111, 376 defined, 110 Endorphins, 41t, 190 Enuresis, defined, 431 Environment in alcoholism, 248 in APD, 221–222 biochemical changes, brain activity, neurology, and, 44 in dependent personality disorder diagnosis, 218 genes and, 43, 122 interventions for cognitive disorders, 410 in mental retardation, 437, 438t

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Environment (cont.) as stressors, 43 and unipolar depression, 310–311 Environmental problems, in DSM Axis IV, 84–85 Epidemiological research, defined, 112 Epilepsy, defined, 406–407 Equanil, 41 Erectile disorder (ED), see Male erectile disorder (ED) Erotomania, 372 Erratic behavior, disorders characterized by, 210–216 Errors, defined, 71 Espiritismo, 94 Essential hypertension, 184–185 defined, 184 Ethical issues in abnormal psychology, 474–496 in assessment, 81–82 in research, 113–114 in suicide, 354–357 Ethical Principles of Psychologists and Code of Conduct (APA), 494–495 Ethnicity, 59–61 alcohol consumption and, 237f antidepressant drug metabolism and, 320 asthma and, 188–189 vs. culture, 10 drinking and, 255 eating disorders and, 452, 460–462 hypertension and, 185f, 186 problems in using references to, 60–61 schizophrenia and, 368, 381, 382t somatic complaints and, 172 stress disorders and, 181 suicide among elderly and, 349 suicide rates by, 339, 341, 342 weight by, 458t See also Race; specific groups Etiology, 83 of acute stress disorder, 177–181 of ADHD, 424–425 of agoraphobia, 134–136 of Alzheimer’s disease (AD), 402–404 of attention deficit/hyperactivity disorder, 424–425 of bipolar disorders, 329–330 of cognitive disorders, 395–400 of conduct disorders, 428–430 defined, 32 of dementia, 394 of dissociative disorders, 157–161 of generalized anxiety disorder (GAD), 139–141 of learning disabilities, 434 of mental retardation, 437–440 of obesity, 469–471 of obsessive-compulsive disorder, 143–146 of panic disorders, 134–136 of paraphilias, 294–296 of pervasive developmental disorders, 419–421 of phobias, 128–131 of posttraumatic stress disorder, 177–181

of psychophysiological disorders, 192–197 of rape, 299 of schizophrenia, 374–378 of sexual dysfunctions, 276–280 of somatoform disorders, 169–172 of substance-use disorders, 246–255 of unipolar depression, 310–322 See also specific conditions Euthanasia, debate over, 355 Evaluation, see Assessment Evidence-based psychotherapy, 25 Excited catatonia, 370 Exhaustion stage, of GAS, 194 Exhibitionism, 289t defined, 291 Existential approach, 53–55, 63t criticisms of, 55 Exorcism, 18 defined, 16 Expectancy, drug use and, 251 Experimental group, 101 Experimental hypothesis, defined, 100 Experiments, 100–103 defined, 100 placebo group in, 102 Exposure therapy, 131–132 defined, 132 for OCD treatment, 146, 147 Expressed emotion (EE), in schizophrenia, 379–380, 380f External validity, 103 defined, 100 Extraversion, 230 Factitious disorder by proxy, 165 Factitious disorders, 87t, 165 defined, 164 Fakama-hari, 382 False memory, determination of, 477t Familial alcoholism, 248 Familial component, of hypertension, 185 Families eating disorders and, 456–457 interventions for schizophrenia and, 388–389 obesity and, 471 of schizophrenics, 387 of suicidal children, 348 suicides and, 346 Family Educational Rights and Privacy Act, 493–494 Family life, of gays, 284 Family systems models, 63t defined, 57 Family therapy for eating disorders, 465 for substance abuse, 255 FAS, see Fetal alcohol syndrome (FAS) Fashion models, body image and, 457 Fathers, antisocial behavior and, 225 Fear vs. disgust, 129 responses to, 122 See also Phobias Fearful behaviors, personality disorders characterized by, 217–220

Fear responses, 178–179 Federal Drug Administration, SSRI studies by, 323 Female orgasmic disorder, 272t defined, 275 treatment for, 282 Females genital changes in sexual response cycle, 270f See also Women Female sexual arousal disorder, 272t, 274 defined, 274 Fetal alcohol syndrome (FAS) defined, 439 mental retardation and, 439–440 Fetishism, 289t conditioning and, 295 defined, 290 Fibrinogen, coronary heart disease and, 196 Field studies, 107, 108 defined, 107 “Fight or flight” response, 178–179 anxiety and, 117 relaxation training and, 197 Final Exit (Humphrey), 355 5-HTTLPR gene, short allele of, 121–122 5-hydroxyindoleacetic acid (5HIAA), 343 Five-factor model, 230 Fixation, 45 Flat affect, 366 Flexibility, of conservatives and liberals, 394 Flooding, defined, 146–147 Fluoxetine, 311, 323 Fluphenazine, 383 Folk medicine, 382 Food hyperactivity and, 425 See also Eating disorders Food addiction, 468 Ford v. Wainwright, 488 Forebrain, 37 Formal standardized interview, 70–71 Frame of reference, of interviewer, 70 Free association, defined, 45 Freebasing, 244 Freedom of choice, 47t Freudian psychodynamic theory, 45 Frotteurism, 289t defined, 292 Functional constipation, encopresis and, 434 Functioning, assessment of, in DSM Axis V, 85 GABA, see Gamma aminobutyric acid (GABA) GAD, see Generalized anxiety disorder (GAD) Gambling, pathological, 228, 229 Gamma aminobutyric acid (GABA), 39, 40, 41t, 121 GAS, see General adaptation syndrome (GAS) Gastric bypass surgery, 472 Gay male subculture, physical attractiveness in, 460

Gays marriage and family life of, 284 suicides among, 346 See also Homosexuality Gender in anxiety disorders, 123 in APD, 226–227 asthma and, 188 body dissatisfaction by, 444 borderline personality order and, 213 bulimia and, 450 dementia and, 396 depression and, 320–322, 321t in diagnosing antisocial personality disorder, 203–204 eating disorders and, 464 exposure to stressors by, 178t hypertension and, 185, 185f mental disorders and, 13 schizophrenia and, 381 social conditioning and, 26 in somatization disorder, 164 stress disorders and, 181 of suicides, 338–339 weight by, 458t Gender bias, in diagnosing mental disorders, 207 Gender factors, 58–59 Gender-identity disorders (GID), 87t, 264–265, 286–288 defined, 286 etiology of, 287–288 treatment of, 288 Gender roles, and depression, 321 General adaptation syndrome (GAS), defined, 194 Generalized amnesia, defined, 152 Generalized anxiety disorder (GAD), 119t, 138–139 concerns of children with, 139 defined, 138 etiology of, 139–141 multipath model for, 139f treatment of, 140–141 Generalized social phobia, 126 General medical condition, cognitive disorders and, 391t General paresis, 21 Genes anxiety disorders and, 121 biochemical theories of behavior and, 38 in depression, 320 environment and, 43, 122 See also Genetic factors Genetic factors in abnormal conditions, 40–41 in addiction, 248–249 in ADHD, 424 in Alzheimer’s disease, 403–404 in APD, 221–222 chronic stress and, 193 connection between stress and depression and, 318 Down syndrome and, 439 in eating disorders, 454 in epilepsy, 408 in GAD, 139 in Huntington’s disease, 406 in hypertension, 185 in mental retardation, 438–439 obesity and, 469 predispositions to fearlessness and, 223 in schizophrenia, 375–377, 389

S UB JEC T I NDEX substance abuse and, 248 See also Genes Genetic linkage studies, defined, 110 Genital changes in female sexual response cycle, 270f in male sexual response cycle, 269f Genital stage, 45 Genome, defined, 40 Genotype, defined, 40 Geodon, 383 GHB, 241 GID, see Gender-identity disorders (GID) Girls ADHD and, 424 weight issues among, 456, 457 See also Women GlaxoSmithKline, scientific integrity at, 97 Global assessment of functioning, in DSM Axis V, 85 Glove anesthesia, 166, 167f Glutamate, 121 Grandeur, delusions of, 8, 362 Grandiosity, 372 Grass, see Marijuana Greco-Roman thought, about abnormal behavior, 16–17 Group homes, for mentally retarded, 441 Group hysteria, 18 Group therapy, defined, 57 Growth dysregulation hypothesis, 420 Guidelines, APA ethical, 113–114 “Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations” (APA), 495 “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” (APA), 27, 495 Guilty, but mentally ill, 481 Gustatory hallucinations, 365 Haldol, 383 Haliperidol, 383 Hallucinations, 8 in borderline personality disorder, 213–214 in schizophrenia, 363, 364–365 Hallucinogens, 235t, 244–245 characteristics of, 237t defined, 244 Halstead-Reitan Neuropsychological Test Battery, 79 Happiness, causes of, 315 Headaches cluster, 188 migraine, 186–187 stress and, 186–188 tension, 187–188 Head injuries, 396–397, 398 Head Start, 440 Health anxiety disorder, hypochondriasis as, 162 Health care, managed, 24–25 Hebephrenic schizophrenia, see Disorganized schizophrenia

Helplessness, in psychophysiological disorders, 194–195 Hemispheres, of brain, 37 Hemlock Society, 355 Hereditary diseases, genes associated with, 40–41 Heredity in alcoholism, 248 in APD, 221–222 in cognitive disorders, 396 in mental retardation, 438t in unipolar depression, 310–311 See also Genes; Genetic entries Heritability of Alzheimer’s disease, 403–404 of depression, 321 Heroin, 237t treating, 256 Hetercyclic antidepressants (HCAs), 323 Heterosexuality, 283 HGP, see Human Genome Project (HGP) Hinckley case, 481 Hindbrain, 37–38 Hippocampus, 120, 312 Hispanic Americans body image among, 462 eating disorders among, 444 suicides among, 346 Historical period, suicides by, 342 Historical research, 112 Historical risk factors, for rape, 299 Histrionic personality disorder, 206t, 215–216 HIV, AIDS dementia complex and, 405 Hmong people, sudden death syndrome among, 183 Homelessness, depression, suicide, and, 344–345 Homophobia, 283 Homosexuality, 283–284 See also Gay entries Hospitalization involuntary, 482–483 for schizophrenia, 360 Hostility, in psychophysiological disorders, 195 Human behavior multicultural models of, 59–61 universality in, 11 Human Genome Project (HGP), 40–41, 110, 111 Humanistic models, 53–55, 63t abnormal behavior and, 19–20, 32 cognitive models and, 53 Maslow and, 54 Rogers and, 54–55 self-actualization and, 54 Humanistic perspectives criticisms of, 55 defined, 54 Human Sexual Inadequacy (Masters and Johnson), 268, 271 Human sexuality, study of, 268 Human Sexual Response (Masters and Johnson), 268, 271 Human sexual response cycle, 268–270, 268f Huntington’s disease, 40–41 defined, 406

Hurricane Katrina, anxiety disorders and, 123 Hyperactivity, in excited catatonia, 370 Hypertension, 184–185 in African Americans, 185, 186, 196 Hypnosis, in treating DID, 160–161, 162 Hypnotism, 22 Hypoactive sexual desire disorder, 271, 272t Hypochondriasis, 162, 163t, 167–168 defined, 167 Hypothalamic-pituitary-adrenal (HPA) axis, 178, 312 Hypothalamus, 37 Hypothesis, 98 defined, 97 experimental, 100 Hysteria as conversion disorder, 171 Galen on, 171 group, 18 mesmerism and, 22 self-hypnosis as, 22 somatization disorder as, 164 in women, 171 Hysterical blindness, 166 I Ask the Right to Die (Humbert), 355 Iatrogenic disorder, 160 Iatrogenic effects defined, 111 of therapy, 111–112 Id, 45 Identical twins bipolar disorders in, 329–330 correlational studies of, 106 Identity, physical appearance and, 462 Illegal substances, substance-use disorders and, 235 Imipramine, 42, 325–326 Immigrants, eating disorders among, 444 Immigrant status, somatic complaints and, 172 Immune system, stress and, 190–191 Impulse control disorders, 228–229 defined, 229 not elsewhere classified, 87t Impulsive unsocialized sensation seeking, 223–224 Incest, defined, 292–293 Incidence, defined, 12 Incidence rate, 112–113 Income, anxiety disorders and, 123 Incompetency, confinement for, 482 Independent variable, defined, 100 Individuality, as value, 60 Indonesia, objective recording of tsunami results, 108 Infancy, disorders diagnosed in, 86t Infections, stress and, 190 Inferiority model, 59–60 defined, 59 Inheritance, of mental disorders, 14 Inhibited male orgasm, 275 Injection phobia, 128

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In-person interviews, as field study, 107 Insanity criteria for, 474–476 determination of, 477t not guilty plea for, 481 Insanity defense, 476, 478–481 Dahmer and, 485, 486 defined, 478 Insanity Reform Act (1984), 481 Instincts, 45 Instrumental conditioning, 49 Insula, 249 Integrated psychological therapy (IPT), for schizophrenia, 388 Intellectual and developmental disabilities, 436 Intelligence in mental retardation, 436, 437 multidimensional nature of, 77–78 Intelligence quotient (IQ), 76 See also IQ scores Intelligence tests, 69, 76–78 Intercourse, 273 Intermittent explosive disorder, 228 defined, 228 Internal consistency, of reliability, 67 Internal control, in panic disorder treatment, 138 Internal validity, 103 defined, 100 International Society for the Study of Dissociation, 160 Internet, cyberbullying on, 428 Internet addiction, 228–229 Interoceptive conditioning, 136 Interpersonal psychotherapy, for depressive disorders, 325 Interpersonal relationships, 47t Interrater reliability, 67 Intervention for ADHD, 424, 425 for cognitive disorders, 410 for eating disorders, 465 for enuresis, 433 family communication and education as, 388–389 for mental retardation, 440–441 through therapy, 5 unexpected results of, 111 See also Treatment; specific conditions Interviews, 69–71, 69t observations and, 69 structure of, 70–71 Intracranial hemorrhaging, 399 Intrusive treatment, 489 Inventories, and psychological tests, 71 Involuntary commitment, 484–485 protection against, 485 See also Civil commitment Involuntary hospitalization, 482–483 IQ scores, 76 labeling and, 91 mental retardation and, 436 normal and abnormal, 9 IQ tests, 69, 76–78 Irrational cognitive processes, 51–52, 52f Irresistible impulse test, defined, 479–480

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Isolation in OCD, 145 in psychophysiological disorders, 195 Jackson v. Indiana, 482 Jails, suicide in, 342 Janus Report, 268 Japanese people, coronary heart disease among, 196, 197 Jealousy, 372 Job training, for mentally challenged, 490 Jury selection, 477t Katrina, see Hurricane Katrina Kaufman Assessment Battery for Children (K-ABC-II), 78 Kendra’s Law, 489 Ketamine, 241 Kleptomania, 228 defined, 229 Klinefelter’s syndrome, 439 Koro, 83t, 156 Kraepelinian system, 84 Labeling effects of, 91 objections to, 90–91 Lacerations, 397 Latency stage, 45 Latinos, see Hispanic Americans Laughter, impact on disease, 191 Law, psychology and, 477t L-dopa, 377 Learned helplessness, 316–317 defined, 316–317 Learning, observational, 51 Learning disorders defined, 434 dyscalculia as, 435t dysgraphia as, 435t dyslexia as, 435t treatment of, 435 Learning paradigms, 47–50 Learning perspectives on APD, 224–225 on sexual dysfunction, 295 on treating sexual deviations, 295–296 Least restrictive environment, defined, 486 Legal issues in abnormal psychology, 474–496 in suicide, 354–357 Legal precedents, on insanity, 479–482 Legal standards, on mental state of defendants, 479f Legal system, standards of proof in, 487 Lesbians, suicides among, 346 Lessard v. Schmidt, 486 Lethality, defined, 350 Levitra, 282 Liberals (political), flexibility of, 394 Libido, 268 Librium, 41 Lifestyle changes for cognitive disorders, 409 for obesity, 471–472 Lifetime prevalence, defined, 12 Light therapy, for SAD, 309 Limbic system, 37

Limited interactional social phobia, 126 Lithium, 41, 42 for bipolar disorder, 330–331 Living arrangements, for mentally retarded, 441–442 Localized amnesia, defined, 151 Lockdown procedures, for school violence, 429 Longitudinal research, 112 on drug use, 253 on psychodynamic explanations for depression, 314 Loosening of associations, in schizophrenia, 365 Loss, as source of depression, 314 LSD, 241, 244–245 characteristics of, 237t Lungs, smoking and, 243 Luria-Nebraska Neuropsychological Battery, 79 Lycanthropy, 18 Lymphocytes, 190 Lysergic acid diethylamide, see LSD Machover D-A-P, 73 Magnetic resonance imaging (MRI), 80–81, 120 defined, 393 Magnification, depression and, 316 Mainstreaming, defined, 490 Major depressive disorder, 305t defined, 307 DSM diagnosis of, 307t Maladaptive assumptions, 51–52 Maladaptive responses, to chronic stress, 193t Male erectile disorder (ED), 272t, 273–274 defined, 273t medical interventions for treating, 281t possible physical causes of, 273t Male orgasmic disorder, 272t defined, 275 Males genital changes in sexual response cycle, 269f sexual aggression by, 297–298 See also Men Malingering, defined, 164 Malleus Maleficarum (The Witch’s Hammer), 19 Malnutrition, anorexia and, 449 Malpractice suits, testifying in, 477t Managed care organizations (MCOs), labeling and, 91 Managed health care, 24–25 Mania, 17 criteria and classification of, 328t defined, 304 drugs for, 42 symptoms of, 306t See also Bipolar disorders MAOIs, see Monoamine oxidase inhibitors (MAOIs) Maria Full of Grace (movie), drug traffic and, 239 Marijuana characteristics of, 237t defined, 244

medical uses of, 245 treatment for use of, 260 Marital status, suicide and, 339, 340f, 341f Marriage, gay, 284 Marriage and family counseling, 6t Masochism, 289t defined, 293 Mass madness, 18 Mass murder(ers), 486 profile of, 477t, 487 Masters and Johnson Therapy Clinic, 267 Masturbation, 273, 282 Mathematics disorder, 435t Mediator variables, in correlational relationships, 402 Medical autopsy, 335 Medical conditions in DSM Axis III, 84 mental disorders due to, 86t in mental retardation, 438t Medical model, 33 Medical orientation, of DSM, 89 Medical student syndrome, 28 Medication, 41–42 for anxiety, 120, 137 for bulimia nervosa, 466 for children, 414 for cognitive disorders, 408–409 for depressive disorders, 323 for OCD, 145 for panic disorder, 138 for schizophrenia, 383–384 for stress disorders, 181 therapeutic drug intoxication from, 399–400 Meditation, 199 Melancholia, 17, 90, 307–308 Memory(ies) B vitamins and, 404 repressed, 99, 152 See also Amnesia Memory bias, cognition, depression, and, 316 Memory loss, in older people, 399–400, 400f Men anxiety disorders in, 123 body image of, 456, 460 depression in, 320–322, 321t eating disorders and, 444–445, 451 height and weight of, 458t reasons for raping women, 300 schizophrenia in, 381 stressors on, 58 tardive dyskinesia in, 384 See also Gender; Male entries Meningitis, 406 Mental activity, for cognitive disorders, 409 Mental decline, interactions with others and, 396 Mental disorders anorexia nervosa and, 449 binge-eating disorder and, 452 bulimia and, 450–451 computer games and, 89 criteria for, 474–476 deinstitutionalization and, 490–492 DSM-IV-TR, 86t–87t early views on causes of, 21–23 frequency and burden of, 12–14 gender bias in diagnosing, 207

Hillside Strangler and, 480 historical treatment of, 20–21 medical student syndrome and, 28 as myth and political construction, 12 one-dimensional models of, 32–44 by racial group, 61 stereotypes about, 14–15 See also specific disorders Mental health conclusions about U.S., 13–14 counseling, 6t Mental Health: A Report of the Surgeon General, 13 Mental Health America, 21 Mental health professions, 6t cultural competence and, 494–495 Mentally challenged, job training for, 490 Mental patients, rights of, 485–490 Mental retardation (MR), 435–442, 436t autistic disorder and, 417 defined, 436 diagnosis of, 436–437 in DSM Axis II, 84 early intervention for, 440–441 estimated number of people by level of retardation, 437t levels of, 436–437 nongenetic biological factors in, 439–440 predisposing factors associated with, 438t programs for people with, 440–442 Mental status examination, 71 Meprobamate, 41 Mesmerism, 22 Metabolism rate, anxiety disorders and, 137 Methadone, 237t, 256 Methedrine, 237t Midbrain, 37–38 Middle Ages, mental disorders during, 18 Migraine headaches, 186–187 defined, 186 Migrants, stress disorders in, 180–181 Mild cognitive impairment (MCI), 402 Milieu therapy, for schizophrenia, 386 Military, PTSD and, 182 Miltown, 41 Mind That Found Itself, A (Beers), 20–21 Minimization, depression and, 316 Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2), 73–74, 76 MMPI-2 clinical scales and sample test items, 75f Minorities anxiety disorders in, 123 behaviors of, 27 See also Ethnicity; Race; specific groups MMPI, see Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2) MMPI-2, 73

S UB JEC T I NDEX M’Naghten Rule, defined, 479 Model(s) defined, 33 See also Multipath model Modeling defined, 50 of drinking, 252 Modeling therapy, 131, 132–133 Model Penal Code (ALI), defined, 480 Moderator variables, in correlational relationships, 402 Monoamine oxidase inhibitors (MAOIs), 42, 311, 323 Mood disorders, 86t, 303–304, 329 bulimia and, 450–451 cross-cultural studies of, 320 defined, 304 eating disorders and, 456 lifetime and 12-month prevalence of, 88f listing of, 305t neurotransmitters and, 311 See also Bipolar disorders Moral issues, in suicide, 354–357 Morality, Victorian, 8 Morality bias, in OCD, 146 Moral treatment movement, 20 Morbidity risk, in blood relatives of people with schizophrenia, 376f Morbid obesity, gastric bypass surgery for, 472 Morphine, 237t Mortality rate, from anorexia deaths, 446–447 Motor disturbances, disorganized, 365–366 Mourning, depression and, 313 MRI, see Magnetic resonance imaging (MRI) Multicultural models, 63t defined, 60 Multicultural psychology, 9–11, 26–27, 59–61 Multimodel treatment, of drug-use disorders, 259–260 Multipath model, 32 of antisocial personality disorder, 221–227, 221f of anxiety disorders, 119–123, 120f biological explanations and, 43–44 in cognitive disorders, 410 for conduct disorders, 428f criticisms of, 61–64 defined, 34 for dissociative disorders, 157f for eating disorders, 454f for generalized anxiety disorder, 139f of mental disorders, 34–36 for obesity, 469f for OCD, 144f for panic disorder, 135f of phobias, 128f on psychological explanations, 55–56 for psychophysiological disorders, 192f for PTSD, 179f of schizophrenia, 374–383, 375f for sexual dysfunctions, 277f

for somatoform disorders, 170f for substance abuse disorders, 247f of suicide, 334f, 343–347 for unipolar depression, 310f Multiple-baseline study, defined, 109 Multiple personality disorder, see Dissociative identity disorder (DID) (multiple personality disorder) Munchausen by proxy, 165 Munchausen syndrome, 165 Naltrexone, 255, 256 Nancy School, 22–23 Narcissistic personality disorder, 206t, 216, 217 Narcotics, 238–239 characteristics of, 237t defined, 238 Nardil, 323 National Academies, on women in United States, 58 National Association of Social Workers on addiction as disease, 250 on school violence, 429 National Center for Children Exposed to Violence, 429 National Committee for Mental Hygiene, 21 National Comorbidity Survey, on PTSD and ASD, 177 National Comorbidity Survey Replication Study, mental disorders incidence study by, 12 National Institute of Mental Health (NIMH) mental disorders incidence study by, 12, 13 violations in scientific studies funded by, 100 National Mental Health Association, 21 National Tattoo Convention, 10 Native Americans depression among, 320 eating disorders among, 444 suicides among, 339, 342, 346–347 Naturalistic observations, 68–69, 70 Naturalistic perspectives, of abnormal behavior, 16–17 Natural-killer (NK) cells, 190 Nature/nurture, 32 in OCD characteristics, 147 Necrophilia, of Dahmer, 486 Negative correlation, 104 Negative expectancy appraisals, negative symptoms of schizophrenia and, 379t Negative information perspectives, on phobias, 130 Negative reinforcement, 50 Negative symptoms, in schizophrenia, 366, 379t Nembutal, 237t Neurasthenia, 83t Neuroanatomical basis, for panic disorders, 121f Neuroanatomy, 25 Neuroendocrine system, 178 Neurofibrillary tangles, 401, 403

Neuroimaging techniques, for anxiety disorders, 120 Neuroleptic malignant syndrome, 384 Neuroleptics, defined, 383 Neurological tests, 69, 80–81 Neuron defined, 37 electrical impulse transmission via, 39 parts of, 39f Neurosis, conversion, 164 Neurostructures, in schizophrenia, 376–377 Neurosyphilis (general paresis), 405 Neuroticism, 230 Neurotransmitters, 25, 41t addiction and, 248–249 Alzheimer’s disease and, 403 in anxiety disorders, 121 binding of, 40f defined, 39 drug blocking of, 39 eating disorders and, 454–455 mood disorders and, 311 in schizophrenia, 377–378 Nicotine, 242 characteristics of, 237t Nicotine fading, 257 Nicotine replacement therapy (NRT), 256–257 Nondirective therapy, 54–55 Nonfamilial alcoholism, 248 Nongenetic biological factors, in mental retardation, 439–440 Nonpurging, in bulimia nervosa, 445t Nonverbal communication, in autistic disorder, 416 Norepinephrine, 41t, 311 Norms behavior disorders and, 11 societal, 8 Not guilty plea, for insanity, 481 Not otherwise specified disorders, 87t Nurture, see Nature/nurture Obesity, 467–468 biological dimension of, 469–470, 469f BMI and, 470 in childhood, 467 in China, 463 defined, 467–468 etiology of, 469–471 increase in, 468f multipath model for, 469f psychological dimension of, 469f, 470–471 social dimension of, 469f, 471 sociocultural dimension of, 469f, 471 stigmatization of, 470–471 treatment of, 471–472 See also Thinness; Weight Objectivity, in recording study results, 108 Object relations, 47t Observational learning, 51 APD and, 225 perspectives on phobias, 130 in psychopathology, 50 Observational learning theory, defined, 50

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Observations, 68–69, 69t as assessment, 68–69 controlled, 68, 70 naturalistic, 68–69, 70 Obsessions, 142f clinical examples of, 143t defined, 141 Obsessive-compulsive disorder (OCD), 119t, 141–147 anorexia and, 449 biological dimensions of, 144–145 compared with OCPD, 219–220 compulsions and, 141, 142–143 defined, 141 etiology of, 143–146 multipath model for, 144f obsessions and, 141, 142 psychological dimensions of, 144–145 social and cultural dimensions of, 146 treatment of, 146–147 Obsessive-compulsive personality disorder (OCPD), 206t, 219–220 compared with OCD, 219–220 defined, 219 Occupation, suicide and, 339 OCD, see Obsessive-compulsive disorder (OCD) O’Connor v. Donaldson, 488 OCPD, see Obsessive-compulsive personality disorder (OCPD) ODD, see Oppositional defiant disorder (ODD) Oedipus complex, phobias and, 129 Olanzapine, 383 Old age, see Aging Older Americans, see Aging; Elderly Olfactory hallucinations, 365 On-Line Gamers Anonymous, 89 Onset, of stress, 318 Operant behavior, defined, 49 Operant conditioning biofeedback as, 198 in classroom, 49 defined, 49 paradigm of, 49 in psychopathology, 49–50 Thorndike on, 49 Operational definitions, defined, 98 Opiates, 235t, 238–239 Opium, 237t Oppositional defiant disorder (ODD), 413, 414, 423t, 426–428 defined, 426 Optimism, in psychophysiological disorders, 195 Oral sex, 265–266 Oral stage, 45, 46 Orbital frontal cortex, OCD in, 145f Organic perspectives, of behavior, 17 Organic view, of mental disorders, 21–22 Orgasmic disorders, 272t, 275 defined, 275 Orgasm phase, of sexual response cycle, 268 Orlistat, 472

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Overeating, 444 Overgeneralization, depression and, 315 Overweight, 444, See also Eating disorders; Obesity; Weight Pacific Americans, suicides among, 346 Pain disorder, 162, 163t defined, 167 Panic, origins of word, 134 Panic attacks, 133 defined, 117 Panic disorder(s), 119t, 138 agoraphobia and, 134–137 catastrophic thoughts in, 136 defined, 133 etiology of, 134–136 multipath model for, 135f neuroanatomical basis for, 121f treatment of, 136–137, 138 Paranoid personality disorder, 205–208, 206t defined, 205 prevalence of, 208 Paranoid schizophrenia, 368t, 369 Paraphilias, 265, 288–296 defined, 288 etiology and treatment of, 294–296 listing of, 289t with nonconsenting persons, 291–293 with nonhuman objects, 290–291 Parent(s) antisocial patterns of, 226 child abuse by, 432–433 Parental modeling, in somatoform disorders, 171 Parent management training, for conduct disorders, 430 Parents Television Council, on correlations between TV violence and behavior, 104–105 Paresis, 21, 38 Parkinsonism, 384 Parkinson’s disease, 39, 394, 404 cognitive symptoms of, 392 defined, 404 Paroxetine, 323 Pathognomic characteristic, 111 Pathological gambling, 228 defined, 229 Pathology, brain, 17 Patient rights, protection of, 477t Pavlovian conditioning, 48 Paxil, 323 for OCD, 145 PCP, 245, 246 characteristics of, 237t Pedophilia, 289t defined, 292 Peers drug-use patterns and, 252–254 eating disorders and, 457 Pencyclidine, see PCP Penetrance, of genetic characteristic, 111 Penile implants, 281t, 282 Performance social phobia, 125–126 Perinatal complications, in mental retardation, 438t

Perphenazine, 383 Persecution, 372 delusions of, 8, 362 Personality, addiction and, 252 Personality disorders, 87t, 201–202 anorexia and, 449 antisocial, 202, 210–212 anxious or fearful behaviors and, 217–220 avoidant, 217–218 borderline, 212–215 characterizations of, 224 defined, 202 dependent, 206t, 218–219 diagnosing, 203–205, 204t dramatic, emotional, or erratic behaviors and, 210–216 in DSM Axis II, 84 histrionic, 206t, 215–216 impulse control disorders, 228–229 listing of, 206t multipath analysis of antisocial personality disorder, 221–227 narcissistic, 206t, 216, 217 odd or eccentric behaviors and, 205–209 paranoid, 205–208 treatment of antisocial personality disorder, 227 Personality inventories, limitations of, 75–76 Personality structure, Freud on, 45 Personality theories, A-B-C theory, 52, 52f Person-centered therapy, 54–55 Pervasive developmental disorder not otherwise specified (PDDNOS), 415, 417, 418t, 419 Pervasive developmental disorders, 414–422 biological dimension of, 419–420 defined, 414 etiology of, 419–421 prognosis for children with, 421 treatment of, 421–422 PET scan, see Positron emission tomography (PET) scan Phagocytes, 190 Phallic stage, 45, 46 Pharmacogenomics, 41 Pharmacological approach, to substance-use disorders, 255–257 Phenelzine, 323 Phenomenology, in humanistic and existential approaches, 55 Phenothiazines, 377 Phenotype, defined, 40 Phenylketonuria (PKU), 110, 439 Phobias, 49, 119t, 124–133 of actors, 127 age and, 13, 127f behavioral perspective on, 130 biological dimension of, 128 classical conditioning perspective on, 130 cognitive-behavioral perspective on, 130–131 defined, 124 etiology of, 128–131 multipath model of, 128f negative information perspective on, 130 and objects, 124t

observational learning perspective on, 130 psychodynamic perspective on, 129–130 psychological dimension of, 128 social, 125–127, 125t specific, 127, 131 treatment of, 131–133 types of, 127 Phobophobia, 124 Phrenitis, 17 Physical disease delusional parasitosis vs., 373 See also Disease Physical stress disorders, see Psychophysiological disorders Physiological effects, of alcohol, 237–238 Physiological symptoms of bipolar disorders, 327–328 of depression and mania, 306t of unipolar depression, 306, 310f Pibloktoq, 156 Placebo group, 102 Playgirl, 460 Pleasure principle, defined, 45 Politics, brain and, 394 Pollutants, asthma and, 190 Polysubstance dependence, defined, 241 Polysubstance use, 240–241 Poor people, see Poverty Positive correlation, 103–104 Positive feedback loop, in panic attacks, 136f Positive reinforcement, 49–50 Positive symptoms, of schizophrenia, 361–366 Positron emission tomography (PET) scan, 80, 120 defined, 392–393 Postpartum psychosis, 308 Posttraumatic model (PTM), for dissociative disorders, 158, 159, 173–174 Posttraumatic stress disorder (PTSD), 176 diagnosis of, 176–177 etiology of, 177–181 exposure to stressors and risk of, 178t military and, 182 multipath model for, 179f rape trauma syndrome and, 298 treatment of, 181 See also Stress disorders “Pot,” see Marijuana Poverty anxiety disorders and, 123 bias against poor people, 59 schizophrenia and, 381 Power rapist, 299 Predictive validity, 67 Predispositions to abnormal behavior, 43 to anxiety, 121–122 Prefrontal cortex, 120 Prefrontal region, of brain, 312 Pregnancy, in mental retardation, 438t Prehistoric beliefs, about abnormal behavior, 16 Premature ejaculation, 272t defined, 275 treatment for, 282–283

Premenstrual dysphoric disorder, as DSM diagnostic category, 89 Pre-morbid personality, 373 Preparedness, in fear reactions, 128 Preponderance of evidence, 487 Prescription drugs, substance-use disorders and, 235 Prevalence, defined, 12 Prevalence rate, 112–113 Prevention of cognitive disorders, 408–410 programs for substance-use disorders, 260–261 of school violence, 429 of suicide, 350–354, 352f Primal Fear (movie), 478 Primary erectile dysfunction, 274 Primary inhibited female orgasm, 275 Primary symptoms, in schizophrenia, 366 Prinzhom Collection, at Psychiatric University Hospital (Heidelberg), 366 Prisons, suicide in, 342 Privacy issues, 493–494 Privileged communication, 492 Pro-ana (anorexia) Web sites, 448 Probability bias, in OCD, 146 Prodromal patients, medication vs. placebo treatment for, 385 Prodromal phase, of schizophrenia, 373 Products test, 480 Professions, mental health, 6t Prognosis for children with pervasive developmental disorders, 421 defined, 84 Program evaluation, 112 Project Achieve, 424 Projective personality tests, 69t, 71–73 defined, 71 Rorschach technique, 72 Thematic Apperception Test, 72–73 Prolixin, 383 Pro-mia (bulimia) Web sites, 448 Propanediols (emprobamate compounds), 41 Prospective studies, in schizophrenia, 379 Protective factors, in suicide assessment and intervention, 350t Prozac, 311, 323 for OCD, 145 Psychiatric disorders of childhood, 412–414 rates in particular groups, 13f Psychiatric social work, 6t Psychiatric University Hospital (Heidelberg), Prinzhom Collection at, 366 Psychiatrists, prescription privileges of, 24 Psychiatry, 6t drug revolution in, 23–24 Psychoactive substances, 39–40 characteristics of, 237t cognitive disorders from, 408 Psychoanalysis, 6t defined, 45 Psychoanalytic/psychodynamic orientation, 44

S UB JEC T I NDEX Psychoanalytic theory post-Freudian and psychoanalytic therapist contributions to, 47t sex in, 268 Psychodiagnosis, 67 defined, 3 Psychodynamic-eclectic treatment, for depression, 325 Psychodynamic models and theories, 32, 44–47, 62t on APD, 224 on borderline personality disorder, 214 contemporary, 46 criticisms of, 46–47 defined, 44 of depression, 313–314 on dissociative disorders, 158 on GAD, 139–140 on OCD, 145 on panic disorder and agoraphobia, 135–136 of personality structure, 45 on phobias, 129–130 psychosexual stages and, 45 on sexual dysfunction, 295 on somatoform disorders, 170 traditional psychodynamic therapy and, 45–46 Psychodynamic therapy traditional, 45–46 See also Therapy; Treatment Psychogenic disorders, 93–95 Psychological autopsy, defined, 335 Psychological dimensions, 44–50 of ADHD, 425 of anxiety disorders, 122–123 of APD, 224–225 of autism, 420–421 behavioral models and, 47–50, 47–51 cognitive models and, 51–53 of conduct disorders, 428f of conversion disorder, 165–166 of dissociative disorders, 158–159 of eating disorders, 454f, 455–456 of enuresis, 433 of GAD, 139–140, 139f of mental disorders, 32–33 multipath, 34, 35f, 55–56 of obesity, 469f, 470–471 of OCD, 145–146 of panic disorder and agoraphobia, 135–136 of phobias, 128 psychodynamic models and, 44–47 of psychophysiological disorders, 194–195 of PTSD, 179–180 of schizophrenia, 378 of sexual disorders, 295 of sexual dysfunction, 278–279 of somatoform disorders, 170–171, 170f of substance abuse disorders, 247f, 249–252 of suicide, 344–345 of unipolar depression, 310f, 313–317 Psychological effects, of alcohol, 237–238 Psychological influences, on gender identity disorder, 287–288

Psychological tests and inventories, 69t, 71–79 for cognitive impairment, 69t, 78–79 defined, 71 intelligence tests, 69t, 76–78 Kaufman Assessment Battery for Children (K-ABC-II), 78 projective personality tests, 69t, 71–73 reliability of, 81 self-report inventories, 69t, 73–76 See also Assessment Psychological treatment of sexual dysfunctions, 282–283 for somatoform disorders, 172–173 Psychological viewpoint, of mental disorders, 22–23 Psychologists, prescription privileges for, 24 Psychology and law, 477t mental health professions and, 6t multicultural, 26–27 Psychometrics, defined, 76 Psychopathology classical conditioning in, 48–49 comparison of models, 62–63t cross-cultural perspectives on, 382–383 defined, 3 models describing, 33–34 observational learning in, 50 operant conditioning in, 49–50 Psychopaths APD and, 223–225 punishment of, 225f treatment of APD and, 227–230 Psychopharmacology, 25, 41–42 Psychophysiological disorders, 182–199 asthma as, 188–190 biological dimension of, 192–194 characteristics of, 183 coronary heart disease as, 183–184 defined, 182 etiology of, 192–197 hypertension and, 184–185 migraine, tension, and cluster headaches as, 186–188 multipath model for, 192f psychological dimension of, 194–195 social dimension of, 196 sociocultural dimension of, 196–197 stress and immune system disorders as, 190–192 treatment of, 197–199 Psychosexual stages, defined, 45, 46 Psychosis, postpartum, 308 Psychosocial problems, in DSM Axis IV, 84–85 Psychosocial stress, 318 Psychosocial therapy, for schizophrenia, 385–388 Psychosurgery, 43 Psychotherapy for depressive disorders, 324–326 See also Depression; Therapy; Treatment

Psychotic disorders, 86t delusional disorder, 372 drug triggers of, 378 once considered schizophrenia, 371 schizoaffective disorder, 372 shared psychotic disorder, 372 Psychotic-like experiences, 365 Psychotic symptoms, and borderline personality disorder, 213–214 Psychotomimetic drug, LSD as, 245 PTSD, see Posttraumatic stress disorder (PTSD) Punishment, effects on psychopaths, 225f Purging, in anorexia nervosa and bulimia nervosa, 445t, 447 Pyromania, 228 defined, 229 Quetiapine, 383 Race, 59–61 vs. culture, 10 in diagnosing antisocial personality disorder, 203 in OCD, 146 problems in using references to, 60–61 schizophrenia and, 368, 381 somatic complaints and, 172 in somatization disorder, 164 suicide rates by, 339, 341, 342, 342f See also Ethnicity Rape, 296–301, 297t date rape, 297 defined, 296 effects of, 298 etiology of, 299 protests against, 298 statistics on, 296 Rape trauma syndrome, defined, 298 Rapists, treatment for, 299–301 Rational intervention, 52f Raves, stimulants used at, 241 Reaction formation, 145 Reactivity, defined, 69 Reading disorders, 435t Reality principle, defined, 45 Reattribution training, for somatoform disorders, 173 Recovered Memory Project, 99 Recovery, for schizophrenics, 389 Recticular formation, 38 Reference, delusions of, 362 Reform movement, abnormal behavior and, 20–21 Reinforcement, 49–50 in somatoform disorders, 171 Reinforcing abstinence, defined, 257 Relapse, 249, 251 in substance abuse, 261–262 Relaxation, 258 Relaxation training, defined, 197–198 Reliability, 98–99 defined, 67 of psychological tests, 81 Religion physical health and, 196 suicide and, 339

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REM sleep disturbance, in depression, 312, 313 Rennie v. Klein, 489 Repeating rituals, 143 Replication, of scientific results, 95 Repressed/recovered memories, 99, 152 determination of, 477t Research, 25–26 allegiance to treatment form in, 105 with animals, 98 biological, 110–112 on comparative forms of therapy, 105 epidemiological and other forms of, 112–113 ethical issues in, 113–114 on schizophrenia, 389 See also Scientific method Residual phase, of schizophrenia, 373 Residual schizophrenia, 368t defined, 370 Resistance, defined, 46 Resistance stage, of GAS, 194 Resolution phase, of sexual response cycle, 268 Resperdal, 383 Response conditioned, 48 unconditioned, 48 Response prevention, for OCD treatment, 146–147 Responsibility, in humanistic and existential approaches, 55 Restricting type, of anorexia, 445t, 447, 449 Retardation, see Mental retardation (MR) Rett syndrome, 415, 418t, 419 Rights of mental patients, 485–490 to refuse treatment, 488–489 to suicide, 354–357 to treatment, 486–488 Right-to-die movement, 355–356 Right to privacy, therapist-client confidentiality and, 492 Right-wrong test, 479 Risk factors defined, 248 for rape, 299 for schizophrenia, 378 for somatoform disorders, 172 in substance abuse, 248 in suicide assessment and intervention, 350t Risperidone, 383 Rituals, in OCD, 143 Rivers v. Katz, 489 Rogers v. Okin, 489 Rohypnol, 241, 242 Roofies, 241, 242 Rootwork, 83t Rorschach technique, 72, 73 controversy over, 74 Rouse v. Cameron, 486–487 SAD, see Seasonal affective disorder (SAD) Sadism, 289t defined, 293 Sadistic rapist, 299 Sadomasochism, 293 ranking of, 294t

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Saint John’s wort, depression and, 322 Saint Vitus’ Dance, 18 Salpêtrière Hospital, 22 Samoa, culture and health in, 197 Samples college students as, 102 standardization, 68 S&M activities, see Sadomasochism Sanity criteria for, 474–476 determination of, 477t tests of, 479–480 SAT, see Scholastic Assessment Test (SAT) Scans, see specific types Schema, defined, 51, 315 Schizoaffective disorder, defined, 372 Schizoid personality disorder, 206t schizophrenia and, 208 Unabomber and, 208 Schizophrenia, 86t, 359–361 antipsychotic drugs with, 39 biological dimension of, 375–378 brief psychotic disorder, schizophreniform disorders, and, 371t catatonia symptoms in, 367f catatonic, 368t, 369–370 cognitive-behavioral therapy for, 386–388 cognitive symptoms of, 367 cognitive therapy for, 388 course of, 373–374, 374f cultural issues in, 367–368 defined, 359–360 disorganized, 368t, 369 dopamine with, 39–40 environment and, 44 in ethnic groups, 368 etiology of, 374–378 expressed emotion in, 379–380, 380f heredity in, 40 long-term outcome studies of, 374 morbidity risk in blood relatives of people with, 376f multipath model of, 374–383, 375f negative symptoms in, 366 painting symptoms of, 366 paranoid, 368t, 369 positive symptoms of, 361–366 prevalence rates of, 360 psychological dimension in, 378 psychosocial therapy for, 385–388 rate of gray matter loss in, 376 research on, 389 residual, 368t, 370 risk characteristics for, 378 schizoid personality disorder and, 208 schizotypal personality disorder and, 209 social dimension of, 379–381 sociocultural dimension of, 381–383 symptoms of, 361–368 therapy for, 386–388 treatment of, 383–389 types of, 368–372, 368t undifferentiated, 368t, 370

Schizophreniform disorders brief psychotic disorder, schizophrenia, and, 371t defined, 371 Schizotypal personality disorder, 206t, 208–209 defined, 208 schizophrenia and, 209 Scholastic Assessment Test (SAT), accuracy with cultural groups, 82 School psychology, 6t School services, for mental retardation, 441 School violence, 429 Scientific method attacks on scientific integrity, 97 base rates in, 99–100 in clinical research, 96–100 correlations in, 103–105, 106 defined, 97 experiments in, 100–103 hypothesizing relationships in, 98 naturalistic perspective and, 17 operational definitions in, 98 potential for self-correction in, 98 reliability and validity in, 98–99 replication in, 95 in single-participant studies, 108–112 See also Research Scream, The (Munch), 134 Seasonal affective disorder (SAD), 309 Seasonal pattern depression, 308–309 Seconal, 237t Secondary erectile dysfunction, 274 Secondary inhibited female orgasm, 275 Secondary symptoms, in schizophrenia, 366 Sedatives, 235t, 236–241 defined, 236 Selected abstraction, depression and, 315 Selective amnesia, 151–152 defined, 151 Selective serotonin reuptake inhibitors (SSRIs), 42, 131, 146, 172, 323 for bulimia nervosa, 466 and stress disorders, 181 Self-actualization, defined, 54 Self-concept, defined, 54 Self-control, by children, 123 Self-correction, in clinical research, 98 Self-destructive behaviors, 212 Self-efficacy in psychophysiological disorders, 195 in treating panic disorder, 138 Self-esteem depression and, 316 eating disorders and, 455 Self-fulfilling prophecies, labels as, 91 Self-help groups, 258–259 Self-hypnosis, hysteria as, 22 Self-image, family dynamics and, 58 Self-report inventories, 73–76 defined, 73 Minnesota Multiphasic Personality Inventory (MMPI), 73–74

Senile dementia, Alzheimer’s as, 403 Senile plaques, 401 Sensation seeking antisocial personality and, 223 APD and, 223 Sensitivity, to anxiety, 122 Sentence-completion test, 73 Separation, as cause of depression, 313 September 11, 2001, terrorist attacks See also World Trade Center terrorist attacks effects of, 13 Serial killers, 486 profile of, 477t, 486–487 Seriously disturbed individuals, treatment of, 47t Seroquel, 383 Serotonin, 38, 39, 41t, 121, 311 Serotonin transporter gene (5-HTTLPR), 43–44, 121 in panic disorder and agoraphobia, 134 Sertraline, 323 Severity, of stress, 318 Sex and sexuality aging and, 284–286 borderline personality disorder and, 212–213 culture and, 266 Freud on, 45 homosexuality and, 283–284 Masters and Johnson on, 271 Victorian, 8 Sexism, in DSM, 89 Sex offenders treatment for, 299 See also Rape Sex reassignment, 287 therapy for, 264 Sexsomnia, 297 Sexual abuse, eating disorders and, 456 Sexual addiction, 267 defined, 266 Sexual aggression, rape and, 297–298 Sexual arousal disorder, 272t, 273–274 defined, 273 Sexual aversion disorder, 271, 272t Sexual behavior compulsive, 266 “normal,” 265–270 Sexual desire disorders, 271–273, 271t defined, 271 Sexual disorders, 87t, 264–265 Sexual dysfunctions, 265, 270–276 biological dimension of, 278 defined, 270 etiology of, 276–280 listing of, 272t multipath model for, 277f orgasmic disorders, 275–276 paraphilias and, 288–296 psychological dimension of, 278–279 sexual arousal disorders, 273–274 sexual desire disorders, 271–273 social dimension of, 279 sociocultural dimension of, 279–280 treatment of, 280–283

Sexual pain disorders, 272t, 275–276 Sexual relationships, between therapist and client, 495 Sexual response cycle, in humans, 268–269, 268f, 270f Sexual violence, see Rape Shared psychotic disorder, defined, 372 Shenjing shuairuo, 83t Short allele 5-HTTLPR gene, 121–122 of serotonin transporter genes, 121 Side effects, of antidepressant drugs, 323 Sign language, for autistic child, 417 Single-participant experiment, 109–110 defined, 109 scientific method in, 108–112 Situationally bound panic attacks, 117 Situationally predisposed panic attacks, 117–118 Skills training, defined, 257 Sleep disturbance, 87t in depression, 312, 313 Smell, in Alzheimer’s disease, 402 Smoking, 236 aversion therapy for, 257 brain damage and, 249 cessation programs for, 256–257 effect on lungs, 243 stopping, 252 treatment of, 257–258 Snake Pit, The (film), 21 Snorting, of alcohol, 251 Social and sociocultural dimensions of dissociative disorders, 159–161 of somatoform disorders, 170f, 171–172 Social conditioning, 26 Social dimensions, 47t, 56–58 in ADHD, 425 in anxiety disorders, 123 of APD, 225–226 of autism, 421 of conduct disorders, 428f of dissociative disorders, 159–161 of eating disorders, 454f, 456–457 family, couples, and group perspectives, 56–57, 58 of GAD, 139f, 140 of obesity, 469f, 471 of OCD, 146 of panic disorder and agoraphobia, 135–136 of psychophysiological disorders, 196 of schizophrenia, 379–381 of sexual dysfunction, 279 social-relational models and, 56, 57 of somatoform disorders, 170f, 171–172, 173 of stress disorders, 180 of substance abuse disorders, 247f, 252–254 of suicide, 345–346 of unipolar depression, 310f, 317–319

SU B JECT I NDEX Social influences, on gender identity disorder, 287–288 Social interactions, in autistic disorder, 416 Social isolation, in psychophysiological disorders, 195 Socialization agents in eating disorders and, 457 in dependent personality disorder, 218 Social learning perspective, on borderline personality disorder, 214 Social models, 33 APD and, 225 multipath, 35f relational models, 56, 57 Social phobias, 119t defined, 125 thoughts reported by patients with, 125–127, 125t Social-relational treatment approaches, 57 Social relationships, ADHD and, 424 Social rhythm therapy, 331 Social skills, in APD, 225 Social work, psychiatric, 6t Society, eating disorders and, 462 Sociobiological perspective, on rape by men, 300 Sociocognitive model (SCM) of DID, 159 for dissociative disorders, 173–174 Sociocultural dimensions, 58–64 of ADHD, 425 of anxiety disorders, 123 of APD, 226–227 of autism, 421 of childhood behaviors, 414 of conduct disorders, 428f of dissociative disorders, 159–161 of eating disorders, 454f, 457–464 of GAD, 139f, 140 gender factors and, 58–59 of obesity, 469f, 471 of panic disorder and agoraphobia, 135–136 of psychophysiological disorders, 196–197 race/ethnicity in multicultural models, 59–61 of schizophrenia, 381–383 of sexual dysfunction, 279–280 socioeconomic class and, 59 of somatoform disorders, 170f, 171–172 of stress disorders, 180–181 of substance abuse disorders, 247f, 254–255 of suicide, 346–347 of unipolar depression, 310f, 319–322 Sociocultural models, 33 multipath, 35f Sociocultural perspective, on rape by men, 300 Socioeconomic class, 59 Socioeconomic level, suicide and, 339

Sociopolitical influences, 27 SODA intervention program, 109 Somatic complaints, 372 in panic attacks, 136 Somatic weakness hypothesis, 193 Somatization disorder, 162, 163t defined, 164 Somatoform disorders, 86t, 162–174, 163t biological dimensions in, 169–170 body dysmorphic disorder, 163t conversion disorder, 163t culture and, 156 defined, 149 etiology of, 169–172 hypochondriasis, 163t multipath model for, 170f pain disorder, 163t social and sociocultural dimensions of, 170f, 171–172 somatization disorder, 162, 163t, 164 treatment of, 172–174 undifferentiated somatoform disorder, 163t, 164 South Africa, rape in, 298 Southeast Asians, depression among, 320 Southern Poverty Law Center, Teaching Tolerance program of, 495 Specific intent, to commit offense, 480 Specific phobias, 119t defined, 127 Specifiers, of depressive disorders, 307–309 Speech, disorganized, 365 Spirituality, physical health and, 196 Splinter skills, of autistic children, 416 SSRIs, see Selective serotonin reuptake inhibitors (SSRIs) Stability, of mentally disturbed people, 15 Standardization defined, 68 of interviews, 70–71 Stanford-Binet scales, 76–77, 78 Stanford-Binet Intelligence Scale, 76 Starvation, anorexia and, 449 Statistical significance, vs. clinical significance, 100 Status, physical appearance and, 462 Stereotypes, 90 about mental illness, 14–15 Stimulants, 235t, 241–244 characteristics of, 237t defined, 241 Stimulus conditioned, 48 unconditioned, 48 Strategic family approaches, 57 Street drugs, PCP as, 245 Stress, 175–176 adaptive (short-term) responses to, 193t cancer and, 191–192 control and, 194–195 conversion symptoms from, 166 and coronary heart disease, 184

defined, 175 depression and, 315, 317–319 and headaches, 186–188 and hypertension, 184–185 immune system and, 190 maladaptive (chronic) responses to, 193t psychosocial, 318 Stress disorders, 175–176 acute stress disorder, 176–181 biological dimension of, 178–179 posttraumatic stress disorder, 176–181 psychological dimension of, 179–180 psychophysiological, 182–199 social dimension of, 180 sociocultural dimension of, 180–181 Stressors anxiety disorders and, 123 defined, 175 depression and, 319 gender and, 58–59 general adaptation syndrome and, 194 lifetime prevalence exposure to, 178t predispositions activated by, 43 in PTSD, 177–178 Strokes, 390, 398–399 defined, 398 results on brain, 398 Structural family approaches, 57 Students compulsions among, 142 See also Adolescents; College students Substance abuse defined, 234 genetics and, 248 schizophrenia and, 378 Substance abuse disorders multipath model for, 247f psychological dimension of, 247f, 249–252 social dimension of, 247f, 252–254 sociocultural dimension of, 247f, 254–255 See also Substance-use disorders Substance dependence, defined, 234 Substance-induced condition, cognitive disorders and, 391t Substance-induced persisting dementia, 394 Substance-related disorders, 86t, 232–262 defined, 233 listing of, 235t reports by persons using substances, 234f Substance-use disorders, 235–246 biological dimension of, 247–249, 247f effectiveness of treatment for, 261–262 etiology of, 246–255 intervention and treatment of, 255–262 lifetime and 12-month prevalence of, 88f

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pharmacological approach to, 255–257 Sudden death syndrome, among Hmong people, 183 Sugar, in ADHD, 425 Suggestion, as cause of mental illness, 22–23 Suicidal ideation, defined, 335 Suicide, 333–335 alcohol and, 345 altruistic, 346 assistance for, 354–356 biological dimension of, 343–344 characteristics of, 338t among children and young people, 337–338 clues to intent, 351 among college students, 310, 338 communication of intent, 342 copycat, 348–349 correlates of, 335–343 defined, 334 depression and, 349 among elderly, 348–349 facts about, 337–343 frequency of, 337 gender and, 338–339 by historical period, 342 homelessness, depression, and, 344–345 in jails, 342 lethality of potential, 350 locations of, 348 marital status and, 339, 340f, 341f methods of, 355 multipath model of, 334f, 343–347 occupation and, 339 prevention of, 350–354, 352f in prisons, 342 psychological dimension of, 344–345 publicity about, 338 rates by race/ethnicity, 339, 341, 342, 342f reasons for, 336 religion and, 339 right to, 354–357 risk in assessment and intervention, 350t social dimension of, 345–346 sociocultural dimensions of, 346–347 socioeconomic level and, 339 victims of, 347–349 weapons for, 339 Suicide bombings, 347 Suicide prevention centers (SPCs), 353–354 effectiveness of, 354 Superego, 45 Supernatural perspectives, on abnormal behavior, 17–19 Support, against depression, 318–319 Surgical castration, for treating sexual offenders, 300–301 Survey research, 112 Symptoms, see specific conditions Synapse, defined, 39 Synaptic transmission, 39f

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S U BJ EC T IN DE X

Syndromes, 21 Syphilis, 21–22, 405 Systematic desensitization, 131, 132, 258 Systematized amnesia, 152 Tachycardia, 184 Tactile hallucinations, 365 Taijin Kyofusho phobia, 126–127 Tarantism, 18 Tarasoff v. Regents of the University of California, 9, 476, 477–478 defined, 493 Tardive dyskinesia, 384, 385 TAT, see Thematic Apperception Test (TAT) Taxometric methods, for diagnosing personality disorders, 205 Tay-Sachs disease, 439 TBI, see Traumatic brain injury (TBI) T-cells, stress and, 190 Teaching Tolerance program, 495 Teenagers, see Adolescents Telephone crisis intervention, for suicide prevention, 353–354 Television, violence correlated with behavior, 104–105, 106 Tension, alcohol for reducing, 249–251 Tension headaches, 187–188 defined, 187 Terminology, racial and ethnic group, 60–61 Terrorist attacks, probability of death from, 178 Test-retest reliability, 67 Tests intelligence, 69, 76–78 neurological, 69, 80–81 psychological, 69, 71–79, 81 See also Assessment; Psychological tests and inventories; specific tests Textbook of Psychiatry (Kraepelin), 21 Thailand, childhood behaviors in, 414 Thematic Apperception Test (TAT), 72–73 Therapeutic drug intoxication, 399–400 Therapist-client relationship, 492–494 sexual relationships with clients and, 495 Therapists, responsibility for dangerousness, 9, 484–485 Therapy for anxiety disorders, 120 for bipolar disorders, 331 for children with pervasive developmental disorders, 421–422 cognitive approaches to, 53 for cognitive disorders, 408–410 for cultural psychogenic disorders, 94–95 defined, 5 for depressive disorders, 324–326 for eating disorders, 465 iatrogenic effects of, 111–112

intervention through, 5 research on comparative forms, 105 for schizophrenia, 386–388 See also Treatment Thin-ideal internalization, 458 Thinness, 457, 458, 459, 461 Thorazine, 42, 383 Thought disorganized, 365 distortions of, 52 irrational, 51–52 Thought broadcasting, delusions of, 362 Thought withdrawal, delusions of, 362 Three Faces of Eve (book and movie), 161, 162 Tics, in OCD, 142 Titicut Follies (film), 21 Tobacco, use of, 236 Toilet training, 431 See also Elimination disorders Tolerance, defined, 234 Tourette’s disorder, 142 Tradition, coronary heart disease risk and, 197 Trait anxiety, PTSD and, 180 Trances, dissociative, 159 Tranquilizers major, 41 minor, 41 Transference, defined, 46 Transsexualism, 286–288 Transvestic fetishism, 289t defined, 290 Trauma effects of, 13 probability of death from, 178 See also Acute stress disorder (ASD); Posttraumatic stress disorder (PTSD) Traumatic brain injury (TBI), 396–397 defined, 396 Treatment for abnormal behavior, 7 of acute stress disorder (ASD), 181 of ADHD, 426 of anorexia nervosa, 448, 464–466 of antisocial behaviors, 230 of APD, 227–230 of binge-eating disorder, 466–467 biology-based, 41–43 for bipolar disorders, 330–331 of bulimia nervosa, 466 of children with pervasive developmental disorders, 421–422 of cognitive disorders, 408–410 of conduct disorders, 430–431 court-ordered, 486–489 cultural in treating unipolar depression, 319–322 of dissociative disorders, 160, 161–162 of eating disorders, 464–467 effectiveness for substance abuse, 261–262 of encopresis, 434 of enuresis, 433 of GAD, 140–141

of gender identity disorder, 288 of learning disabilities, 435 least intrusive forms of, 489 of obesity, 471–472 of OCD, 144, 146–147 of panic disorder, 136–137, 138 of paraphilias, 294–296 of phobias, 131–133 of posttraumatic stress disorder (PTSD), 181 of psychophysiological disorders, 197–199 for rapists, 299–301 researcher allegiance to, 105 right to, 486–488 right to refuse, 488 of schizophrenia, 383–389 for schizotypal personality disorder, 209 of sexual dysfunctions, 280–283 of somatoform disorders, 172–174 of substance-use disorders, 255–262 for unipolar depression, 322–326 See also Therapy Treatment outcome studies, 112 Treatment process studies, 112 Trephining, defined, 16 Trial, competency to stand, 477t, 481–482 Trichotillomania, 228 defined, 229 Tricyclic antidepressants (TCAs), 42, 323 Trilafon, 383 Trisomy, of Down syndrome, 440 Tumors, cerebral, 406, 407 Turner’s syndrome, 439 28 Days (movie), 252 Twins, bipolar disorders in, 329–330 Twin studies, 112 of APD, 222 of autism, 420 correlational, 106 genetic linkage studies and, 110 psychological dimension of stress in, 179–180 Uncertainty, in OCD, 145–146 Unconditional positive regard, 54 Unconditioned response (UCR), defined, 48 Unconditioned stimulus (UCS), defined, 48 Unconscious, 44 Uncued panic attacks, 118 Underachiever, use of term, 9 Undergraduates, compulsions among, 142 Undifferentiated schizophrenia, 368t defined, 370 Undifferentiated somatoform disorder, 163t defined, 164 Undoing, in OCD, 145 Unexpected panic attacks, 118 Unipolar depression, 304–310 biological dimension of, 310–313, 310f bipolar disorders and, 330 defined, 304

etiology of, 310–322 prevalence of, 309–310, 309f psychological dimension of, 310f, 313–317 social dimension of, 310f, 317–319 sociocultural dimension of, 310f, 319–322 symptoms of, 304–306, 306t treatment for, 322–326 twelve-month and lifetime prevalence of, 309f United States alcohol consumption in, 236 children in, 59 Uppers, 241 Vaginismus, 272t, 275–276 defined, 275 treatment for, 283 Validity, 67–68, 98–99 defined, 67 external, 100, 103 internal, 100, 103 Valium, 41, 237t, 241 Values behavior disorders and, 11 cultural, 26–27 Variables correlations between, 103–105 dependent, 100 independent, 100 possible correlation between two, 104f Vascular dementia, defined, 399 Ventricular fibrillation, 184 Verbal communication, in autistic disorder, 416 Viagra, 281t, 282 Vicarious conditioning, 50 Victims identification with suicides and, 338 of suicide, 347–349 warning of, 493 Victorian era, sexuality during, 8 Violence predicting, 484 in schools, 429 sexual, 298 on TV, correlated with behavior, 104–105, 106 at Virginia Tech, 2, 3, 4–6 Virginia Tech shootings, 2, 3, 4–6, 487 Virtual reality display, schizophrenia and, 367 Virtual-reality therapy, 258 Visual hallucinations, 364 Voluntary commitment, 484 Vomiting, in bulimia, 450 Voodoo ceremony, dissociative trance states in, 159 Voyeurism, 289t, 291 defined, 292 WAIS, WAIS-III, see Wechsler scales, Wechsler Adult Intelligence Scale (WAIS, WAIS-III) Washington, D.C., sniper shootings, 487 Weapons, for suicide, 339 Web sites, for anorexia and bulimia, 448

SU B JECT I NDEX Wechsler scales, 76, 436 items similar to Adult Intelligence Scale-III, 77t Wechsler Adult Intelligence Scale (WAIS, WAIS-III), 76, 78 Wechsler Intelligence Scale for Children (WISC-III), 76 Wechsler Preschool and Primary Scale of Intelligence (WPPSIIII), 76 Weight binge-eating disorder and, 452 body image and, 457 concerns in African American and white females, 461t concerns of youth grades 5-12, 444t of men and women, 458t normalcy perceptions, 462–463 thinness and, 457, 458, 459 See also Eating disorders Werewolves, 18

Western Fiji, standards of beauty in, 463 Wet cultures, 254 White blood cells, stress, immune system, and, 190 White females, body image and weight concerns of, 461t Will power, mental illness and, 15 Witchcraft, 18–19 Withdrawal, defined, 235 Withdrawn catatonia, 370 Women anxiety disorders in, 123 depression in, 320–322, 321t eating disorders and, 444–445, 451 eating disorders NOS and, 453 height and weight of, 458t hysteria in, 171 panic disorder in, 136 plus-size models and, 459 schizophrenia in, 381

social phobias in, 126 stressors on, 58 tardive dyskinesia in, 384 See also Female entries; Gender; Rape World Laughter Day, 401 World Laughter Tour, 191 World Trade Center terrorist attacks field study interviews after, 107 stress from, 185 survivors of, 177 Worldview, cultural determinant of, 10 WPPSI-III, see Wechsler scales, Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III) Written expression, disorder of, 435t Wyatt v. Stickney, 487

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Youngberg v. Romeo, 488 Young people weight concerns of, 444t See also Adolescents; Children; College students Yo-yo dieting, 471 Zar (state of possession), 156 Ziprasidone, 383 Zoloft, 323 for OCD, 145 Zyprexa, 383

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DSM-IV-TR CLASSIFICATION From the American Psychiatric Association, 2000* DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR ADOLESCENCE Mental Retardation Note: These are coded on Axis II. Mild Moderate Severe Profound Learning Disorders Reading Disorder Mathematics Disorder

Tic Disorders Tourette’s Disorder Chronic Motor or Vocal Tic Disorder Transient Tic Disorder Elimination Disorders Encopresis Enuresis (Not Due to a General Medical Condition) Other Disorders of Infancy, Childhood, or Adolescence

Amphetamine (or Amphetamine-like) Disorders Caffeine-Related Disorders Cannabis-Related Disorders Cocaine-Related Disorders Hallucinogen-Related Disorders Inhalant-Related Disorders Nicotine-Related Disorders Opioid-Related Disorders Phencyclidine- (or Phencyclidine-Like) Related Disorders

Separation Anxiety Disorder

Disorder of Written Expression

Sedative-Hypnotic or AnxiolyticRelated Disorders

Selective Mutism

Polysubstance-Related Disorders

Motor Skills Disorder Developmental Coordination Disorder

Reactive Attachment Disorder of Infancy or Early Childhood Stereotypic Movement Disorder

Communication Disorders Expressive Language Disorder

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS Schizophrenia

Mixed Receptive-Expressive Language Disorder

DELIRIUM, DEMENTIA, AND AMNESTIC AND OTHER COGNITIVE DISORDERS

Paranoid Type

Phonological Disorder

Delirium

Catatonic Type

Stuttering

Dementia

Undifferentiated Type

Pervasive Developmental Disorders

Dementia of the Alzheimer’s Type, with Early Onset

Schizophreniform Disorder

Autistic Disorder Rett’s Disorder Childhood Disintegrative Disorder Asperger’s Disorder

Disorganized Type

Residual Type

Dementia of the Alzheimer’s Type, with Late Onset

Schizoaffective Disorder

Vascular Dementia

Brief Psychotic Disorder

Dementia Due to HIV Disease

Shared Psychotic Disorder

Delusional Disorder

Attention-Deficit and Disruptive Behavior Disorders

Dementia Due to Head Trauma Dementia Due to Parkinson’s Disease

MOOD DISORDERS

Attention-Deficit/Hyperactivity Disorder Combined Type

Dementia Due to Huntington’s Disease

Depressive Disorders

Dementia Due to Pick’s Disease

Single Episode

Dementia Due to Creutzfeldt-Jakob Disease

Recurrent

Dementia Due to Substance-Induced Persisting or Multiple Etiologies

Bipolar Disorders

Predominantly Inattentive Type Predominantly Hyperactive-Impulsive Type Conduct Disorder Oppositional Defiant Disorder Feeding and Eating Disorders of Infancy or Early Childhood

Amnestic Disorders

Pica

SUBSTANCE-RELATED DISORDERS

Rumination Disorder

Alcohol Use Disorders

Feeding Disorder of Infancy or Early Childhood

Alcohol Dependence Alcohol Abuse

Major Depressive Disorder

Dysthymic Disorder Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder ANXIETY DISORDERS Panic Disorder Without Agoraphobia

*Note: Within major categories, additional diagnoses may include: (Disorder) Not Otherwise Specified, (Disorder) Due to General Medical Condition, (Disorder) Substance Induced.

DSM-IV-TR CLASSIFICATION (continued) Panic Disorder with Agoraphobia Agoraphobia Without History of Panic Disorder

Sexual Pain Disorders

Trichotillomania

Dyspareunia (Not Due to a General Medical Condition)

ADJUSTMENT DISORDERS Adjustment Disorder

Specific Phobia

Vaginismus (Not Due to a General Medical Condition)

Social Phobia

Paraphilias

With Anxiety

Obsessive-Compulsive Disorder

Exhibitionism

Posttraumatic Stress Disorder

Fetishism

With Mixed Anxiety and Depressed Mood

Acute Stress Disorder

Frotteurism

With Disturbance of Conduct

Generalized Anxiety Disorder

Pedophilia

With Mixed Disturbance of Emotions and Conduct

Sexual Masochism

With Depressed Mood

SOMATOFORM DISORDERS

Sexual Sadism

Somatization Disorder

Transvestic Fetishism

PERSONALITY DISORDERS Note: These are coded on Axis II.

Undifferentiated Somatoform Disorder

Voyeurism

Paranoid Personality Disorder

Gender Identity Disorders

Schizoid Personality Disorder

Gender Identity Disorder in Children

Schizotypal Personality Disorder

Body Dysmorphic Disorder

Gender Identity Disorder in Adolescents or Adults

Borderline Personality Disorder

FACTITIOUS DISORDERS

EATING DISORDERS

Conversion Disorder Pain Disorder Hypochondriasis

Anorexia Nervosa DISSOCIATIVE DISORDERS

Bulimia Nervosa

Dissociative Amnesia

Antisocial Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder

Dissociative Fugue

SLEEP DISORDERS

Dissociative Identity Disorder

Primary Sleep Disorders: Dyssomnias

MULTIAXIAL SYSTEM

Depersonalization Disorder

Primary Insomnia

Axis 1

Primary Hypersomnia SEXUAL AND GENDER IDENTITY DISORDERS

Breathing-Related Sleep Disorder

Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention

Sexual Dysfunctions

Circadian Rhythm Sleep Disorder

Axis II

Sexual Desire Disorders

Primary Sleep Disorders: Parasomnias

Hypoactive Sexual Desire Disorder Sexual Aversion Disorder Sexual Arousal Disorders Female Sexual Arousal Disorder

Narcolepsy

Nightmare Disorder

Personality Disorders Mental Retardation

Sleep Terror Disorder

Axis III

Sleepwalking Disorder

General Medical Condition Axis IV

Male Erectile Disorder

IMPULSE-CONTROL DISORDERS NOT ELSEWHERE CLASSIFIED

Orgasmic Disorders

Intermittent Explosive Disorder

Female Orgasmic Disorder

Kleptomania

Male Orgasmic Disorder

Pyromania

Premature Ejaculation

Pathological Gambling

Psychosocial and Environmental Problems Axis V Global Assessment of Functioning