Understanding Abnormal Behavior - Cengage Learning
Understanding Abnormal Behavior - Cengage Learning
Understanding Abnormal Behavior - Cengage Learning
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Instructor’s Resource Manual<br />
<strong>Understanding</strong> <strong>Abnormal</strong><br />
<strong>Behavior</strong><br />
EIGHTH EDITION<br />
David Sue / Derald Sue / Stanley Sue<br />
Revised by Fred W. Whitford<br />
Montana State University<br />
David Sue<br />
Western Washington University<br />
Derald Wing Sue<br />
Teachers College, Columbia University<br />
Stanley Sue<br />
University of California, Davis<br />
HOUGHTON MIFFLIN COMPANY BOSTON NEW YORK
Vice President and Publisher: Charles Hartford<br />
Sponsoring Editor: Jane Potter<br />
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Editorial Associate: Liz Hogan<br />
Project Editor: Aileen Mason<br />
Editorial Assistant: Susan Miscio<br />
Marketing Manager: Laura McGinn<br />
Marketing Assistant: Erin Lane<br />
Copyright © 2006 by Houghton Mifflin Company. All rights reserved.<br />
Houghton Mifflin Company hereby grants you permission to reproduce the Houghton Mifflin material<br />
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including reproducing or transmitting the material or portions thereof in any form or by any electronic<br />
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Mifflin Company, you must obtain permission from the rights holder. Address inquiries to College<br />
Permissions, Houghton Mifflin Company, 222 Berkeley Street, Boston, MA 02116-3764.<br />
Printed in the U.S.A.<br />
ISBN: 0-618-52830-X
Contents<br />
PREFACE................................................................................................................................................. V<br />
THE CASE OF STEVEN V. ....................................................................................................................VIII<br />
CHAPTER 1 - ABNORMAL BEHAVIOR ................................................................................................. 1<br />
CHAPTER 2 - MODELS OF ABNORMAL BEHAVIOR............................................................................ 17<br />
CHAPTER 3 - ASSESSMENT AND CLASSIFICATION OF ABNORMAL BEHAVIOR................................. 35<br />
CHAPTER 4 - THE SCIENTIFIC METHOD IN ABNORMAL PSYCHOLOGY ............................................ 52<br />
CHAPTER 5 - ANXIETY DISORDERS................................................................................................... 70<br />
CHAPTER 6 - DISSOCIATIVE DISORDERS AND SOMATOFORM DISORDERS....................................... 87<br />
CHAPTER 7 - PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITIONS............................... 102<br />
CHAPTER 8 - PERSONALITY DISORDERS AND IMPULSE CONTROL DISORDERS.............................. 119<br />
CHAPTER 9 - SUBSTANCE-RELATED DISORDERS ........................................................................... 134<br />
CHAPTER 10 - SEXUAL AND GENDER IDENTITY DISORDERS ......................................................... 152<br />
CHAPTER 11 - MOOD DISORDERS................................................................................................... 170<br />
CHAPTER 12 - SUICIDE.................................................................................................................... 190<br />
CHAPTER 13 - SCHIZOPHRENIA: DIAGNOSIS AND ETIOLOGY......................................................... 207<br />
CHAPTER 14 - COGNITIVE DISORDERS ........................................................................................... 237<br />
CHAPTER 15 - DISORDERS OF CHILDHOOD AND ADOLESCENCE ................................................... 258<br />
CHAPTER 16 - EATING DISORDERS AND SLEEP DISORDERS........................................................... 270<br />
CHAPTER 17 - THERAPEUTIC INTERVENTIONS ............................................................................... 280<br />
CHAPTER 18 - LEGAL AND ETHICAL ISSUES IN ABNORMAL PSYCHOLOGY ................................... 297<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Preface<br />
This Instructor’s Manual is designed for instructors to use in conjunction with the Eighth Edition of<br />
<strong>Understanding</strong> <strong>Abnormal</strong> <strong>Behavior</strong> by Sue/Sue/Sue. It is meant to be both a guide to using the text and<br />
a handy reference, filled with numerous teaching aids and ideas for enlivening classroom presentations.<br />
Whether novice or expert, each instructor should be able to select material from these resources to suit<br />
his or her needs.<br />
ORGANIZATION OF THIS MANUAL<br />
The Chapters. This manual contains eighteen chapters that correspond to the textbook chapters. Each<br />
chapter in the manual is filled with teaching suggestions and resources designed to enhance teaching<br />
and learning.<br />
CHAPTER-BY-CHAPTER ORGANIZATION<br />
Chapter Outlines Chapter outlines are one of the most important features in any Instructor’s Manual.<br />
The outlines in this manual are very detailed and highlight critical information for student mastery.<br />
Instructors can follow the outlines and be assured that they will cover all the key material in each<br />
chapter, or instructors can edit the outlines to accommodate their own teaching objectives.<br />
<strong>Learning</strong> Objectives <strong>Learning</strong> objectives, intended to aid students’ mastery of essential facts and<br />
concepts, appear in both the Instructor’s Resource Manual and the student Study Guide; text pages<br />
corresponding to the objectives are also identified. In addition, multiple-choice questions in the Test<br />
Bank are keyed to the learning objectives. This interactive approach to learning is unique and designed<br />
to maximize students’ understanding of text material.<br />
Classroom Topics for Lecture and Discussion At least three topics for classroom lectures and<br />
discussions are given in each chapter. We have chosen topics that are current, complex, and interesting<br />
to students—ones we hope will encourage them to connect abstract principles and theories to their daily<br />
lives. Also, throughout the chapters we have added topics that allow students to think clinically and<br />
make differential diagnoses. Internet annotations are included to support key topics in this section.<br />
These Internet annotations will allow you to have the most current information on a specific topic, thus<br />
enhancing your lectures.<br />
Classroom Demonstrations Every chapter contains at least three classroom demonstrations, selected<br />
for their ability to draw students into many of the issues and challenges confronting abnormal<br />
psychology. Many of the demonstrations come with handouts that can easily be removed from the<br />
perforated manual and copied for classroom use. Internet annotations for the classroom demonstrations<br />
are also included in this section. These Internet annotations will allow you to have the most current<br />
information on the specific demonstration, thus enhancing your effectiveness.<br />
Selected Readings A list of selected readings is supplied in each chapter to support text material and<br />
classroom discussions. The lists comprise many articles and books dealing with important issues in<br />
abnormal psychology.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
vi Preface<br />
Video Resources An annotated list of films and tapes, dealing with high-interest topics in abnormal<br />
psychology, completes each chapter of the Instructor’s Manual. Instructors can use these resources to<br />
support classroom presentations or as discussion starters.<br />
On the Internet Information is provided about web addresses for Internet sites related to abnormal<br />
psychology. Internet addresses are listed, with annotations about sites to visit for general topics<br />
presented in the chapter.<br />
ADDITIONAL ANCILLARIES AVAILABLE<br />
Supplements for Instructors<br />
New! <strong>Abnormal</strong> Psych in Film ® DVD/VHS is a hybrid product that contains clips from popular<br />
films such as The Deer Hunter, and Apollo Thirteen that illustrate key concepts in abnormal<br />
psychology, as well as thought-provoking footage from documentaries and client interviews. Each clip<br />
is accompanied by overviews and discussion questions to help bring the study of abnormal psychology<br />
alive for students. This DVD works in tandem with the <strong>Abnormal</strong> Psychology, Eighth Edition Student<br />
CD-ROM as a unique learning system. On the Student CD-ROM are select, corresponding video clips<br />
with overviews, multiple-choice and essay questions, designed to stimulate critical thinking about the<br />
diagnosis and treatment of various disorders. Punctuate your lecture with engaging videos from the<br />
DVD; then have your students use the Student CD-ROM to further study the concepts presented in<br />
those videos.<br />
HM ClassPrep CD-ROM with HM Testing This CD-ROM provides one convenient location for<br />
testing and presentation materials. It contains PowerPoint slides, the Instructor’s Resource Manual, and<br />
the Computerized Test Bank. Our HMTesting program offers delivery of test questions in an easy-touse<br />
interface, compatible with both Mac and Windows platforms.<br />
Test Bank The Test Bank features 100 multiple-choice and three essay questions (with sample<br />
answers) per chapter. Each question is labeled with the corresponding text page reference as well as the<br />
type of question being asked for easier test creation. The Test Bank is available on our HM ClassPrep<br />
CD-ROM with HM Testing.<br />
PowerPoint Slides A completely revamped set of PowerPoint slides is available with the Eighth<br />
Edition. Each chapter’s show contains dozens of slides that include tables and illustrations that help<br />
highlight the major topics in abnormal psychology. The PowerPoint slides are available on the<br />
instructor web site and the HM ClassPrep CD-ROM with HM Testing.<br />
Instructor Website For maximum flexibility, much of the material from the HM ClassPrep CD-ROM<br />
is also available on our website, which may be accessed at<br />
http://psychology.college.hmco.com/instructors. Easy to navigate, this site offers a range of<br />
instructional strategies and tools.<br />
Course Cartridges for WebCT and Blackboard Course cartridges for WebCT and Blackboard are<br />
available for the Eighth Edition, allowing instructors to use text-specific material to create an online<br />
course on their own campus course management system.<br />
Supplements for Students<br />
Study Guide The Study Guide provides a complete review of the chapter with chapter outlines,<br />
learning objectives, fill-in-the-blank review of key terms, and multiple-choice questions. Answers to<br />
test questions include an explanation for both the correct answer and incorrect answers.<br />
Student CD-ROM The CD that accompanies every copy of the student is designed to reinforce<br />
concepts presented in the textbook as well as provide engaging, interactive activities that sharpen<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Preface vii<br />
critical thinking skills. The CD includes select video clips, accompanied by overviews, multiple-choice<br />
and essay questions, Flashcards, Focus Question Activities, Myth Vs. Reality Exercises, and Case<br />
Study Exercises, all of which provide extra review of concepts and terms studied in the abnormal<br />
psychology course.<br />
Student Website The student web site contains additional study aids, including Ace self-tests,<br />
interactive Critical Thinking exercises and multimedia tutorials—all designed to help students improve<br />
their grades while learning more about abnormal psychology. All web resources may be accessed by<br />
logging onto our website at http://psychology.college.hmco.com/students.<br />
Case Studies in <strong>Abnormal</strong> Psychology Case Studies in <strong>Abnormal</strong> Psychology, by Clark Clipson,<br />
California School of Professional Psychology, and Jocelyn Steer, San Diego Family Institute, contains<br />
16 studies and can be shrink-wrapped with the text at a discounted package price. Each case represents<br />
a major psychological disorder. After a detailed history of each case, critical-thinking questions prompt<br />
students to formulate hypotheses and interpretations based on the client’s symptoms, family and<br />
medical background, and relevant information. The case proceeds with sections on assessment, case<br />
conceptualization, diagnosis, and treatment outlook, and is concluded by a final set of discussion<br />
questions.<br />
<strong>Abnormal</strong> Psychology in Context: Voices and Perspectives This supplementary text, written by<br />
David Sattler, College of Charleston, Virginia Shabatay, Palomar College, and Geoffrey Kramer, Grand<br />
Valley State University, features 40 cases and can be shrink-wrapped with the text at a discounted<br />
package price. This unique collection contains first-person accounts and narratives written by<br />
individuals who live with a psychological disorder and by therapists, relatives, and others who have<br />
direct experience with someone suffering from a disorder. These vivid and engaging narratives are<br />
accompanied by critical-thinking questions and a psychological concept guide that indicates which key<br />
terms and concepts are covered in each reading.<br />
Fred W. Whitford<br />
Montana State University<br />
whitford@montana.edu
The Case of Steven V.<br />
A NOTE ABOUT STEVEN V.<br />
Readers familiar with previous editions of <strong>Understanding</strong> <strong>Abnormal</strong> <strong>Behavior</strong> will notice that the<br />
extended case of Steven V. now appears only in Chapter 2. Recognizing that instructors may want to<br />
use all of the Steven V. material, the full text of the case from the Fifth Edition has been included here,<br />
as well as this guide to using the case in chapters throughout the current edition of the text.<br />
GUIDE TO USING THE CASE OF STEVEN V.<br />
Chapter 2 (Models of <strong>Abnormal</strong> <strong>Behavior</strong>): This condensed chapter describing six approaches to<br />
abnormal behavior is an excellent place to use the Steven V. case. Students can be assigned to use one<br />
or more of the approaches to explain Steven’s behavior, thoughts, and feelings. Written assignments,<br />
panel discussions, and debates are activities that can engage students in the important process of<br />
analyzing this single case from different angles.<br />
Chapter 3 (Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong>): Because this chapter surveys the<br />
many forms that assessment can take, it suggests that Steven V.’s strengths and weaknesses might have<br />
been assessed in many different ways. Each theoretical orientation emphasizes certain forms of data and<br />
using particular methods to collect them. Again, an assignment requiring students to describe, compare,<br />
and contrast assessment approaches taken by clinicians of different theoretical stripes reinforces the<br />
importance of flexible thinking. An integrative approach to assessment, using neurological,<br />
psychological, and observational techniques, could be emphasized here since most clinicians are<br />
eclectic rather than purist.<br />
Chapter 10 (Sexual and Gender Identity Disorders): Some of Steven V.’s symptoms entail violent<br />
sexual fantasies. Sexual performance concerns and embarrassment with his genitalia are both relevant<br />
to the material in this chapter. His use of sexually violent videos in adolescence illustrates some of the<br />
points made in the text about a behavioral explanation for sexual disorders. His Oedipal relationship<br />
with his mother relates to the psychoanalytic explanation.<br />
Chapter 11 (Mood Disorders): Bipolar disorder is one of the diagnoses Steven V. received. Here you<br />
can compare the diagnostic criteria for bipolar and major depressive disorder with the symptoms that<br />
Steven displays. Ask students which signs are missing, which are present, and which ones we must<br />
speculate about.<br />
Chapter 12 (Suicide): Steven V. seems like a young man with a high potential for violent behavior<br />
directed either at himself or at others. Have students do a lethality assessment of Steven based on what<br />
they are told. Give them a reasonable amount of discretion in speculating on the circumstances in which<br />
he would become more and more suicidal. What kinds of suicide prevention efforts might have been<br />
put in place on his university campus? How might his parents have responded if they knew he was<br />
suicidal?<br />
Chapter 15 (Disorders of Childhood and Adolescence): Steven V. is a late adolescent when he arrives at<br />
the university counseling service. Students are likely to see him as having adult disorders. But what<br />
disorders would have been diagnosed when he was eight or twelve or fifteen? Students can review the<br />
information on childhood depression, separation anxiety disorder, and conduct disorder to see if the<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
The Case of Steven V. ix<br />
symptoms and events in Steven V.’s traumatic childhood match. Ask students what interventions with<br />
his parents might have changed the trajectory of his personality development.<br />
Chapter 17 (Therapeutic Interventions): Here, as in Chapters 2 and 3, students have an opportunity to<br />
describe, differentiate, and critique the use of different theoretical approaches with one case. Written<br />
assignments, panel discussions, debates, or role-played “therapy sessions” can impress upon students<br />
how different therapies would highlight different aspects of Steven’s behavior, thoughts, and feelings.<br />
Once again, you could ask students to design an integrative approach that would take the best of the<br />
many approaches described to effectively treat him and, perhaps, his family. Family therapy is a<br />
particularly intriguing option for Steven. The conflict between and among him, his father, and his<br />
mother may trigger some strong reactions from students who often face similar, if less intense,<br />
circumstances. An entertaining and thought-provoking activity is to have students role-play a family<br />
therapy session with the V. family.<br />
Chapter 18 (Legal and Ethical Issues in <strong>Abnormal</strong> Psychology): Clearly, a key issue in the case of<br />
Steven V. is the dilemma faced by his therapist. Should the therapist take seriously Steven’s threats and<br />
break confidentiality or keep these secrets? Students should see the links between the Tarasoff ruling<br />
and the case of Steven V. They can also think about the means by which a therapist attempts to predict<br />
dangerousness. Ask students what evidence from the past would indicate that Steven was prepared to<br />
harm his former girlfriend; have them assess the risks of overpredicting dangerousness versus the risks<br />
of underpredicting it. Finally, compare the list of exemptions from privileged communications given in<br />
the text and the situation the counseling center therapist found himself in when Steven discussed his<br />
plans to harm his girlfriend.
x The Case of Steven V.<br />
THE CASE OF STEVEN V.<br />
Steven V. had been suffering from a severe bout of depression. Eighteen months earlier, Steve’s woman<br />
friend, Linda, had broken off her relationship with Steve. Steve had fallen into a crippling depression.<br />
During the past few weeks, however, with the encouragement of his therapist, Steve had begun to open<br />
up and express his innermost feelings. His depression had lifted, but it was replaced by a deep anger<br />
and hostility toward Linda. In today’s session, Steve had become increasingly loud and agitated as he<br />
recounted his complaints against Linda. Minutes ago, with his hands clenched into fists, his knuckles<br />
white, he had abruptly lowered his voice and looked his therapist in the eye. “She doesn’t deserve to<br />
live,” Steve had said. “I swear, I’m going to kill her.”<br />
The therapist could feel himself becoming tense, apprehensive, and uncertain: How should he interpret<br />
the threat? How should he act on it? One wheel of his swivel chair squealed sharply, breaking the<br />
silence, as he backed away from his client.<br />
Until this session, the therapist had not believed Steve was dangerous. Now he wondered whether Steve<br />
could be the one client in ten thousand to act out such a threat. Should Linda or the police be told of<br />
what Steve had said?<br />
Steve V. had a long psychiatric history, beginning well before he first sought help from the therapist at<br />
the university’s psychological services center. (In fact, his parents wanted their son to continue seeing a<br />
private therapist, but Steven stopped therapy during his junior year at the university.) Steve had actually<br />
been in and out of psychotherapy since kindergarten; while in high school, he was hospitalized twice<br />
for depression.<br />
His case records, nearly two inches thick, contained a number of diagnoses, including labels such as<br />
schizoid personality, paranoid schizophrenia, and manic-depressive psychosis (now referred to as<br />
bipolar mood disorder). Although his present therapist did not find these labels particularly helpful,<br />
Steve’s clinical history did provide some clues to the causes of his problems.<br />
Steven V. was born in a suburb of San Francisco, California, the only child of an extremely wealthy<br />
couple. His father was a prominent businessman who worked long hours and traveled frequently. On<br />
those rare occasions when he was at home, Mr. V. was often preoccupied with business matters and<br />
held himself quite aloof from his son. The few interactions they had were characterized by his constant<br />
ridicule and criticism of Steve. Mr. V. was greatly disappointed that his son seemed so timid, weak, and<br />
withdrawn. Steven was extremely bright and did well in school, but Mr. V. felt that he lacked the<br />
“toughness” needed to survive and prosper in today’s world. Once, when Steve was about ten years old,<br />
he came home from school with a bloody nose and bruised face, crying and complaining of being<br />
picked on by his schoolmates. His father showed no sympathy but instead berated Steve for losing the<br />
fight. In his father’s presence, Steve usually felt worthless, humiliated, and fearful of doing or saying<br />
the wrong thing.<br />
Mrs. V. was very active in civic and social affairs, and she too spent relatively little time with her son.<br />
Although she treated Steve more warmly and lovingly than his father did, she seldom came to Steve’s<br />
defense when Mr. V. bullied him. She generally allowed her husband to make family decisions.<br />
When Steve was a child, his mother at times had been quite affectionate. She had often allowed Steve<br />
to sleep with her in her bed when her husband was away on business trips. She usually dressed<br />
minimally on these occasions and was very demonstrative—holding, stroking, and kissing Steve. This<br />
behavior had continued until Steve was twelve, when his mother abruptly refused to let Steve into her<br />
bed. The sudden withdrawal of this privilege had confused and angered Steve, who was not certain<br />
what he had done wrong. He knew, though, that his mother had been quite upset when she awoke one<br />
night to find him masturbating next to her.<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
The Case of Steven V. xi<br />
Most of the time, however, Steve’s parents seemed to live separately from one another and from their<br />
son. Steve was raised, in effect, by a full-time maid. He rarely had playmates of his own age. His<br />
birthdays were celebrated with a cake and candles, but the only celebrants were Steve and his mother.<br />
By age ten, Steven had learned to keep himself occupied by playing “mind games,” letting his<br />
imagination carry him off on flights of fantasy. He frequently imagined himself as a powerful figure—<br />
Superman or Batman. His fantasies were often extremely violent, and his foes were vanquished only<br />
after much blood had been spilled.<br />
As Steve grew older, his fantasies and heroes became increasingly menacing and evil. When he was<br />
fifteen, he obtained a pornographic videotape that he viewed repeatedly on a video player in his room.<br />
Often, Steve would masturbate as he watched scenes of women being sexually violated. The more<br />
violent the acts against women, the more aroused he became. He was addicted to the Nightmare on Elm<br />
Street films, in which the villain, Freddie Kruger, disemboweled or slashed his victims to death with his<br />
razor-sharp glove. Steve now recalls that he spent much of his spare time between the ages of fifteen<br />
and seventeen watching X-rated videotapes or violent movies, his favorite being The Texas Chainsaw<br />
Massacre, in which a madman saws and hacks women to pieces. Steve always identified with the<br />
character perpetrating the outrage; at times, he imagined his parents as the victims.<br />
At about age sixteen, Steven became convinced that external forces were controlling his mind and<br />
behavior and were drawing him into his fantasies. He was often filled with guilt and anxiety after one of<br />
his mind games. Although he was strongly attracted to his fantasy world, he also felt that something<br />
was wrong with it and with him. After seeing the movie The Exorcist, he became convinced that he was<br />
possessed by the devil.<br />
Until this time, Steve had been quiet and withdrawn. In kindergarten the school psychologist had<br />
described his condition as autisticlike because Steve seldom spoke, seemed unresponsive to the<br />
environment, and was socially isolated. His parents had immediately hired a prominent child<br />
psychiatrist to work with Steve. The psychiatrist had assured them that Steve was not autistic but would<br />
need intensive treatment for several years. And throughout these years of treatment, Steve never acted<br />
out any of his fantasies. With the development of his interest in the occult and in demonic possession,<br />
however, he became outgoing, flamboyant, and even exhibitionistic. He read extensively about<br />
Satanism, joined a “Church of Satan” in San Francisco, and took to wearing a black cape on weekend<br />
journeys into that city. Against his will, he was hospitalized twice by his parents with diagnoses of,<br />
respectively, bipolar affective disorder and schizophrenia in remission.<br />
Steve was twenty-one years old when he met Linda at an orientation session for first-year university<br />
students. Linda struck him as different from other women students: unpretentious, open, and friendly.<br />
He quickly became obsessed with their relationship. But although Linda dated Steve frequently over the<br />
next few months, she did not seem to reciprocate his intense feelings. She took part in several<br />
extracurricular activities, including the student newspaper and student government, and her willingness<br />
to be apart from him confused and frustrated Steve. When her friends were around, Linda seemed<br />
almost oblivious to Steve’s existence. In private, however, she was warm, affectionate, and intimate.<br />
She would not allow sexual intercourse, but she and Steve did engage in heavy petting.<br />
Even while he and Linda were dating, Steve grew increasingly insecure about their relationship. He felt<br />
slighted by Linda’s friends and began to believe that she disliked him. Several times he accused her of<br />
plotting against him and deliberately making him feel inadequate. Linda continually denied these<br />
allegations. Finally (on one occasion), feeling frightened and intimidated by Steve, she acquiesced to<br />
having sex with him. Unfortunately, Steve could not maintain an erection. When he blamed her for this<br />
“failure” and became verbally and physically abusive, Linda put an end to their relationship and refused<br />
to see him again.
xii The Case of Steven V.<br />
During the next year and a half, Steve suffered from severe bouts of depression and twice attempted<br />
suicide by drug overdose. For the past six months, up to the time of his threat, he had been seeing a<br />
therapist regularly at the university’s psychological services center.<br />
A Biological View of Steven V.<br />
How would a psychologist oriented toward biogenic explanations view the case of Steven V.? If Steve’s<br />
therapist were so oriented, we believe that he or she would discuss Steve’s behavior in the following<br />
terms.<br />
Before I interpret the symptoms displayed by Steven V. and speculate on what they mean, I must stress<br />
my belief that many “mental disorders” have a strong biological basis. I do accept the importance of<br />
environmental influences, but in my view, the biological bases of abnormality are too often overlooked<br />
by psychologists. This seems clearly to be the case with Steven V.<br />
Much of Steve’s medical history is missing from his case records, along with important information<br />
about his biological and developmental milestones. We do not have the data necessary to chart a family<br />
tree, which would show whether other members of his family have suffered from a similar disorder.<br />
This lack of information about possible inherited tendencies in Steve’s current behavior pattern is a<br />
serious shortcoming.<br />
At age fifteen, Steve was given a diagnosis of bipolar affective disorder (formerly called manicdepressive<br />
psychosis). Pharmacological treatment was moderately effective in controlling his<br />
symptoms. After Steve’s condition became stabilized, lithium carbonate treatment was instituted for a<br />
period of time, and Steve was free of symptoms during that period. Unfortunately, Steve apparently<br />
disliked taking medication and did so only sporadically.<br />
In any case, evidence documents and supports a diagnosis of bipolar affective disorder. Steve displays<br />
the behaviors associated with this disorder, ranging from manic episodes (elevated mood characterized<br />
by expansiveness, hyperactivity, flight of ideas, and inflated self-esteem) to depressive episodes<br />
(depressed mood characterized by loss of interest, feelings of worthlessness, and thoughts of death or<br />
suicide). These symptoms are not of recent origin but probably were evident very early in his life.<br />
Steve’s first contact with a mental health professional was with the school psychologist in kindergarten,<br />
who described him as “autisticlike.” I believe the child psychiatrist whom Steve subsequently visited<br />
was correct in saying that Steve was not autistic. The chief symptoms described in his early years,<br />
which appeared to indicate autism (social isolation and unresponsiveness), are similar to those of<br />
depression. I suspect Steve was experiencing a major depressive episode as early as kindergarten, and it<br />
may not have been his first. Unfortunately, we do not have access to Steve’s pediatrician, who may<br />
have observed even earlier signs of bipolar disorder. What we do have, however, are several statements<br />
from his parents indicating that “even at birth, Steve did not respond in the normal way.”<br />
Thus the following conclusions can be drawn: Steve’s disorder was evident early in his life, and he<br />
suffered from a chemical imbalance. In spite of a shortage of information, there is some indication that<br />
some of Steve’s relatives may have suffered from a similar disorder. The most defensible diagnosis is<br />
bipolar affective disorder. The most effective way to treat this disorder is through drug therapy.<br />
These conclusions strongly support a biological interpretation of the patient’s psychopathology.<br />
Heredity seems to have played a part; we have some evidence that relatives may have suffered a similar<br />
disorder. The precise biological mechanism that triggered the disorder is probably within one of the two<br />
major classes of neurotransmitters (catecholamines and indoleamines). If this diagnosis is accurate, the<br />
patient should resume taking medication. Of course, stressful life events may also be contributing to<br />
Steve’s emotional problems, and I intend to continue psychotherapy with him. But I believe that many<br />
of Steve’s depressive episodes would have occurred regardless of psychological intervention. And they<br />
will probably continue to occur unless Steve controls his biological problem with medication. I am not<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
The Case of Steven V. xiii<br />
an M.D. and therefore cannot prescribe drugs, so I have arranged for Steve to visit a physician at the<br />
college medical center. Only when Steve’s organic problem is under control can I or any other therapist<br />
begin to make headway with Steve’s problems in relating to other people.<br />
A Psychoanalytic View of Steven V.<br />
Let us hypothesize again. Suppose that Steven V.’s therapist had a psychoanalytical orientation. Here is<br />
what we believe that he or she might have to say about Steve.<br />
In Steve’s case records, I see many possible explanations for his continuing problems. I will focus on<br />
four areas that I find particularly important: Steve’s early childhood experiences; his repression of<br />
conflicts, intense feelings, and other impulses; the oedipal dynamics that seem to be at work; and the<br />
unconscious symbolism behind his relationship with Linda.<br />
Steve did not receive the love and care, at crucial psychosexual stages, that a child needs to develop<br />
into a healthy adult. He was neglected, understimulated, and left on his own. The result was that he felt<br />
unloved and rejected. We have evidence that he was prone to “accidents”—being hit on the head by a<br />
swing, burning himself severely on an electric range, numerous falls. I believe that these were not really<br />
accidents. They represented Steve’s unconscious attempts to gain attention and to test his parents’ love<br />
for him. Furthermore, I believe that his proneness to accidents was the forerunner of his attempts at<br />
suicide, a reflection of the death instinct and a desire to punish himself. Although Steve may not have<br />
been conscious of his feelings or able to verbalize them, it is obvious that he was deeply affected by his<br />
parents’ negative attitudes. It must be an awful experience for a young child to believe that he or she is<br />
unloved. For many of us, it is easier to deny or repress this belief than to face up to it.<br />
Steve may have been the victim of marital unhappiness between his mother and father. The records<br />
indicate that they lived rather separate lives and that Mr. V. kept several mistresses whom he saw on his<br />
frequent “business trips.” In one therapy session, when Mrs. V. was seen alone, she stated that she<br />
knew of her husband’s extramarital affairs but never confronted him about them. Apparently she was<br />
fearful of his dominating and abusive manner at home, and she avoided potential conflicts by playing a<br />
passive role. When Mr. V. belittled Steve, she chose not to intervene; secretly, however, she identified<br />
with her son’s predicament. Unable to form an intimate relationship with her husband, she became<br />
physically seductive toward Steve. As you recall, Mrs. V. frequently caressed and kissed her son and<br />
even had him sleep with her. To a youngster still groping his way through oedipal conflicts, nothing<br />
could have been more damaging. Steve’s sexual feelings toward the mother were no doubt intensified<br />
by her actions.<br />
Mr. V.’s verbal abuse of Steve also aggravated Steve’s problems. One of his father’s common remarks<br />
to Steve was “You’ve got no balls.” Abuse such as this deepened and prolonged Steve’s oedipal<br />
feelings of rivalry with and fear of his father. Steve’s oedipal conflict was never adequately resolved.<br />
His continued feelings of inadequacy and anger, and his sexual drives as well, have remained repressed<br />
and are expressed symbolically.<br />
Steve’s repressed anger is certainly present in both his fantasies and behavior. His violent “mind<br />
games” and his preference for sadistic pornographic films are an indirect expression of anger at his<br />
father, whom he continues to see as a powerful feared rival (he has failed to identify with his father in<br />
resolution of the oedipal conflict), and at his mother, who never came to his defense and suddenly<br />
withdrew his “bed privileges” when she became aware of Steve’s sexual excitement. There also appears<br />
to be a strong relationship between Steve’s anger and his depression. Steve’s periodic bouts of<br />
depression are probably the result of anger turned inward. His frequent accidents, his episodic<br />
depression, and his attempts at suicide are classic manifestations of the death instinct.<br />
Steve’s early childhood experiences continue to affect his behavior with women. Note the similarities<br />
between his woman friend, Linda, and his mother. Linda is described as being active in student affairs;
xiv The Case of Steven V.<br />
the mother was always involved in civic affairs. Linda seemed oblivious to Steve’s existence in the<br />
presence of others, and he felt slighted by her friends; the mother seems never to have introduced Steve<br />
to her friends and relatives. Linda was “warm, affectionate, and intimate” in private; the mother, when<br />
“alone with Steve,” was quite affectionate. Linda would consent to “heavy petting” but drew the line<br />
short of intercourse; the mother suddenly withdrew “bed privileges” when Steve showed incestuous<br />
sexual interest. It is clear that Steve continues to search for a “mother figure” and unconsciously<br />
selected a woman who is most like his mother. His impotence with Linda is additional evidence that<br />
Steve unconsciously views her as his mother. (In our society, incest is an unthinkable act.)<br />
If Steve is to become a healthier individual, he must commit himself to intensive, long-term therapy<br />
aimed at helping him gain insight into his deep conflicts and repressed experiences. Resolving past<br />
traumas, overcoming resistance, and working through a transference relationship with the therapist will<br />
be crucial components of his therapy.<br />
A Humanistic-Existential View of Steven V.<br />
A therapist who strongly endorses the humanistic or existential approach would see Steven V. quite<br />
differently from the way a psychoanalyst or a proponent of the biogenic model would see Steve. If<br />
Steve’s therapist were so oriented, we believe that he or she would consider the case of Steven V. very<br />
much as follows.<br />
I must begin by stressing a point that is likely to be underemphasized by many other psychologists.<br />
Steven V. is not merely the sum of the voluminous case records I have before me. Steve is a flesh-andblood<br />
person, alive, organic, and moving, with thoughts, feelings, and emotions. How could anyone<br />
hope to understand Steve by reading a pile of material that is static and inorganic and occasionally<br />
seeks to pigeonhole him into diagnostic categories? To classify Steve as schizophrenic, manicdepressive,<br />
or suicidal does not help me understand him. Indeed, such labels might serve as barriers to<br />
the development of a therapeutic relationship with him.<br />
I intend to develop such a relationship with Steve, to engage him in a dialogue that will require no<br />
pretenses or self-justifications, and to travel with him on a journey whose destination neither of us will<br />
know until we get there. What makes me so sure that such a journey will be worthwhile? Almost<br />
everything I know of Steve, I learned from Steve himself. Here, for example, is an entry from Steve’s<br />
diary, written when he was in his junior year in high school.<br />
Seems like I can’t do anything right. Why does he always pick on me? Came home with top<br />
scores on my SAT. Mother was impressed. Showed Dad. Wouldn’t even look up from his<br />
newspaper. All he’s interested in is the Wall Street Journal. Make money, that’s the goal!!<br />
Tried to tell him at dinner again. Got top score, Dad!! Don’t you care?? Of course not! Said he<br />
expected it from me. Said he wanted me to do better next time. Said I should sit up and not slurp<br />
my soup. . . . Said I should learn better table manners. . . . Said I was an asshole!!! I am an<br />
asshole, I am, I am, who am I? Who cares?<br />
Steve expresses strong feelings and emotions in this passage. Steve is deeply hurt by his father, he is<br />
angry at his father, and he seems to be seeking approval and validation from his father; he is also<br />
grappling with identity issues. These themes, but especially that of seeking approval from his father, are<br />
sounded throughout Steve’s diary. His self-image and self-esteem seem to depend on his father’s<br />
reaction to him. He clings to this perception of himself because he is afraid that without it he would not<br />
know who he is. This is illustrated in his questions: “Who am I? Who cares?” Until Steve knows who<br />
he is, he cannot understand what he might become. Now here is another diary entry, this one during his<br />
senior year in high school:<br />
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The Case of Steven V. xv<br />
Hello diary! Another do-nothing day! Parents won’t let me do anything. Maybe I should jack<br />
off. . . . Got another good porno tape. This room’s like a prison. Hello walls. . . . hello desk . . .<br />
hello fly . . . hello hell! Ha, that’s a good one . . .<br />
Every day’s the same.<br />
When you’re in the well!<br />
Every day’s a game.<br />
When you’re in hell.<br />
This passage reveals another aspect of what is happening with Steve. He feels trapped, immobilized,<br />
lonely, and unable to change his life. He has never recognized or accepted the responsibility of making<br />
choices. He externalizes his problems and views himself as a passive victim. In this way Steve evades<br />
responsibility for choosing and protects himself by staying in the safe, known environment of his room.<br />
Steve needs to realize that he is responsible for his own actions, that he cannot find his identity in<br />
others. He needs to get in touch with, and express directly, his feelings of anxiety, guilt, shame, and<br />
anger. And he needs to be open to new experiences. All this can be accomplished through a free, open,<br />
and unstructured client-therapist relationship.<br />
A <strong>Behavior</strong>al View of Steven V.<br />
Now suppose that Steve’s therapist is strongly oriented toward the behavioral models. He or she would<br />
then discuss Steve’s problems in terms very much like the following.<br />
Let me start by drawing an analogy between behavior and music. In music, all the songs a performer<br />
has learned make up the performer’s repertoire. Quite similarly, all an individual’s behaviors—all the<br />
responses the person has learned to make in each situation—constitute the person’s behavioral<br />
repertoire.<br />
The roots of Steve’s problems can be traced to his behavioral repertoire. Many of the behaviors he has<br />
learned are inappropriate (much like songs that nobody wants to hear), and his repertoire lacks useful,<br />
productive behaviors.<br />
Many of Steve’s troubles stem from his deficiency in, or lack of, social skills. He has had little practice<br />
in social relationships, and so has difficulty distinguishing between appropriate and inappropriate<br />
behavior. You can see evidence of these problems in his withdrawn behavior when he is in the<br />
company of relatives or his parents’ or Linda’s friends. Steve himself reports that he feels apprehensive<br />
and anxious in the company of others (for example, Linda’s friends) and finds himself with no idea of<br />
what to do or say. While others seem to have no difficulty making “small talk,” Steve remains silent.<br />
When he does speak, his statements are usually perfunctory, brief, and inappropriate. I think this<br />
deficiency stems from Steve’s early social isolation, which prevented him from developing<br />
interpersonal skills, and from his lack of good role models. His parents seldom interacted with one<br />
another or with Steve. Recall that Mr. V.’s manner of relating to his son was generally antagonistic; he<br />
did not model effective and appropriate skills.<br />
I am also interested in exploring Steve’s bouts of depression, but I need to know several things: first,<br />
through what specific behaviors is Steve’s depression made manifest? Does he withdraw from social<br />
contact? Lose his appetite? Weep? Make negative statements? If we are to help Steve change his<br />
behavior, we must know what behavior we are talking about. Too often terms such as depression,<br />
passivity, and anxiety are used without a common referent. For example, when a client calls himself<br />
“shy,” we must be sure that both therapist and client understand the term in the same way.<br />
Second, what situations tend to elicit his depression? If the events share common characteristics, then<br />
we may be able to control or alter them to Steve’s advantage. Again, it appears that Steve experiences
xvi The Case of Steven V.<br />
depression when he believes himself to be worthless: when rejected by his woman friend, when<br />
belittled by his father, and on becoming impotent in his first sexual encounter. Steve may be able to<br />
master such situations by developing more effective behaviors. He might benefit, for example, from<br />
learning to respond to his father’s bullying by telling his father how hurt and angry he feels when his<br />
father belittles him. A behavioral program designed to enhance Steve’s sexual functioning could also<br />
prove helpful in combating his depression. And Steve must learn to challenge his own irrational<br />
beliefs—for example, the belief that his father’s failure to acknowledge Steve’s academic achievements<br />
is somehow Steve’s fault.<br />
Steve’s heterosexual anxiety and impotence must also be addressed. I believe that Steve has a<br />
conditioned or learned anxiety toward women and especially toward sexual intercourse. This anxiety<br />
not only blocks his ability to relate to members of the opposite sex but also directly affects his<br />
autonomic nervous system, so that his sexual arousal is impaired. We must teach Steve through<br />
classical conditioning how to subtract anxiety from the sexual encounter. Counterconditioning<br />
techniques seem to offer promise in treating Steve’s impotence; relaxation could be used as a response<br />
that is antagonistic to his anxiety about sexual intercourse.<br />
I have purposefully saved the discussion of Steve’s delusions for last. Perhaps you find it difficult to<br />
imagine a behavioral analysis of delusions. But I am not concerned with the phenomena of Steve’s<br />
imagination; my concern is with the behavior that are alleged to expressed a delusional system. Many<br />
people display inappropriate behaviors that are considered aversive, odd, or unusual but that may be<br />
somehow reinforced. Steve’s repeated assertion that he is controlled by demonic forces and his<br />
continual thinking about Satanism disturb many people. But the people who call him crazy and are<br />
occasionally frightened by him may actually be reinforcing these behaviors.<br />
When Steve behaves in this way, he garners much attention from his parents, peers, and onlookers.<br />
Fully seven pages of a ten-page psychological report, prepared by a therapist two years ago, are devoted<br />
to Steve’s delusions. I submit that by finding the topic fascinating and spending a lot of time talking<br />
with Steve about his delusions, the therapist thus reinforced the client’s verbal behavior! I am not the<br />
only behaviorist who contends that psychoanalytically oriented therapists make this mistake. Many<br />
behavioral therapists believe, for example, that psychoanalysts elicit so much sexual material from their<br />
clients precisely because they unwittingly reinforce this concentration on sex. Is it possible that Steve’s<br />
verbal and other behavioral evocations of Satanism would diminish if people ignored them? It is more<br />
than possible.<br />
In sum, a behavioral program including modeling, role playing, and assertiveness training could be used<br />
to enhance Steve’s social skills. I would use cognitive strategies and teach him behaviors through which<br />
he may more adequately control his environment to combat his depression. His heterosexual anxiety<br />
and impotence would be treated via counterconditioning methods and relaxation training. Finally, the<br />
use of extinction strategies might reduce his excessive concern with Satanism.<br />
A Cognitive-<strong>Behavior</strong>al View of Steven V.<br />
What if Steve were working with a cognitively oriented therapist? How would the therapist view Steve’s<br />
problems and how would he or she help him?<br />
In essence, it is important to show Steve that the psychological problems he is experiencing derive from<br />
the many irrational beliefs that he uses to judge himself and others. First, it is very easy for us to<br />
conclude that the problems he now encounters are a function of unrealistic and illogical standards that<br />
he learned from his family and significant others in his life. This would be simplistic, however, because<br />
the real problem is not the learned values in his childhood, but rather the many dogmatic, rigid “musts,”<br />
“shoulds,” and “oughts” that he has creatively constructed around these standards and around the<br />
unfortunate events that occur in his life. Second, as a practicing cognitive therapist, I would attempt to<br />
work with Steve in a highly didactic, cognitive, and behavior-oriented manner, stressing Steve’s need to<br />
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The Case of Steven V. xvii<br />
(1) recognize the role thinking and belief systems play in his problems; (2) identify self-statements,<br />
belief systems, or assumptions that are irrational and maladaptive and rationally dispute them; and (3)<br />
learn to replace irrational self-statements with productive ones. Let us use an example to illustrate this<br />
approach.<br />
As you recall, Steve first came to the attention of the university therapist after a breakup with his<br />
woman friend, Linda. Initially, he became severely depressed and withdrew from almost all social<br />
activities. Most of us, including Steve, could easily conclude that the reason he became depressed was<br />
because of the breakup of a valued relationship. However, this simple cause-effect analysis negates the<br />
importance of Steve’s internal cognitions. Ending a relationship is certainly unpleasant and unfortunate.<br />
Most people do not feel good about such an event, and the negative reactions we experience might even<br />
be normal and expected. Nevertheless, Steve’s reactions to the breakup are too severe, intense, and<br />
prolonged to be considered normal.<br />
The breakup with Linda must have other personal significance and meaning to him, contained in<br />
irrational beliefs he holds. Using Ellis’s A-B-C theory of personality we might say that the breakup with<br />
Linda is the activating event A and Steve’s depression and withdrawal is the consequence C. Steve’s<br />
beliefs and interpretations B about A, however, cause his psychological reactions C. It is quite clear that<br />
Steve has irrational beliefs about himself and others that are the basis of his problems. He might be<br />
saying something like this to himself: “Linda’s rejection of me shows me how inadequate and worthless<br />
I am. I’ll never be able to find another woman again. I’m a miserable failure as a man. No one will ever<br />
love me again.” These thoughts are very active in Steve and he keeps telling himself that they are true.<br />
Some of the irrational assumptions that seem to be operating in Steve’s thought processes are as<br />
follows:<br />
1. “I should always please my parents. I must live up to their expectations or I will be a failure as a<br />
son and person.”<br />
2. “If everyone doesn’t love me and approve of me, it would be awful. I’m a worthless and miserable<br />
person.”<br />
3. “I must be perfect in school. I must get straight A’s. If I don’t get good grades, I am stupid.”<br />
4. “A real ‘man’ would never be rejected by a woman. A real ‘man’ should always be able to<br />
perform sexually.”<br />
5. “I’m a prisoner of my past. No matter what I do I cannot change how screwed up I am. I can’t<br />
help being crazy. My future looks bleak.”<br />
These irrational beliefs are at the basis of much of Steve’s problems. He must be helped to distinguish<br />
between the real event and the unrealistic assumptions he makes about its consequences. Because<br />
human beings have the capacity for both rational and irrational thinking, I would utilize Steve’s<br />
capacity for rational thinking to attack his belief system. Logic could help Steve recognize and dispute<br />
faulty assumptions and reasoning, using statements such as “Where is it written that one’s self-worth is<br />
based on being universally loved?” He could be taught realistic and productive self-statements to<br />
replace irrational ones: “I’m catastrophizing again. It’s okay to flub up occasionally. I’m a worthwhile<br />
person even though my father doesn’t approve.” Having Steve understand the cognitive source of his<br />
problems, helping him attack these irrational beliefs, replacing them with realistic values and standards,<br />
and correcting his faulty logic will go a long way to help Steve become a more productive and healthy<br />
individual.<br />
The Family Systems Model of Psychopathology<br />
What if Steve were working with a family systems oriented therapist? How would the therapist view<br />
Steve’s problems and how would he or she help him?
xviii The Case of Steven V.<br />
Steve’s problem is not an isolated phenomenon. It resides in the family system, which should be the<br />
primary unit of treatment. Although Steve is manifesting the disorders, his father and mother are also<br />
suffering, and their pathological symptoms are reflected in Steve. Attempts to help Steve must therefore<br />
focus on the entire family. It is obvious that the relationships between Steve and his father, between<br />
Steve and his mother, and between his father and mother are unhealthy.<br />
Furthermore, the relationship of Mr. and Mrs. V. can be characterized as isolative. Each seems to live a<br />
separate life, even when they are together in the same house. Each has unfulfilled needs, and each<br />
denies and avoids interactions and conflicts with the other. As long as Steve is the “identified patient”<br />
and is seen as “the problem,” Mr. and Mrs. V. can continue in their mutual self-deception that all is well<br />
between them. I recommend that Steve’s entire family be included in a program of therapy.<br />
Models of Diversity and Psychopathology<br />
How would a therapist oriented toward the multicultural model of therapy view Steve’s problems?<br />
What if Steve were working with this therapist? How would he or she help Steve?<br />
Steven V. is not only a biological, feeling, behaving, thinking, and social being, but a person with a<br />
culture. The cultural context in which his problems arise must be considered in understanding Steve’s<br />
dilemma. He is a European American of Scottish descent, born to an extremely wealthy family in the<br />
upper socioeconomic class. He is a male, raised in a cultural context that values individual<br />
achievement. All of these characteristics mean that many of his experiences are likely to be very<br />
different from those of a person who is a member of a minority group, economically indigent, or of<br />
female gender. One might argue, for example, that Steve’s father values American individualistic<br />
competitiveness and achievement in the extreme. He has succeeded by his own efforts but,<br />
unfortunately, his success has come at the emotional cost of his family. To truly understand Steve, we<br />
must recognize that the many multicultural variables—race, culture, ethnicity, gender, religion, sexual<br />
orientation, and so on—are powerful factors. As such, they influence the types of social-psychological<br />
stressors Steve is likely to experience, the ways he will manifest disorders, and the types of therapeutic<br />
approaches most likely to be effective.<br />
An Integrative Approach to the Case of Steven V.<br />
I am the therapist who has worked with Steve throughout his college career. I’ve been asked to<br />
comment on our sessions and to give you insights into Steve’s progress, but before I do so, it is<br />
important that I explain my therapeutic approach and goals.<br />
I believe strongly that therapy should involve a blend of techniques aimed at recognizing that each<br />
client is a whole human being. Many current schools of psychotherapy are one-dimensional; they<br />
concentrate only on feelings, or only on cognitions, or only on behaviors. It is important to realize that<br />
each of us comprises all these and more. I also believe that no single theory or approach to therapy is<br />
appropriate for all populations and all problems. People are similar in many respects, but each is also<br />
different and unique. To recognize this difference means to use different strategies and techniques for<br />
each individual.<br />
I have tried to organize my comments topically. This may give you the impression that I worked with<br />
isolated parts of Steve’s makeup, but that impression would be wrong. I try always to work in an<br />
integrated fashion and to deal with all aspects of the client’s cognitive, affective, and behavioral<br />
makeup.<br />
Meeting Steve: The Initial Session Steven V. first came to my attention during the early part of his<br />
junior year. A very “unstable” relationship with Linda, his woman friend, had just ended, and he<br />
seemed quite disturbed by it. As I found out later, his own private therapist was on vacation, and he did<br />
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The Case of Steven V. xix<br />
not like the therapist who was on call. As a result, he contacted the university psychological services<br />
center and was assigned to me.<br />
During our initial contact, Steve appeared extremely suspicious, withdrawn, and reluctant to disclose<br />
his thoughts or feelings. I can recall the long periods of silence following my questions and his short but<br />
sarcastic responses. It was almost as though he were testing me to see what kind of therapist I was, to<br />
see whether he could trust me. Usually I try to be less active at first and to encourage the client to tell<br />
his or her own story. I employ almost a person-centered approach, listening and mirroring the client’s<br />
thoughts, feelings, and perceptions. It was obvious, however, that this was not having the desired effect<br />
with Steve. It seemed to be alienating him and to be compounding a relationship problem.<br />
Here is a portion of our first conversation.<br />
Therapist: My name is Dr. S., Steve.—I wonder if we could begin by having you tell me what<br />
brought you here. (Long silence; Steve looks down, looks up at the therapist, looks down again,<br />
crosses his arms in front of his chest, and turns away.)<br />
Therapist: It’s hard for you to tell me what’s on your mind.<br />
Steve: Yeah (sarcastic tone, but does not change body posture). I’m not sure you can help me.—<br />
My therapist is on vacation, otherwise I would be seeing him. He’s a psychiatrist, you know.<br />
Therapist: It must be hard to begin a new therapy relationship again—to start all over.<br />
Steve: Great, that’s real perceptive.<br />
Therapist: You sound angry right now.—Where is your anger coming from?<br />
(Silence from Steve)<br />
This type of interaction—or lack of interaction—was characteristic of nearly the entire first half of our<br />
first session. My attempts to get Steve to open up and to trust me didn’t seem to work. It was at this<br />
point that I felt a change in approach was necessary. I took on an active and directive manner<br />
characteristic of the behavioral therapies.<br />
Therapist: We don’t seem to be connecting, Steve; something is blocking us from working<br />
together.<br />
Steve: You’re the therapist, so you tell me what it is!<br />
Therapist: You want me to tell you what the answer is.<br />
Steve: I don’t need a damned parrot for a therapist!<br />
Therapist (raising voice): Look, Steve! If you want to waste this session in a tug-of-war, let’s<br />
just end it now. I’m not going to sit here and be insulted by you. You respect me, and I’ll respect<br />
you!—I know it must be difficult to trust a stranger. You’d rather be seeing your own therapist,<br />
but the fact is, he’s not available. You’re hurting enough to come for help. If you want to waste<br />
the session playing games, go ahead!<br />
Steve (looking up and obviously surprised): I didn’t mean to be disrespectful—I was only—<br />
only—<br />
Therapist: Testing me—to see if you could trust me, to see where I’m coming from—to see if<br />
you could manipulate me.<br />
Steve: Yeah, it was nothing personal.<br />
Therapist: I know. Now suppose we start over again.—What brings you here, Steve?
xx The Case of Steven V.<br />
As I look back, I believe this brief but heated exchange represented the beginning of our relationship. I<br />
think Steve realized that I was an authentic person who could get angry but would not let the anger<br />
become destructive. Clients like Steve often test the therapist with attempts at manipulation. They are<br />
ambivalent about this ploy because they want it to succeed (so they can “win”), but they also want it to<br />
fail (which means the therapist is perceptive and competent enough to see through their manipulations<br />
and thus to give them the help they need). In any event, this tactic changed the entire tone of our<br />
session. Steve became much more cooperative and open, and he lost the conscious antagonism and<br />
resistance of the early part of our meeting. It also became much easier for me to use a nondirective<br />
approach.<br />
Gathering Information Gather biographical information is very important to my understanding of<br />
clients, and I do much of it during the actual therapy sessions. I needed to know Steve V. Who is he?<br />
How does he see things? What are the important events and relationships of his past and present? What<br />
type of medical history does he have? Are there any biological conditions that have a major impact on<br />
his psychological or social life? What type of therapy has Steve had in the past, and how successful was<br />
it? The more information I have about a client, the better I can identify his or her problems and<br />
formulate treatment strategies.<br />
In some of our early sessions, Steve briefly mentioned how much he had hated physical education<br />
classes in high school. When I asked why, he referred to the “jocks” who were always exhibiting<br />
themselves in the shower rooms.<br />
Steve: They strut around like Greek gods, showing off their bodies.—They don’t seem to have<br />
any shame at all.<br />
Therapist: Shame of what?<br />
Steven: I mean, I don’t exactly mean shame.—Yes—they’re trying to make the others feel<br />
ashamed of their own—well, you know.<br />
Therapist: Tell me what you mean.<br />
Steve: Just because they have bigger genitals, they’re trying to show off and make the others feel<br />
bad.<br />
Therapist: When they did that, how did it make you feel?<br />
Steve: I didn’t pay any attention to them. They’re not worth it.—Let them strut around, I got<br />
bigger grades than all of them.<br />
Therapist: But how did that make you feel?<br />
Steve: I know what you’re trying to imply. (Raising voice) You’re trying to get me to say I felt<br />
inadequate!<br />
(Silence)<br />
Steve: The size of a penis is no measure of a man! Those dumb pricks—most of them barely<br />
made it out of high school.—I could outthink all of them.<br />
Therapist: You sound very angry at them. What exactly did they do?<br />
Steve: When I had to take a shower, they—they made fun of me.<br />
Therapist: How did they make fun of you?<br />
Steve: Nothing in particular—but I knew what they were thinking.<br />
Therapist: What were they thinking?<br />
Steve: I don’t want to talk about it.<br />
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The Case of Steven V. xxi<br />
Therapist: I know it’s difficult to talk about these things, Steve.—Maybe when you feel ready.<br />
Steve: You’d laugh at me.<br />
Therapist: Is that what you really think?<br />
Steve (after a silence): I had this operation when I was young; they removed my left—I mean,<br />
I’ve only got one. And those bastards never let me forget it. They wanted to humiliate me.<br />
When Steve was six years old, his left testicle was surgically removed because of a malignant growth.<br />
Apparently this incident and Steve’s self-consciousness about it had haunted him throughout his life. I<br />
am not particularly psychoanalytic in orientation, but I believe that Steve did relate his sexual potency<br />
and his own masculinity to the absence of a testicle. His feelings of inferiority, low self-esteem, and<br />
periodic impotence may have evolved from his erroneous interpretation of this relationship. In this<br />
discussion Steve also made what might be labeled a Freudian slip (or a slip of the tongue) in describing<br />
his grades as bigger (unconscious equation of penis size?) when he probably meant better. (Steve’s<br />
Rorschach responses also led the therapist who originally administered the test to infer a severe<br />
castration anxiety related to his surgery.)<br />
Our discussions also revealed some potential areas for treatment. For example, cognitive strategies<br />
might be used to directly attack Steve’s implicit equating the size and intactness of his genitals with the<br />
idea of masculinity. Perhaps strategies aimed at helping Steve get in touch with his feelings would be<br />
helpful; he continually avoided “feeling” statements in our conversations.<br />
Using Tests and Formal Assessment To gather information about my clients, I sometimes resort to<br />
more structured, formal assessment means. I may use homework assignments (asking the client to keep<br />
a diary of important events or to write an autobiography) or actual psychological tests. I rarely use<br />
projective testing but rely more on objective personality measures. (The use of tests is consistent with<br />
the behavioral, the cognitive, and even the psychoanalytic approaches. It is inconsistent, however, with<br />
the humanistic-existential school.) When I do use tests, I consider them mainly as a source of<br />
corroborating data. I try to demystify testing for the client by explaining what testing is, what its<br />
limitations are, and how we will use the results.<br />
The computer interpretation of Steve’s MMPI responses, for example, seems to reinforce what I have<br />
learned during our interviews. The interpretation suggests that Steve is moderately to severely<br />
disturbed. It indicates that he is defensive, is hostile, and has a tendency to blame others. (I saw many of<br />
these tendencies in our first interview.) The MMPI suggests that a more confrontative, direct approach<br />
might work best with Steve. Other problems that are noted, like Steve’s poor perception of his social<br />
impact on others, difficulty in getting close to people, confusion of aggression with sexuality, and<br />
depression and suicidal tendencies seem right on target. The MMPI interpretation does note, however,<br />
that patients with Steve’s profile are typically poor academic achievers. But Steve is an exception to<br />
this. He has consistently performed well in school, despite his emotional problems.<br />
Steve keeps a diary, so I asked him to write a brief autobiography, emphasizing important childhood<br />
experiences, relationships with peers, relationships with his parents, current struggles, and future goals<br />
and aspirations. My intent was, first, to help Steve actively sort out his life experiences, away from our<br />
therapy sessions, and second, to help me understand his subjective world. The following portion reveals<br />
his reactions to our first therapy session; I believe Steve copied it out of his diary.<br />
My first time with Dr. S. was very confusing. I thought I was in complete control. I’m still not<br />
sure what really happened. I know I was angry and resentful the moment I saw him. He was<br />
sitting there sipping a cup of coffee without offering me one. When I called the center, they told<br />
me I could only come in for an 8 A.M. appointment. I’m not even alive at that time of the<br />
morning. Usually Dr. J., the psychiatrist I’ve been seeing, sees me in the afternoons. I guess I was
xxii The Case of Steven V.<br />
angry at Dr. J. for going on vacation and making me see another therapist who isn’t even a<br />
psychiatrist.<br />
I really wanted to talk to somebody about Linda. I guess I was pretty bad with Dr. S. I wasn’t sure<br />
I could trust him, and I took out my anger on him. I tried to put him down and make him<br />
uncomfortable. I tried to make him feel defensive by saying he was only a psychologist and not a<br />
psychiatrist. It scared the shit out of me when he got angry back at me. I never had a therapist do<br />
that to me. It was like he knew what I was doing. He thinks I do it with other people too. Maybe<br />
he’s right. He seems to be able to see through me, and I don’t like that. I’m afraid to have<br />
someone really know what’s going on inside. What is going on inside? I don’t know! Why should<br />
I be afraid? Strange, I really don’t like Dr. S. Or do I? Why am I seeing him now instead of my<br />
therapist? Mom and Dad are angry at me because I don’t go back to Dr. J.<br />
There are some very revealing elements in this passage. First, it supports my previous impression that<br />
Steve finds it difficult to trust people and behaves so as to push others away. Second, he is beginning to<br />
gain some insight into his behaviors—how he attributes his feelings to others and blames them for his<br />
troubles. Third, he has a long way to go. There is something that he is afraid to reveal to himself and<br />
others. When he expresses the fear that I can “see through” him, his writing becomes disjointed and<br />
fragmented. Obviously, this “dark secret” is deeply frightening to him. It affects not only his emotional<br />
state but his cognitive state as well.<br />
What was encouraging was that despite his discomfort with me, Steve decided to continue in therapy—<br />
and with me rather than with his previous therapist. A part of him didn’t want to look at himself, but<br />
another part seemed to know that this was the only way he could ever get better.<br />
Overall Objectives in Therapy As I got to know Steve better and better, I was able to identify some<br />
treatment objectives that would benefit him. Again, let me emphasize that I saw Steve as I see each of<br />
my clients—as a complex individual who feels, thinks, experiences emotions, behaves, and is a social<br />
being. I had to deal with each of these aspects during the two years I worked with him. Here, though,<br />
I’ll discuss only a few facets of Steve’s self to illustrate my therapeutic approaches.<br />
Dealing with Steve’s Feelings One theme that persisted throughout my work with Steve was his<br />
inability to get in touch with his feelings. He found it difficult to experience feelings or to make<br />
“feeling” statements. The autobiographical passage suggests that there is something he was afraid to<br />
acknowledge. He was ambivalent about therapy because it was forcing him to face frightening parts of<br />
his existence; he could no longer be safe and avoid taking risks.<br />
It would have been a mistake to directly reassure Steve that he could trust me and that things would turn<br />
out well. Such reassurance would have been transitory at best, unless Steven ventured out on his own to<br />
take the risk and to confront his own fears. I saw myself as a guide who would use various strategies to<br />
help Steve confront himself. In this respect I relied on existential psychology, which places choice and<br />
responsibility clearly in the hands of the client. Here is an example, from one of our sessions.<br />
Steve: My parents are upset with me for terminating with Dr. J. They think I should continue<br />
because he’s a psychiatrist, and I’ve been with him for years.—I like him—and he really<br />
understands me. I feel comfortable with him.<br />
Therapist: What made you decide to continue seeing me instead of Dr. J.?<br />
Steve: I don’t know, I mean—I’m not sure I even like you. Maybe it’s just so much more<br />
convenient to go to a campus shrink than to travel across town.<br />
Therapist: I don’t believe that’s the reason. You’re hiding from yourself again! When are you<br />
finally going to start facing yourself?<br />
Steve (angrily): That’s what I mean. I don’t know if I like you—you’re always picking on me. —<br />
Shit!<br />
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The Case of Steven V. xxiii<br />
Therapist: Say it again.<br />
Steve: Shit! (Pounds the table.)<br />
Therapist: Again and louder!<br />
Steve: Shit! Shit!<br />
Therapist: What are you feeling?<br />
Steve: I’m pissed off at you!<br />
Therapist: That’s not a feeling!<br />
Steve: I’m angry! (Yells at the top of his lungs.) Are you satisfied now?<br />
Therapist (after a silence): That was real.<br />
Steve: Yeah. (Exhales.) Funny how I felt like an overcooked artichoke crumbling just then.<br />
Therapist: I want you to close your eyes and become that artichoke. What are you feeling now?<br />
Steve: I want to keep all the leaves from falling away so that no one will see my artichoke heart.<br />
I want to strike out at whoever tries to peel the leaves off.<br />
Therapist: Imagine the leaves being peeled away—<br />
Steve: No, I can’t do it!<br />
Therapist: You don’t want to do it.—What are you afraid of?<br />
Steve: I’m afraid you’ll see me—what’s really wrong with me.<br />
Therapist: Become that fear and tell me what’s going on now.<br />
Steve: I’ve got to hide.—All the artichoke leaves help me hide, so others won’t see.<br />
Therapist: Can you peel off just a few of the leaves?<br />
Steve: Yes, but it doesn’t feel good.<br />
Therapist: For each leaf you peel off, say what it is.<br />
Steve: I’m peeling off my phony self—I’m peeling off my mask—I’m peeling off my<br />
rationalizations—I’m peeling off my anger.<br />
Therapist: Okay, open your eyes. What’s happening now?<br />
Steve: I feel naked, I feel everyone can see how inadequate I really am. I don’t like myself<br />
either.—I feel scared—scared you won’t like me anymore. I feel ashamed because you saw a part<br />
of me that no one else did.<br />
Therapist: I know. It’s scary to let others see the real you.—But look at you. Before we began<br />
this session you were very uptight and defensive. Your fists were clenched; you were sitting bolt<br />
upright on the edge of your chair; you had a strained expression on your face; your voice was<br />
tight. Now your body looks more relaxed.—Can you feel it?<br />
Steve: Yeah—<br />
Therapist: Get into your body.—What does it tell you?<br />
Steve: It’s funny—I don’t like what I see in myself, but—but—I hate myself but I feel relieved. I<br />
don’t have to always hide from you.<br />
Therapist: You mean you don’t have to always hide from yourself.
xxiv The Case of Steven V.<br />
Steve: Yeah.<br />
Dealing with Irrational Thoughts I had to discover how Steve’s feelings and many of his selfdefeating<br />
behaviors were related to his cognitions. I had enough evidence to indicate that Steve created<br />
his own miseries through the thoughts and beliefs he held. My work with him in this vein tended to<br />
parallel cognitive behavior modification and rational-emotive therapy: in some way, Steve was feeding<br />
himself irrational and unrealistic assumptions. My task was to identify these irrational beliefs, show<br />
Steve that he was constantly reindoctrinating himself with these messages, and teach him how to<br />
challenge or dispute them.<br />
Some of Steve’s irrational beliefs are evident in these words of his, taken from another session:<br />
I just feel like I’m a miserable failure. I’ve disappointed my parents. I know Dad wanted someone<br />
who was more athletic. I tried, but I’m not a jock. I did well in school and Mom is proud of that—<br />
but—I thought when I went to college and could do well at the university, Dad would come<br />
around. So far I have a 3.75 GPA, but I should have a 4.0. In several classes I missed an A by just<br />
a few points. When I told him [Steve’s father] my grade point average last night, he told me Jeff,<br />
my cousin, has a 3.9 GPA. I guess I let him down again. I was so bummed out last night—I<br />
couldn’t sleep—maybe it’s not worth going on. Life just isn’t worth it. Why should I keep trying?<br />
Maybe I should just take courses I know I’ll do well in.<br />
Several themes in this paragraph appear to form the basis for Steve’s feelings of worthlessness and his<br />
low self-esteem. These absolutist themes are often punctuated with must, should, and ought:<br />
1. “I must do what is necessary to please my parents, especially Dad. I must get my parents’<br />
approval, love, and recognition. If I fail to do this, I will never be able to value myself or feel I<br />
have succeeded. If they don’t love me, I can’t love myself. And life would not be worth living<br />
without their love and approval.”<br />
2. “I must be at the top of my class. I must live up to the expectations of my professors, peers, and<br />
parents. I must be perfect. If I fail to attain straight A’s, it means I’ve failed again and am<br />
basically stupid.”<br />
3. “I must be thoroughly competent in everything I do. If I can’t, I’ll avoid trying anything new. I<br />
cannot make mistakes because they will prove how deficient I really am.”<br />
After identifying these themes with Steve, I discussed with him how these thoughts and selfindoctrinations<br />
lie at the root of many of his problems. For example, he thinks his parents’ lack of<br />
approval has caused him to feel unloved and unappreciated. I tried to show Steve that it is his belief<br />
about a real or imagined situation, rather than an actual situation, that is causing his difficulties. In<br />
therapy sessions, I confronted his belief system by having him respond to these following questions:<br />
1. Who is telling you that you are worthless unless your parents approve of you?<br />
2. Do you need to be loved and liked by everyone?<br />
3. Do you want to spend the rest of your life in a futile attempt to win over your father?<br />
This line of questioning was helpful in getting Steve to think, to challenge himself, and to decide—for<br />
himself—how he would live.<br />
<strong>Learning</strong> New <strong>Behavior</strong>s One thing that I have discovered is that a client’s insight into or<br />
understanding of a problem doesn’t necessarily lead to a behavior change. The understanding that he<br />
feared rejection by members of the opposite sex because he equated rejection with his “worthlessness”<br />
would not have made it easier for Steve to interact with women. And from my work with Steve, it had<br />
become clear that he suffered from immense interpersonal anxiety, especially with women. Not only<br />
did he not know how to interact with others or to “make small talk,” but he also engaged in<br />
inappropriate behaviors that put people off. When Steve was with his friend Linda, he had constantly<br />
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The Case of Steven V. xxv<br />
tried to make her prove she “cared for him.” He had accused her of not being faithful to him, of not<br />
caring for him, and of not including him in her extracurricular school activities. This continual “prove<br />
you love me” testing of their relationship never ended because no amount of reassurance seemed to be<br />
enough. In fact, it pushed Linda away from him.<br />
This mode of interaction was characteristic of nearly all Steve’s relationships. While he worked to<br />
combat this irrational belief (“I am worthless; therefore no one can like me”), I felt it was important to<br />
help Steve become more comfortable in interpersonal and heterosexual relationships. I attempted to<br />
help Steve subtract anxiety from his interpersonal encounters by using a behavioral technique:<br />
assertiveness training.<br />
Here is Steve talking to me again:<br />
The truth is I’m always afraid. I panic when I think about being in a group of people and having to<br />
talk to them. What am I going to say? Even if I could say something, who would listen? Last<br />
month I went to a party with Linda—it was thrown by her friends. —When she introduced me all<br />
I could say was “hi.” I stuttered when I said anything else. It was like in class—I really felt<br />
inadequate. And one of the guys was trying to hustle Linda. He knew Linda came with me, but he<br />
ignored me completely. He asked her to dance, and I spent the whole evening sitting in the corner.<br />
I was really angry at him and Linda too, but I couldn’t do anything about it. Then he came over<br />
and asked if I would mind if he took her home. I could only say, “Sure, go ahead.” When I really<br />
wanted to say was “Go to hell.” I feel like I’m a doormat for the world.<br />
Obviously we had to work on Steve’s assertive behaviors. What I intended to do was, briefly, the<br />
following:<br />
1. Identify Steve’s unassertive behaviors that were linked to specific situations (for example,<br />
withdrawing and sitting in a corner by himself and not being able to say no).<br />
2. Determine the specific skills he needed for assertion (saying no, introducing himself to strangers,<br />
asking Linda to dance, and so on). Then try to grade these skills from least to most assertive.<br />
3. Re-create the problem situations, as vividly as possible, in the consultation room. Engage Steve in<br />
role playing and behavioral rehearsal with me or volunteers.<br />
4. Get Steve to practice the assertive behaviors in actual situations, under my guidance and<br />
monitoring.<br />
Our first use of the procedure will illustrate how we implemented it. Steve and I identified an upcoming<br />
event that was causing him considerable apprehension—a class assignment. He was to give an oral<br />
critical analysis of an assigned novel in his English class and then lead a discussion of the novel.<br />
Steve needed to practice the assertive skills related to the oral presentation. First to desensitize him, I<br />
had him practice very low-level assertive skills in front of groups. For example, he practiced raising his<br />
hand in class in situations where he was sure he would not be called on—for example, when many other<br />
students raised their hands or while he was out of sight of the professor. To Steve, this act was an<br />
assertive one. After he became comfortable with that, I asked him to raise his hand and ask a simple<br />
question (a safe assertive skill), such as “Could you repeat that last point?” After his anxiety regarding<br />
this act was conquered, he proceeded to paraphrase what the instructor had said and finally to state an<br />
opinion. Each succeeding act represented an increase in assertiveness.<br />
While he was practicing these classroom acts, Steve was finishing his book report. I then asked him to<br />
do his oral report for me. Next I asked another counselor and the two clerical staff members to be<br />
present while he repeated the report. After a second repetition, we simulated a question-and-answer<br />
session and then repeated that several times.
xxvi The Case of Steven V.<br />
This systematic training helped Steve greatly when he finally presented his report to his English class.<br />
Although he was anxious throughout the presentation, he felt that he had the anxiety under control.<br />
A similar program, which I developed for his heterosexual anxiety, proved only moderately successful.<br />
Steve’s Threat Against Linda ”She doesn’t deserve to live—I swear, I’m going to kill her.” Given<br />
the conduct in which it occurred, Steve’s threat to kill Linda placed me in a dilemma. My conflicting<br />
feelings and apprehensions were, no doubt, similar to those experienced by any therapist whose client<br />
threatens to kill someone or to commit suicide. Today more than ever, we as therapists must recognize<br />
that our work does not occur in a social vacuum. What we do or don’t do in therapy has not only<br />
clinical implications but ethical, moral, and legal ramifications as well.<br />
In that particular session Steve was becoming increasingly agitated about his breakup with Linda; his<br />
expressions of anger were stronger and stronger. He was quite depressed at the time, and in my<br />
therapeutic judgment, his venting of feelings was healthy. I had been working on that with him when he<br />
blurted out his threat. The first thoughts that came to my mind were questions: Does he really mean<br />
what he’s saying? How likely is he to carry out the threat? Is this just an empty threat characteristic of<br />
his anger and hostility? What should I do? Should I inform the proper authorities, breaking<br />
confidentiality, and risk losing Steve’s trust?<br />
I chose to go along with my clinical judgment to let Steve continue to express his feelings without<br />
cutting him off, while constantly assessing the strength of his anger and the likelihood of his acting<br />
impulsively. I made that decision for several reasons. First, in the time I had known Steve, he had made<br />
several suicide threats. In each case, when he was allowed to express his feelings, the suicidal ideation<br />
and threats diminished. I felt that his threat to kill Linda would follow a similar course. Second, despite<br />
his often bizarre thoughts and behaviors, I had never considered Steve to be a danger to others. He was<br />
more a danger to himself than to anyone else. Third, I felt that some other perspective was needed.<br />
There was still time to consult with colleagues about the case and to get their input. And last, I was<br />
prepared to cancel other appointments and extend our session if that became necessary. I felt that I<br />
could monitor Steve closely, and I even made an appointment for him to return the following day. In<br />
other words, after pondering all the issues, including the need to protect myself by informing the proper<br />
authorities or even Linda, I decided that the likelihood of his carrying out the threat was very low.<br />
Luckily this did prove to be the case.<br />
The dilemma for me as a therapist was not whether I should inform a potential victim or the appropriate<br />
authorities about a homicide that I deemed likely. I have no doubt that I would have taken that action if<br />
it were necessary. I was disturbed that I lacked the ability to precisely assess dangerousness and—even<br />
more—was unable to inform a client about the legal limits of confidentiality without adversely<br />
affecting our therapist-client relationship.<br />
An Epilogue to the Case Several years have passed since my sessions with Steve came to an end. He<br />
graduated from the university with a degree in English literature and went to a graduate school in the<br />
east. I did get the chance to see some changes in Steve that are definitely for the better. He relates<br />
reasonably well to people now, though I still consider him a loner. His bizarre behavior and ideation<br />
have eased off, but he still suffers from periodic bouts of depression. Whereas most clients need only<br />
brief periodic therapy to help them cope with life’s problems, I’m afraid Steve is one of those people<br />
who will need some form of therapy for the rest of his life. He has chosen to work toward a doctorate<br />
degree and to become a teacher, doing research and writing. I think this is as good a vocational choice<br />
as any. Not only does it play to his strengths (writing, reading, and research), but the college<br />
environment seems to be one of the few in which Steve has done well and has felt sufficiently secure.<br />
Perhaps this is a statement about academic life as well as about Steve. Some perceive it as a protected<br />
environment that is structured and, in some ways, undemanding.<br />
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The Case of Steven V. xxvii<br />
I don’t know what has happened to Steve since he left this university. I am aware that he signed a<br />
release of information form so that his case records could be transferred to the university he now<br />
attends. I can only assume that he has chosen to continue therapy, and I wish him well.
CHAPTER 1<br />
<strong>Abnormal</strong> <strong>Behavior</strong><br />
CHAPTER OUTLINE<br />
I. The concerns of abnormal psychology<br />
A. Describing abnormal behavior<br />
B. Explaining abnormal behavior<br />
C. Predicting abnormal behavior<br />
D. Controlling abnormal behavior<br />
II. Defining abnormal behavior<br />
A. Conceptual definitions<br />
1. Statistical deviation: based on frequency but no distinction of desirable and undesirable<br />
2. Deviations from ideal mental health<br />
3. Multicultural perspectives<br />
a) Cultural universality: symptoms same regardless of culture<br />
b) Cultural relativism: abnormality defined by culture<br />
B. Practical definitions<br />
1. Discomfort (physical or psychological pain)<br />
2. Deviance (disorientation, hallucinations, and delusions)<br />
3. Dysfunction (gap between potential and performance)<br />
C. Integrated definitions<br />
1. Three vantage points (Strupp & Hadley, 1977): individual, society, professional<br />
2. Biological facts and social values (Wakefield, 1992): “harmful dysfunction” where<br />
social norm defines harmful and biological sciences defines dysfunction<br />
D. The Surgeon General’s and DSM-IV-TR definitions<br />
1. <strong>Abnormal</strong> behavior: Before that departs from some norm and that harms the affected<br />
individual or others.<br />
2. The Surgeon General’s report on mental health (DHHS, 1999) and the American<br />
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders<br />
(DSM-IV-TR, 2000); clinically significant syndrome associated with distress,<br />
disability, or increased risk of suffering<br />
III. The frequency and burden of mental disorders<br />
A. Current research into the epidemiology of mental disorders<br />
1. Roughly 29 to 38 percent of the population has at least one DSM disorder<br />
2. No change in prevalence since 1980 Srole and Fisher study<br />
3. Gender differences: alcohol problems in 24 percent of men, 4 percent of women;<br />
depression and anxiety higher in women<br />
4. Age differences: substance abuse in younger groups; cognitive impairment in older<br />
5. groups<br />
6. Mental illness is more debilitating than malignant diseases such as cancer.<br />
B. Stereotypes of the mentally disturbed<br />
1. Easily recognized as deviant<br />
2. Disorder due to inheritance<br />
3. Incurable<br />
4. Weak willed<br />
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2 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
5. Never contribute to society<br />
6. Dangerous<br />
IV. Historical perspective on abnormal behavior<br />
A. Prehistoric and ancient beliefs<br />
1. Trephining: chipping away portion of skull<br />
2. Exorcism: prayers, drugs, starvation<br />
B. Naturalistic explanations (Greco-Roman thought)<br />
1. Hippocrates: brain pathology, classification<br />
2. Galen: role of brain and nervous system<br />
C. Reversion to superstition (the Middle Ages)<br />
1. Dark Ages: sinfulness<br />
2. Mass madness (thirteenth century): tarantism, lycanthropy<br />
3. Witchcraft (fifteenth through seventeenth centuries)<br />
a) Related to church under attack<br />
b) Pope Innocent VIII’s papal decree (1484) to identify and exterminate witches<br />
c) Although some witches may have been mentally ill, most were not<br />
D. Rise of humanism (the Renaissance)<br />
1. Emphasizes human welfare<br />
2. Johann Weyer challenges notion of witchcraft (1563)<br />
E. Reform movement (eighteenth and nineteenth centuries)<br />
1. Moral treatment movement (Pinel in France, Tuke in England)<br />
2. American reformers<br />
a) Benjamin Rush insists on respect and dignity for patients<br />
b) Dorothea Dix campaigns for mental hospitals<br />
c) Clifford Beers exposes cruel treatment<br />
V. Causes: early viewpoints<br />
A. The biological viewpoint<br />
1. Emil Kraepelin observes syndromes<br />
2. Emphasis on brain pathology<br />
3. Discovery of organic basis to general paresis<br />
B. The psychological viewpoint<br />
1. Mesmerism and hypnotism<br />
a) Anton Mesmer: treatment of hysteria; assumptions discredited, but spur debate<br />
about psychogenic nature of disorders<br />
b) Hypnotism<br />
2. The Nancy School<br />
a) Jean-Martin Charcot: hypnosis produces and removes hysteric symptoms<br />
b) Josef Breuer and Sigmund Freud: the cathartic method<br />
VI. Contemporary trends in abnormal psychology<br />
A. The drug revolution<br />
B. Prescription privileges for psychologists<br />
C. Managed health care<br />
1. Health care costs in the U.S. have exploded<br />
2. Managed health care: industrialization of health care<br />
3. Fear of psychologists: decisions made for business reasons, not health reasons<br />
D. Appreciation for research<br />
E. Diversity and multicultural psychology<br />
1. Social conditioning<br />
2. Cultural values and influences<br />
3. Sociopolitical influences<br />
4. Bias in diagnosis<br />
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VII. Some closing thoughts<br />
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Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong> 3<br />
LEARNING OBJECTIVES<br />
1. Describe the primary objectives of abnormal psychology, including description, explanation,<br />
prediction, and control of abnormal behavior. (pp. 3–5)<br />
2. Identify and distinguish between the various kinds of mental health professionals. (p. 7)<br />
3. Identify four definitions psychologists use to define abnormal behavior and their assumptions,<br />
strengths, and limitations. (pp. 6-12; Figure 1.2)<br />
4. Describe the multicultural perspectives in defining abnormal behavior including definitions of the<br />
terms cultural universality and cultural relativism. (pp. 9–10)<br />
5. Distinguish between Szasz’s views on mental illness and Wakefield’s (1992) views of abnormal<br />
behavior, the textbook authors’ definition of abnormal behavior, and that of the DSM-IV-TR. (pp.<br />
12–13)<br />
6. Discuss how researchers determine the scope of mental disorders in the United States. (pp. 13–17)<br />
7. Describe the most prevalent disorders and how mental disorders are influenced by age and gender.<br />
(pp. 15–16; Figures 1.3 and 1.4)<br />
8. Discuss common myths concerning the mentally disturbed and the facts that refute them. (pp. 16–<br />
18)<br />
9. Summarize the various explanations of abnormal behavior from prehistoric times through the<br />
Middle Ages. (pp. 18-20)<br />
10. Describe the changes that occurred in the conceptualization and treatment of abnormal behavior<br />
after the era of witchcraft, including the rise of humanism and the reform movement of the<br />
eighteenth and nineteenth centuries until the present. (pp. 21–23)<br />
11. Discuss the main assumptions of the biological and psychological viewpoints on perceptions of<br />
abnormal behavior. (pp. 23–25)<br />
12. Discuss the contributions of mesmerism and hypnosis to the psychodynamic viewpoint. (p. 24)<br />
13. Describe the impact of the drug revolution and managed care on the mental health profession. (pp.<br />
25–28; Mental Health and Society)<br />
14. Discuss the rise of multicultural psychology, and explain how social conditioning, cultural values,<br />
and sociopolitical influences may account for apparent differences in abnormality in minority<br />
groups. (pp. 29–31)<br />
15. Explain the term biopsychosocial approach and its use in conceptualizing the multiple factors<br />
underlying abnormal behavior. (p. 31)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. During the first class meeting, it is generally helpful to explain your grading policies, the number<br />
and types of tests to be given, and reading and research assignments. A detailed syllabus is an<br />
invaluable tool for helping students know what is coming and for preventing later confusion<br />
concerning what was expected. A detailed syllabus should give the dates for each reading<br />
assignment, test, paper, or other requirement and explain the policy on missed exams, grade<br />
cut-offs, and other such matters. Since most of the students will not have the textbook in time for<br />
the first class, it is best to spend time asking students what they think abnormal means. This word
4 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
can be compared and contrasted with mentally ill or deviant or in need of treatment, all of which<br />
have their own connotations.<br />
Internet Site: http://www.psychologynet.org/dsm.html. Contains terms and definitions of DSM<br />
criteria.<br />
2. This chapter gives students a good opportunity to compare and contrast the training experiences,<br />
qualifications, and work-setting roles of the various mental health professionals. On the<br />
blackboard the instructor can make four columns labeled clinical psychologist, psychiatrist,<br />
psychiatric social worker, and marriage/family counselor and then indicate the educational<br />
requirements, clinical and research training, certification requirements, and typical work settings<br />
for these major categories of mental health professionals. A sample handout is provided.<br />
Students are likely to be interested in the career opportunities these fields present and the<br />
academic preparation necessary for each. A career-counseling specialist in the college or<br />
university student services office may be helpful in this discussion. Even better is to invite a<br />
psychiatrist, a social worker, and a counselor to class to discuss their own experiences. At a<br />
minimum, the instructor can present his or her own training and clinical experience so as to<br />
establish credibility for teaching the course.<br />
Internet Sites: http://www.psychologicalscience.org/American Psychological Society. Contains<br />
information on this organization, including schedules of conventions, teaching, research, and other<br />
information.<br />
http://www.apa.org/American Psychological Association Contains information about the<br />
organization and its services.<br />
3. One way to probe the criteria that students use to define abnormality is to present a variety of<br />
small vignettes and ask students to rate them in terms of abnormality. The instructor can vary<br />
certain aspects of the stories to see whether perceived deviance increases or decreases. For<br />
example, a vignette might be<br />
Martin is a 40-year-old manager, husband, and father of three who works fourteen hours a day and<br />
brings work home on the weekends. His wife complains that he is more interested in work than he<br />
is in her and the children. Martin has trouble sleeping, is often irritated by small inconveniences,<br />
wishes he spent more time with his family, and has been diagnosed as having a stomach ulcer.<br />
The instructor can ask students whether Martin has a mental disorder or is abnormal or needs<br />
psychological treatment. (The terms have important connotative differences.) Ask a person who is<br />
convinced that Martin has a mental disorder why he or she takes that view. Ask a person with the<br />
opposite perception for his or her reasons. (The case of Martin should emphasize problems with<br />
statistical rarity and personal distress.) Ask students whether their perceptions would change if<br />
they knew that Martin’s boss forced him to work this hard, or that, in his corporate culture,<br />
managers were supposed to be relaxed about coming to work.<br />
4. The risk of mental disorder varies with demographic groups. One of the fastest growing groups in<br />
the United States is people of Hispanic ancestry. A study (Shrout et al., 1992) compared<br />
epidemiological statistics on rates of mental disorders for adults living in Puerto Rico, and three<br />
groups of adults in Los Angeles—Mexican American immigrants, Mexican American natives, and<br />
non-Hispanic whites. The large samples (1505, 610, 488, and 1092, respectively) increase the<br />
reliability of the statistics given. Mexican American immigrants had the fewest mental health<br />
problems of all groups. Puerto Ricans had more somatization disorders (0.7 percent versus almost<br />
0 percent in the other three groups) but less affective and alcohol disorders than did U.S.-born<br />
Mexican Americans or non-Hispanic whites.<br />
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Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong> 5<br />
These results underscore the need to consider cultural group membership when discussing the<br />
scope of mental disorders. If also shows the need to look at subcultural groups—Puerto Ricans<br />
versus Mexicans or immigrants versus second-generation individuals. Further, immigration may<br />
not have identical effects on different subgroups. Previous research showed no global differences<br />
in rates of depression between poor, island Puerto Ricans and economically similar Puerto Ricans<br />
living in the New York City area (Vera, M., et al., 1991).<br />
Sources: Shrout, P. E., Canino, G. J., Bird, H. R., Rubio-Stipec, M., Bravo, M., & Burnam, M. A.<br />
(1992). Mental health status among Puerto Ricans, Mexican Americans, and Non-Hispanic<br />
whites. American Journal of Community Psychology, 20, 729–752<br />
Vera, M., Alegria, M., Freeman, D., Robles, R. R., Rios, R., & Rios, C. F. (1991). Depressive<br />
symptoms among Puerto Ricans: Island poor compared with residents of New York City area.<br />
American Journal of Epidemiology, 134, 502–510.<br />
Internet Site: http://www.psych.org/American Psychiatric Association. Links to sites associated<br />
with the psychiatric profession.<br />
5. Students often have difficulty placing the changes in psychological thinking in a historical<br />
context. Try to make the point that explanations for mental disorders always come out of the<br />
social and intellectual atmosphere of the time. A timeline written in a handout, on the board, or on<br />
a transparency can help make links between psychological thinking and what was going on in the<br />
wider world at the time. A timeline for the last two hundred years could show how the American<br />
and French revolutions coincided with the advent of moral treatment. Both movements stressed<br />
the value of the individual and the virtue of personal freedom. Dorothea Dix’s reforms and<br />
advocacy for institutions for the poor coincided with the great waves of immigration in the United<br />
States. Many people who came to the United States did not cope well with the stresses of a new<br />
culture and city life, and many recent immigrants were admitted to state hospitals. The rise of the<br />
medical model in mental health during the latter half of the nineteenth century coincided with the<br />
scientific discoveries linking microbes to diseases. Physicians such as Kraepelin and even Freud<br />
emerged from an era of boundless optimism that explanations and cures were just around the<br />
corner. The devastation of World War I altered Freud’s thinking, and he invented the death<br />
instinct in response. After World War II, when the veterans’ hospitals were filled with<br />
psychological war casualties, clinical psychologists exploded in numbers and influence. The civil<br />
rights movement of the 1950s and 1960s also coincides with a mental patients rights movement<br />
and the beginnings of the multicultural approach. Finally, you can point out the current discussion<br />
in managed health care related to the rapid increases in health care costs during the 1990s.<br />
A sample handout is provided, but obviously you can choose from an infinite number of historical<br />
events and teach many economic, political, and social lessons. Regardless of the specific<br />
examples you use, this exercise should show students that wider forces were and are at work to<br />
influence the field of abnormal psychology.<br />
Internet Sites: http://www.geocities.com/Athens/Delphi/6061/en_linha.htm. Contains information<br />
on the early history of psychology and has a timetable of significant events in psychology from<br />
1846 to 1935.
6 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
HANDOUT FOR CLASSROOM TOPIC 2:<br />
MENTAL HEALTH PROFESSIONALS:<br />
TRAINING AND PRACTICE SETTINGS<br />
Profession Degree Training Specialties Settings<br />
Psychiatrist M.D. Four years at<br />
medical school;<br />
internship; three-<br />
Clinical<br />
psychologist<br />
Psychiatric social<br />
worker<br />
Marriage and<br />
family counseling<br />
Ph.D. or<br />
Psy.D.<br />
year residency<br />
Four years at<br />
university or<br />
professional school;<br />
internship<br />
M.S.W. Two years at<br />
university social<br />
work school;<br />
internship<br />
M.S. Two years at<br />
university<br />
counseling<br />
department<br />
Prescribe<br />
medications;<br />
therapy<br />
Assessment;<br />
research; therapy;<br />
prevention<br />
Therapy; family<br />
and community<br />
advocacy<br />
Marital and family<br />
therapy<br />
Private; hospitals;<br />
mental health<br />
centers<br />
Private; hospitals;<br />
mental health<br />
centers; universities<br />
Private; hospitals;<br />
mental health<br />
centers<br />
Private; mental<br />
health centers<br />
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Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong> 7<br />
HANDOUT FOR CLASSROOM TOPIC 5:<br />
TIMELINE OF POLITICAL EVENTS AND PSYCHOLOGICAL<br />
MILESTONES<br />
1790 French Revolution<br />
1810 Pinel unchains patients in Paris;<br />
Tuke establishes York Retreat<br />
1830 Irish immigration to United States<br />
1850 Dorothea Dix works for improved care for mentally ill<br />
1870<br />
1890<br />
Pasteur and others show impact of<br />
microbes on health<br />
1910 Muckraker journalists in United<br />
States expose corruption; World<br />
War I<br />
Freud studies hysteria and hypnosis,<br />
Kraepelin develops diagnostic system, Freud writes<br />
Interpretation of Dreams<br />
1930 World War II Beers exposes brutality in mental hospitals<br />
<strong>Behavior</strong>ism begins<br />
1950 Humanistic psychology; growth of clinical psychology<br />
1970 Vietnam War<br />
Reagan administration cutbacks on<br />
human services; health cost<br />
increases<br />
1990 Rise of managed care<br />
Development of antipsychotic and antidepressant<br />
medications; behavior therapy; recognition of PTSD<br />
CLASSROOM DEMONSTRATIONS<br />
1. An important function of the abnormal psychology course is to break down some of the pernicious<br />
attitudes that laypersons have about people with behavior disorders. One concern is the tendency<br />
to stereotype people who are different and thereby classify everyone into an “us” category<br />
(meaning “normal and good”) or a “them” category (meaning “abnormal and bad”). During the<br />
first or second class meeting, hand out the survey questionnaire for Demonstration 1, the results of<br />
which can debunk the idea that behavior disorders happen only to other people. Make sure the<br />
students understand that they should not identify themselves on the paper. Tell them to turn the<br />
page face down when they are finished filling it out and when they pass it forward and that only<br />
group data will be reported back to them.<br />
Problem Family (percent) Friend (percent)<br />
Drinking problem 37.2 49.1<br />
Depression 34.9 40.9<br />
Stress-related illness (for example, migraine) 34.6 27.9<br />
Alzheimer’s disease 27.1 6.8<br />
Anxiety disorders 13.8 13.0<br />
Illicit drug dependency 10.8 35.7<br />
Eating disorders 11.1 46.8<br />
Mental retardation 3.3 6.3<br />
Schizophrenia 2.6 5.2
8 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
After computing the percentages for the current class, you can put the class’s data and the<br />
averages from previous classes on a blank questionnaire form. Before returning these data, you<br />
can ask students which problems they think are most common. The ensuing discussion provides<br />
an easy and thought-provoking entrance into the text material on epidemiology.<br />
2. Depending on your acting skills, you can use this exercise to clarify the differences in thinking<br />
that mark historical eras. First describe the popular explanations and treatments for abnormal<br />
behavior during the Greco-Roman period, the era of witchcraft, the moral treatment movement,<br />
and the early twentieth century (medical model). Then describe a deviant individual. Here is an<br />
example: a 55-year-old woman is suddenly unable to take care of her normal responsibilities—she<br />
no longer cooks or cleans. She talks to herself and seems to hear voices that no one else can hear.<br />
She is frightened easily and cries often.<br />
Tell students that you will play, one at a time, the roles of several different people living in<br />
different historical eras. Students are to ask you questions about how you explain this woman’s<br />
odd behavior and the treatments you think will address her problems. You should answer as if you<br />
lived in that era. For instance, if you were pretending to be a monk in the fifteenth century, you<br />
would discuss this woman’s soul, her lack of religious devotion, her probable status as a witch,<br />
and the appropriate “cures” of exorcism or execution. Respond to the questions and comments as<br />
though everyone accepts your point of view. A goal of this exercise is to show that we are<br />
somewhat trapped in our thinking by the conventional wisdom of our day, including our own<br />
time.<br />
For a more dramatic presentation, you might invite some colleagues to play the various roles,<br />
which will allow debate among the role-players and increase the enthusiasm for audience<br />
participation. Be sure to give colleagues adequate preparation concerning the thinking of each<br />
historic era. If you and your colleagues come to class in costume, this class meeting will be one of<br />
the most memorable sessions of the year!<br />
Internet Site: http://www.cwu.edu/~warren/today.html. Today in the History of Psychology, an<br />
APA searchable site devoted to the history of psychology.<br />
3. Students are often surprised at the prevalence of mental disorders. They often underestimate rates<br />
of disorder, although some go to the other extreme and claim that “everyone is crazy.” This<br />
demonstration gets students to think more carefully about the proportion of adults in the United<br />
States with various disorders and supplies statistics from a nationwide epidemiological survey to<br />
bring home the point.<br />
Very briefly describe the symptoms of substance use disorders, anxiety disorders, affective<br />
(mood) disorders, schizophrenia, antisocial personality disorder, and cognitive disorders. You<br />
may want to use the following descriptions:<br />
Substance use disorders: excessive use of chemicals (for example, alcohol, marijuana,<br />
heroin) that jeopardizes health, social, or occupational functioning or that involves tolerance<br />
(need for larger doses) or withdrawal (physical symptoms after stopping intake).<br />
Anxiety disorders: persistent problems of anxiety and worry either in response to a specific<br />
object (a phobia), a specific situation (social phobia or agoraphobia), sudden bouts of intense<br />
anxiety (panic attacks), or posttraumatic stress syndrome.<br />
Affective disorders: uncontrolled and persistent intense emotions—either depression<br />
(including eating and sleeping problems, apathy, fatigue, and thoughts of suicide or<br />
hopelessness) or swings of mood from extreme elation to depression.<br />
Schizophrenia: inability to function due to incoherent thought; withdrawal from social<br />
relationships; hallucinations; and delusions.<br />
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Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong> 9<br />
Antisocial personality disorder: exploitative interactions with others; disdain for following<br />
social rules often leading to impulsive criminal acts, lack of empathy or remorse, and thrill<br />
seeking.<br />
Cognitive disorders: severe problems in memory or judgment caused by brain damage in<br />
such conditions as Alzheimer’s disease, stroke, and traumatic brain injury.<br />
Tell students to think of all the people in the United States over age 18. Ask students to estimate<br />
the percentage of people who, over a one-month period, could be diagnosed with any of the<br />
disorders named above. (This figure is the one-month prevalence for mental disorders in the<br />
United States.) Ask which disorder they think is most common and which is least common. Ask if<br />
they think certain disorders are more common in men than women or more common in women<br />
than in men. Ask if they think age groups differ in their likelihood of suffering these disorders. Put<br />
their verbal responses on the blackboard. See if there is a consensus in estimated magnitude of the<br />
problem of mental disorder. Then distribute the handout based on the Epidemiological Catchment<br />
Area survey (Robins et al., 1984). Point out the high level of anxiety problems in women in early<br />
and middle age; the big jump in cognitive disorders among the elderly; and the sex differences in<br />
substance disorders, affective disorders, and antisocial personality disorders. Ask students why<br />
discrepancies between their estimates and these nationwide data might exist.<br />
As a final point, tell students that for every 1 percent indicated on the table, roughly two million<br />
Americans are suffering with the disorder. Alternatively, use your town or city’s population to<br />
estimate the number of people who, in the month you give this lecture, suffer from the disorders.<br />
Source: Robins, L. N., Helzer, J. E., Weissman, M. M., Orvaschel, H., Gruenberg, E., Burke, J.<br />
D., & Regier, D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites.<br />
Archives of General Psychiatry, 41, 949–958.<br />
Internet Site: http://www.psyweb.com/Mdisord/DSM_IV/dsm_iv.html . An APA site that defines<br />
and describes all behaviors that the American Psychiatric Association considers abnormal.<br />
4. The following quotations give students an idea of how mental patients were treated before the<br />
advent of moral therapy. The information comes from Glover, M. R. (1984). The retreat York: An<br />
early Quaker experiment in the treatment of mental illness. York, England: Williams Sessions.<br />
At the time The Retreat was founded (1796), when William Tuke and his physician,<br />
Timothy Maud, were reading books and visiting hospitals in order to learn as much as they<br />
could about the treatment of the insane, they discovered a dominant orthodoxy, which based<br />
medical treatment on what was roughly dehydration, the draining away of fluid out of the<br />
body. For this purpose a number of methods were used: bleeding, vomits, purges, and<br />
blisters. In many hospitals these treatments were a matter of routine. Dr. Monro, the<br />
physician at Bethlem, described the practice there: “They are ordered to be bled about the<br />
latter end of May, or the beginning of May, according to the weather; and after they have<br />
been bled they take vomits once a week for a certain number of weeks, after that we purge<br />
the patients; that has been the practice invariably for years, long before my time. It was<br />
handed down to me by my father, and I do not know any better practice.” A naval hospital<br />
for the insane was criticized for not using these treatments.<br />
A letter from William Tuke dated February 1798 speaks of treatment procedures in use at<br />
The Retreat:<br />
“James Fawcett has bn v bad. Frequently high and noisy. He made gt efforts for mastery,<br />
and if in his power would have done a mischief to those about him, but for some days past<br />
has bn pretty quiet…he was bled in the arm; had a pretty strong Emetic and Cathartic, also a<br />
blister, and since that was bled with leaches.”
10 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
Patients were then as now sometimes treated by shock, but the 18 th century shocks were<br />
cruder. One of them was the “bath of surprise”; the patient fell without warning through a<br />
trap door into cold deep water. Another in common use was the revolving chair; the patient<br />
was strapped into the chair which was then whirled around until he lost consciousness. (pp.<br />
8–9)<br />
Internet Site: http://www.netaxs.com/people/aca3/LPM.HTM . The Lifschitz Psychology<br />
Museum, the world’s first Virtual Museum of Psychology.<br />
5. This exercise will get students thinking about the criteria they use to define abnormality. Before<br />
you lecture on the practical definitions of abnormality (deviance, discomfort, and dysfunction),<br />
write up a hypothetical case study in four versions. An example is given in the Handout for<br />
Demonstration 5, which varies gender and duration of symptoms. Distribute the write-ups<br />
randomly throughout the class. Each student reads and rates only one. Ask students to rate on a<br />
ten-point scale the degree or severity of abnormality they feel the case deserves. After they have<br />
made their ratings, tell them that they are involved in a little experiment to see if gender and<br />
duration of symptoms are influential factors in their definitions of abnormal. Explain how the<br />
independent variables were manipulated. On the board, draw the cells for a two-by-two study and,<br />
for each cell (group) ask what their rating was. Compute the averages for each of the four groups<br />
and record in the appropriate cell on the board. Although it is too unwieldy to compute standard<br />
deviations and actually do the statistics to see if a significant difference occurred (this possibility<br />
could be alluded to in the class when you discuss research methods), you can eyeball the data to<br />
see if trends exist.<br />
If gender appears to be influential in ratings, link this trend to the multicultural perspective<br />
discussed in the text. Your data would support the proposal that some of the gender differences in<br />
epidemiological findings are a result of diagnostic bias. Differences in ratings due to duration of<br />
symptoms seem more benign and are “legitimate” criteria used in the DSM. However, students<br />
can notice that the term too long is culturally defined. Depressive symptoms that last ten weeks<br />
may be seen as normal (after parental divorce) or abnormal (after the death of a pet turtle).<br />
Ask students what other factors might influence ratings of disorder severity. Likely candidates are<br />
age of the individual, proximity of symptoms to stressful events (the ease with which symptom<br />
onset can be explained), race or ethnic status, and income. All these factors support the<br />
multicultural perspective’s case that disorder is in the eye of the culture and is affected by cultural<br />
majority standards.<br />
Internet Site: http://www.psyweb.com/Mdisord/DSM_IV/dsm_iv.html An APA site that defines<br />
and describes all behaviors that the American Psychiatric Association considers abnormal in the<br />
DSM series.<br />
6. Try introducing your students to the idea that not only individuals can be dysfunctional but that<br />
families, workplaces, neighborhoods, cities, and universities can be, too. Have the students form<br />
small groups of 4-7 individuals, depending on your class size and space limitations. Each group is<br />
to develop a listing of dysfunctional workplaces or jobs they have had. Have each group describe<br />
the features that were dysfunctional: mean coworkers, random management style, and rules of<br />
conduct that changed. Ask each group to develop this list with the most salient examples first.<br />
Each group could then have a spokesperson deliver a short talk about the best examples. You<br />
could provide a blank overhead transparency to each group at the beginning of this demonstration.<br />
7. Using the same group format as in number 6 above, assign students to work in small groups.<br />
Have each group develop a list of words they use in everyday life to label normal persons and<br />
then develop a second list of words used to label abnormal persons. Each group could then have a<br />
spokesperson deliver a short talk about the best examples. You could provide a blank overhead<br />
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Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong> 11<br />
transparency to each group at the beginning of this demonstration. As an alternative, collate the<br />
lists into two master lists and make a brief overhead transparency of the best examples. Often you<br />
will find that more words are listed for abnormal persons than for normal ones. Ask for<br />
suggestions about why these lists are of different length. Finally, ask students to evaluate the<br />
positive and negative connotations of the list. Lead a discussion of the negative effects of<br />
labeling.<br />
Internet Site: http://www.mentalhealth.com/p.html. Internet Mental Health, an encyclopedia of<br />
mental health information.<br />
8. To make the students aware of services that are available to them on campus, invite the director of<br />
the campus mental health/counseling services to discuss the range of services offered. The main<br />
purpose of this guest speaker is to reduce the fear and stigma of seeking any type of personal<br />
counseling services on campus. The second purpose of this activity is to let the students know<br />
where to seek help should any personal issues arise during the semester. Be sure to allow your<br />
students time for questions and answers. Ask them to write down a list, without identifying<br />
themselves, of services or information sessions they would like to see offered by the campus<br />
mental health/counseling center. Let the students know you will compile the recommendations<br />
into one list. The results will later be shared with both the class and the director of the campus<br />
mental health/counseling center.
12 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
HANDOUT FOR DEMONSTRATION 1:<br />
STUDENT SURVEY OF PSYCHOLOGICAL PROBLEMS<br />
This is a survey to assess the prevalence of psychological problems in students’ lives. Please do not<br />
identify yourself. You can be assured that the data will be kept confidential. Only group data will be<br />
shared with the class.<br />
If a close family member currently has or once had a particular psychological problem, check the space<br />
under “close family member.” Do the same under “close friend.” The problem could have been<br />
diagnosed as such by a professional or be one you feel the individual has or had. If more than one<br />
family member or friend has had the problem, you should indicate with as many check marks as<br />
individuals involved.<br />
Psychological Problem Close Family Member Close Friend<br />
1. Drinking problem (alcohol abuse or alcoholism) ___________________ _____________<br />
2. Frequent periods of anxiety or seriously limiting fears ___________________ _____________<br />
3. Stress-related physical disorder such as migraine or ulcer ___________________ _____________<br />
4. Schizophrenia ___________________ _____________<br />
5. Dependency on illicit drug such as marijuana or cocaine ___________________ _____________<br />
6. Alzheimer’s disease ___________________ _____________<br />
7. Depression lasting at least two weeks ___________________ _____________<br />
8. Eating disorders such as anorexia or bulimia ___________________ _____________<br />
9. Mental retardation ___________________ _____________<br />
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Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong> 13<br />
HANDOUT FOR DEMONSTRATION 3:<br />
ONE MONTH PREVALENCE RATES FOR MENTAL DISORDERS,<br />
UNITED STATES, OVER 18 YEARS OLD<br />
Group/Disorder Any Sub Anxiety Aff Schiz ASP Cogn<br />
Both sexes, all ages 15.4 3.8 7.3 5.1 0.6 0.5 1.3<br />
Men, all ages 14.0 6.3 4.7 3.5 0.6 0.8 1.4<br />
18–24 16.5 4.9 4.9 3.4 0.7 1.5 0.7<br />
25–44 15.4 7.9 4.7 4.5 0.8 1.2 0.5<br />
45–64 11.9 4.1 5.1 3.1 0.6 0.2 1.4<br />
65 and older 10.5 1.8 3.6 1.4 0.1 0.1 5.1<br />
Women, all ages 16.6 1.6 9.7 6.6 0.6 0.2 1.3<br />
18–24 17.3 4.5 10.4 5.3 0.7 0.4 0.5<br />
25–44 19.2 1.9 11.7 8.2 1.1 0.3 0.4<br />
45–64 14.6 0.4 8.0 7.2 0.3 0.0 1.0<br />
65 and older 13.6 0.3 6.8 3.3 0.1 0.0 4.7<br />
Sub = Substance use disorder<br />
Anxiety = Anxiety disorders<br />
Aff = Affective (mood) disorders<br />
Schiz = Schizophrenias<br />
ASP = Antisocial Personality Disorder<br />
Cogn = Cognitive disorders
14 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
HANDOUT FOR DEMONSTRATION 5:<br />
RATING THE SEVERITY OF ABNORMAL BEHAVIOR<br />
Hypothetical case 1<br />
Tiffany is a junior college student whose parents have divorced after 25 years of marriage. The divorce<br />
came as a complete surprise to her and shook her confidence in both parents. She has become quite<br />
depressed—sleeping poorly, eating little, and showing little interest in school work. These symptoms<br />
have now gone on for two weeks.<br />
Rate the severity of Tiffany’s abnormality on a scale from 1 to 10 where 10 is “very severe.”<br />
__________<br />
Hypothetical case 2<br />
Timothy is a junior college student whose parents have divorced after 25 years of marriage. The divorce<br />
came as a complete surprise to him and shook his confidence in both parents. He has become quite<br />
depressed—sleeping poorly, eating little, and showing little interest in school work. These symptoms<br />
have now gone on for two weeks.<br />
Rate the severity of Timothy’s abnormality on a scale from 1 to 10 where 10 is “very severe.”<br />
__________<br />
Hypothetical case 3<br />
Tiffany is a junior college student whose parents have divorced after 25 years of marriage. The divorce<br />
came as a complete surprise to her and shook her confidence in both parents. She has become quite<br />
depressed—sleeping poorly, eating little, and showing little interest in school work. These symptoms<br />
have now gone on for ten weeks.<br />
Rate the severity of Tiffany’s abnormality on a scale from 1 to 10 where 10 is “very severe.”<br />
__________<br />
Hypothetical case 4<br />
Timothy is a junior college student whose parents have divorced after 25 years of marriage. The divorce<br />
came as a complete surprise to him and shook his confidence in both parents. He has become quite<br />
depressed—sleeping poorly, eating little, and showing little interest in school work. These symptoms<br />
have now gone on for ten weeks.<br />
Rate the severity of Timothy’s abnormality on a scale from 1 to 10 where 10 is “very severe.”<br />
__________<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong> 15<br />
SELECTED READINGS<br />
Freedheim, D. K., Freudenberger, J. J., Kessler, J. W., Messer, S. B., Peterson, D. R., Strupp, H. H., &<br />
Wachtel, P. L. (Eds.) (1992). History of psychotherapy: A century of change. Washington, DC:<br />
American Psychological Association.<br />
Humphreys, K. (1996). Clinical psychologists as psychotherapists: History, future, and alternatives.<br />
American Psychologist, 51, 190–197.<br />
Rosen, G. (1975). Madness in society: Chapters in the historical sociology of mental illness. New York:<br />
Anchor Books.<br />
Rosenhan, D. (1973). On being sane in insane places. Science, 179, 250-258. p. 253.<br />
Spanos, N. P. (1978). Witchcraft in the histories of psychiatry: A critical appraisal and an alternative<br />
conceptualization. Psychological Bulletin, 35, 417–439.<br />
Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15, 113–118. This is a must<br />
read classic article.<br />
VIDEO RESOURCES<br />
<strong>Abnormal</strong> Psychology (video, color, 29 min.). Emphasizes the problems of distinguishing between<br />
normal and abnormal behavior within the context of the DSM system of classification. Coast District<br />
Telecourses, 11460 Warner Avenue, Fountain Valley, CA 92708.<br />
Dr. Pinel Unchains the Insane (16 mm, 25 min.). An enactment of Pinel’s plea to bring moral treatment<br />
to the mentally ill. McGraw-Hill Text films, 1221 Avenue of the Americas, New York, NY 10020.<br />
Emotional Illness (16 mm, 30 min.). Introductory movie discusses abnormal behavior and distinguishes<br />
neurotic, psychotic, and psychosomatic illnesses. Audio Visual Center, Indiana University,<br />
Bloomington, IN 47405.<br />
Sigmund Freud: The View from Within (16 mm, color, 29 min.). Describes the influences that moved<br />
Freud in the direction of psychoanalytic theory. Department of Cinema, University of Southern<br />
California, University Park, Los Angeles, CA 90007.<br />
Brainwaves (VHS, color, 60 min.). From the PBS Madness series. Explores the physical explanations<br />
and treatments for mental illness from late eighteenth-century Europe to the present. PBS Video<br />
Catalog. 1-800-344-3337.<br />
The Dark Side of the Moon (VUS, color, 25 min.). Chronicles the lives of three men with mental<br />
disorders, from living on the streets to becoming useful members of society. They now work to help<br />
other people in similar situations. Fanlight Productions. 1-800-937-4113.<br />
Out of Sight (VHS, color, 60 min.). From the PBS Madness series. Discusses the development of<br />
institutions for the mentally ill and traces custodial care practices of the mentally disturbed. PBS Video<br />
Catalog. 1-800-344-3337.<br />
To Define True Madness (VHS, color, 60 min.). From the PBS Madness series. Examines mental illness<br />
through history and considers the progress of understanding these disorders. PBS Video Catalog. 1-800-<br />
344-3337.<br />
ON THE INTERNET<br />
http://www.apa.org is the American Psychological Association, the first and largest association devoted<br />
to psychology in the United States (also has many members from Canada and other countries).
16 Chapter 1: <strong>Abnormal</strong> <strong>Behavior</strong><br />
http://www.cmhc.com is the web site for a company that develops and provides technology and<br />
management information systems for mental health centers.<br />
http://www.mentalhealth.com is the web site for Internet Mental Health, which provides resources and<br />
some full-length articles of psychological disorders, medications, and other important research.<br />
http://www.mhsource.com is a general resource provided by Mental Health InfoSource.<br />
http://www.nami.org is the web site for the National Alliance for the Mentally Ill, an advocacy<br />
organization for people with mental illness and their families.<br />
http://www.nimh.nih.gov is the web site for the National Institute of Mental Health (a division of the<br />
National Institutes of Health), which offers information about diagnosis and treatment of numerous<br />
mental health disorders and other useful references.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
CHAPTER 2<br />
Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
CHAPTER OUTLINE<br />
I. Models in the study of psychopathology<br />
1. The case of Steven V.<br />
A. The biological models<br />
1. The human brain (composed of neurons)<br />
a) The forebrain<br />
b) The midbrain and hindbrain<br />
2. Biochemical theories<br />
3. Genetic explanations<br />
4. Criticisms of the biological model<br />
B. Psychodynamic models<br />
1. Personality structure<br />
2. Psychosexual stages<br />
3. Anxiety and psychopathology: realistic, moralistic, and neurotic anxiety<br />
4. Defense mechanisms<br />
5. Psychoanalytic therapy<br />
6. Post Freudian's perspective<br />
7. Criticisms of psychodynamic models<br />
C. Genetic explanations<br />
1. The Human Genome Project<br />
D. Criticisms of the biological model<br />
II. Humanistic and existential approaches: agree on importance of subjective reality, freedom of<br />
choice, and wholeness of person<br />
A. The humanistic perspective<br />
1. Actualizing tendency<br />
a) Self-actualization: motive to enhance self<br />
b) Self-concept: view of self and values attached to self<br />
2. Development of abnormal behavior<br />
a) Conditions of worth distort self-concept<br />
b) Incongruence leads to symptoms<br />
c) Need for unconditional positive regard<br />
3. Person-centered therapy: nondirective; use of reflection of feelings<br />
B. The existential perspective<br />
1. Differences from humanistic approach<br />
a) Less optimistic<br />
b) Individual seen in larger context<br />
c) Greater stress on responsibility to others<br />
C. Criticisms of the humanistic and existential approaches<br />
1. Emphasis on subjective makes empirical investigation difficult<br />
2. Limited usefulness with severely disturbed clients<br />
III. Psychodynamic models<br />
A. Personality structure<br />
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18 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
B. Psychosexual stages<br />
C. Anxiety and psychopathology: realistic, moralistic, and neurotic anxiety<br />
D. Defense mechanisms<br />
E. Psychoanalytic therapy<br />
F. Post-Freudian perspectives<br />
G. Criticisms of psychodynamic models<br />
IV. <strong>Behavior</strong>al models<br />
A. The classical conditioning model<br />
B. Classical conditioning in psychopathology<br />
C. The operant conditioning model<br />
D. Operant conditioning in psychopathology<br />
E. The observational learning model<br />
F. Observational learning model in psychopathology<br />
G. Criticisms of the behavioral models<br />
V. Cognitive models<br />
A. Irrational and maladaptive assumptions and thoughts<br />
B. Distortions of thought processes<br />
C. Cognitive approaches to therapy<br />
D. Criticisms of the cognitive models.<br />
VI. Humanistic and existential approaches: agree on importance of subjective reality, freedom of<br />
choice, and wholeness of person<br />
VII. The family systems model: personality ruled by family attributes; abnormality reflects unhealthy<br />
family dynamics; treat whole system<br />
A. Family treatment approaches<br />
1. Communications<br />
2. Strategic (power issues)<br />
3. Structural (relationship involvement)<br />
B. Criticisms of the family systems model<br />
1. Definition of family is culture bound<br />
2. Excessively blames parents<br />
VIII. Models of diversity and psychopathology<br />
A. Multicultural models of psychopathology<br />
B. Criticisms of the multicultural model<br />
1. Universality of some disorder symptoms<br />
2. Lack of empirical validation<br />
IX. An integrative approach to models of psychopathology<br />
A. A tripartite framework for understanding abnormal psychology<br />
1. Individual level<br />
2. Group level<br />
3. Universal level<br />
LEARNING OBJECTIVES<br />
1. Define psychopathology and describe what a model is. Discuss how models are used in describing<br />
psychopathology and how a clinician’s choice of a model influences thought and action toward<br />
abnormal behavior. (pp. 35–37; Figure 2.1)<br />
2. Discuss why the mind/body dualism is a false one. Describe the biological models, including the<br />
major structures of the human brain, neurons, and the role of neurotransmitters, and how<br />
knowledge of biochemistry can be used in the treatment of mental disorders. (pp. 37–41; Table<br />
2.1)<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 19<br />
3. Discuss the relationship between genetics and psychopathology, including the differences between<br />
genotype and phenotype, and explain how the Human Genome Project is revolutionizing our<br />
understanding of the impact that genes have on human life. (pp. 41–43)<br />
4. List the criticisms of the biological model and describe how the diathesis-stress approach has tried<br />
to address some of these criticisms. (p. 43)<br />
5. Describe the basic concepts of psychodynamic theory, including the components of personality<br />
structure, the concepts of psychosexual stages and defense mechanisms, and the role anxiety plays<br />
in the development of psychopathology. (pp. 43–46)<br />
6. Briefly describe psychoanalytic therapy and how the psychoanalysis of the post-Freudians<br />
differed from traditional Freudian psychoanalysts. (pp. 46–47)<br />
7. Discuss the criticisms of the psychodynamic model. (pp. 46-47)<br />
8. Discuss the concerns of the behavioral models of psychopathology. Describe the components of<br />
the classical conditioning model and relate those components to psychopathology. (pp. 49–50)<br />
9. Discuss how operant conditioning can be applied to understanding psychopathology. Specify the<br />
assumptions of the operant conditioning model and compare them with classical conditioning.<br />
(pp. 50–52)<br />
10. Describe the observational learning model and its relevance to psychopathology. Evaluate the<br />
behavioral models. (pp. 52–53)<br />
11. Describe the assumptions of the cognitive models and how unproductive schemas, irrational and<br />
maladaptive thoughts, and distortions of thought processes contribute to psychopathology.<br />
Describe the elements of cognitive therapy. (pp. 53–55)<br />
12. Evaluate the cognitive models. (pp. 55–56)<br />
13. Describe the contributions of the humanistic and existential approaches including the notions of<br />
the concept of the self and the actualizing tendency. Discuss the development of abnormal<br />
behavior and its treatment according to Carl Rogers. (pp. 56–58)<br />
14. Discuss the criticisms of the humanistic and existential approaches. (pp. 58-59)<br />
15. Identify the three distinct assumptions of the family systems approach, including the development<br />
of personality and identity within the family, the relationship between family dynamics and<br />
psychopathology, and treatment approaches. (pp. 59–60)<br />
16. Evaluate the strengths and limitations of the family systems model. (p. 60)<br />
17. Discuss the assumptions of the multicultural models of psychopathology, including the inferiority<br />
and deprivations/deficit models, and relate these ideas to psychopathology. Evaluate the strengths<br />
and limitations of the multicultural model. (pp. 60–64)<br />
18. Using Table 2.4, compare and contrast the biological, psychodynamic, humanistic/existential,<br />
behavioral, cognitive, family systems, and multicultural models of psychopathology. Discuss the<br />
utility of integrating models into an eclectic approach such as that found in the “tripartite<br />
framework.” (pp. 64–69; Table 2.4)<br />
19. Discuss the case of Steven V. from various etiological models and how each model would treat<br />
Steven V. (pp. 36-37; 65–67)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Two important issues that all models should address are (l) whether people with disorders are<br />
responsible for their problems, and (2) whether they are responsible for solutions to their
20 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
problems. These ideas are wonderfully summarized in an American Psychologist article by Philip<br />
Brickman et al. (1982). The medical model assumes that people are responsible for neither their<br />
problems nor the solutions to them. The model implies that professionals must provide help and<br />
that disturbed people are relatively passive during recovery. In the extreme form,<br />
humanistic-existential thinkers suggest that people are responsible for both creating and solving<br />
their difficulties. Some might consider this a moral model: Only the sinner can help himself or<br />
herself. Two other quadrants exist as well. One asserts that although people may create their own<br />
troubles, they must rely on to solve them. Finally, a “compensatory” model argues that people<br />
may not be responsible for the cause of their problems, but they must be responsible for solving<br />
them.<br />
You can use the handout for this lecture topic and ask students where the biogenic model and the<br />
humanistic-existential perspective should be placed and why. This should lead to a discussion of<br />
what helpers can do, the disturbed person’s adoption of a “sick role,” the phenomenon of blaming<br />
the victim, and other consequences of adopting a particular model. Another related topic is the<br />
disease model of addiction. If alcoholics are the cause of their own problem and should be<br />
responsible for the solution, they would be seen in the “moral” cell. In many people’s minds,<br />
alcoholism is a disease (the alcoholic is responsible for neither the problem nor its solution). Do<br />
students agree with this model? Do they see people addicted to cigarettes in the same way? What<br />
about compulsive gamblers? Another point implicit in the grid is that responsibility for the cause<br />
of a problem does not necessitate responsibility for its solution (and vice versa). Ask students if<br />
they can think of disorders or other life problems in which a person who is not responsible for the<br />
cause is held responsible for its solution. Does this model seem “fair”? The discussion could<br />
conclude with the idea that adopting a model is anything but a neutral act.<br />
Source: Brickman, P., Rabinowitz, V. C, Karuza, J., Coates, D., Cohn, E., & Kidder, L. (1982).<br />
Models of helping and coping. American Psychologist, 37, 368–384.<br />
Internet Site: http://www.neuropsychologycentral.com/index.html. Massive site with links to all<br />
topics in the neurosciences.<br />
2. You can ask students to assess their own preferred theoretical perspective and its implications.<br />
Present the following short hypothetical case as the focus for this discussion:<br />
John is 17 and has been drinking heavily since he was 12. He drinks almost every day, but when<br />
he is particularly anxious, he drinks until he passes out. His father and his grandfather were<br />
diagnosed alcoholics; the father drank himself to death when John was 14. His mother and older<br />
brother do not drink at all, and they have always told John that he is the family’s black sheep, the<br />
rebellious who is destined to be like his father.<br />
Ask students what they think causes John‘s behavior—genetics? Early childhood experiences?<br />
Problems with feelings and thoughts? Current circumstances? Wider society? Ask them to defend<br />
their choice. The ensuing discussion may lead to an examination of the methods by which we<br />
could discover the causes of alcoholism. It should also show how multiple perspectives can shed<br />
light on a single case.<br />
From the biogenic perspective, you could list genetic vulnerability and briefly explain the concept<br />
of concordance. If John had an identical twin, would he, too, drink heavily and at the same times?<br />
Also under the biogenic heading, neurochemical differences can be discussed. If we found that<br />
John metabolized alcohol differently from his older brother, would that support a biogenic<br />
explanation? Point out the need for a preexisting biological difference. Finally, this example can<br />
give students an appreciation of diathesis-stress theory. If John has a preexisting, inherited<br />
vulnerability, is he doomed to become an alcoholic? (Most likely, a combination of genetic factors<br />
and family and social stressors produced this pattern of use.)<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 21<br />
From the psychodynamic perspective, you could discuss oral fixation. Is dependency a result or a<br />
cause of drinking? What information would suggest that early deprivation caused John’s<br />
adolescent behavior? John probably engages in the defenses of rationalization, denial, and<br />
projection.<br />
Humanistic theorists might focus on John’s lack of self-esteem or the conditions of worth that his<br />
family might have placed on loving him. Alienated from society, he may find comfort in<br />
intoxication and escape from responsibility. Does he freely choose to drink heavily? Is he being<br />
honest with his feelings?<br />
<strong>Behavior</strong>ists would look at how John’s father and grandfather modeled how to drink heavily. At<br />
the same time, they probably introduced a good deal of stress in the boy’s life, and he probably<br />
learned that drinking reduced that stress. If his mother and brother criticized him a great deal,<br />
perhaps drinking became an operant behavior that alleviated the criticism temporarily, illustrating<br />
operant conditioning’s concept of negative reinforcement. Finally, if the sight and smell of alcohol<br />
now produce an automatic response in John, we could see his use as having a classically<br />
conditioned quality, too.<br />
If students mention that John probably thinks that he can function only when he is drunk, they<br />
appreciate the cognitive viewpoint. He may catastrophize discomforting circumstances in his life<br />
and thereby give himself a rationale for drinking heavily. Irrational beliefs such as “unless I am<br />
perfect no one will love me, so I might as well get drunk” are part of Ellis’s A-B-C theory of<br />
personality. Beck would emphasize illogical thought processes John might have, such as a<br />
tendency to maximize any perceived hurt and minimize the effects drinking has on his life.<br />
If students focus on the family’s definition of John as black sheep and the brother as perfect, they<br />
are in tune with systems thinking. His mother and father most likely were in frequent conflict;<br />
perhaps John resented that or was ignored. How did the family deal with the father’s death?<br />
John’s symptoms may only reflect a wider family pathology; in fact, the family may need to have<br />
a black sheep so other members maintain their roles. Therefore, mother and brother may<br />
unconsciously assist John in staying drunk. You can discuss “enabling” here.<br />
Finally, John may be acting out sex- and age-role stereotypes. The multicultural perspective<br />
would look at the cultural norms for John and adolescents like him. What is the peer culture like?<br />
Are others labeling him “alcoholic” prematurely or using a cultural standard that is inappropriate?<br />
The discussion should show that the same information about a person can be interpreted quite<br />
differently and that each perspective has something valuable to offer. An eclectic approach is<br />
attractive, but note that complete eclecticism is untenable. For example, isn’t it logically<br />
impossible for John to be both free in his actions and the product of determinism?<br />
3. A pair of articles points out the tendency for researchers who support a particular orientation to<br />
selectively report evidence. The issue in this case is the explanation for the phenomenon of violent<br />
men fostering the development of violent sons. Widom (1989) presented what she considered a<br />
comprehensive examination of evidence on the question of violence begetting violence. She<br />
concluded that violence in adolescence and adulthood stems from being abused as a child. She<br />
marshaled considerable support for her environmental/familial explanation.<br />
Not long afterwards, DiLalla and Gottesman (1991) argued that Widom left out part of the story.<br />
With equal vigor and credibility, DiLalla and Gottesman show that evidence from twin and<br />
adoption studies, plus physiological research (on testosterone and 5-HIAA levels, for example),<br />
suggests a biological contribution to violence. They do not deny the importance of the<br />
environment but suggest that “cultural influence is just one of the paths that make children similar<br />
to their parents” (p. 128).
22 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
Discuss with your students whether scientists are more or less likely than nonscientists to look in<br />
an unbiased fashion at the evidence for and against their position. Ask them what, as consumers of<br />
information, they must do to protect themselves from researchers who present a biased<br />
interpretation of information while claiming to be thorough in their analysis.<br />
Sources: DiLalla, L. F., & Gottesman, I. I. (1991). Biological and genetic contributions to<br />
violence—Widom’s untold tale. Psychological Bulletin, 109, 125–129; Widom, C. S. (1989).<br />
Does violence beget violence? A critical examination of the literature. Psychological Bulletin,<br />
106, 3–28.<br />
4. The diathesis-stress model has become paradigmatic for much of the field. A good way to show<br />
the diathesis-stress idea is by drawing on the board a graph with low and high vulnerability along<br />
the x-axis and low and high stress along the y-axis. A diagonal line would separate those who<br />
develop the disorder from those who do not: At very high levels of vulnerability, almost any stress<br />
exceeds threshold values; at very low levels of vulnerability, even very high stress levels fail to<br />
generate the disorder. However, even a simple two-factor model (genetic vulnerability plus<br />
environmental stress) becomes quite complicated, given greater sophistication in our<br />
understanding of life stress. Monroe and Simons (1991) note that we have trouble determining a<br />
threshold level of vulnerability (who is vulnerable?) or gradations of vulnerability (who is highly<br />
vulnerable?). Furthermore, we cannot yet determine what type of life stress is important, in what<br />
context, with what frequency, and for what disorder. Monroe and Simon’s work focuses on<br />
depression. A more complete review of the concept is provided for schizophrenia (Fowled, 1992).<br />
Sources: Fowled, D. C. (1992). Schizophrenia: Diathesis-stress revisited. Annual Review of<br />
Psychology, 43, 303–336; Monroe, S. M., & Simon, A. D. (1991). Diathesis-stress theories in the<br />
context of life stress research: Implications for depressive disorders. Psychological Bulletin, 110,<br />
406–425.<br />
5. Information that supplements the text’s coverage of operant conditioning will prove important in<br />
explaining disorders later in the book. Students will need to understand positive and negative<br />
reinforcement, punishment, extinction, and shaping. A handout using a four-cell diagram can<br />
communicate this clearly and quickly.<br />
The diagram shows four operant processes by which we can alter the strength of a response, all<br />
related to the consequences that immediately follow the response. Consequences can either be<br />
positive or negative and can either be presented or removed. This should simplify the underlying<br />
mechanisms of operant conditioning.<br />
It is always difficult for students to differentiate negative reinforcement from punishment. Use the<br />
example of behavior in a rainstorm. If you walk out into the rain and get soaked and cold, you are<br />
unlikely to do the same thing again. If you walk out into the rain and then put up an umbrella, it<br />
removes a negative stimulus and you are more likely to use an umbrella in the next storm. The<br />
former is punishment; the latter is negative reinforcement or avoidance learning.<br />
Shaping is crucial for understanding abnormal behavior. Explain to students that complex<br />
behaviors are made up of component tasks. If we are required to master the complex behavior<br />
before receiving any reinforcement, we are unlikely to ever learn it. Parents and coaches know<br />
this; they expect and reinforce only the crudest approximations of the “finished” behavior at first.<br />
The standard for reinforcement increases incrementally as more and more components of the<br />
behavior are added. Ask student athletes how they first learned a complex motor behavior such as<br />
a tennis serve or golf swing. Did their coach shape them at an appropriate rate? What happened<br />
when they had an off day and dropped back in performance?<br />
Next discuss how shaping naturally occurs in families—without the conscious effort involved in<br />
teaching a motor skill. How do parents shape their children for keeping their rooms clean, for<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 23<br />
table manners, for the expression of feelings? Further, don’t children also shape their parents for a<br />
variety of behaviors? A good way to end this portion of your lecture is to discuss how you shape<br />
your students (smiling when they take notes or ask good questions) and how they shape you<br />
(laughing at your jokes, making eye contact). Everyday life is a shaping dance: a pattern of<br />
reinforcing interactions in which we often unconsciously attempt to alter others’ behavior even as<br />
they attempt to alter ours.<br />
Internet Site: http://www.indiana.edu/~iuepsyc/topics/cognitive.htm. Contains examples and<br />
demonstrations of classical and operant conditioning.<br />
6. Many professionals and nonprofessionals make liberal use of the term dysfunctional family.<br />
Unfortunately, the term has stretched to the point of describing everything, and, therefore,<br />
nothing. You can start a discussion by asking students to list the behaviors or factors they think<br />
define dysfunctional. You can compare these with the following concepts presented by Epstein<br />
and Bishop (1981) in what they call the McMaster model of family systems:<br />
Problem-solving difficulties. Most-effective families are able to identify problems, communicate<br />
their existence to other family members or relevant outsiders, develop alternative solutions to the<br />
problem, decide on a solution, take action to implement the solution, and evaluate its impact.<br />
Families are less and less effective if they are incapable of performing these problem-solving<br />
tasks. The most dysfunctional cannot do the first step of identifying the problem.<br />
Communication problems. Most-effective families communicate directly (to the person to whom<br />
the message is intended) and in a clear manner. Least-effective families communicate indirectly<br />
(to someone other than the message’s target) and in a masked manner. This sets up a four-cell<br />
model: clear and direct, clear and indirect, masked and direct, masked and indirect. Examples help<br />
teach these concepts.<br />
Tom’s wife is angry with him for not listening to her. Here are examples of communications<br />
for each of the four cells.<br />
Clear and direct: Tom, when you don’t listen to me, I get really angry.<br />
Clear and indirect: Boy, men can really make you angry when they don’t listen.<br />
Masked and direct: Tom, you look like hell today!<br />
Masked and indirect: Men! What are you gonna do about them?<br />
Roles in the family. Most-effective families have specific roles for family members (provide<br />
nurturance, make decisions, provide financial resources), although the roles are flexible when<br />
circumstances change. The least-effective families are chaotic; no one knows or maintains a role<br />
so no one can depend on another family member.<br />
Difficulties in expressing emotions. Most-effective families are able to get emotional needs taken<br />
care of. Family members can be sad, happy, angry, guilty, or relaxed as they need to be, although<br />
there are limitations on the intensity of such expression. Least-effective families allow no<br />
emotional expression or are out of control.<br />
Difficulties in being emotionally involved with one another. Most-effective families show interest<br />
in the welfare and activities of other family members. Least-effective families, in accordance with<br />
Minuchin’s structural approach, are either enmeshed (overinvolved) or disengaged (completely<br />
uninvolved) from one another.<br />
<strong>Behavior</strong> control difficulties. Most-effective families can control family members’ actions so there<br />
are clear expectations for specific situations. However, these families use a flexible and rational<br />
system of control so that the reasons for controls and opportunities for change are clear.<br />
Least-effective families are inconsistent, where one parent operates on a laissez faire basis while
24 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
the other is rigidly controlling, or worse, both parents shift suddenly from one extreme to the<br />
other.<br />
Source: From “Problem-Centered Systems Therapy of the Family,” by N. B. Epstein & D. S.<br />
Bishop, in Handbook of Family Therapy, edited by A. Gurman & D. Kniskern, copyright © 1981.<br />
Reprinted with permission from Brunner/Mazel, Inc., and the author.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 25<br />
HANDOUT FOR CLASSROOM TOPIC 1: THE BRICKMAN GRID<br />
Attribution to Self of Responsibility for Problem Attribution to Self of Responsibility for Solution<br />
High Low<br />
High Moral Enlightenment<br />
Perception of self Lazy Guilty<br />
Actions expected of self Striving Submission<br />
Actions expected of others Exhortation Discipline<br />
View of human nature Strong Bad<br />
Low Compensatory Medical<br />
Perception of self Deprived Ill<br />
Actions expected of self Assertion Acceptance<br />
Actions expected of others Mobilization Treatment<br />
View of human nature Good Weak
26 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
HANDOUT FOR CLASSROOM TOPIC 5:<br />
FOUR PROCESSES IN OPERANT CONDITIONING<br />
Type of Consequence<br />
Positive Negative<br />
Present Positive reinforcement Punishment<br />
(increased response strength) (decreased response strength)<br />
Remove Extinction (negative punishment) Negative reinforcement<br />
(decreased response strength) (increased response strength)<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 27<br />
CLASSROOM DEMONSTRATIONS<br />
1. It is important for students to think about the implications of genetically transmitted mental<br />
disorders. A role-play exercise may bring this home. Divide the class into groups of seven or so<br />
and distribute the handout for Demonstration 1, which provides information about the<br />
revolutionary (and hypothetical) discovery of a genetic marker for depression. Tell the students<br />
that the U.S. government wants them to brainstorm on how this new discovery can or should be<br />
used to prevent depression. Ask them to analyze each idea group members suggest in terms of its<br />
cost and the benefits it would provide. Each group should come to a consensus on what should be<br />
done nationally. Allow ten to fifteen minutes for this discussion. Circulate to answer any<br />
questions. Then ask each group to report to the full class. Write their recommendations on the<br />
board. Ask about ideas that were rejected. Ethical concerns over invasion of privacy,<br />
self-fulfilling prophecies, and overprediction should arise. You may want to note that an<br />
American geneticist was motivated to identify the gene for Huntington’s disease because her<br />
family has a history of this tragic disorder. After years of work she was successful and helped<br />
develop a test that can identify a carrier of the gene. However, she herself would not submit to<br />
testing—she would rather not know.<br />
Internet Site: http://health.yahoo.com/health/centers/depression/1295 An in-depth discussion of<br />
genetics and inheritance.<br />
2. An in-class exercise that reveals unconscious processes is a helpful teaching demonstration. Find<br />
several ambiguous pictures from magazines that show men and women in some form of<br />
interaction. Advertisements are a good source of pictures. Hold up the pictures or, if they<br />
reproduce well, photocopy them and hand them out to the class. Ask students to write out<br />
TAT-type stories for each picture: “Make up a creative story about what is going on in this<br />
picture. What led up to this scene? How will it turn out? What are the people feeling?”<br />
Do not ask for public readings of student stories, but explain how their stories about the<br />
protagonists might reveal aspects of their own needs and concerns. Discuss how males and<br />
females might be described differently and how recurring themes might reveal unconscious<br />
feelings toward men (father) and women (mother) in general. Student skepticism should be<br />
accepted. Responses to skepticism can range from how a psychoanalyst would identify disbelief<br />
as a form of repression to how critics of psychoanalytic assessment would question the reliability<br />
and validity of such interpretations.<br />
3. In the class period before you lecture on psychoanalytic concepts, ask for eight volunteers. Tell<br />
them that you want them to pair up and write skits that illustrate the major defense mechanisms.<br />
The students will be more accurate in their depictions if you supply a handout that lists four<br />
defenses—repression, reaction formation, projection, and displacement—and gives a brief<br />
description of each. The volunteers can pick the defense they want to illustrate. Encourage them to<br />
be creative in their role play; the more dramatic, the better the point is driven home to the other<br />
students.<br />
When the class period for discussing defense mechanisms arrives, have the students come to the<br />
front of the room and give their skits. Do not announce to the class which defense each pair is<br />
supposed to be illustrating. Ask the class to identify the defense they think is being depicted.<br />
Provide any corrections that are needed.<br />
Ask the participants in the skits how they felt while performing. Help the class discuss how the<br />
exaggeration of each defense could lead to interpersonal conflicts and disorders. You may want to<br />
link certain disorders with defenses (projection with delusions, repression with dissociative
28 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
disorders). Also, you could point out the need for defenses. Students often think that defenses are<br />
either good or bad; you should emphasize the balance that is required for good mental health.<br />
4. The humanistic-existential perspective stresses personal freedom and responsibility. The biogenic<br />
and psychodynamic perspectives place much greater emphasis on determinism based on past<br />
biological or psychological events. Present students with this short story:<br />
Bill suffers from auditory hallucinations (he hears voices telling him to kill). If he tries very hard,<br />
he can keep the voices from being loud enough to influence him, but it is tiring to do so. One day,<br />
Bill was too worn out to stop the voices. He listened to them, picked up a gun, and shot a complete<br />
stranger on the sidewalk.<br />
Ask students if they think Bill’s actions were done out of free will. Should he be held personally<br />
responsible for his actions? Is Bill a product of biological or psychological forces outside his<br />
control? Urge students to take a position. Use two corners of the classroom to segregate students<br />
into those that take a free will position and those that take a determinism position. Ask students<br />
from each group to explain their thinking and describe which of the theoretical perspectives<br />
(biogenic, psychoanalytic, humanistic-existential) they agree with most. Ask several students what<br />
additional facts could get them to move from one corner to the other corner or more toward the<br />
middle.<br />
5. Classical and operant conditioning lend themselves to in-class demonstrations. Classical<br />
conditioning demonstrations using loud noises and some conditioned stimulus (for example,<br />
picking up an eraser) can be very effective. The demonstration also allows examination of<br />
generalization (Will students cringe if another professor picks up an eraser?) and discrimination<br />
(Will students cringe only when they walk into your classroom?). Habituation can also be pointed<br />
out.<br />
For operant conditioning, shaping can be demonstrated with a clicker or even finger snaps. A<br />
volunteer from the class is asked to leave the room for a moment while the rest of the class is<br />
informed that shaping will be demonstrated. Tell the other students that you will use the sounds of<br />
a clicker or finger snaps to tell the volunteer that he or she is “getting warmer” or “getting colder”<br />
to a target behavior such as walking in a circle or scratching his or her nose. The volunteer is<br />
invited back and is asked to move about the front of the room and to consider the clicks he or she<br />
hears as reinforcers. The greater the frequency of clicks, the greater the reinforcement. This<br />
demonstration will show students the small increments of change that some behavior therapists<br />
must come to expect when teaching complex skills.<br />
Internet Site: http://www.indiana.edu/~iuepsyc/topics/cognitive.htm. Examples and<br />
demonstrations of classical and operant conditioning.<br />
6. This demonstration (Hughes, 1990) is appropriate for students with moderate anxiety in the<br />
presence of certain animals. Earthworms, snakes, and spiders are often the object of<br />
squeamishness if not outright phobic responses. You or some expert you know should come to<br />
class with the animal you choose, hold it with confidence, and discuss some facts about the<br />
animal, stressing its essential harmlessness. Students who fear the animal should be encouraged,<br />
but not coerced, to come forward and take gradual steps toward it. Deep breathing and<br />
encouragement should be used to help the student or students take an additional step: standing<br />
next to the animal, examining it carefully, touching it for an instant, touching it for longer, and<br />
finally holding it.<br />
The demonstration shows the power of modeling and, perhaps more subtly, the power of positive<br />
peer pressure. Both are important in understanding the development and treatment of<br />
psychopathology. The demonstration can also be expanded to ask the students who come forward<br />
to verbalize their thoughts. This will increase their awareness (and that of the other students in the<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 29<br />
class) of cognitive mediating properties. As students take steps closer to making contact with the<br />
animal, suggest that they talk to themselves to remain calm and to give themselves reinforcing<br />
self-statements (“I’m pretty brave to be doing this. Good for me!”).<br />
Source: Adapted from “Participant Modeling as a Classroom Activity,” by D. Hughes, Teaching<br />
of Psychology, 17, 1990, pp. 238–240. Copyright © 1990. Used by permission of Lawrence<br />
Erlbaum Associates, Inc. and the author.<br />
7. Put the students into discussion groups. Ask the groups to develop an explanation for alcohol<br />
abuse and dependence using the concepts of modeling and social learning theory. Ask one person<br />
from each group to share a summary of the group discussion with the entire class. This topic<br />
usually provokes a lively discussion, with students relating examples about their family and<br />
friends.
30 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
HANDOUT FOR DEMONSTRATION 1:<br />
IMPLICATIONS OF GENETICALLY TRANSMITTED<br />
MENTAL DISORDERS<br />
You have been selected by the U.S. government to participate in a task force to decide how the nation<br />
should use some startling information. Pretend that researchers have discovered that severe depression,<br />
one of the most common and lethal forms of mental disorder, can be genetically predicted to a degree.<br />
A simple blood test is all that is needed to detect this genetic vulnerability. Further, imagine that<br />
scientists know that if this genetic marker shows up in the blood, in 75 percent of cases the person will<br />
become severely depressed within five years unless he or she takes a certain medication. In the other 25<br />
percent of cases, there will either be mild or no depression at all without medication and no chance of<br />
depression if the medication is taken.<br />
The government wants to know what to do with this information. Can or should it be used to prevent a<br />
terrible mental disorder? What are the dangers, if any, of making this news public? What are the costs<br />
and benefits of massive blood screenings? What should be done about making the medication<br />
available?<br />
Your group must come to a consensus about what, if anything, the nation should do with the<br />
information the task force has. You can assume that no one else knows about this hypothetical scientific<br />
breakthrough except your group and the scientists.<br />
Be prepared to report the results of your deliberations to the full class.<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 31<br />
HANDOUT FOR DEMONSTRATION 3:<br />
DEPICTIONS OF DEFENSE MECHANISMS<br />
You and your partner will be assigned to do a short skit depicting one of the following defense<br />
mechanisms. First, decide on an interpersonal situation in which the defense mechanism is likely to be<br />
used. Provide the audience with some background to the scene you will play: what led up to the<br />
situation, where it takes place, and the relationship between the two people. Then develop a script for<br />
the interaction so that you can accurately illustrate the defense. Your skit will be especially effective if<br />
you add the voice quality and gestures that might accompany the defense.<br />
1. Repression: the defense mechanism that prevents unacceptable impulses from reaching<br />
consciousness. Repression always involves some form of motivated forgetting. Sometimes<br />
emotionally charged life events, such as being assaulted by another person, are pushed out of<br />
consciousness. In other cases, unacceptable impulses or thoughts (sexual or violent) are banished<br />
from consciousness so that people who may have lustful or rageful impulses are unaware that they<br />
have them. Be clear that repression is not intentional; people who consciously decide not to think<br />
about or remember certain events are not engaged in defense mechanisms.<br />
2. Reaction formation: the defense mechanism in which a repressed desire is expressed by taking<br />
on an opposite attitude or pattern of behavior. One illustration of this defense mechanism is when<br />
people threatened by their strong sexual feelings express a strict, puritanical attitude. They might<br />
vehemently campaign against anything that is even slightly sexual in nature. Another example is<br />
the daredevil individual who seems to laugh at death but, according to psychoanalysts, is<br />
defending against an unacceptable fear of death. The phrase Shakespeare used, “Me thinks the<br />
lady doth protest too much” is a good summary of reaction formation.<br />
3. Projection: the defense mechanism by which a person attributes to others the objectionable<br />
characteristics that are actually in him or herself. A person who feels violent impulses toward<br />
others will not accept these feelings but rather see others as intending to harm him or her.<br />
Projection often takes the form of inaccurate mind reading: believing that others are motivated by<br />
or thinking about certain emotionally charged ideas that are actually within the observer’s mind.<br />
In its extreme form, projection becomes paranoia—believing that others are in a conspiracy to<br />
harm one despite a lack of plausible evidence for this belief.<br />
4. Displacement: the defense mechanism that redirects an unacceptable emotional response from an<br />
object that is seen as threatening or unacceptable toward one that is less so. Misplaced anger is a<br />
classic example of displacement: kicking the cat when you are really angry with a friend.<br />
However, other emotional responses can be displaced, such as when a child who is fearful of a<br />
bully at school unconsciously develops a phobia of going to school.
32 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
SELECTED READINGS<br />
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. This book is a must<br />
read.<br />
Beck, A. T., & Clark, D. A. (1988). Anxiety and depression: An information processing perspective.<br />
Anxiety Research, 1, 23–36.<br />
Blatt, S. J., & Lerner, H. (1991). Psychodynamic perspectives on personality theory. In M. Hersen, A.<br />
E. Kazdin, & A. S. Bellack (Eds.) The clinical psychology handbook (2 nd ed.). New York: Pergamon,<br />
pp. 147–169.<br />
Mahoney, M. J. (1988). Recent developments in cognitive approaches to counseling and psychotherapy.<br />
Counseling Psychologist, 16, 190–234.<br />
Rosenhan, D. (1973). On being sane in insane places. Science, 179, 250-258. p. 253<br />
Urban, H. (1991). Humanistic, phenomenological, and existential approaches. In M. Hersen, A. E.<br />
Kazdin, & A. S. Bellack (Eds.) The clinical psychology handbook (2 nd ed.). New York: Pergamon, pp.<br />
200–219.<br />
VIDEO RESOURCES<br />
Albert Bandura, Parts 1 and 2 (video, color, 57 min.). Bandura reviews his theoretical and research<br />
contributions, including modeling, cognitive behavior modification, the classic Bobo doll experiment,<br />
media effects on violence, self-efficacy, and his plans for the future. University Film & Video,<br />
University of Minnesota, Suite 108, 1313 Fifth Street, S.E., Minneapolis, MN 55414-1524.<br />
B. F. Skinner and <strong>Behavior</strong> Change: Research, Practice, and Promise (16 mm, color, 45 min.). Skinner<br />
and other psychologists discuss the philosophical, ethical, and scientific questions generated by<br />
behavioral psychology. Research Press, Box 317740, Champaign, IL 61820.<br />
<strong>Behavior</strong> Therapy: An Introduction (VHS, color, 29 min.). Shows three models of learning (classical,<br />
operant, and observational) applied to treatment. Penn State University Film Library, University Park,<br />
PA 16802.<br />
Charting the Unconscious Mind (2 parts, 13 min. each). Teaches the basics of psychoanalytic theory.<br />
Human Relations Media, 175 Tompkins Avenue, Pleasantville, NY 10570.<br />
Childhood Aggression: A Social <strong>Learning</strong> Approach to Family Therapy (16 mm, color, 35 min.). Dr.<br />
Gerald Patterson’s behavioral family intervention in treating a coercive child. Shows changes in family<br />
as treatment progresses; based on an actual case. Psychological Cinema Register, Pennsylvania State<br />
University, University Park, PA 16802.<br />
Freud: The Hidden Nature of Man (16 mm, 29 min.). Actors play Freud and his patients to show the<br />
development and power of unconscious motivations and repression. Audio Visual Center, Indiana<br />
University, Bloomington, IN 47405<br />
Hillcrest Family Series (16 mm, color, times range from 12 to 32 min.). Eight films—four family<br />
interviews, all with the same family, and four brief talks with the therapists who conducted the<br />
interviews. Family is seen by Nathan Ackerman, Murray Bowen, Don Jackson, and Carl Whitaker.<br />
Psychological Cinema Register, Pennsylvania State University, University Park, PA 16802.<br />
Hugs ‘n’ Kids: Parenting Your Preschooler (video, color, 36 min.). This type of video, combined with<br />
a manual, is used in behaviorally oriented parenting classes. It presents common parent-child impasses<br />
and ways to solve them. Available in Spanish and English. Guilford Publications, 72 Spring Street,<br />
New York, NY 10012-9941.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong> 33<br />
Maslow: Self-Actualization (16 mm, 60 min.). Abraham Maslow discusses his theory of<br />
self-actualization by assessing case material. Psychological Films, Inc., 189 N. Wheeler Street, Orange,<br />
CA 92669.<br />
Neurotic <strong>Behavior</strong>: A Psychodynamic View (16 mm, color, 19 min.). Shows operation of various<br />
defense mechanisms in reducing anxiety. CRM Educational Films, 1011 Camino Del Mar, Del Mar,<br />
CA 92014.<br />
“Neurotransmitter Animation” from The Psychology Show videodisc series (55 min.). Houghton Mifflin<br />
Company.<br />
Otto Series (video, color, 25–30 min. each). A series of five films. The first presents a dramatized case<br />
study of a middle-aged man. The four others present an analysis of the case from a psychoanalytic,<br />
behavioral, phenomenological, and sociocultural perspective, followed by a panel discussion of the<br />
merits of each perspective’s view of Otto. Audio Visual Center, Indiana University, Bloomington, IN<br />
47405.<br />
Psychological Birth of the Human Infant (16 mm or video, 48 min.). Margaret S. Mahler narrates her<br />
psychoanalytic concept of separation-individuation. The film covers the four subphases of the process<br />
(differentiation, practicing, rapprochement, and object constancy) over the first three years of life.<br />
Mahler Foundation Film Library, P.O. Box 315, Franklin Lakes, NJ 07417.<br />
“Psychotherapy” from Discovering Psychology series (#22) (VHS, color, 30 mins.). The relationships<br />
among theory, research, and practice and how treatment of psychological disorders has been influenced<br />
by historical, cultural, and social forces. The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345,<br />
S. Burlington, VT 05407-2345; to order, call 1-800-532-7637.<br />
Rollo May on Existential Psychology (16 mm, color, 28 min.). May discusses what existential<br />
psychology is and how we give meaning to experience. Concepts covered include will, freedom, being,<br />
and anxiety. American Association for Counseling and Development, 5999 Stevenson Avenue,<br />
Alexandria, VA 22304.<br />
“The Enlightened Machine” from The Brain series (#1) (VHS, color). Covers material from nineteenth<br />
century phrenology to current use of microphotography to show how neurotransmitters cross the<br />
synaptic gap. The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S. Burlington, VT 05407-<br />
2345; to order, call 1-800-532-7637.<br />
Three Approaches to Psychotherapy, Part III: Dr. Albert Ellis (16 mm, 37 min.). Dr. Ellis describes<br />
rational-emotive psychotherapy and illustrates by interviewing a patient. Film Rental Library,<br />
University of Kansas, Division of Continuing Education, Lawrence, KS 66045.<br />
B. F. Skinner on <strong>Behavior</strong>ism (VHS, color, 28 mm.). Skinner discusses behavior modification and<br />
shaping of human behavior using positive reinforcement. Insight Media. 1-800-233-9910.<br />
Carl Rogers: Part I (VHS, color, 50 mm.). Dr. Rogers discusses his humanistic theories, comparing<br />
them to other established theories of the time. Insight Media. 1-800-233-9910.<br />
Conversations with Albert Ellis: Introduction (VHS, color, 30 mm.). Dr. Ellis discusses his theory of<br />
rational-emotive therapy (RET). Insight Media. 1-800-233-9910.<br />
Sigmund Freud (VHS, color, 50 mm.). This video covers Freud's life from childhood through most of<br />
his adult years. It discusses many of Freud's theories of psychoanalysis and personality development.<br />
Insight Media. 1-800-233-9910.<br />
ON THE INTERNET<br />
http://www.apa.org is the site for The American Psychological Association
34 Chapter 2: Models of <strong>Abnormal</strong> <strong>Behavior</strong><br />
http://gablab.stanford.edu/brainiac The site is designed to help you learn about fMRI scanning and SPM<br />
statistical analysis.<br />
http://www.rebt.org/ is the site for Rational Emotive Therapy, where you can find additional<br />
information on Ellis’s rational-emotive therapy.<br />
http://www.apsa.org is the American Psychoanalytic Association’s Web page<br />
http://www.coedu.usf.edu/behavior/bares.htm is the web site for <strong>Behavior</strong> Analysis Resources, and<br />
provides excellent resources on behaviorism and learning.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
CHAPTER 3<br />
Assessment and Classification of <strong>Abnormal</strong><br />
<strong>Behavior</strong><br />
CHAPTER OUTLINE<br />
I. Reliability and validity<br />
A. Reliability: consistent results under same circumstances<br />
B. Validity: test performs function it was intended to<br />
C. Standard administration and standardization sample aid reliability and validity<br />
II. The assessment of abnormal behavior<br />
A. Observations<br />
1. Controlled and naturalistic<br />
2. Problems: check validity of observations when patient is from another culture;<br />
reactivity<br />
B. Interviews: affected by professional discipline and theoretical orientation<br />
1. Standardization: degree of structure<br />
2. Errors: information exchange blocked, anxiety in interviewee, interviewer orientation<br />
C. Psychological tests and inventories<br />
1. Projective personality tests<br />
a) Rorschach technique (inkblots)<br />
b) Thematic Apperception Test (pictures)<br />
c) Sentence-completion test<br />
d) Draw-a-person test<br />
2. Self-report inventories<br />
a) Minnesota Multiphasic Personality Inventory (MMPI, revised into MMPI-2): 567<br />
true-false items; yields scores on ten clinical and three validity scales; pattern<br />
analysis)<br />
b) Beck Depression Inventory (BDI): example of inventory for specific trait or<br />
problem<br />
3. Intelligence tests<br />
a) Wechsler Adult Intelligence Scale (WAIS-III) for adults; WISC-III (for children<br />
ages 6 and older); and WPPSI-R (for ages 4 to 6)<br />
b) Stanford-Binet Scale: more complicated; gives one IQ score<br />
c) Controversies: debate re innate intelligence versus cultural/social factors;<br />
disagreement re predictive validity; disagreement re criterion variables;<br />
inadequacy of current conceptions of IQ tests and intelligence<br />
4. Kaufman Assessment Battery for Children (K-ABC): for wide range of children<br />
5. Tests for cognitive impairment<br />
a) Large discrepancy between WAIS verbal and performance IQ<br />
b) Bender-Gestalt Visual-Motor Test: designs copied<br />
c) Halstead-Reitan Neuropsychological Test Battery: eleven tests (six or more<br />
hours)<br />
d) Luria-Nebraska Neuropsychological Battery: twelve scales (21/2 hours)<br />
D. Neurological tests<br />
Copyright © Houghton Mifflin Company. All rights reserved.
36 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
1. Computerized axial tomography (CAT scan)<br />
2. Positron emission tomography (PET scan)<br />
3. Electroencephalogram (EEG)<br />
4. Magnetic resonance imaging (MRI)<br />
5. Functional magnetic resonance imaging: high resolution, noninvasive views of neural<br />
activity<br />
E. Ethics of assessment: questions of privacy and long-range benefits<br />
1. Use of computers in assessment<br />
2. Cultural differences lead to biased assessments<br />
III. The classification of abnormal behavior<br />
A. Problems with early diagnostic classification systems<br />
1. Reliability<br />
a) Poor interrater reliability in early DSM editions<br />
b) Improvements in DSM-III, DSM-IV, and DSM-IV-TR<br />
2. Validity<br />
a) Critics question validity of psychiatric classification<br />
B. The current system: DSM-IV-TR<br />
1. Uses five factors (axes)<br />
a) Axis I—clinical syndrome and other conditions that may be a focus of clinical<br />
attention<br />
b) Axis II—personality disorders and mental retardation<br />
c) Axis III—general medical conditions<br />
d) Axis IV—psychosocial and environmental problems<br />
e) Axis V—global assessment of function (GAF)<br />
C. DSM-IV mental disorders<br />
1. Disorders usually first diagnosed in infancy, childhood, or adolescence<br />
2. Delirium, dementia, amnestic, and other cognitive disorders<br />
3. Mental disorders due to a general medical condition<br />
4. Substance-related disorders<br />
5. Schizophrenia and other psychotic disorders<br />
6. Mood disorders<br />
7. Anxiety disorders<br />
8. Somatoform disorders<br />
9. Factitious disorders<br />
10. Dissociative disorders<br />
11. Sexual and gender identity disorders<br />
12. Eating disorders<br />
13. Sleep disorders<br />
14. Impulse control disorders<br />
15. Adjustment disorders<br />
16. Personality disorders<br />
D. Evaluation of the DSM classification system<br />
1. Problems: medical emphasis; usefulness; sexist (controversy over premenstrual<br />
dysphoric disorder); symptoms more valuable than placement in categories<br />
2. Alternative: behavioral classification scheme (superior to DSM in reliability and<br />
validity) but DSM is dominant system<br />
E. Objections to classification and labeling<br />
1. A label can predispose people to interpret all activities of the affected individual as<br />
pathological<br />
2. A label may lead others to treat a person differently<br />
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Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 37<br />
3. A label may lead those who are labeled to believe that they do indeed possess such<br />
characteristics<br />
4. A label may not provide the precise, functional information that is needed<br />
LEARNING OBJECTIVES<br />
1. Define the term psychodiagnosis and describe its functions. (p. 73)<br />
2. Identify the characteristics of good tests, including reliability and validity. Define reliability, and<br />
differentiate among test-retest, internal, and interrater reliability. Define validity, and differentiate<br />
among predictive, criterion-related, construct, and content validity. (pp. 73–74)<br />
3. Define assessment and discuss its role in clinical psychology. Describe and discuss various<br />
psychological assessment techniques and their strengths and limitations, including observation of<br />
behavior, clinical interviews, and tests and inventories. (pp. 74–87; Table 3.1)<br />
4. Describe the nature and purposes of projective personality tests, including the Rorschach,<br />
Thematic Apperception Test (TAT), sentence-completion test, and draw-a-person test. Discuss the<br />
strengths and weaknesses of projective tests. (pp. 77–80)<br />
5. Describe the nature and purposes of self-report inventories, including the Minnesota Multiphasic<br />
Personality Inventory (MMPI-2). Discuss the strengths and weaknesses of personality inventories.<br />
(pp. 80–82; Figure 3.1)<br />
6. Describe the purposes and characteristics of the Wechsler and Stanford-Binet intelligence tests<br />
and the Kaufman Assessment Battery for Children (K-ABC). Discuss the strengths and limitations<br />
of these tests. (pp. 82-85)<br />
7. Describe methods for assessing cognitive impairments due to brain damage (organicity),<br />
including the WAIS-III, Bender-Gestalt Visual-Motor Test, Halstead-Reitan Neuropsychological<br />
Test Battery, and Luria-Nebraska Neuropsychological Battery. (pp. 85-86)<br />
8. Describe neurological procedures for detecting brain damage, including CAT and PET scans,<br />
EEGs, ,MRIs, and functional MRIs. (pp. 86–87)<br />
9. Discuss ethical issues involved in assessment, particularly how cultural differences may influence<br />
clinical judgments. (pp. 87–89; Critical Thinking)<br />
10. Explain the goals of classifying abnormal behaviors and review the history of classification<br />
systems. Discuss how validity problems have been raised and dealt with. (pp. 89-92)<br />
11. Describe the characteristics of the DSM-IV-TR, including its five axes, the broad categories of<br />
mental disorders, and how the DSM-IV-TR places diagnosis in a cultural context. (pp. 92-99)<br />
12. Discuss the objections to the DSM classification system and the arguments supporting its use. (p.<br />
99)<br />
13. Describe four problems associated with classification and labeling and the research related to<br />
these problems. Discuss how the findings of Rosenhan (1973) relate to the impact of labeling. (pp.<br />
99-101)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Students need to understand that a diagnosis has many long-lasting implications. Incorrectly<br />
labeling someone with a psychiatric diagnosis has a greater stigmatizing effect than mislabeling a<br />
person with a medical diagnosis. The instructor can illustrate this with a simplified version of<br />
signal detection theory. Put the following diagram on the board:
38 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
Clinician’s Diagnosis<br />
Actual State of Affairs<br />
Person Is Sick Person Is Not Sick<br />
Person is sick Hit False alarm<br />
Person is not sick Miss Correct rejection (another kind of hit)<br />
First, explain the terms hits, misses, and false alarms and then ask the class to consider this<br />
scenario: An adult comes to a general-practice physician (GP) complaining of headaches, blurred<br />
vision, and nausea. The GP is not sure whether these symptoms are signs of a peculiar flu or, at<br />
worst, a brain tumor. Assuming that the patient is sick with something serious (and hoping that he<br />
or she isn’t), the GP sends the patient to the hospital for tests. When the tests show nothing and<br />
the symptoms go away, we have a false alarm; everyone is happy and relieved, and no harm has<br />
been done. Physicians are trained to be on the safe side and consider people sick even if they<br />
aren’t.<br />
Now ask the class to consider this scenario: An adult comes to a psychologist complaining of<br />
voices that say “thud” and “empty” (the same symptoms Rosenhan’s pseudopatients used). The<br />
psychologist isn’t sure what’s wrong. What are the effects of assuming that the person may have<br />
schizophrenia and sending the person to a mental hospital for a psychological evaluation (the<br />
equivalent of medical tests)? What happens if there is a false alarm? This exercise will help<br />
students see that what is “conservative” diagnostic practice in medicine can be dangerous in<br />
psychology.<br />
2. Instructors may want to expand on the text’s treatment of reliability and validity and the<br />
relationship between the two by subdividing reliability into internal consistency, test-retest, and<br />
interrater. You can explain the first two categories in terms of the evaluation method an instructor<br />
uses for teaching abnormal psychology. Ask students how they would feel if questions unrelated<br />
to course material (What is the capital of New Jersey? What is the shape of benzene?) appeared on<br />
their first exam. All items should contribute to the test’s total score; otherwise error is introduced.<br />
Suggest to students that it is a good idea for exams to evaluate them repeatedly at about the same<br />
level. For example, how much faith could they put in exams if on the first one they got an A, on<br />
the second they got a D, and on the third they got a B? This discussion should lead them to think<br />
about changes in study habits, motivation, and test content. Point out that psychologists have the<br />
difficult task of measuring something that is in flux. Then ask them what would happen if they<br />
could take precisely the same test over again. This question should start discussion on invalidation<br />
of psychological tests. Finally, interrater reliability should be discussed in relation to some<br />
physical attribute such as attractiveness or neatness. Ask the class to rate you (or some celebrity)<br />
on a scale from 1 to 10 on the attribute. If there is disagreement on ratings, how useful are any of<br />
them? Conclude with a discussion of training people to rate consistently; perhaps this is a goal of<br />
graduate training.<br />
You can also explain validity in terms of classroom evaluations. To what extent do consistent<br />
scores on in-class tests reflect actual knowledge? Ask students why they think the assumption that<br />
“consistent data equal useful data” is fallacious. By what criteria do we judge that an A in a course<br />
really measures what we want to measure? Finally, a helpful way to show the relationship<br />
between reliability and validity is to use Venn diagrams. A large circle labeled Reliability should<br />
have a smaller circle labeled Validity within its borders.<br />
3. Students are often interested in the methods of administering and interpreting psychological tests.<br />
Objective and projective tests should be highlighted and demystified (without invalidating them).<br />
A short self-report inventory such as the Crowne-Marlowe Social Desirability Scale can provide<br />
insight into objective tests. Students can begin to see the difficulties of developing tests that<br />
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Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 39<br />
cannot be faked, but that measure what they are supposed to. In this regard the Crowne-Marlowe<br />
is particularly useful, as is discussion of the validity scales on the MMPI. An abbreviated version<br />
of the Crowne-Marlowe scale is provided in a handout. Faking is also important when you discuss<br />
projectives. You could draw several symmetrical blobs on the board and ask students to write<br />
down what they see in each. Ask them how they could fake their responses and whether their<br />
responses would be different if they knew the responses would be made public.<br />
Given the doubts about testing that this discussion and the text’s information might suggest, you<br />
should balance this picture with information about test batteries. The student needs to know that<br />
single tests are never the sole determinant of a diagnosis and that hypotheses are continually<br />
supported, modified, and rejected by test, interview, and observational data.<br />
4. The new version of the Minnesota Multiphasic Personality Inventory (MMPI-2) represents the<br />
first overhaul in over fifty years of the most used objective personality test. The MMPI-2 has been<br />
normed on a much larger and more representative sample than the original MMPI, which used as<br />
its normative sample 600 visitors to the University of Minnesota hospitals in 1940. Another<br />
improvement is that separate adolescent norms were used in creating the MMPI-2. The new<br />
version also generates, in addition to the 10 clinical scales, 15 content scales that assess<br />
self-esteem, cynicism, family problems, and anxiety, among other issues.<br />
Although the new edition uses improved norms and may measure new clinically important<br />
concepts, some of the problems with the old test have gone unsolved and some new problems may<br />
have been added (Helmes & Reddon, 1993). The MMPI and MMPI-2 are very long tests, using<br />
567 items. However, they are inefficient because only 383 items are actually scored on the clinical<br />
and validity scales, whereas those items making up these scales are scored on an average of 2.07<br />
times. Considerable overlap occurs in the clinical scales, and the tests still remain to be<br />
cross-validated. The complexity of using pattern analysis on the old version is retained in the<br />
MMPI-2. Finally, the developers of the MMPI-2 curiously used a 704-item experimental version<br />
of the new test on the normative sample, not the actual 567-item final version. As Helmes and<br />
Reddon (l993) mention, old users of the test will not be dissuaded by the MMPI-2, but this<br />
celebrated test missed an opportunity to address old problems.<br />
Source: Helmes, E., & Reddon, J. R. (1993). A perspective on developments in assessing<br />
psychopathology: A critical review of the MMPI and MMPI-2. Psychological Bulletin, 113, 453–<br />
471.<br />
Internet Site: http://www1.umn.edu/mmpi/. Contains information on the MMPI-2.<br />
5. Accurately reading nonverbal communication is a vital part of assessment, especially in<br />
interviewing. Cultural and gender differences in nonverbal communication styles are potential<br />
reasons for weak reliability and validity in assessment. One form of nonverbal communication is<br />
the degree of personal space people require when communicating. The study of personal space is<br />
called proxemics. Each culture has norms for the “personal bubble,” the comfortable space<br />
between us and others. In all cultures, the personal bubble is much smaller for people with whom<br />
we have intimate relationships and much larger for strangers. However, Americans have a larger<br />
bubble than people from Middle Eastern or Latin American cultures. In the United States, 4 to 12<br />
feet separate us from most of our coworkers, acquaintances, and friends in face-to-face meetings.<br />
This “social distance zone” can be violated at crowded parties, in elevators, and in waiting lines.<br />
We make great efforts not to touch or to excuse touching in these situations. In elevators, we take<br />
pains not to make eye contact. In Middle Eastern or Latin American cultures, the social distance<br />
zone is often several feet less. Since this issue is rarely talked about, the European or American<br />
diagnostician may find the Arab or Latin client to be aggressive or disrespectful if he or she stands<br />
too close while the client may see the American as being aloof and disinterested.
40 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
You can illustrate the personal bubble idea by walking up to a student in the first row while you<br />
make these comments. You will probably get nonverbal messages of discomfort as you break the<br />
4-foot barrier: giggles, angling of the torso away from you, and so on.<br />
In spite of gender differences, the ways women and men send and receive nonverbal messages<br />
overlap considerably. Small differences exist, however, and may contribute to the misreading of<br />
clients’ communication. For example, women are more likely than men to display messages that<br />
convey warmth and submission and less likely to engage in touching. Women are also more likely<br />
to adopt “closed” body postures—sitting up straight, having both feet on the floor, and keeping<br />
their arms close to the body. Men are more likely to have “open” postures—their backs angled<br />
back in a chair and one ankle crossed over the thigh of the other leg. This posture looks more<br />
relaxed. Gender differences probably relate to status differences. High-status individuals tend to<br />
communicate nonverbally that they are dominant (touching is a means of showing higher status)<br />
and relaxed in the situation. Women are less likely than men to have experienced high status.<br />
Women are more likely to make eye contact while speaking and listening. This difference, too, is<br />
probably connected to status issues since low-status individuals gaze longer at a high-status<br />
individual than the other way around. However, when eye gaze goes on too long, it is perceived as<br />
staring, a dominant cue. Women stare less than men. It is also interesting that cultures vary on the<br />
meaning of eye contact. Native Americans are taught that making eye contact is a sign of<br />
disrespect.<br />
Finally, children have much smaller personal bubbles than adults and are largely unaware of how<br />
they may invade others’ space. Girls have greater interest in and awareness of nonverbal messages<br />
than boys have. Girls are consistently more accurate than boys are in interpreting others’<br />
nonverbal signals, that is, in reading emotional states and intentions. The diagnostician who is<br />
unaware of cultural, gender, and age differences in nonverbal communications is likely to make<br />
many unfounded judgments about the personality of interviewees.<br />
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Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 41<br />
HANDOUT FOR CLASSROOM TOPIC 3:<br />
EXAMPLE OF SOCIAL DESIRABILITY ITEMS<br />
The following items come from the Crowne-Marlowe Social Desirability Scale, a research instrument<br />
that has been used to identify an individual’s tendency to present himself or herself in a socially<br />
approved light. Answering True to the first five items and False to the next five indicates a person who<br />
is high in social desirability. Consider how the validity of psychological assessment based on self-report<br />
inventories would be jeopardized in such a person. How would self-report inventories need to<br />
compensate for such a tendency?<br />
1. I never hesitate to go out of my way to help someone in trouble.<br />
2. I have never intensely disliked anyone.<br />
3. I am always careful about my manner of dress.<br />
4. No matter who I am talking to, I am always a good listener.<br />
5. I don’t find it particularly difficult to get along with loud-mouthed, obnoxious people.<br />
6. It is sometimes hard for me to go on with my work if I am not encouraged.<br />
7. I sometimes feel resentful when I don’t get my way.<br />
8. Sometimes I feel like rebelling against people in authority even though I know they are right.<br />
9. I sometimes try to get even, rather than forgive and forget.<br />
10. Sometimes I feel like smashing things.<br />
CLASSROOM DEMONSTRATIONS<br />
1. This in-class exercise can illustrate the behavioral approach to assessment and, at the same time,<br />
may assist students in evaluating their study habits. Ask students to individually assess their study<br />
habits on the basis of the components of the behavioral classification system. By using the<br />
Handout for Demonstration 1, students will have a better understanding of the frequency and<br />
quality of their study behavior (behavioral repertoire), the antecedent conditions (stimulus<br />
controls) that facilitate or impede studying, and the consequences that increase or decrease<br />
studying frequency (incentive systems). In addition, they can examine the self-reinforcement or<br />
self-punishment components in their behavior pattern (aversive self-reinforcing systems).<br />
After you have allowed time for their individual assessments, ask the students what they think is<br />
the most common impediment to more frequent or higher quality studying. List some of these<br />
impediments on the board and categorize them in terms of the behavioral classification system.<br />
Ask students for suggested “treatments.” This demonstration should illustrate how behaviorists<br />
use monitoring and functional analysis to direct therapy.<br />
2. Conducting an interview before the class can illustrate the various types of interviews that exist<br />
and the sources of assessment error in interviewing that Kleinmuntz delineates (the interviewee,<br />
the interviewer, and the relationship). A classroom volunteer or a colleague should be contacted<br />
before class. In the first interview, use a structured format, as in Spitzer’s evaluation form (for<br />
example, what kind of moods have you been in recently? What kind of things do you worry<br />
about? How often do you feel tense or nervous? When you are nervous, do you react physically<br />
[nausea, diarrhea, etc.]?). Read the questions from a clipboard and record responses with a pencil<br />
while making little eye contact with the interviewee. Then ask the interviewee to discuss how this<br />
interview felt. Ask the class how they would have reacted to such an interviewer.
42 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
In a second interview with the same person, ask more Rogerian questions and ask for reflections<br />
of feeling (for example, Can you tell me what concerns you today? You seem to feel ________<br />
about that.) while making appropriate eye contact and leaning forward in the chair. Allow the<br />
interview to be guided by the responses of the interviewee. Then ask the interviewee to comment<br />
on how this interview felt. Ask the students for their feelings. What are the pros and cons of doing<br />
unstructured interviews? To what extent are reactions based on the nonverbal behavior of the<br />
interviewer and not the structure?<br />
3. If drawing a person (Machover’s Draw-a-Person test) is a method for assessing personality, what<br />
about doodling? Pass out sheets of unlined paper and ask your students to doodle on the page. Ask<br />
them not to draw a figure and reassure them that drawing ability is not important. Give them five<br />
minutes or so, and then collect the pages and shuffle them. Hand back the shuffled pages.<br />
Use the following scoring scheme or make up your own. Students should give one point for each<br />
occurrence of the following in their doodles:<br />
Squares masculine<br />
Circles feminine<br />
Arrows or points aggression<br />
Eyes paranoid<br />
Houses security needs<br />
Small doodles depression<br />
Dark shading confidence<br />
Light shading tentativeness<br />
Highly symmetrical and detailed obsessive<br />
Half completed easily distracted<br />
Ask students for additional scoring ideas. Discuss their difficulties in scoring the doodles. You<br />
will probably find that many doodles are “unscorable” because their features do not overlap with<br />
the scoring classifications. This should spark discussion on the reliability of projective tests, since<br />
scoring them tends to be subjective and somewhat inconsistent. Mention that the scoring system<br />
above reflects a psychoanalytic viewpoint and tends to find pathology in personality. Ask students<br />
how much validity they feel this kind of test would have. Do they believe in handwriting analysis?<br />
Finally, discuss with them the methods by which doodle testing could become more reliable and<br />
valid. The following points should be made: (1) the need to form a large normative sample; (2) the<br />
development of a standardized way of administering the test; (3) a classification and scoring<br />
scheme that includes the most common types of doodles; (4) correlational statistics to determine<br />
the interrater reliability of classifying and scoring doodles; (5) the statistical identification of<br />
scoring patterns that discriminate one personality from another; (6) the use of an existing, reliable<br />
indicator of personality with which to correlate doodling scores; and (7) the cross-validation of<br />
findings with another sample. There are still other phases in the development of a<br />
psychometrically strong test, but this activity will give students an appreciation for what goes into<br />
valid assessments.<br />
Source: Adapted from Annotated Instructor’s Manual for Morris, Psychology, 6/e by T. F.<br />
Pettijohn. Copyright © 1986. Used by permission of Prentice-Hall.<br />
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Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 43<br />
4. As the cognitive approach becomes stronger in abnormal psychology, so will cognitive<br />
assessment. This out-of-class assignment will help students appreciate the prospects and problems<br />
concerning cognitive assessment. One or two class periods before you discuss assessment,<br />
distribute the handout for this demonstration. Instruct students to complete each section at the end<br />
of each day. Encourage them to be honest and thorough. Assure them that you will not collect<br />
these pages but that they will be used in a classroom discussion.<br />
On the day you discuss assessment, ask students to consult their monitoring sheet(s). Ask for a<br />
show of hands from those who recorded at least one interaction that was negative (embarrassing,<br />
anger- or anxiety-provoking). Ask for a show of hands if at least one interaction was positive<br />
(joyful, reassuring, relaxed). If there is bias in the conversations we choose to recall, it will affect<br />
any such monitoring project. According to Beck, anxious individuals are likely to monitor and<br />
have automatic thoughts about anxiety-provoking incidents, whereas depressed individuals are<br />
more likely to monitor thoughts about failure (Beck & Clark, 1988). The bias in recollections may<br />
thus assist diagnosis. In fact, automatic thoughts questionnaires have been developed for adults<br />
(Hollon & Kendall, 1980) and children (Stark et al., 1986).<br />
Discuss with students the types of thoughts they had during and after conversations. Some<br />
students will “speak” positively about themselves (“You were very clever in that conversation.”<br />
“That was really neat!”); many others will be more negative (“Why can’t you think of anything to<br />
say?” “I need to keep my mouth shut.”).<br />
Ask students if the types of thoughts (positive versus negative) were different during the study<br />
period. Studying, which is less interpersonal, may provoke more thoughts involving ability or<br />
intellectual challenge than ones having to do with embarrassment or other emotions. This topic<br />
could spark a discussion of the types of thoughts we have about ourselves in different situations.<br />
Finally, the representative ness and accuracy of thought monitoring is important. In cardiology,<br />
monitoring of heart rhythms has been improved by giving patients portable electrocardiograms so<br />
that continuous monitoring or monitoring in specific situations (such as when the heart skips a<br />
beat) is possible. In psychological research, teenagers have been asked to write down their<br />
emotions when signaled by a beeper they wore. Results showed large and frequent mood swings,<br />
sometimes within the space of minutes (Csikszentmihalyi & Larson, 1984). A similar use of<br />
technology could help psychotherapy clients monitor their thoughts and the situations in which<br />
they occur.<br />
Sources: Beck, A. T., & Clark, D. A. (1988). Anxiety and depression: An information processing<br />
perspective. Anxiety Research, 1, 23–36.<br />
Csikszentmihalyi, M., & Larson, R. (1984). Being adolescent: Conflict and growth in the teenage<br />
years. New York: Basic Books.<br />
Hollom S. D., & Kendall, P. C. (1980). Cognitive self-statements in depression: Development of<br />
an automatic thoughts questionnaire. Cognitive Therapy and Research, 4, 383–395.<br />
Stark, K. D., Best, L., & Adam, T. (1986). The automatic thoughts questionnaire for children: The<br />
development and validation of a measure of depressive cognitions in children. Unpublished<br />
manuscript, University of Texas, Austin.<br />
5. This demonstration will get students thinking about matching assessment tools with specific<br />
referral questions. First, provide a handout listing the assessment tools available to the clinician,<br />
including<br />
Controlled observations in clinic or laboratory<br />
Naturalistic observations in office, home, school
44 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
Logs kept by parents, friends, the client<br />
Interviews (structured and unstructured)<br />
Projective personality tests (Rorschach, TAT, sentence-completion, draw-a-person)<br />
Self-report inventories (MMPI-2, Beck Depression Inventory)<br />
Intelligence tests (WAIS-R, WISC-R, WPPSI; Stanford-Binet; K-ABC)<br />
Tests for organicity (Bender-Gestalt, Halstead-Reitan, Luria-Nebraska)<br />
Neurological tests (CAT and PET scans, EEG, MRI)<br />
Divide the class into small groups. Each group will be presented with several hypothetical cases.<br />
The task is to decide how to best assess the individual. Instruct group members to use any of the<br />
list of assessment tools and be able to explain how that tool helps in the assessment. Caution them<br />
against “throwing in the kitchen sink,” since it is unethical to subject individuals to invalid test<br />
procedures. Excessive testing is also costly in time and money.<br />
Allow 15 minutes for groups to discuss the cases. One person in each group should record the<br />
assessment tools agreed upon and the reasons for using each. What, exactly, will the assessment<br />
devices discover that is relevant to the referral question? The recorder should tell the rest of the<br />
class what the group decided.<br />
Here are satisfactory responses for hypothetical case #1: Observe the child in school and at home<br />
as well as in the diagnostician’s office. Try to simulate school situations (following instructions,<br />
repetitive tasks). Note his responses when there are noises or other distractions and when there is<br />
silence. Give intelligence test (WISC-R or Stanford-Binet) to determine intellectual ability. Have<br />
parents and teachers keep logs of his behavior over time. Ask the boy what he thinks is going on<br />
(unstructured interview).<br />
Satisfactory responses for hypothetical case #2 are the following: observation and logs in work<br />
environment to assess level of impairment at work; MMPI-2 and projective tests (Rorschach and<br />
TAT) to assess man’s personality; Beck Depression Inventory to assess level of depression;<br />
interview man and his wife (separately and together) in unstructured interview to get their<br />
understanding of the problems and to observe their behavior; WAIS-R or Luria-Nebraska test<br />
battery to assess degree of cognitive impairment; neurological tests such as PET scan and MRI to<br />
assess any brain damage.<br />
6. Bring a copy of the DSM-IV-TR to class and point out the axes approach it uses. If you have<br />
access to other editions bring them to class and read the descriptions of disorders that the students<br />
would like to understand from different versions. You could use an overhead transparency to<br />
keep a list of the differences among editions. Are the criteria similar to what students thought<br />
they would be? Discuss how the DSM-IV-TR arrived at these specific criteria and acknowledge<br />
the many controversial classifications that still exist.<br />
Internet Site: http://www.psyweb.com/Mdisord/DSM_IV/dsm_iv.html . A site that consists of<br />
terms and definitions of DSM criteria.<br />
7. Assign your students to collect questionnaires from popular magazines or self-help books. Many<br />
students will have taken these "pop" psychology items in their favorite magazines. On an<br />
overhead transparency, compare items from different sources. Then compare these items with<br />
standardized personality inventories such as the MMPI. Lead a discussion on the differences and<br />
why they are important.<br />
Internet Site: http://www1.umn.edu/mmpi/.. Butcher’s guide to the MMPI-2.<br />
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Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 45<br />
HANDOUT FOR DEMONSTRATION 1:<br />
STUDY BEHAVIOR ASSESSMENT EXERCISE<br />
This exercise is designed to help you assess your own studying behavior. Please be as honest as<br />
possible.<br />
For each of the last five days, remember and record the following information about your studying<br />
behavior: how long you studied, the quality of the studying time (on a scale from 1 to 10), where you<br />
studied, how you felt before and after studying, and the activity in which you engaged immediately<br />
after studying.<br />
Day<br />
Length of<br />
Time You<br />
Studied<br />
Quality<br />
Rating<br />
(1–10) Place<br />
Feelings<br />
Before<br />
(+ or –)<br />
1. Do any particular situations typically precede high-quality studying?<br />
Describe.<br />
2. Do any particular situations typically precede poor-quality studying?<br />
Describe.<br />
3. How are your feelings, before and after, related to studying?<br />
Describe.<br />
Feelings<br />
After<br />
(+ or – )<br />
4. What kind of immediate rewards might you use to increase the quantity and quality of studying?<br />
Describe.<br />
5. While you are studying do thoughts go through your head that reduce your ability to concentrate?<br />
Describe.
46 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
HANDOUT FOR DEMONSTRATION 4:<br />
MONITORING YOUR THOUGHTS<br />
Over the next two days, monitor your thoughts during interpersonal interactions and while studying. At<br />
the end of each day, think of a specific conversation—with a close friend, an acquaintance, or even a<br />
stranger. As accurately as possible, record the topic of the conversation, what you were thinking while<br />
it was occurring, and what you said to yourself immediately after it was over. Also, at the end of each<br />
day, think about a particular study period and, as accurately as possible, record what you were studying,<br />
and what you were thinking during and after studying.<br />
Topic of the What You What You<br />
Day 1 Conversation Thought During Thought After<br />
Subject You What You What You<br />
Were Studying Thought During Thought After<br />
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Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 47<br />
Topic of the What You What You<br />
Day 2 Conversation Thought During Thought After<br />
Subject You What You What You<br />
Were Studying Thought During Thought After
48 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
HANDOUT A FOR DEMONSTRATION 5:<br />
LISTING OF PSYCHOLOGICAL ASSESSMENT TOOLS<br />
1. Controlled observations in clinic or laboratory<br />
2. Naturalistic observations in office, home, school<br />
3. Logs kept by parents, friends, the client<br />
4. Structured interview<br />
5. Unstructured interview<br />
6. Projective personality tests (Rorschach, TAT, sentence-completion, draw-a-person)<br />
7. Self-report inventories (MMPI-2, Beck Depression Inventory)<br />
8. Wechsler’s tests (WAIS-III, WISC-III, WPPSI-III)<br />
9. Neuropsychological tests for organicity (Bender-Gestalt, Halstead-Reitan, Luria-Nebraska)<br />
10. Neurological tests (CAT and PET-scans, EEG, MRI, fMRI)<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 49<br />
HANDOUT B FOR DEMONSTRATION 5:<br />
HYPOTHETICAL CASES NEEDING ASSESSMENT<br />
Hypothetical case 1<br />
A 10-year-old boy who seems very intelligent to his parents and teacher is getting very low grades. He<br />
is frequently inattentive to the teacher and seems “spaced out.” There is no history of trauma to the head<br />
and no indications of serious mental disorder. It is not clear whether his problems occur solely in the<br />
classroom or elsewhere, too. The boy and his parents come to you for an assessment.<br />
Discuss and list relevant assessment tools.<br />
Hypothetical case 2<br />
A 57-year-old man with a history of heavy drinking is frequently sad, angry, and anxious. His work<br />
performance has suffered—he is forgetful, disorganized, and low in energy. The man’s doctor wonders<br />
if the drinking has impaired his cognitive abilities; his wife wonders if he is simply very depressed. The<br />
man himself feels that he has lived his life for everyone but himself. Your assessment should respond to<br />
the concerns of the client, his doctor, and wife.<br />
Discuss and list relevant assessment tools.
50 Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong><br />
SELECTED READINGS<br />
Burke, M. J., & Normand, J. (1987). Computerized psychological testing: Overview and critique.<br />
Professional Psychology: Research and Practice, 18, 42–51.<br />
Dana, R. H. (1993). Multicultural assessment perspectives for professional psychology. Boston: Allyn<br />
& Bacon.<br />
Matarazzo, J. D. (1992). Psychological testing and assessment in the 21st century. American<br />
Psychologist, 47, 1007–1018.<br />
Pope, B. (1979). The mental health interview: Research and application. New York: Pergamon Press.<br />
Rosenhan, D. (1973). On being sane in insane places. Science, 179, 250-258. p.253.<br />
Widiger, T. A., & Trull, T. J. (1991). Diagnosis and clinical assessment. Annual Review of Psychology,<br />
42, 109–133.<br />
VIDEO RESOURCES<br />
Administration of Projective Tests (16 mm, 19 min.). The film demonstrates TAT and sentencecompletion<br />
tests. Psychological Cinema Register, Pennsylvania State University, University Park, PA<br />
16802.<br />
Assessment (VHS or Beta video, color, 30 min.). This film uses the case of Larry P. v. Riles to illustrate<br />
cultural bias in IQ testing and recent research on reducing bias in testing. Indiana University Radio and<br />
Television Services, Indiana University, Bloomington, IN 47401.<br />
<strong>Behavior</strong>al Interviewing with Couples (16 mm, color, 14 min.). Interviewing techniques from a<br />
behavioral perspective during initial counseling sessions. Research Press, Box 317740, Champaign, IL<br />
61820.<br />
Context Analysis of Family Interviews, Part I (16 mm, color, 28 min.). Analysis of an interview<br />
between professionals and a family. Concerned with visible and audible behaviors as they relate to one<br />
another in a pattern. Psychological Cinema Register, Pennsylvania State University, University Park,<br />
PA 16802.<br />
“Looking at <strong>Abnormal</strong> <strong>Behavior</strong>” from The World of <strong>Abnormal</strong> Psychology (video, color, 60 min.).<br />
This segment explores the definitions of abnormal behavior and explains how psychologists employ<br />
interviews and testing to assess individuals. The Annenberg/CPB Collection, Dept. CA94, P.O. Box<br />
2345, S. Burlington, VT 05407-2345; to order, call 1-800-532-7637.<br />
“Measuring Intelligence” from The Psychology Show videodisc series (3:11). Houghton Mifflin<br />
Company.<br />
Personality (16 mm, color, 30 min.). A college student undergoes an assessment by clinical<br />
psychologists, including a number of traditional tests (MMPI, WAIS, TAT). The student’s way of<br />
viewing himself and the perceptions of his parents, roommate, and girlfriend are included, too. The<br />
student is impressed with the accuracy of the assessment. CRM McGraw-Hill Films, 110 Fifteenth<br />
Street, Del Mar, CA 920l4.<br />
“Testing and Intelligence” from Discovering Psychology series (#16) (video, color, 30 min.).<br />
Psychological testing reveals how values are assigned to different abilities, behaviors, and personalities.<br />
The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S. Burlington, VT 05407-2345; to order,<br />
call 1-800-532-7637.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 3: Assessment and Classification of <strong>Abnormal</strong> <strong>Behavior</strong> 51<br />
Basic Interviewing Skills (VHS, color, 51 mm.). Focuses on the five basic skills needed to interview a<br />
client. Insight Media.<br />
The Clinical Psychologist (VHS, color, 24 mm.). Shows an initial assessment using both formal and<br />
informal methods of assessment. Insight Media.<br />
ON THE INTERNET<br />
http://www.apa.org is The American Psychological Association home page.<br />
http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm This site contains terms and<br />
definitions of DSM criteria.<br />
http://www.psyweb.com/Mdisord/DSM_IV/dsm_iv.html is a site that consists of terms and definitions<br />
included in the DSM series This site defines and describes all behaviors that are considered to be<br />
abnormal by the American Psychiatric Association.
CHAPTER 4<br />
The Scientific Method in <strong>Abnormal</strong> Psychology<br />
CHAPTER OUTLINE<br />
I. Reasons for skepticism when reading research<br />
A. Nonreplicated results, many examples offered<br />
II. The scientific method in clinical research (tests hypotheses and uses theory)<br />
A. Characteristics of clinical research<br />
1. Potential for self-correction<br />
2. Hypothesizing relationships<br />
3. Operational definitions<br />
4. Reliability and validity of measures and observations<br />
5. Base rates<br />
a) If high, investigator may mistakenly assume phenomenon causes disorder<br />
6. Statistical versus clinical significance<br />
III. Experiments<br />
A. The experimental group: exposed to independent variable<br />
B. The control group: similar in every way to experimental, but no independent variable<br />
C. The placebo group: controls for expectations<br />
D. Additional concerns in clinical research<br />
1. Blind design: clinicians do not know purpose of research study<br />
2. Double-blind design: neither subjects nor the individual researchers know experimental<br />
conditions<br />
IV. Correlations: measure extent to which variables co-vary<br />
A. Correlational coefficient<br />
B. Does not imply causation<br />
C. Problems with Sanders and Giolas (1991) correlational study<br />
V. Analogue studies<br />
A. Simulate real situation under controlled conditions<br />
B. Give insight into behavior but only an approximation of real life<br />
VI. Field studies—events recorded in natural environment<br />
A. Primary technique is observation<br />
B. Requires training and self-discipline<br />
VII. Single-subject studies<br />
A. Idiographic approach: in-depth study of one person; valuable for clinical work<br />
B. The case study: clinical data on one person<br />
C. Single-participant experiment: person’s own behavior acts as control condition<br />
VIII. Biological research strategies<br />
A. Human Genome Project<br />
B. Genetic linkage studies<br />
C. Biological markers: biological indicators that may or may not cause disorder<br />
D. Other concepts in biological research<br />
1. Iatrogenic effects: unintended changes in behavior due to treatment; hypnosis by<br />
therapist may create memories<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 53<br />
2. Penetrance: degree to which genetic characteristic is seen in people carrying a gene<br />
associated with it<br />
3. Pathognomonic: degree to which symptom is specific to a disorder<br />
4. Biological challenge tests: monitor behavior change after presentation of a specific<br />
chemical<br />
IX. Epidemiological and other forms of research<br />
A. Survey<br />
B. Longitudinal<br />
C. Historical<br />
D. Twin studies<br />
E. Treatment outcome studies<br />
F. Treatment process studies<br />
G. Program evaluation<br />
H. Epidemiological research<br />
1. Prevalence: number of cases of disorder in population<br />
2. Incidence: number of new cases in a specific period<br />
X. Ethical issues in research: balancing harm to participants versus benefit to humanity<br />
A. Withholding treatment from controls<br />
B. Deceiving subjects<br />
C. Creating discomfort or embarrassment<br />
D. Using detrimental treatment with participants<br />
E. Inducing pain in animal subjects<br />
F. Bias in diagnosis<br />
LEARNING OBJECTIVES<br />
1. Explain the roles of skepticism and replication in science. Discuss the current status of scientific<br />
“facts” in abnormal psychology that have received subsequent investigation, including facilitated<br />
communication and the identification of an alcoholism gene. (pp. 105-106)<br />
2. Discuss the characteristics of the scientific method in clinical research, including the proper<br />
stating of hypotheses, operational definitions, and the need for reliable and valid measures and<br />
observations. (pp. 106-110)<br />
3. Describe the concepts of base rates, statistical significance, and clinical significance. (pp. 110-<br />
112)<br />
4. Identify the components of a basic experiment, and describe the need for placebos, blind and<br />
double-blind research designs. (pp. 112-115)<br />
5. Discuss the characteristics of correlational studies and their strengths and limitations, specifically<br />
their ambiguous conclusions with respect to causality. Use the Sanders and Giolas (1991) study to<br />
discuss how correlational research can be improved. (pp. 115–119)<br />
6. Describe analogue and field studies, and discuss their strengths and limitations. (pp. 119-120)<br />
7. Define the nomothetic and idiographic orientations toward research. Discuss the characteristics<br />
and limitations of case studies and single-participant experiment designs. (pp. 120-122)<br />
8. Discuss the biological research strategies, including genetic linkage studies, biological markers,<br />
iatrogenic effects, genetic penetrance, pathognomonic symptoms, and biological challenge tests.<br />
(pp. 122-124)<br />
9. Describe various research strategies used in the study of abnormal behavior, including<br />
epidemiological research. Differentiate between prevalence and incidence. (pp. 124–125)
54 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
10. Discuss the ethical issues in conducting research and the American Psychological Association’s<br />
guiding principles on ethics, including the use of animals, and research with culturally diverse<br />
populations. (pp. 125-127)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. The word Experiment is frequently misused. It is important to clarify the term’s use so that<br />
students will understand that experiment is not a synonym for “research.” The concepts of<br />
independent and dependent variables are often difficult for students to master. A good way to<br />
teach these concepts is to state that every experimental hypothesis is an “if, then” statement. The<br />
independent variable fills in the blank after the “if,” and the dependent variable fills in the blank<br />
after the “then.” In other words, experiments tend to be titled “The effects of (independent<br />
variable) on (dependent variable).”<br />
Correlations, on the other hand, involve hypotheses that read, “As X goes up, Y goes up/down.”<br />
Two factors are presumed to be related to each other in a particular way, but the assumption of<br />
causality is missing. Correlational studies tend to be titled “The relationship between X and Y”<br />
(when neither factor is an independent variable) or at least fail to include language that indicates<br />
an independent variable.<br />
To test students on this concept, read the titles of several recent articles from the Journal of<br />
<strong>Abnormal</strong> Psychology or Journal of Consulting and Clinical Psychology. A handout of<br />
appropriate titles is included. Ask students whether or not they think there was an independent<br />
variable. Have them identify the dependent variables. After they have speculated on the nature of<br />
these studies, distribute a summary (the abstract) from the article, provided below.<br />
Source: Jeffrey, R. W., & Wing, R. R. (1995). Long-term effects of interventions for weight loss<br />
using food provision and monetary incentives. Journal of Consulting and Clinical Psychology, 63,<br />
793–796.<br />
One hundred and seventy-seven men and women who had participated in an eighteen-month<br />
trial of behavioral interventions involving food provision and financial incentives were<br />
examined twelve months later. Food provision, but not financial incentives, led to better<br />
weight loss than standard behavior treatment during the eighteen-month trial, but over<br />
twelve additional months of no-treatment follow-up, all treated groups gained weight,<br />
maintained only slightly better weight losses than a no-treatment control group, and did not<br />
differ from each other. [The study illustrates an experiment in which food provision and<br />
monetary incentives were independent variables and weight loss was the dependent variable.<br />
It also illustrates a therapy outcome study.]<br />
Source: King, C. A., Radpour, L., Naylor, M. W., Segal, H. G., et al. (1995). Parents’ marital<br />
functioning and adolescent psychotherapy. Journal of Clinical and Consulting Psychology, 63,<br />
749–753.<br />
Parents’ marital functioning and adolescent psychotherapy were investigated in two studies.<br />
The first study compared parents’ marital satisfaction, conflict over child rearing, affective<br />
communication, and traditional role orientation in matched samples of psychiatric inpatient<br />
and control-group adolescents. The second study examined associations between specific<br />
dimensions of marital functioning and adolescent depression severity, suicidal ideation, and<br />
social adjustment in a larger sample of adolescent inpatients. In Study 1, parents of<br />
inpatients reported less marital satisfaction and more conflicts over child rearing than<br />
parents of control-group adolescents reported. In Study 2, marital conflicts over child rearing<br />
were associated with a less active or involved father-adolescent relationship and more severe<br />
school behavior and spare time problems. Marital functioning was not associated with<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 55<br />
depression severity or suicidal ideation. [Although there are two groups in Study 1, both<br />
studies are correlational because subjects were not randomly assigned to conditions—people<br />
were not placed in inpatient care randomly. The second study is more clearly an illustration<br />
of a correlational study relating marital functioning to children’s problems.]<br />
Source: Seguin, J. R., Pihl, R. O., Harden, P. W., Tremblay, R. E., et al. (1995). Cognitive and<br />
neuropsychological characteristics of physically aggressive boys. Journal of <strong>Abnormal</strong><br />
Psychology, 104, 614–624.<br />
Cognitive-neuropsychological tests were given to adolescent boys (N = 177) to investigate<br />
processes associated with physical aggression. Factor analysis yielded four factors<br />
representing verbal learning, incidental spatial learning, tactile-lateral ability, and executive<br />
functions. Physical aggression was assessed at ages 6, 10, 11, 12, and 13, and three groups<br />
were created: stable aggressive, unstable aggressive, and nonaggressive. The authors found<br />
main effects for only the executive functions factor—nonaggressive boys performed better<br />
than stable or unstable aggressive boys performed. [This study is a longitudinal,<br />
correlational study because no variable under the control of the experimenter was<br />
introduced. Executive functions, those dealing with planning and self-control, were<br />
associated with aggression.]<br />
Source: Sutker, P. B., Davis, J. M., Uddo, M., & Ditta, S. R. (1995). War zone stress, personal<br />
resources, and posttraumatic stress disorder in Persian Gulf War returnees. Journal of <strong>Abnormal</strong><br />
Psychology, 104, 444–452.<br />
Posttraumatic stress disorder (PTSD) can occur subsequent to war stress, but not all troops<br />
are negatively affected. A discriminant function model was used to study associations<br />
between personal and environmental resources and psychological outcomes subsequent to<br />
war zone stress. Among 775 Persian Gulf War exposed troops, two subsets were identified:<br />
97 returnees with PTSD diagnoses and 484 who had no psychological distress. Personality<br />
hardiness commitment, avoidance coping, and perceived family cohesion emerged as<br />
consistent predictors of PTSD diagnosis. [This study is a correlational study because neither<br />
war zone experiences nor personal resources could be manipulated by the researcher. The<br />
two groups that formed (those with PTSD and those with no distress) can be compared. This<br />
research design is frequently used in abnormal psychology, but it still does not fit the<br />
formula for a true experiment.]<br />
Source: Telch, M. J., Schmidt, N. B., Jaimez, T. L, Jacquin, K. M., et al. (1995). Impact of<br />
cognitive-behavioral treatment on quality of life in panic disorder patients. Journal of Consulting<br />
and Clinical Psychology, 63, 823–830.<br />
Panic disorder (PD) is associated with significant social and health consequences. This study<br />
examined the impact of treatment on PD patients’ quality of life. Patients (N = 156) meeting<br />
DSM-III-R criteria for PD with agoraphobia were randomly assigned to group cognitive<br />
behavioral treatment (CBT) or a delayed-treatment control. An assessment battery<br />
measuring the major clinical features of PD as well as quality of life was administered at<br />
baseline, posttreatment (week 9), and six-month follow-up. Compared with delayedtreatment<br />
control participants, CBT participants showed significant reductions in impairment<br />
that were maintained at follow-up. [This study is a true experiment because subjects were<br />
randomly assigned to treatment and control conditions; it is also an illustration of an<br />
outcome study.]<br />
Internet Site: http://www.ats.ucla.edu/stat/spss is UCLA’s Academic Technology Services, which<br />
provides resources to help learn and use SPSS.
56 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
2. Operational definitions get some space in the text, but sampling does not. To a considerable<br />
degree, the usefulness of psychological research depends on the quality of sampling. Note that<br />
research is always an endeavor that balances the practical against the ideal. In abnormal<br />
psychology, the difficulty of obtaining large and representative samples is, by definition, much<br />
harder than in most other fields of psychology, since the topic ensures rarity and some level of<br />
stigmatization.<br />
Easily obtained samples are often not representative ones. Describe for students some<br />
characteristics of antisocial personalities—such as impulsive, risk-taking, law-breaking, and<br />
callous behaviors. Now ask them how a researcher would get a sample of such people for<br />
research. One often-suggested source is prison, and, in fact, the prison system is where many<br />
subjects for research come from. However, ask how a prison population is likely to be a biased<br />
sample. Point out that factors such as socioeconomic status, intelligence, and prison life itself may<br />
make these subjects nonrepresentative. Prisoners, after all, are the ones who got caught, convicted,<br />
and not yet paroled or released. One researcher had an ingenious method of attracting<br />
nonincarcerated antisocial personalities: she put classified personal ads in the newspaper offering<br />
a research stipend to people “who like to take risks and live on the edge.” Explore with students<br />
other populations that are difficult to recruit: drug addicts, people with sexual problems,<br />
introverts, and agoraphobes (those fearful of being in public alone). Further, note how much easier<br />
it is to obtain treated samples but how their very status of being in treatment affects their thinking,<br />
behavior, and feeling.<br />
As consumers of research, students need to see that conclusions from research can only go as far<br />
as the representativeness of the sample involved. We know a great deal more about college<br />
students than we know about other age groups and we know more about treated mental patients<br />
than we know about the majority of mental patients who receive no care. You can make this point<br />
by bringing in several research articles and describing in depth the means by which sampling was<br />
done. Ask students to describe the limitations that the sample places on generalization to other<br />
groups.<br />
Epidemiological research is an excellent topic for discussing sampling as well. Ask students how<br />
we could know the incidence or prevalence of lung cancer in the United States. They will<br />
probably suggest the use of medical records. We assume that most people with lung cancer will<br />
see a family doctor or visit an emergency room sometime after developing symptoms. Now ask<br />
students how we could learn the incidence and prevalence of childhood depression. Mental health<br />
facilities might supply some statistics, but they might not be useful. First, the child is dependent<br />
on parents or teachers to identify such problems. Second, the symptoms of childhood depression<br />
are far less clear than the symptoms of lung cancer. Third, there is greater social stigma in the<br />
label "childhood depression" than in lung cancer, so parents and even professionals may be less<br />
likely to acknowledge the condition. In short, individuals with mental disorders are more difficult<br />
to locate and count (the essence of epidemiology) compared with individuals with most physical<br />
disorders. The most reasonable way to do the work is extremely labor intensive: ring doorbells<br />
and interview thousands of people. Here again, sampling the doorbells (census tracts) is a highly<br />
complex task as is deciding whom to interview and how to substitute for those who refuse<br />
participation or are not home. Given this information, students should be impressed with the fact<br />
that the National Institute of Mental Health’s Epidemiological Catchment Assessment survey<br />
(used in many places in the text) interviewed approximately 20,000 people in five different<br />
locations.<br />
Internet Site: http://www.ats.ucla.edu/stat/spss is UCLA’s Academic Technology Services, which<br />
provides resources to help learn and use SPSS.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 57<br />
3. Students are usually unaware of the process by which research is conducted, written up, judged<br />
worthy, and published. In fact, frequently asked questions are, who does this research, anyway?<br />
And why do they do it? (The second question is much harder to answer than the first.) If you plan<br />
to assign a research term paper in the course, this is a good time to explain how research comes to<br />
be done, the journal and peer review system, and the library strategies for finding published<br />
research articles.<br />
As a kind of show-and-tell, bring to class copies of the American Journal of Psychiatry, the<br />
Journal of <strong>Abnormal</strong> Psychology, Psychological Bulletin, and Psychological Abstracts. Showing<br />
students the subject index of Psychological Abstracts will impress upon them the enormous<br />
amount of research in the field of psychology, and paging to one topic, such as schizophrenia, will<br />
document how much is written in abnormal psychology. If your library or department subscribes<br />
to PsychLit (the CD-ROM search resource), you can do a demonstration search on a specific topic<br />
prior to class, or ask your students for several topics about which they would like more<br />
information and produce the search results in the next class period. The advertisements in the<br />
American Journal of Psychiatry can spark a good discussion of the medical model and possible<br />
political/economic involvements of pharmaceutical companies in the business of science.<br />
Psychological Bulletin will show students the difference between a research article and a review<br />
article and highlight the treasure trove that is a reference section in a Psychological Bulletin<br />
article. Finally, the Journal of <strong>Abnormal</strong> Psychology can show the range of research articles in<br />
abnormal behavior.<br />
If you conduct research, it is useful to describe your personal research interests, how particular<br />
research studies came into being, funding issues, how manuscripts are submitted and to whom,<br />
and the peer review experiences you have had. It is eye opening for students to find out that, in<br />
many journals, the rejection rate for manuscripts is 80 percent or higher. This topic might lead to a<br />
discussion of the “tyranny” of the 0.05 level and the temptations of fudging data.<br />
Internet Site: http://www.apa.org/journals. Home page for the American Psychological<br />
Association; contains listings on many journals.<br />
4. Three conditions must be met to answer the most important question in abnormal psychology:<br />
What causes a disorder? The three conditions correspond to different forms of research:<br />
correlational, longitudinal, and experimental. Condition 1 is the covariation of events. It is<br />
necessary to demonstrate a reliable association between the presence or change of two events or<br />
characteristics. If we are to say that child abuse causes eating disorders, we must first show that<br />
when child abuse is present so are the symptoms of eating disorders. Moreover, we would assume<br />
that as child abuse varies (in severity or frequency, for instance) eating disorders vary, too.<br />
Students can be asked what type of research can fulfill condition 1. They should be able to see the<br />
value of correlational and epidemiological research here. However, these research methods cannot<br />
easily fulfill condition 2: the time-order relationship of the variables. To have a causal<br />
relationship, one event or factor must precede the other. Child abuse must reliably predate the<br />
onset of eating disorders in order for it to be a cause. Longitudinal research is crucial to establish<br />
this piece of information.<br />
It is tempting to see causal relationships in cross-sectional information, but such an inference<br />
should be resisted. For example, if child abuse is reported in a group of nine year olds, abuse and<br />
early signs of eating disorders in a group of twelve year olds, and full-blown eating disorders in<br />
fifteen year olds, we might imagine that six years later, the nine year olds (now experiencing<br />
abuse) will become the eating-disordered fifteen year olds. However, we cannot distinguish cohort<br />
effects (the nine year olds are living in a different social situation than the fifteen year olds) from<br />
longitudinal ones unless we follow the nine year olds through time to see if they have a<br />
disproportionate rate of developing eating disorders. In abnormal psychology, longitudinal
58 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
research is extremely valuable and just as difficult. It is difficult because we are looking for rarely<br />
occurring conditions (requiring large samples at the outset of the study) and because these<br />
conditions usually take many years to develop (leading to high attrition rates among subjects and<br />
burnout rates among researchers).<br />
What clinches a causal relationship is condition 3: the elimination of plausible alternatives.<br />
Actually, this condition is never met completely because another plausible explanation must<br />
always be ruled out. However, only the experiment can shed bright light on this condition, and<br />
experimentation in abnormal psychology is exceedingly difficult. In the research above, even if<br />
we found that child abuse reliably predated the onset of the eating disorder, we could not know<br />
whether child abuse was the sole explanation. Perhaps parents who abuse their children also<br />
advocate unreasonable body images in their teenage daughters. If such were the case, we could<br />
hardly say that the abuse was causal. But how could we do an experiment to tell? Ethics, of<br />
course, would preclude such an investigation; how could we allow some children (chosen at<br />
random) to be abused (in a prescribed way) and followed without intervention while waiting for<br />
eating disorders to arise? Perhaps an analogue study on nonhuman animals might be ethical, but<br />
hardly anyone thinks that rats or mice starve themselves out of fear of becoming fat. What we<br />
gain in internal validity in controlled experiments, we may lose in external validity because the<br />
subjects or conditions of the experiment bear little resemblance to real life. In short, research on<br />
the causes of psychological disorders is just as difficult to do as it is important to do.<br />
Internet Site: http://www.psyweb.com/Mdisord/DSM_IV/dsm_iv.html . A glossary of terms and<br />
definitions of DSM criteria.<br />
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Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 59<br />
HANDOUT FOR CLASSROOM TOPIC 1:<br />
TITLES OF RECENT JOURNAL ARTICLES<br />
The following journal article titles are taken from the Journal of <strong>Abnormal</strong> Psychology and the Journal<br />
of Consulting and Clinical Psychology, two of the major professional publications in the field. From the<br />
titles, try to guess whether the research study was an experiment in which there is an independent<br />
variable (one manipulated by the experimenter) or a correlational study in which variables are not<br />
manipulated by the experimenter. The nature of some of the factors described in the title will probably<br />
help you decide.<br />
“Long-term effects of interventions for weight loss using food provision and monetary incentives”<br />
Experiment or correlation? Identify independent (if any) and dependent variables.<br />
“Parents’ marital functioning and adolescent psychotherapy”<br />
Experiment or correlation? Identify independent (if any) and dependent variables.<br />
“Cognitive and neuropsychological characteristics of physically aggressive boys”<br />
Experiment or correlation? Identify independent (if any) and dependent variables.<br />
“War zone stress, personal resources, and posttraumatic stress disorder in Persian Gulf War returnees”<br />
Experiment or correlation? Identify independent (if any) and dependent variables.<br />
“Impact of cognitive-behavioral treatment on quality of life in panic disorder patients”<br />
Experiment or correlation? Identify independent (if any) and dependent variables.
60 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
CLASSROOM DEMONSTRATIONS<br />
1. Students often imagine that there is one perfect way to study a particular problem. This exercise<br />
may help students learn that there are many paths to understanding.<br />
2.<br />
Before students break up into groups of four or five, describe this problem in abnormal behavior:<br />
Laypeople (and some mental health professionals) often make two assumptions about alcohol use<br />
and anxiety. First, they assume that the two are positively correlated (as anxiety increases, so does<br />
consumption). Second, they assume that anxiety causes alcohol consumption. Because these<br />
assumptions are often based on armchair speculation, there is no way to determine whether they<br />
are correct. Your group’s job is to propose three different types of research studies (experimental,<br />
longitudinal, and field) that might shed light on the accuracy of these assumptions.<br />
Guided by the Handout for Demonstration 1, each group should brainstorm and discuss the<br />
specific features of three original studies. Each group needs to reach a consensus about the best<br />
way to study the problem given the constraints of the research method. Tell students that money<br />
and logistics are of no concern.<br />
After the groups have completed their discussions, they should present their proposals to the rest<br />
of the class. Draw a grid on the board; write the words Experiment, Longitudinal, and Field at the<br />
top of the grid and Group 1, Group 2, Group 3, and so on, down the left side. Write a brief<br />
summary of each group’s ideas in each of the cells and comment on similarities or differences as<br />
they arise. A fitting conclusion to the class period is to say that researchers can have honest<br />
differences of opinion about how to “skin the cat” and that no one way is perfect.<br />
American Psychological Association ethical guidelines suggest that the value of research must<br />
outweigh the risks of performance. This guideline is not as straightforward as it sounds. A<br />
demonstration can help students understand how complicated the issues are and can clarify their<br />
own ethical principles.<br />
Present the students with this hypothetical research study: Anxiety is a key component of many<br />
forms of psychological disorder. A researcher wants to study the biochemical aspects of anxiety,<br />
specifically which changes in brain chemistry contribute to anxiety and which eliminate it. To<br />
conduct this study, chemicals that induce extremely uncomfortable anxiety are injected into<br />
subjects, followed by other chemicals that are intended to reduce the anxiety. There is no doubt<br />
that subjects in these experiments will be uncomfortable for several hours, but the researcher sees<br />
little risk of discomfort after that. The question for students is: At what point do the potential<br />
benefits of this research outweigh its risks or discomforts?<br />
Put the following grid on the board:<br />
Useful Application of Research Results<br />
Probability of Complete Success<br />
25%<br />
50%<br />
75%<br />
95%<br />
Within 1 to 2 Years Within 8 to 10 Years<br />
The grid is intended to indicate that the value of the research can be seen in two ways. First, every<br />
chemical that is used has some probability of becoming an anxiety eliminator (a complete<br />
success). As the likelihood of success increases, does the willingness to take risks increase, too?<br />
Second, the value of some research is delayed, either because it is basic research or because a long<br />
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Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 61<br />
chain of discoveries must be made before it can be applied. Other studies may have almost<br />
immediate applicability. As the likelihood of immediate benefits increases, does the willingness to<br />
take risks increase, too?<br />
Now ask students to imagine they are on a research review board. They need to vote (by raising<br />
their hands) on whether this proposed research on anxiety (with the extreme discomfort described<br />
above) should be allowed under the circumstances of potential value described in each cell of the<br />
grid. Larger numbers of students are likely to say yes in the “southwest” corner of the grid. Ask<br />
those who say no to explain their answer. As a final question, ask students whether they would<br />
have a different opinion about the study if they were participants rather than review board<br />
members.<br />
Internet Site: http://www.apa.org/ethics/code.html. The American Psychological Association site<br />
that deals with ethical principles of psychologists and defines the code of conduct.<br />
3. This short demonstration gives students feedback on how well they understand various types of<br />
research designs and their value. You can describe these hypothetical studies orally or use the<br />
handout provided. Students then critique each and identify the strengths and weaknesses of that<br />
type of design.<br />
a. A teenager with severe obsessions (unwanted thoughts) and compulsions (uncontrolled,<br />
ritualistic behaviors) tried to commit suicide by shooting himself in the head. He survived<br />
the shooting and discovered that all his obsessions and compulsions were gone. A<br />
psychologist did in-depth interviews with this person and linked the area of brain damage<br />
from the shooting with obsessions and compulsions.<br />
(Case study. Strengths: rich information, naturalistic setting, promising leads for future<br />
research, rare event can be studied. Weaknesses: low generalizability, no control over<br />
variables, cannot determine cause-effect relationship.)<br />
b. Ninety adults with chronic abdominal pain keep records on the frequency and intensity of<br />
their pains. Family members are interviewed concerning their experiences of illness, family<br />
conflict, and behaviors that encourage expression of pain. It is discovered that subjects with<br />
highest frequency and intensity of pain reports have families in which illness is common and<br />
family members engage in behaviors that encourage pain expression.<br />
(Correlational study. Strengths: studies a problem that cannot be experimentally induced,<br />
allows statistical measurement of covariation in two or more factors, is generalizable to<br />
other populations. Weaknesses: cannot assert causal relationship.)<br />
c. Thirty phobic and thirty nonphobic individuals are shown slides of either fear-inducing<br />
scenes or non-fear-inducing scenes. Measures of brain functioning (PET scan and<br />
electroencephalogram) show higher levels of arousal in phobics, but only when they observe<br />
the fear-inducing slides.<br />
(Biological marker and experimental designs combined. Strengths: controls for factors other<br />
than the slides and implies that fear-inducing scenes alter the brain functioning of phobics.<br />
Weaknesses: without controlling for expectations (it needs a placebo condition) cannot<br />
determine if effects are due to slide watching, may not be realistic (does not use actual<br />
fear-inducing situation.)<br />
4. This activity has two goals: increasing class participation and illustrating basic research concepts.<br />
It also shows you have a sense of humor. It is a modification by Fein and Spencer (1996) of<br />
Bernardo Carducci’s (1990) icebreaker activity that tests the irrational belief of some students that<br />
participating in class will kill them.
62 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
Random selection and assignment. The first step is to select at random a sample of students from<br />
the class. The sample is then divided into two conditions. The size of the sample depends on your<br />
class size and the time you want to devote to the activity. Half of the sample will be asked to say a<br />
few brief things to the rest of the class, so budget your time accordingly. Twenty students, ten in<br />
each condition, is a reasonable sample.<br />
How you do random selection will illustrate an important point. One way is to select students in<br />
advance using a random number table, but it is better to show students the use of such a table in<br />
class. Have the students take a small piece of paper as they enter the classroom. Each piece of<br />
paper has a number on it ranging from one to the number enrolled in the class. Use a random<br />
number table to select the sample. Call out the number and ask the students whose numbers were<br />
called to stand. After the sample is selected, flip a coin to assign each student to either a<br />
Treatment or Control condition. You could ask students sitting next to the sampled students to do<br />
the coin flip as a way to increase audience participation. Have the selected students write down<br />
whether they have been assigned to the Treatment or Control condition and have them return to<br />
their seats. Also, explain the purposes of random selection and random assignment and how they<br />
differ from convenience sampling or self-selection.<br />
State the hypotheses as follows: “Class participation benefits all students by increasing<br />
involvement and providing ideas from students as well as the instructor. I know that some<br />
students are afraid to speak out in class. They fear that something awful will happen if they make<br />
a mistake. I sympathize with your concerns. This experiment will demonstrate scientifically that<br />
you should not be afraid.” Now write on the board the following statement: Hypothesis 1: Class<br />
participation will kill you. Further down write the following: Hypothesis 2: Class participation<br />
will not kill you. Announce that you are going to test these rival hypotheses and that you are so<br />
sure of Hypothesis 2 that you are willing to bet their lives on it. (To add more humor, you may<br />
want to say something like, “Of course, I could be wrong, so people in the Treatment condition<br />
may want to hug their neighbors goodbye, if it’s OK with them.”)<br />
Hand out the pretreatment questionnaire.<br />
The treatment: class participation. Have students who are not in either condition come up with<br />
three questions that students in the Treatment condition should answer in front of the class.<br />
Explain that these questions should be innocuous, ones they would be willing to answer<br />
themselves. Examples might be hometown, favorite movie, name, or reason for taking the course.<br />
Explain that, for the purpose of testing the hypotheses, this will signify “class participation.” Note<br />
here that this is but one operational definition of the term. Once the three questions are decided,<br />
have everyone in the Treatment condition come forward and answer the questions in front of the<br />
class. You may want to ask each student a lighthearted follow-up question to establish a norm that<br />
give-and-take (conversation) is likely in the class. Students in the Control condition should walk<br />
to the front of the room but not be asked anything. Point out that you have attempted to control for<br />
all factors except participation.<br />
Now hand out the posttreatment questionnaire (on the same page as the pretreatment<br />
questionnaire). Explain that the dependent measure is whether or not subjects were killed during<br />
the experiment. Point out the need for reliable pre- and posttreatment measures and that you are<br />
using a self-report instrument. Indicate the limitations of self-report measures, particularly in<br />
abnormal psychology. Ask students to help you design an observational measure of whether<br />
students were killed in the experiment. Now conduct your observation of subjects and record the<br />
number alive in each condition.<br />
Data collection, analysis, and conclusions. Collect the questionnaires and report to the class the<br />
number of subjects in each condition, the number of subjects in each condition reporting<br />
themselves alive in the pretreatment questionnaire, the number of subjects in each condition<br />
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Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 63<br />
reporting themselves alive in the posttreatment questionnaire, and the number observed to be<br />
alive. Results should show that class participation did not kill more participants than<br />
nonparticipants. If some students, trying to be funny, indicated they were dead, you can<br />
emphasize the point about the reliability of self-reports and the value of multiple measures. Ask<br />
students why a control was necessary in the experiment. Be sure to explain the importance of<br />
random selection if you have not already done so.<br />
If you are at all concerned with using the words kill or dead as part of the activity, you could<br />
substitute other hypotheses, such as class participation will not cause students to spontaneously<br />
combust or be laughed out of the class room.<br />
Sources: Fein, S., & Spencer, S. (1996). Instructor’s resource manual for social psychology (3rd<br />
ed.). Boston: Houghton Mifflin.<br />
Carducci, B. J. (1990). Will class participation “kill” you? Refuting a common irrational belief by<br />
teaching research methods. In V. P. Makosky, C. C. Sileo, L. G. Whittemore, C. P. Landry, & M.<br />
L. Skutley (Eds.) Activity handbook for the teaching of psychology (Vol. 3, pp. 203–205).<br />
Copyright © 1990 by the American Psychological Association. Reprinted with permission.<br />
5. This activity shows students how to think scientifically about common psychological concepts<br />
that are the focus of abnormal psychology research. Distribute the handout and have students<br />
record individually how they think each concept can be defined operationally. That is, require<br />
them to define each term that could be tested in a research study. Emphasize that there are<br />
multiple ways of defining each of the terms and that after they are finished working alone, they<br />
will be able to see the range and originality of definitions.<br />
If you wish, you can review the material from Chapter 2 on different perspectives and assign<br />
certain groups in the class to define terms from a particular perspective. For example, one group<br />
of students might be assigned the biological perspective and they would be expected to define<br />
anxiety in terms of heart rate, perspiration, or muscle tension. Those assigned to a cognitive<br />
perspective would be expected to define the same term as, for example, “frequency of thoughts<br />
about threatening events.”<br />
6. This demonstration can introduce your students to the concept of validity in testing. Have the<br />
students form small groups of between 4-7 individuals depending on your class size and space<br />
limitations. Most of your students have taken the SATs or ACTs. Ask your students to discuss<br />
whether the tests were valid for college admission. Do they believe that the SATs or ACTs were a<br />
good predictor of their college GPA? If these tests were not used for college admission, what<br />
method or methods should be used instead? Ask each group to develop this list with the most<br />
salient examples first. Each group could then have a spokesperson deliver a short talk about the<br />
best examples. You could provide a blank overhead transparency to each group at the beginning<br />
of this demonstration.<br />
Internet Site: http://www.ets.org/. The Educational Testing Service Web site. This organization<br />
is the copyright holder on many standardized tests.<br />
7. How would it feel to be labeled schizophrenic or bipolar? Ask the students to imagine that they<br />
have been diagnosed with one of these disorders⎯or any other, for that matter⎯and think about<br />
the implications such a diagnosis might have for other areas of their lives, such as finding jobs,<br />
insurance coverage, and relationships. Now have students develop a method to tell their best<br />
friend that they have a diagnosable mental disorder. Ask for student volunteers to share how they<br />
would tell their best friend. Ask each volunteer what they expect the reaction to be from their<br />
friends. Would they be treated the same or differently by their friends after this revelation?
64 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
HANDOUT FOR DEMONSTRATION 1:<br />
PROPOSALS FOR RESEARCH STUDIES<br />
Your group’s assignment is to develop proposals for three different research studies. All the research is<br />
aimed at answering some aspect of this problem: Does stress cause alcohol consumption? Please<br />
recognize that stress can be defined in many ways and that alcohol consumption can range from light,<br />
social drinking to heavy, daily use. Be sure to give operational definitions for all the variables you use<br />
when describing your proposed studies.<br />
1. The first proposal should be in the form of an experiment that could be performed within the walls<br />
of the psychology department at your college or university. Remember that in all experiments the<br />
researcher manipulates the existence or absence of an independent variable and randomly assigns<br />
subjects to experimental and control groups.<br />
2. The second proposal should be a longitudinal study. In longitudinal studies, you collect data on<br />
the same group of people several times over a span of time. Please consider the type of people and<br />
the amount of time necessary so that stress and drinking are likely to occur.<br />
3. The third proposal should be a field study. In field studies you must leave the laboratory and<br />
collect data about behaviors and events as they are happening “in the wild.” Please consider<br />
settings in which both stress (as you define it) and alcohol consumption are likely to happen. Also<br />
consider a way of collecting data that will not disturb the behavior you want to study.<br />
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Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 65<br />
HANDOUT FOR DEMONSTRATION 3:<br />
STRENGTHS AND WEAKNESSES OF RESEARCH DESIGNS<br />
1. A teenager with severe obsessions (unwanted thoughts) and compulsions (uncontrolled, ritualistic<br />
behaviors) tried to commit suicide by shooting himself in the head. He survived the shooting and<br />
discovered that all his obsessions and compulsions were gone. A psychologist did in-depth<br />
interviews with this person and linked the area of brain damage from the shooting with obsessions<br />
and compulsions.<br />
What type of research is illustrated here? _____________________________________________<br />
______________________________________________________________________________<br />
What are the strengths of this type of research? ________________________________________<br />
______________________________________________________________________________<br />
What are the weaknesses of this type of research? ______________________________________<br />
______________________________________________________________________________<br />
2. Ninety adults with chronic abdominal pain keep records on the frequency and intensity of their<br />
pains. Family members are interviewed concerning their experiences of illness, family conflict,<br />
and behaviors that encourage expression of pain. It is discovered that subjects with highest<br />
frequency and intensity of pain reports have families in which illness is common and family<br />
members engage in behaviors that encourage pain expression.<br />
What type of research is illustrated here? _____________________________________________<br />
______________________________________________________________________________<br />
What are the strengths of this type of research? ________________________________________<br />
______________________________________________________________________________<br />
What are the weaknesses of this type of research? ______________________________________<br />
______________________________________________________________________________<br />
3. Thirty phobic and thirty nonphobic individuals are shown slides of either fear-inducing scenes or<br />
non-fear-inducing scenes. Measures of brain functioning (PET scan and electroencephalogram)<br />
show higher levels of arousal in phobics, but only when they observe the fear-inducing slides.<br />
What type of research is illustrated here? _____________________________________________<br />
______________________________________________________________________________<br />
What are the strengths of this type of research? ________________________________________<br />
______________________________________________________________________________<br />
What are the weaknesses of this type of research? ______________________________________<br />
______________________________________________________________________________
66 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
HANDOUT FOR DEMONSTRATION 4:<br />
PRETREATMENT QUESTIONNAIRE<br />
Please respond to each of the following questions by circling the appropriate answer.<br />
Pretreatment Questionnaire<br />
To which condition were you assigned? Control Treatment<br />
Are you currently alive or dead? Alive Dead<br />
Posttreatment Questionnaire<br />
To which condition were you assigned? Control Treatment<br />
Are you currently alive or dead? Alive Dead<br />
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Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 67<br />
HANDOUT FOR DEMONSTRATION 5:<br />
MAKING OPERATIONAL DEFINITIONS<br />
For each of the following concepts, develop a definition that could be used in a research study. The<br />
concept should be defined so that anyone would recognize it. Furthermore, it should be defined so that<br />
it can be observed by someone other than the subject experiencing it. For instance, anger might be<br />
defined as a state during which a person’s voice is louder than usual, facial expression includes baring<br />
of teeth and narrowing of eyebrows, and objects are thrown.<br />
Anger: ____________________________________________________________________________<br />
__________________________________________________________________________________<br />
Sociability: _________________________________________________________________________<br />
__________________________________________________________________________________<br />
Anxiety: ___________________________________________________________________________<br />
__________________________________________________________________________________<br />
Addiction: _________________________________________________________________________<br />
__________________________________________________________________________________<br />
Depression: ________________________________________________________________________<br />
__________________________________________________________________________________
68 Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology<br />
SELECTED READINGS<br />
Critelli, J. W., & Neumann, K. F. (1984). The placebo: Conceptual analysis of a construct in transition.<br />
American Psychologist, 39, 32–39.<br />
Garber, J., & Hollon, S. D. (1991). What can specificity designs say about causality in psychopathology<br />
research? Psychological Bulletin, 110, 129–136.<br />
Hock, R. R. (1992). Forty studies that changed psychology: Explorations into the history of<br />
psychological research. Englewood Cliffs, NJ: Prentice-Hall.<br />
Keith-Speigel, P., & Koocher, G. P. (1985). Ethics in psychology: Professional standards and cases.<br />
New York: Random House.<br />
Monroe, S. M., & Roberts, J. E. (1991). Psychopathology research. In M. Hersen, A. E. Kazdin, & A.<br />
S. Bellack (Eds.) The clinical psychology handbook (2nd ed.). New York: Pergamon.<br />
VIDEO RESOURCES<br />
Inferential Statistics: Hypothesis-Testing—Rats, Robots, and Roller Skates (16 mm, 28 min.). Uses<br />
humorous sketches to illustrate hypothesis testing, random assignment, control and experimental<br />
conditions, and statistical inference. John Wiley & Sons, Inc., 605 Third Avenue, New York, NY<br />
10016.<br />
Methodology: The Psychologist and The Experiment (film, color, 31 min.). This is a fast-paced and<br />
enjoyable introduction to the experiment; using as examples the work of Stanley Schachter’s fear-andaffiliation<br />
study and Austin Riesen’s work on kitten visual-motor behavior. Terms such as independent<br />
variable and dependent variable and concepts such as control, replication, and random assignment are<br />
nicely illustrated. McGraw-Hill Films, 1221 Avenue of the Americas, New York, NY 10020.<br />
Research Methods for the Social Sciences (video, 1995). This program describes different types of<br />
experimental designs and when they would be appropriate. It shows the seven steps of the scientific<br />
method and conveys both the practice and ethical issues in experimentation. Insight Media, 2162<br />
Broadway, New York, NY 10024; to order, call 212-721-6316.<br />
Statistics: For All Practical Purposes (video, 30 min. each program). This five-part series covers<br />
sampling, data collection, descriptive statistics, sampling distributions and the normal curve, standard<br />
deviation, central limit theorem, and inferential statistics. Insight Media, 2162 Broadway, New York,<br />
NY 10024; to order, call 212-721-6316.<br />
“<strong>Understanding</strong> Research” from Discovering Psychology Series (#2) (video, 30 min.). The<br />
Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S. Burlington, VT 05407-2345; to order, call<br />
1-800-532-7637.<br />
Writing for the Social Sciences (video, 30 min.). Very useful if you are assigning a term paper or<br />
research report, this video illustrates the key points in writing for the social sciences. Insight Media,<br />
2162 Broadway, New York, NY 10024; to order, call 212-721-6316.<br />
How We Study Children (VHS, color, 24 mm.). Looks at research techniques used with children.<br />
Focuses on different types of observational techniques. Insight Media, 2162 Broadway, New York, NY<br />
10024; to order, call 212-721-6316.<br />
ON THE INTERNET<br />
http://www.apa.org/ is the American Psychological Association’s home page.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
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Chapter 4: The Scientific Method in <strong>Abnormal</strong> Psychology 69<br />
Good sites for discussions of casual relationships and experimental research, including online<br />
demonstrations (as well as experiments your students may wish to participate in) are:<br />
http://www-psych.stanford.edu/~psiexp<br />
http://psychexps.olemiss.edu/Exps/labexperiments.htm This site has many lab experiments for use in<br />
the classroom.<br />
http://writing.colostate.edu/references/research/experiment/pop2b.cfm These sites may be useful in<br />
designing your lectures for this chapter.
CHAPTER 5<br />
Anxiety Disorders<br />
CHAPTER OUTLINE<br />
I. Manifestations of anxiety<br />
A. Anxiety disorders meet one of these criteria<br />
1. Anxiety itself is a major disturbance<br />
2. Anxiety is manifested only in particular situations<br />
3. Anxiety results from attempt to master other symptoms<br />
B. Cognitive manifestation: thoughts ranging from worry to panic<br />
C. <strong>Behavior</strong>al manifestation: avoidance of fear-inducing situations<br />
D. Somatic manifestation: changes in muscular tension, indigestion, and so on<br />
E. Five groups of anxiety disorders: panic disorder, generalized anxiety disorder, phobias,<br />
obsessive-compulsive disorder, acute and posttraumatic stress disorders<br />
F. Panic attacks: intense fear with somatic symptoms; can occur in all anxiety disorders<br />
1. Situationally bound: attacks in response to specific stimulus<br />
2. Situationally predisposed: tendency to have attacks in response to stimulus<br />
3. Unexpected: attacks occur without warning<br />
II. Panic disorder and generalized anxiety disorder (GAD)<br />
A. Panic disorder: severe apprehension and feelings of impending doom lasting minutes to<br />
hours; recurrent unexpected attacks and at least one month worry about another attack<br />
1. Sometimes develops into agoraphobia<br />
2. Risk factors: disturbed childhood environment, stressors<br />
3. Lifetime prevalence: 3.5 percent; two times more likely in women<br />
4. Panic attacks common (45 percent of college coeds within past year)<br />
B. Generalized anxiety disorder: persistent anxiety and worry, hypervigilance, physiological<br />
symptoms (but less reactive than panic disorder) lasting six months or more<br />
1. Lifetime prevalence 5 percent of adult population; two times as likely for women<br />
2. Risk factors: lower threshold for uncertainty; erroneous beliefs<br />
C. Etiology of panic disorder and generalized anxiety disorder<br />
1. Psychodynamic perspective: stresses internal conflict originating in sexual and<br />
aggressive impulses<br />
2. Cognitive behavioral: negative thoughts or overattention to bodily sensations serve as<br />
internal triggers for panic attacks; sets up feedback loop<br />
3. Biological perspective<br />
a) Focus on neural structures/neurochemical responses to stressful stimuli<br />
preliminary and conflicting<br />
b) Panic disorder associated with oxygen misregulation resulting from dysfunction<br />
in locus ceruleus in brain<br />
c) Biological challenge tests: sodium lactate or carbon dioxide produces panic<br />
attack in those with the disorder<br />
d) Genetic studies: higher concordance rates for MZ than for DZ twins for panic<br />
disorder; less support for genetics in GAD<br />
D. Treatment of panic disorder and generalized anxiety disorder<br />
1. Biochemical treatment<br />
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Chapter 5: Anxiety Disorders 71<br />
a) Antidepressant and antianxiety medications; relapse after stopping drug therapy<br />
quite common<br />
b) Benzodiazepines (Valium and Librium) useful in GAD but cause tolerance and<br />
dependence<br />
2. <strong>Behavior</strong>al treatment: higher success rates than medication; a high percent getting<br />
cognitive behavioral treatments for panic disorder were panic free<br />
III. Phobias<br />
A. Agoraphobia: fear of being in public places where escape or help may not be readily<br />
available; fear of panic symptoms<br />
1. More common in females than in males<br />
2. Panic attacks typically precede agoraphobia, but relationship is unclear<br />
3. 81 percent report catastrophic cognitions; they may misinterpret events and bodily<br />
sensations<br />
B. Social phobia: fear of being scrutinized<br />
1. Three subcategories: performance (such as public speaking), limited interactional (such<br />
as going out on a date), and generalized (extreme anxiety in most social situations)<br />
2. Prevalence: 3.7 percent of adults; twice as common in females than males<br />
C. Specific phobias: irrational fear to object or situation<br />
1. In DSM-IV-TR, five types: animals, natural environmental (such as thunder), blood/<br />
injection, situational (such as elevators), and other (such as choking)<br />
2. Most common are small animals, heights, the dark, and lightning<br />
3. Two times more prevalent in women than in men; men may lie about fears more than<br />
women<br />
4. Most children with phobias lose fear without treatment<br />
D. Etiology of phobias<br />
1. Psychodynamic perspective: displaced sexual or aggressive conflict; little Hans’s fear<br />
that a horse would bite him<br />
2. <strong>Behavior</strong>al perspective<br />
a) Classical conditioning perspective: conditioned emotional responses; some<br />
research and clinical support<br />
b) Observational learning perspective: negative information and modeling are major<br />
factors accounting for childhood fears<br />
c) Negative information perspective: negative information acquired largely from<br />
television<br />
d) Cognitive behavioral: negative thoughts and overestimates of unpleasant future<br />
events in those with phobias<br />
3. Biological perspective: genetic predisposition for fear reactions<br />
E. Treatment of phobias<br />
1. Biochemical treatments<br />
a) Drugs used typically affect neurotransmitters and/or reduce depression<br />
b) Methodological flaws hamper evaluation research on effectiveness<br />
2. <strong>Behavior</strong>al treatments<br />
a) Exposure therapy: gradually introduce contact with feared situation<br />
b) Cognitive strategies: alter unrealistic thoughts<br />
c) Systematic desensitization: relaxation while imagining increasingly anxietyprovoking<br />
situations<br />
d) Modeling therapy<br />
IV. Obsessive-compulsive disorder: intrusive repetitive thoughts and need to perform ritual acts<br />
A. Symptoms are ego-dystonic (seem alien and beyond voluntary control)<br />
B. Lifetime prevalence: 2.5 percent; equal in men and women<br />
C. Obsessions: most common are bodily wastes, germs, and environmental contamination
72 Chapter 5: Anxiety Disorders<br />
1. 80 percent of normal samples report unpleasant intrusive thoughts<br />
2. Obsessive-compulsive obsessions are more intense, longer lasting, and harder to<br />
dismiss than “normal” obsessions<br />
D. Compulsions: need to perform an act to reduce anxiety; if severe must be performed<br />
perfectly<br />
E. Etiology of obsessive-compulsive disorder<br />
1. Psychoanalytic perspective: obsessive-compulsive behaviors are attempts to fend off<br />
sexual urges<br />
2. <strong>Behavior</strong>al and cognitive perspectives<br />
a) Obsessive-compulsive behaviors reduce anxiety<br />
b) Obsessions are the result of a “catastrophic misinterpretation” of intrusive<br />
thoughts or images<br />
3. Biological perspective: relate to brain structure, genes, and biochemical abnormalities<br />
F. Treatment of obsessive-compulsive disorder<br />
1. Biological treatments:<br />
a) SSRIs are more helpful than minor tranquilizers, but 60-80 percent of people<br />
with OCD do not respond to the medications<br />
b) relapse after medication is discontinued<br />
2. <strong>Behavior</strong>al treatments:<br />
a) Exposure (continued actual or imagined exposure to fear-arousing stimuli)<br />
b) Response prevention (prevented from performing rituals)<br />
c) Cognitive component (identify and modify irrational thoughts)<br />
V. Acute and posttraumatic stress disorder<br />
A. Acute stress disorder (ASD): from exposure to traumatic stress results in dissociation,<br />
reliving experience, and avoiding reminders of traumatic event lasting more than two and<br />
less than thirty days occurring within four weeks of event<br />
B. Posttraumatic stress disorder (PTSD): lasts more than thirty days; develops in response to<br />
specific stressor; intrusive memories of the traumatic event, emotional withdrawal,<br />
heightened autonomic arousal<br />
C. Diagnosis of acute and posttraumatic stress disorder<br />
1. Most people with ASD develop PTSD<br />
2. DSM-IV-TR criteria:<br />
a) Reexperiencing the event in disturbing dreams of intrusive memories<br />
b) Emotional numbing, or avoiding stimuli associated with trauma<br />
c) Heightened autonomic arousal<br />
3. Prevalence for Americans between ages 15 and 54 is 8 percent; twice as many women<br />
as men<br />
D. The individual’s perception of the event: strong correlation between level of danger<br />
perceived from a trauma and likelihood of developing PTSD<br />
E. Etiology and treatment of acute and posttraumatic stress disorder<br />
1. <strong>Behavior</strong>al perspective:<br />
a) Classical conditioning: lack of extinction, low support, thoughts about events:<br />
treatment with exposure, modeling, virtual reality<br />
b) Cognitive factors: treat with crisis intervention, cognitive coping strategies<br />
c) EMDR (eye movement desensitization and reprocessing): visualizing disturbing<br />
imagery, describing it using all sensory modalities, then track lateral movements<br />
of clinician’s finger or pencil<br />
2. Biological perspective and treatment<br />
a) Hypersensitivity to stimuli similar to traumatic event<br />
b) Neurochemical and neuroanatomical circuitry in amygdala<br />
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Chapter 5: Anxiety Disorders 73<br />
c) Use of tricyclic antidepressants and SSRIs, which alter serotonin levels at the<br />
level of the amygdala and its connections, desensitizing the fear network;<br />
unfortunately, the side effects lead to twice the discontinuation rate as behavioral<br />
treatments<br />
LEARNING OBJECTIVES<br />
1. Describe the nature and cognitive, behavioral, and somatic manifestations of anxiety in anxiety<br />
disorders and list the five major groups of anxiety disorders. (pp. 131-134; Figure 5.1)<br />
2. Describe the symptoms and discuss the prevalence of panic disorder. (pp. 134-136)<br />
3. Describe the symptoms and frequency of generalized anxiety disorder. (p. 136)<br />
4. Discuss the psychodynamic, cognitive-behavioral, and biological theories of cause for panic<br />
disorder and generalized anxiety disorder. (pp. 136-140)<br />
5. Compare the biochemical and behavioral treatment approaches for panic disorder and generalized<br />
anxiety disorder and discuss their relative efficacy in treating these disorders. (pp. 140-142)<br />
6. Discuss the symptoms and prevalence of phobias, including agoraphobia, specific phobia, and<br />
social phobia. (pp. 142-147; Tables 5.1 and 5.2)<br />
7. Discuss the psychodynamic, behavioral, cognitive, and biological theories for the cause of<br />
phobias. (pp. 147-150)<br />
8. Discuss the biochemical and behavioral treatment of phobias, including systematic<br />
desensitization, exposure, and modeling therapy. (pp. 151-153)<br />
9. Distinguish between obsessions and compulsions and describe the symptoms and prevalence of<br />
obsessive-compulsive disorder. (pp. 153-156)<br />
10. Discuss the psychodynamic, behavioral, and biological theories of the cause of obsessivecompulsive<br />
disorder. (pp. 156-159)<br />
11. Describe and discuss the biological, behavioral, and cognitive treatment of obsessive-compulsive<br />
disorder. (pp. 159-160)<br />
12. Differentiate between acute stress disorders (ASD) and posttraumatic stress disorders (PTSD) and<br />
the DSM-IV’s criteria for their diagnoses. (pp. 161-164)<br />
13. Discuss the causes and treatment of PTSD, including prolonged exposure and eye movement<br />
desensitization and reprocessing. (pp. 164-167)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Panic attacks appear to be rather common, but it is possible that some “panic attacks” are not<br />
psychologically induced at all. It is increasingly clear that another common problem having to do<br />
with the heart may be the cause of some panic attacks. This heart defect, which is rarely life<br />
endangering or severe, is called mitral valve prolapse. The mitral valve of the heart usually closes<br />
flush with the wall that separates the atrium from the ventricle. In mitral valve prolapse, for<br />
reasons that are not well understood, the valve folds in on itself when it closes. The effect is to<br />
produce a racing heart, fainting, profuse sweating, and dizziness—many of the signs of a panic<br />
attack. These episodes occur randomly, and not all attacks are a result of psychological panic. The<br />
wise clinician would encourage a client to have a physical examination to rule out such physical<br />
causes as mitral valve prolapse.<br />
Internet Site: http://www.apa.org/pubinfo/panic.html. An APA site that covers the basics on panic<br />
attacks and treatments.
74 Chapter 5: Anxiety Disorders<br />
2. The world seems to be a more and more dangerous place. The problem of posttraumatic stress<br />
disorder and its prevention should be mentioned in this section of the course. Whether natural or<br />
caused by human agency, the disasters people suffer need not lead to long-lasting and disabling<br />
conditions. One description of such a prevention effort was a response to the 1981 Hyatt Regency<br />
Hotel disaster in Kansas City, Missouri. Two skywalks in the hotel collapsed, killing 113 people<br />
and injuring 200 others. The survivors had significant psychological aftereffects, as did the rescue<br />
workers. Grist and Stolz (1982) describe what mental health professionals in the region did to<br />
prevent posttraumatic stress disorder.<br />
A good discussion question is, "Should local or state governments provide funds and facilities so<br />
that citizens who are victims of such disasters are assured of psychological services?" A follow-up<br />
question is, "How much should we provide if, as research indicates, about 15 percent of those<br />
involved in disasters need professional treatment within a year of the event?"<br />
Sources: Gist & Stolz (1982) Community response to the Kansas City hotel disaster. American<br />
Psychologist, 37, 1136–1139.<br />
3. The textbook does not give a clear indication of the scenes that are used in flooding therapy. A<br />
good discussion topic is the need for truly graphic imagery and the ethical considerations for both<br />
client and therapist. For a person with a spider phobia, the following script might be used.<br />
Close your eyes and see a hairy spider at your feet. See it crawl around your feet and ankles.<br />
Make yourself pick it up and put it in your lap. You don’t want to do it, but you make<br />
yourself pick it up. Look at the spider in your lap. Feel it moving around. Keep your hand on<br />
the spider and prevent it from walking away. Feel the texture of its hairy surface as it moves<br />
around in your hand. Bring the spider up closer to your face. Force yourself to look at it.<br />
The intense anxiety that the client with spider phobia will feel is exactly what must occur, but<br />
explain to students that this therapy is done only after the client is informed of what will happen<br />
and the reasons for it. Also note that the therapist, who probably does not enjoy the thought of<br />
creating terror in a client, must believe in the therapy and “stick it out” despite the client’s anxiety.<br />
If the therapist starts to use flooding, there is no turning back. Stopping the presentation of<br />
fear-inducing scenes before there has been an extinction of anxious responses will reinforce<br />
avoidance. Students may want to discuss whether the slower, more comfortable (but often less<br />
effective) process of systematic desensitization is preferable to the distressing (but effective)<br />
method of flooding.<br />
4. A new theory of anxiety and depression (Higgins, 1987) proposes that people define themselves in<br />
terms of an actual self (the attributes that describe how they actually are), an ideal self (the way<br />
they aspire to be), and an ought self (the way they are morally obligated to be). The latter two are<br />
considered “self guides” and may be based on a personal standpoint or the standpoints of<br />
important others such as parents or teachers. The degree of inconsistency between actual and ideal<br />
or ought selves is a person’s self-discrepancy. Higgins argues that depressive emotions are related<br />
to discrepancy between the actual and the ideal self. Anxiety is related to discrepancy between the<br />
actual and the ought self, particularly the ought self as defined by others.<br />
Scott and O’Hara (1993) identified small samples (Ns were less than 10) of university students<br />
who met the criteria for depression or generalized anxiety disorder and had them complete the<br />
Selves Questionnaire (Higgins et al., 1985). As predicted, depressed students showed greater<br />
actual-ideal self-discrepancy than anxious or normal students showed. Anxious students showed<br />
greater actual-ought self (other-defined) than depressed or normal students showed. These<br />
findings largely replicate those of Strauman (1992), extend Strauman’s work by including<br />
students with anxiety problems other than social phobias, and, given the small samples, indicate<br />
that a real effect is present.<br />
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Chapter 5: Anxiety Disorders 75<br />
Sources: Higgins, E. T. (1987). Self-discrepancy: A theory relating self and affect. Psychological<br />
Review, 94, 319–340.<br />
Higgins, E. T., Klein, R., & Strauman, T. J. (1985). Self-concept discrepancy theory: A<br />
psychological model for distinguishing among different aspects of depression and anxiety. Social<br />
Cognition, 3, 51–76.<br />
Scott, L., & O’Hara, M. W. (1993). Self-discrepancies in clinically anxious and depressed<br />
university students. Journal of <strong>Abnormal</strong> Psychology, 102, 282–287.<br />
Strauman, T. J. (1992). Self-guides, autobiographical memory, and anxiety and dysphoria:<br />
Toward a cognitive model of vulnerability to emotional distress. Journal of <strong>Abnormal</strong><br />
Psychology, 101, 87–95.<br />
CLASSROOM DEMONSTRATIONS<br />
1. The Velten method of inducing mood (Velten, 1968) has been successfully applied to a range of<br />
emotional states including anxiety. The method uses a stack of cards that contain statements<br />
associated with a particular emotion. Subjects first read the cards silently, then aloud, and finally<br />
spend five or so minutes concentrating on a time in their life when they experienced the same<br />
emotional state. Borkovec and colleagues (Borkovec et al., 1983; York et al., 1987) have<br />
developed mood inductions for both worry and somatic anxiety. In the first case, statements focus<br />
on cognitive concerns: “I am plagued by my racing mind” or “I am so worried that I cannot<br />
concentrate on anything.” The somatic anxiety statements highlight bodily sensations brought on<br />
by anxiety: “My stomach is starting to feel queasy” or “I can feel my muscles tensing up.”<br />
Borkovec has shown that both worry-induced and somatic-anxiety-induced subjects had more<br />
intrusive negative thoughts in a subsequent testing session than those in a neutral emotional<br />
condition. Cardiovascular activity was also significantly increased in both induced states.<br />
You could either make a set of such cards or present the statements to the class via overhead<br />
transparencies or verbally. Statements should take the following form: “I am very tense and<br />
nervous.” “My heart is beating very fast now.” “My muscles are tense and twitching.” “I am<br />
worried.” “I can’t deal with the uncertainties in my life.” “I have many fears.” “I must avoid<br />
upsetting places at all costs.” “My stomach feels queasy because of my nervousness.” “I worry<br />
that I will not be able to keep my mind from racing.” You must make a lengthy presentation of<br />
such statements (at least 20–30) to alter the mood state of the reader/listener. Further, the public<br />
nature of the classroom may work against the “suspension of disbelief” necessary for such<br />
statements to induce mood. However, the fact that such statements are often made by clients with<br />
anxiety disorders can be a point of departure for discussion of the cognitive cause or maintenance<br />
of such problems as panic disorder, generalized anxiety disorder, phobias, and<br />
obsessive-compulsive disorder.<br />
Sources: Borkovec, T. D., Robinson, E., Pruzinsky, T., & Depree, J. A. (1983). Preliminary<br />
exploration of worry: some characteristics and processes. Behaviour Research & Therapy, 21, 9–<br />
16.<br />
Velten, E. (1968). A laboratory task for the induction of mood states, <strong>Behavior</strong> Research and<br />
Therapy, 6, 473–482.<br />
York, D., Borkovec, T. D., Vasey, M., & Stern, R. (1987). Effects of worry and somatic anxiety<br />
induction on thoughts, emotion, and physiological activity. Behaviour Research & Therapy, 25,<br />
523–526.<br />
2. The treatment of all anxiety disorders involves the elimination of anxiety. Systematic<br />
desensitization accomplishes this in a gradual and comforting way. You can demonstrate the basic
76 Chapter 5: Anxiety Disorders<br />
elements of systematic desensitization by giving a quick, deep muscle-relaxation demonstration<br />
and suggesting how an anxiety hierarchy would be constructed and used. You can make this<br />
exercise even more relevant and useful by applying it to test anxiety, a problem in any class. A<br />
script for the relaxation training is provided in a handout. Completion of the relaxation<br />
demonstration takes about five minutes. You can either read it to the class or distribute the<br />
handout and instruct students to practice on their own time. An example of an individual’s<br />
hierarchy of fears dealing with classroom examinations is given below. The intensity of anxiety in<br />
each situation is averaged and rated in terms of what Joseph Wolpe called Standard Units of<br />
Distress (SUDS). Make it clear to students that each person has his or her own anxiety hierarchy;<br />
those in the class who suffer from test anxiety will relate to the listing on the next page but will<br />
undoubtedly apply different numbers to the test-related situations in their own lives.<br />
SUDS Situation<br />
10 Reading the syllabus and finding out that there will be three exams in a course<br />
20 Reading course material and thinking that there will be an exam on it<br />
50 Hearing the instructor ask whether anyone has questions about the exam next<br />
class period<br />
70 Studying for the exam the night before<br />
80 Walking toward the classroom on the day of the exam<br />
90 Taking the exam paper from the instructor and looking at the first item<br />
100 Reading three items and not knowing the answer to any of them<br />
After a client (student) learns to relax quickly and completely, relaxation is paired with imagined<br />
scenes of the least anxiety-provoking situations. When anxiety is felt, the client “turns off” the<br />
scene, becomes relaxed again, and imagines the scene again. People are rarely able to imagine<br />
highly stressful scenes while completely relaxed, but reducing anxiety to manageable levels<br />
usually improves performance.<br />
Internet Site: http://www.guidetopsychology.com/sysden.htm An in-depth discussion of selfsystematic<br />
desensitization.<br />
3. The cognitive component in anxiety disorders is receiving considerable research attention. In<br />
1986, Reiss et al. developed a research instrument to measure people’s beliefs that anxiety<br />
experiences (cognitive, behavioral, and somatic) have negative consequences such as illness,<br />
humiliation, and further anxiety. Ever alert to even small body changes, people with this anxiety<br />
sensitivity interpret a skipped heart beat to be a sign of a heart attack. Fearful of the consequences<br />
of anxiety symptoms, they even worry about becoming anxious. In a series of studies, Reiss et al.<br />
(1986) reported that their Anxiety Sensitivity Index (ASI) had good psychometric properties (testretest<br />
reliability was .75; internal consistency was shown by 13 of the 16 items having a factor<br />
analytic loading of .4 or more).<br />
The demonstration will show students a research instrument and allow class members to compare<br />
their scores with those of other college students and two samples of patients with anxiety<br />
disorders. Reiss et al. reported that scores on the ASI for female college students were<br />
significantly higher (mean = 20.5) than scores for male college students (mean = 15.4). Scores<br />
were significantly higher among agoraphobic outpatients (mean = 38.3) than among outpatients<br />
with other anxiety disorders (mean = 23.9) who scored higher than the college students. The<br />
findings give support to the idea that agoraphobia is associated with a fear of fear.<br />
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Chapter 5: Anxiety Disorders 77<br />
Preface this demonstration with some cautionary statements. Make it clear that scores on the index<br />
diagnose no condition and that the completion of the index is for educational purposes—to see<br />
how researchers in the field measure concern about anxiety symptoms. Insist that students not<br />
identify themselves on the scale and assure them that you are interested in group data only—<br />
comparing the class’s means with those that Reiss et al. (1986) reported. Scoring is<br />
straightforward: “Very little” scores 0 points; “a little” scores 1 point; “some” scores 2 points;<br />
“much” scores 3 points; and “very much” scores 4 points. An individual’s ASI score is the sum of<br />
the scores on all 16 items.<br />
Source: Reprinted from <strong>Behavior</strong> Research and Therapy, Vol. 24, Reiss, S., Peterson, R. A.,<br />
Gursky, D. M., and McNally, R. J., “Anxiety Sensitivity, Anxiety Frequency, and the Prediction<br />
of Fearfulness,” pp. 1–8. Copyright 1986, with permission from Elsevier Science Ltd., The<br />
Boulevard, Langford Lane, Kidlington OX5 1GB, UK.<br />
Internet Site: http://www.healthyplace.com/site/tests/psychological.asp#anxiety A variety of<br />
online screening for anxiety disorders.<br />
4. Wolpe (1973) suggests that the Willoughby Personality Schedule can be used prior to beginning<br />
systematic desensitization. This questionnaire identifies interpersonal situations that elicit anxiety,<br />
presumably more important for those with social phobias. Have your students fill it out, but<br />
caution them that the purpose of the exercise is to better appreciate what goes on in behavioral<br />
assessment and treatment; it is not designed for self-diagnosis. Norms are not available.<br />
Another useful questionnaire is the Wolpe-Lang Inventory (Wolpe & Lang, 1969), which assesses<br />
sources of more specific fears than the Willoughby Personality Schedule. The full questionnaire<br />
has 108 items, but five samples from it are listed below. Ask your students to generate a longer<br />
list on their own or have them make suggestions in class to gain a more complete understanding of<br />
the exercise.<br />
Items in the Wolpe-Lang Inventory questionnaire refer to things and experiences that may cause<br />
fear or other unpleasant feelings. Students should indicate how much each item disturbs them,<br />
using the following categories: Not at All, A Little, A Fair Amount, Much, and Very Much.<br />
• Speaking in public<br />
• Thunder<br />
• Receiving injections<br />
• Cats<br />
• Being in an elevator<br />
Source: From J. Wolpe & P.J. Lang. Fear Survey Schedule. Copyright © 1969. Reprinted with<br />
permission from Wolpe, J. (1973). The practice of behavior therapy (2nd ed.). New York:<br />
Pergamon.<br />
5. People who are high in trait anxiety (generalized anxiety disorder) seem to interpret life as more<br />
threatening than it needs to be. Presented with alternative interpretations of situations, anxious<br />
people disproportionately endorse dangerous ones (Butler & Mathews, 1983). Anxious<br />
individuals tend to write down more threatening meanings to words that sound alike but have<br />
different meanings (homophones) (Mathews et al.,1989).<br />
Sources: Butler, G., & Mathews, A. (1983). Cognitive processes in anxiety. Advances in<br />
Behaviour Research and Therapy, 5, 51–62.<br />
Mathews, A., Richards, A., & Eysenck, M. (1989). Interpretation of homophones related to threat<br />
in anxiety states. Journal of <strong>Abnormal</strong> Psychology, 98, 31–34.
78 Chapter 5: Anxiety Disorders<br />
6. Since panic attacks are so common, students will want to know the symptoms that accompany<br />
them. The corresponding handout lists the DSM-IV-TR diagnostic criteria for panic attack.<br />
Remind students of “medical students’ syndrome” at this junction. This chapter represents the first<br />
of the chapters devoted to clinical disorders, and you need to remind students to “take with a grain<br />
of salt” any concern they may have that they have a disorder.<br />
Internet Site: http://www.apa.org/pubinfo/panic.html. An APA site that answers your questions<br />
about panic disorder. It covers the basics on panic attacks and treatments.<br />
7. Use the following to demonstrate what a mild panic attack might be like. This demonstration is<br />
best done with a class with which you have developed a positive rapport. Assign some outside<br />
reading, and the publications put on reserve in the library several weeks prior to this<br />
demonstration. Ask the students to complete these readings by the date of this demonstration for<br />
discussion in class.<br />
On the day of this demonstration, come to class late and act very angry. Explain that you have<br />
learned that a student from the class was in your office the last hour complaining about cheating<br />
on the last test. Indicate that you have decided to invalidate the last test and give everyone a zero<br />
on it since you cannot identify the specific students who cheated. You have decided to give a pop<br />
quiz on the assigned reading to replace the test.<br />
Be very formal if any students question your authority. Hand out a real pop quiz. Tell the<br />
students that they have until the end of the class to finish. Sit at the front of the classroom for<br />
about five minutes; this will allow most of the students to experience a mild panic attack. Stop the<br />
demonstration and tell the students that they will not be graded on this pop quiz. I have even<br />
given extra credit for the students that started the pop quiz. Begin to brief the students and lead a<br />
discussion of the mild anxiety they felt. The level of panic they experienced is relatively low; use<br />
this time to summarize the symptoms of panic attack.<br />
Internet Site: http://www.apa.org/pubinfo/panic.html. An APA site that answers your questions<br />
about panic disorder. It covers the basics on panic attacks and treatments.<br />
8. Invite a clinical professional to be a guest lecturer for your class on the topic of anxiety disorders.<br />
A person who deals with individuals who have these disorders can give a short introduction with<br />
some examples and then invite discussion. Real examples will help the students understand the<br />
types of problems these individuals experience and how they are treated by the professional<br />
community.<br />
Internet Site: http://www.apa.org/pubinfo/panic.html. An APA site that answers your questions<br />
about panic disorder. It covers the basics on panic attacks and treatments.<br />
9. Bring the DSM-IV-TR to class, and prepare an overhead transparency or PowerPoint slide ahead<br />
of time for your lecture on anxiety disorders. Describe the in-depth material from the DSM-IV-<br />
TR while using the transparency or PowerPoint slide as an outline. Lead a discussion on the<br />
differences between different anxiety disorders. Encourage student input about individuals they<br />
have known with these symptoms.<br />
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Chapter 5: Anxiety Disorders 79<br />
HANDOUT FOR DEMONSTRATION 2:<br />
SCRIPT FOR RELAXATION TRAINING<br />
The following script can be used to make a tape recording that will help the listener learn to relax. It<br />
incorporates three of the major techniques in relaxation training: progressive muscle relaxation,<br />
breathing control, and visualization. Students should practice relaxation training for 15 to 20 minutes<br />
twice per day for five days or so. After that amount of practice they should be able to determine which<br />
component—muscle tightening, breathing, or visualization—is most relaxing. They can modify the<br />
script to increase the amount of time they spend on the relaxation that works best for them.<br />
Relaxation practice should be done in a place and at a time when few interruptions are likely. It is<br />
advisable to keep the lighting low, to sit or lie comfortably, and to keep one’s eyes closed. Practicing in<br />
bed late at night may interfere with acquiring the relaxation response, because rather than practicing,<br />
the person will simply go to sleep. This result is valuable for people with insomnia, but not for those<br />
with test anxiety.<br />
Sit in a comfortable position with your legs uncrossed and your arms at your sides. Now make<br />
your hands into fists. Notice the tension in your hands, wrists, and forearms. Hold it. Now open<br />
your hands and let the muscles completely relax. Note the contrast between the tension that was<br />
there and the relaxation that you now feel. Try to let the relaxation go even further than usual.<br />
(Pause) Now tighten your hands into fists again and try to touch your shoulders with your fists.<br />
Feel the tension throughout your arms. Hold it. (Pause) Now drop your arms and open your hands.<br />
Let the tension flow down your arms and out through your fingertips. If you haven’t already, close<br />
your eyes to help imagine the tension flowing out. Let your arms become completely relaxed.<br />
To tighten the muscles in your shoulders, try to touch your shoulders to your ears. Hunch up and<br />
hold it. Now relax. Let the muscles loosen up and get quiet. (Pause). [Instructions are discontinued<br />
here, but, in full relaxation training, they would include the face, back, chest, stomach, buttocks,<br />
legs, toes, and so on.]<br />
Now concentrate on your breathing. Try to make your breathing perfectly smooth and regular.<br />
Breathe slowly, smoothly, and very regularly. Concentrate only on your breathing. Each time you<br />
breathe out, think the word relax and let your body grow just a bit more limp. Every breath is a<br />
chance to relax a bit more. If your mind wanders, just bring it back to your breathing. Make your<br />
breathing perfectly regular and relax a bit more each time you exhale. Let your body become<br />
completely quiet and calm. Enjoy the relaxed feeling. (Pause.)<br />
While you are breathing smoothly and becoming more and more relaxed, I want you to imagine<br />
that you are at the top of a hill overlooking the ocean. The sky is blue with small puffy clouds; the<br />
ocean is a sparkling blue with small white waves. Try to be there now. Feel the warm, salty breeze<br />
in your hair. See the ocean as the waves come in regularly. You are alone and quiet in this place.<br />
You have no worries; you can be completely relaxed and at peace. Notice that the waves come in<br />
perfectly timed with your breathing. And every time you breathe out, you get a little more relaxed.<br />
Enjoy this peaceful place. Allow yourself to enjoy the wonderful feeling of being relaxed and<br />
peaceful. (Thirty-second pause)<br />
Soon we will have to come back to the classroom. When I count to three, you will be back in the<br />
class but feeling relaxed and alert. One: You can begin to move your arms and legs. Two: Slowly<br />
open your eyes. Three: You are fully back and feeling fine.
80 Chapter 5: Anxiety Disorders<br />
HANDOUT FOR DEMONSTRATION 3: ANXIETY SENSITIVITY INDEX<br />
Please do not identify yourself in any way. Your instructor is interested in group data and will compute<br />
only the average scores for males and females in your class. Consider this an educational exercise. It<br />
cannot and should not be used to diagnose an anxiety disorder.<br />
For each item, respond by circling a phrase (very little, a little, some, much, or very much). Please be<br />
sure to answer all 16 items with one phrase each.<br />
1. It is important to me not to appear nervous.<br />
very little a little some much very much<br />
2. When I cannot keep my mind on a task, I worry that I might be going crazy.<br />
very little a little some much very much<br />
3. It scares me when I feel “shaky” (trembling).<br />
very little a little some much very much<br />
4. It scares me when I feel faint.<br />
very little a little some much very much<br />
5. It is important to me to stay in control of my emotions.<br />
very little a little some much very much<br />
6. It scares me when my heart beats rapidly.<br />
very little a little some much very much<br />
7. It embarrasses me when my stomach growls.<br />
very little a little some much very much<br />
8. It scares me when I am nauseous.<br />
very little a little some much very much<br />
9. When I notice that my heart is beating rapidly, I worry that I might have a heart attack.<br />
very little a little some much very much<br />
10. It scares me when I become short of breath.<br />
very little a little some much very much<br />
Copyright © Houghton Mifflin Company. All rights reserved.
11. When my stomach is upset, I worry that I might be seriously ill.<br />
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Chapter 5: Anxiety Disorders 81<br />
very little a little some much very much<br />
12. It scares me when I am unable to keep my mind on a task.<br />
very little a little some much very much<br />
13. Other people notice when I feel shaky.<br />
very little a little some much very much<br />
14. Unusual body sensations scare me.<br />
very little a little some much very much<br />
15. When I am nervous, I worry that I might be mentally ill.<br />
very little a little some much very much<br />
16. It scares me when I am nervous.<br />
very little a little some much very much<br />
Reprinted from <strong>Behavior</strong> Research and Therapy, Vol. 24, Reiss, S., Peterson, R. A., Gursky, D. M., and<br />
McNally, R. J., “Anxiety Sensitivity, Anxiety Frequency, and the Prediction of Fearfulness,” pp. 1–8.<br />
Copyright 1986, with permission from Elsevier Science Ltd., The Boulevard, Langford Lane,<br />
Kidlington OX5 1GB, UK.
82 Chapter 5: Anxiety Disorders<br />
HANDOUT FOR DEMONSTRATION 4:<br />
WILLOUGHBY PERSONALITY SCHEDULE, REVISED<br />
Instructions: The questions in this schedule are intended to indicate various emotional personality traits.<br />
It is not a test in any sense because the questions do not have right or wrong answers.<br />
After each question, you will find a row of numbers whose meaning is given below. All you have to do<br />
is to circle the number that describes you best.<br />
0 means no, never, not at all, or similar terms.<br />
1 means somewhat, sometimes, a little, or similar terms.<br />
2 means about as often as not, an average amount, or similar terms.<br />
3 means usually, a good deal, rather often, or similar terms.<br />
4 means practically always, entirely, or similar terms.<br />
1. Do you get anxious if you have to speak or perform in any way in 0 1 2 3 4<br />
front of a group of strangers?<br />
2. Do you worry if you make a fool of yourself or feel you have been 0 1 2 3 4<br />
made to look foolish?<br />
3. Are you afraid of falling when you are on a high place from which 0 1 2 3 4<br />
there is no real danger of falling—for example, looking down from a<br />
balcony on the tenth floor?<br />
4. Are you easily hurt by what other people do or say to you? 0 1 2 3 4<br />
5. Do you keep in the background on social occasions? 0 1 2 3 4<br />
6. Do you have changes of mood that you cannot explain? 0 1 2 3 4<br />
7. Do you feel uncomfortable when you meet new people? 0 1 2 3 4<br />
8. Do you daydream frequently, that is, indulge in fantasies not<br />
involving concrete situations?<br />
0 1 2 3 4<br />
9. Do you get discouraged easily by failure or criticism? 0 1 2 3 4<br />
10. Do you say things in haste and then regret them? 0 1 2 3 4<br />
11. Are you ever disturbed by the mere presence of other people? 0 1 2 3 4<br />
12. Do you cry easily? 0 1 2 3 4<br />
13. Does it bother you to have people watch you work even when you do<br />
it well?<br />
0 1 2 3 4<br />
14. Does criticism hurt you badly? 0 1 2 3 4<br />
15. Do you cross the street to avoid meeting someone? 0 1 2 3 4<br />
16. At a reception or tea, do you go out of your way to avoid meeting the<br />
important person present?<br />
0 1 2 3 4<br />
17. Do you often feel just miserable? 0 1 2 3 4<br />
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Chapter 5: Anxiety Disorders 83<br />
18. Do you hesitate to volunteer in a discussion or debate with a group of<br />
people whom you know more or less?<br />
0 1 2 3 4<br />
19. Do you have a sense of isolation, either when alone or among<br />
people?<br />
0 1 2 3 4<br />
20. Are you self-conscious before “superiors” (teachers, employers,<br />
authorities)?<br />
0 1 2 3 4<br />
21. Do you lack confidence in your general ability to do things and to<br />
cope with situations?<br />
0 1 2 3 4<br />
22. Are you self-conscious about your appearance even when you are<br />
well-dressed and groomed?<br />
0 1 2 3 4<br />
23. Are you scared at the sight of blood, injuries, and destruction even<br />
though there is no danger to you?<br />
0 1 2 3 4<br />
24. Do you feel that other people are better than you? 0 1 2 3 4<br />
25. Is it hard for you to make up your mind? 0 1 2 3 4<br />
From Joseph Wolpe, The Practice of <strong>Behavior</strong> Therapy. Copyright © 1973 by Allyn and Bacon.<br />
Reprinted with permission.
84 Chapter 5: Anxiety Disorders<br />
HANDOUT FOR DEMONSTRATION 6:<br />
DIAGNOSTIC CRITERIA FOR PANIC ATTACK<br />
The main feature of a panic attack is a period of intense fear or discomfort that develops abruptly and<br />
reaches a peak within ten minutes. To be considered a panic attack, the episode must be accompanied<br />
by four or more of the following symptoms:<br />
1. Palpitations, pounding heart, or accelerated heart rate<br />
2. Sweating<br />
3. Trembling or shaking<br />
4. Sensations of shortness of breath or of smothering<br />
5. Feeling of choking<br />
6. Chest pain or discomfort<br />
7. Nausea or abdominal distress<br />
8. Feeling dizzy, unsteady, lightheaded, or faint<br />
9. Derealization (feelings of unreality) or depersonalization (being detached from oneself)<br />
10. Fear of losing control or going crazy<br />
11. Fear of dying<br />
12. Paresthesias (numbness or tingling sensations)<br />
13. Chills or hot flushes<br />
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Chapter 5: Anxiety Disorders 85<br />
SELECTED READINGS<br />
Clark, D. M (1988). A cognitive model of panic attacks. In S. Rachman & J. D. Maser (Eds.), Panic:<br />
Psychological perspectives. Hillsdale, NJ: Lawrence Erlbaum, 71–89.<br />
McNally, R. J. (1987). Preparedness and phobias: A review. Psychological Bulletin, 100, 283–303.<br />
Neal, A., & Turner, S. M. (1991). Anxiety disorder research with African-Americans: Current status.<br />
Psychological Bulletin, 109, 400–410.<br />
Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., Nunez, F., & Fairbanks, L.<br />
(1987). Life threat and posttraumatic stress in school age children. Archives of General Psychiatry, 44,<br />
1057–1063.<br />
Turner, S. M., Beidel, D. C., & Nathan, R. S. (1985). Biological factors in obsessive-compulsive<br />
disorders. Psychological Bulletin, 97, 430–450.<br />
Sattler, D., Shabatay, V., & Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 1, Anxiety Disorder.<br />
Clipson, C. & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 2, Panic Disorder. Chapter 3, Obsessive-Compulsive Disorder. Chapter 4,<br />
Posttraumatic Stress Disorder.<br />
VIDEO RESOURCES<br />
Anxiety: The Endless Crisis (16 mm, color, 60 min). Describes the causes and types of anxiety as well<br />
as physiological and psychological reactions. Differentiates between state and trait anxiety. Indiana<br />
University, Audiovisual Center, Bloomington, IN 47405.<br />
<strong>Behavior</strong>al Therapy Demonstration (16 mm, color, 32 min). Dr. Joseph Wolpe demonstrates his<br />
therapy with a woman showing social phobia. Deep muscle-relaxation training and pairing of relaxation<br />
and imagined scenes are depicted. PCR, Pennsylvania State University, University Park, PA 16802.<br />
The Concept of Anxiety (16 mm, 44 min). Anxiety as a universal experience. Video Nursing, Inc., 2645<br />
Girard Avenue, Evanston, IL 60201.<br />
Interview with an Obsessive-Compulsive (VHS or Beta video, color, 50 min). Part of a series of case<br />
histories, this video explores the symptoms and experience of being obsessive-compulsive. Media<br />
Guild, 118 South Acacia, Box 881, Solana Beach, CA 92075.<br />
Neurotic <strong>Behavior</strong>: A Psychodynamic View (16 mm, color, 19 min). The film uses compulsive behavior<br />
to illustrate how irrational thinking leads to self-defeating behavior and exaggerated fears. Defense<br />
mechanisms are shown, as well as means for exploring and facing them so as to reduce neurotic<br />
symptoms. PCR, Pennsylvania State University, University Park, PA 16802.<br />
Obsessive-Compulsive Neurosis (16 mm, 28 min). The case of a middle-aged man with<br />
obsessive-compulsive behaviors. Modern Talking Picture Services, 1212 Avenue of the Americas, New<br />
York, NY 10036.<br />
Pathological Anxiety (16mm, 30 min). A disturbed office worker experiences panic and terror when he<br />
is unable to suppress his hostilities. PCR, Pennsylvania State University, University Park, PA 16802.<br />
Cognitive Therapy for Panic Disorder (VHS, color, 45 mm.). From the APA Psychotherapy Videotape<br />
Series II: Specific Treatments for Specific Populations. American Psychological Association. 1-800-<br />
374-2721.
86 Chapter 5: Anxiety Disorders<br />
Obsessive-Compulsive Disorder (VHS, color, 75 mm.). Covers diagnosis and treatment of obsessivecompulsive<br />
disorder. Insight Media. 1-800-233-9910.<br />
Obsessive-Compulsive Disorder: The Boy Who Couldn't Stop Washing (VHS, color, 28 mm.). Specially<br />
adapted Phil Donahue show with Dr. Judith Rapport, author of the book by the same title considers<br />
symptoms, diagnosis, and possible cures. Films for the Humanities and Science. 1-800-257-5126.<br />
Panic Attacks (VHS, color, 15 mm.). Covers the diagnosis and treatment of panic attacks and related<br />
disorders. Films for the Humanities and Science. 1-800-257-5126.<br />
ON THE INTERNET<br />
http://www.algy.com/anxiety/ is the Anxiety Panic internet resource.<br />
http://www.apa.org is the American Psychological Association's home page. This site contains<br />
information on anxiety disorders.<br />
http://www.lexington-on-line.com/naf.html is the west site for the National Anxiety Foundation.<br />
http://www.nimh.nih.gov is the National Institute of Mental Health home page, which offers<br />
information about diagnosis, treatment, and research into anxiety disorders, obsessive-compulsive<br />
disorder, and phobias.<br />
An e-mail discussion group called ANXIETY-L has a great deal of activity on the whole range of<br />
anxiety-related subjects. To subscribe, address the message SUBSCRIBE ANXIETY-L YOURNAME<br />
to listproc@frank.mtsu.edu<br />
Copyright © Houghton Mifflin Company. All rights reserved.
CHAPTER 6<br />
Dissociative Disorders and Somatoform<br />
Disorders<br />
CHAPTER OUTLINE<br />
I. Dissociative disorders dissociative amnesia, dissociative fugue, dissociative identity disorder<br />
(multiple personality), and depersonalization disorder<br />
A. Most are rare, but reports of dissociative identity disorder in United States have increased<br />
B. Dissociative amnesia: partial or total loss of personal information (due to traumatic event)<br />
1. Types<br />
a) Localized amnesia—loss of all memory for a short time (most common type)<br />
b) Selective amnesia—loss of details about an incident<br />
c) Generalized amnesia—total loss of memory for past<br />
d) Systemized—loss of memory for selected types of information<br />
e) Continuous amnesia—inability to recall any events from a specific time until<br />
present (least common type)<br />
2. May be analogous to posthypnotic amnesia, but difficult to tell<br />
C. Dissociative fugue: dissociative amnesia plus travel; usually incomplete change of identity;<br />
recovery usually abrupt and complete<br />
D. Depersonalization disorder: feelings of unreality and perceptual distortion<br />
1. Most common form of dissociative disorder<br />
2. May create great anxiety<br />
3. Precipitated by physical or psychological stress<br />
E. Dissociative identity disorder (formerly multiple personality disorder)<br />
1. Characteristics<br />
a) Two or more independent personalities exist in one person<br />
b) One personality evident at a time; usually amnesia in personality that is not<br />
present, although personalities may have awareness of other personalities<br />
c) Often opposite personalities<br />
d) More prevalent in women in United States, but no gender differences found in<br />
Switzerland<br />
e) Conversion symptoms, depression, and anxiety are common<br />
2. Diagnostic controversy<br />
a) Fewer than 200 cases reported worldwide prior to 1970s, now about 6,000 new<br />
cases per year<br />
b) Some clinicians believe it is underreported, others believe it is iatrogenic<br />
c) Core symptoms (amnesia, lack of autobiographical memory for childhood,<br />
chronic depersonalization, alteration of identity) are distinct with DID<br />
d) Rare outside United States and Canada<br />
F. Etiology of dissociative disorders<br />
1. Hard to separate faking from real; reliable diagnostic methods do not currently exist<br />
2. Psychodynamic perspective<br />
a) If repression to block traumatic events doesn’t work, dissociation may occur<br />
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88 Chapter 6: Dissociative Disorders and Somatoform Disorders<br />
b) Four factors necessary for DID: capacity to dissociate, exposure to severe stress,<br />
walling off experience, and developing different memory systems<br />
3. <strong>Behavior</strong>al perspective<br />
a) Avoidance of stress by indirect means<br />
b) Iatrogenic or therapist-produced<br />
G. Treatment of dissociative disorders<br />
1. No specific medications for DID; medications prescribed for associated problems of<br />
anxiety or depression<br />
2. Three-part group format<br />
a) Psychoeducation<br />
b) Use of group resources<br />
c) Develop cognitive and social skills<br />
3. Dissociative amnesia and fugue and spontaneously<br />
4. Depersonalization disorder has slower rate of spontaneous remission, so treatment<br />
focuses on relieving anxiety, depression, or fear of going insane<br />
5. Dissociative identity disorder<br />
a) Treatment more likely successful with those who can integrate their personalities<br />
b) Combination of psychotherapy and hypnosis<br />
c) Develop coping skills, even if personalities not integrated<br />
d) Problem-focused therapy holds patients responsible for their behavior as a whole<br />
person<br />
II. Somatoform disorders: physical symptoms without physiological basis<br />
A. Cross-cultural differences in somatic complaints<br />
B. Somatization disorder<br />
1. DSM-IV-TR criteria: physical complaints involving four or more sites on body (at<br />
least two gastrointestinal, one sexual, one pseudoneurological), doctor-shopping,<br />
unnecessary operations, anxiety, and depression<br />
2. Undifferentiated somatoform disorder: not fully meeting criteria, but at least one<br />
physical complaint for six months<br />
3. Overall prevalence rate of 2 percent; more prevalent among females and African<br />
Americans<br />
C. Conversion disorder<br />
1. Characteristics: physical impairment without physical cause<br />
2. Differentiate from physical by lack of atrophy in paralyzed extremity, neurological<br />
impossibility (glove anesthesia), relation to stress<br />
3. Discriminating those who fake is difficult<br />
D. Pain disorder<br />
1. Characteristics: severe or excessive pain with no physiological basis or long after<br />
injury has healed<br />
2. Pain is complex phenomenon with both physiological and psychological bases, but<br />
descriptions of the pain and its location are vague.<br />
E. Hypochondriasis<br />
1. Characteristics: preoccupation with health, anxiety and depression; reassurance has no<br />
impact<br />
2. Prevalence: 4 to 9 percent of general medical patients<br />
3. Predisposing factors: history of physical illness, parental attention to somatic<br />
symptoms, low pain threshold, greater sensitivity to somatic cues<br />
F. Body dysmorphic disorder<br />
1. Characteristics: preoccupation with imagined defect in appearance in a normalappearing<br />
person/excessive concern over slight physical defect producing marked<br />
clinical distress; mirror checking; frequent surgery<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 6: Dissociative Disorders and Somatoform Disorders 89<br />
2. Diagnostic problems<br />
a) Normal dissatisfaction with appearance high (46 percent of college students have<br />
some preoccupation with appearance)<br />
b) Overlap with delusional disorder or obsessive-compulsive disorder<br />
G. Etiology of somatoform disorders<br />
1. Diathesis-stress: hypervigilance and sensitivity to body sensations followed by stressor<br />
2. Psychodynamic perspective<br />
a) Repression of conflict converted to physical<br />
b) Primary gain: protected from anxiety<br />
c) Secondary gain: attention and dependency needs met<br />
3. <strong>Behavior</strong>al perspective<br />
a) Assume sick role for reinforcement/avoidance<br />
b) Modeling important<br />
c) Fordyce (1988) reports physicians unwittingly reinforce; male patients with<br />
supportive wives experience more pain when wife is present<br />
4. Sociocultural perspective<br />
a) Term hysteria (now conversion disorder) comes from Greek for uterus<br />
b) Freud’s case of Anna O. was actually unsuccessful treatment<br />
c) Social restrictions on women lead to symptoms<br />
5. Biological perspective<br />
a) High arousal levels, higher sensitivity to bodily sensations<br />
H. Treatments of somatoform disorders<br />
1. Psychodynamic treatment<br />
a) Psychoanalysis to relive feelings associated with repressed event<br />
b) Hypnotherapy<br />
2. <strong>Behavior</strong>al treatment<br />
a) Exposure and response prevention to extinction and prevent reinforcement of<br />
complaints<br />
b) Operant-behavioral: change social and environmental reinforcers to reinforce<br />
appropriate behavior, ignore complaints<br />
c) Cognitive approach: modify patient’s cognitions about pain by identifying<br />
negative thoughts and replacing with more adaptive ones<br />
3. Biological treatment<br />
a) Antidepressant medications and SSRIs<br />
b) Increasing physical activity<br />
4. Family systems treatment<br />
a) Explore function of the problem<br />
b) Teach the family adaptive ways to support each other and to deal with problems<br />
LEARNING OBJECTIVES<br />
1. Discuss the fundamental characteristics involved in dissociative disorders, and list the four types<br />
of dissociative disorders. (pp. 171-172; Figure 6.1)<br />
2. Discuss the characteristics of the four types of dissociative amnesia and the process by which they<br />
occur. (pp. 172-174)<br />
3. Describe the characteristics of dissociative fugue and depersonalization disorder. (pp. 174-177)<br />
4. Discuss the controversy over the validity of “repressed memories” and research that indicates the<br />
possibility of false memories. (pp. 175; Critical Thinking)
90 Chapter 6: Dissociative Disorders and Somatoform Disorders<br />
5. Describe the characteristics of dissociative identity (multiple personality) disorder and its<br />
prevalence. (pp. 177-178)<br />
6. Discuss the diagnostic controversies concerning dissociative identity disorder. (pp. 179-180)<br />
7. Discuss and distinguish the psychodynamic, behavioral, and iatrogenic (therapist-produced)<br />
explanations for dissociative disorders. (pp. 181-183)<br />
8. Discuss the treatment of dissociative amnesia and fugue, depersonalization disorder, and<br />
dissociative identity disorder. (pp. 183-186)<br />
9. Describe the basic characteristics of somatoform disorders and distinguish them from malingering<br />
and factitious disorders. (pp. 186-187)<br />
10. List and describe the five subtypes of somatoform disorder, including somatization disorder,<br />
conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder. (pp. 187-196)<br />
11. Describe and discuss the causes of somatoform disorders from the psychodynamic, behavioral,<br />
sociocultural, and biological perspectives, and the diathesis-stress model. (pp. 196-199)<br />
12. Describe and discuss the treatment of somatoform disorders with psychoanalytic, behavioral, and<br />
family systems therapies. (pp. 199-200)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Dissociative identity disorder (multiple personality) is a favorite topic for discussion and<br />
evaluation because it is so bizarre and dramatic. A good way to start a discussion is to contrast this<br />
disorder with schizophrenia, even if the psychoses have not yet been presented, since there are<br />
many misconceptions about what “split personality” means. One way of clarifying the difference<br />
is to draw a set of partially interconnected circles on the board to show the relatively distinct<br />
components that make up multiple personality and a dotted circle next to these to indicate the<br />
fractured nature of schizophrenia, where not even one intact personality is found.<br />
Once these differences are established, it is useful to examine the functions of separate<br />
personalities for a person who has endured prolonged physical or sexual abuse. The cases of Billy<br />
Milligan (Keyes, 1981), Sybil (Schreiber, 1973), and Jonah (Ludwig et al., 1972) all show a timid<br />
(superego) core personality with opposite personalities that are sexually promiscuous, aggressive,<br />
or both (id). Ask the class to imagine the events that might produce such dissociated personalities.<br />
In addition, a competent, rational personality often “bails out” the other two. This can be seen as<br />
pure ego. Students who are skeptics of psychoanalysis are often impressed with this tripartite split<br />
among personalities. It even seems that Eve (who had some 21 faces before she was successfully<br />
treated) had personalities that came out in groups of three (Sizemore & Pittillo, 1977).<br />
Sources: Keyes, D. (1981). The minds of Billy Milligan. New York: Bantam.<br />
Ludwig, A. M., Brandsma, J. M., Wilbur, C. B., Bendfeldt, F., & Jameson, D. H. (1972). The<br />
objective study of multiple personality. Archives of General Psychiatry, 26, 298–310<br />
Schreiber, F. R. (1973). Sybil. Chicago: Regnery.<br />
Sizemore, C., & Pittillo, E. (1977). I’m Eve. New York: Doubleday.<br />
Internet Site: http://www.issd.org/indexpage/isdguide.htm. Contains guidelines for treating<br />
dissociative identity disorder (DID).<br />
2. What are the advantages of being sick? Students can better understand the behavioral and family<br />
systems view on somatoform disorder by looking at the positive consequences of making somatic<br />
complaints. Ask students how many of them when they were younger faked or exaggerated<br />
illnesses to get out of difficult academic or interpersonal situations. How did their parents react to<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 6: Dissociative Disorders and Somatoform Disorders 91<br />
3.<br />
these complaints, and what effect did the reactions have? If parents helped these children avoid<br />
responsibilities, we can expect that illness complaints increased in frequency. On the other hand,<br />
if parents routinely ignored such complaints, children probably learned to face responsibility.<br />
This discussion should raise questions about soft- and hard-heartedness and the danger of parents<br />
wrongly suspecting fakery. This mirrors the dilemma of the physician or psychologist with a<br />
client who repeatedly complains of pain or other problems in the absence of a physiological<br />
explanation. Instructors can suggest a reasonable middle ground: that complaints need to be<br />
thoroughly checked out for possible physical causes before one assumes that there are other<br />
reasons. Even so, it is dangerous to assume that medical assessment has reached the zenith of<br />
accuracy.<br />
The idea of iatrogenic disorders deserves expanded attention. The instructor can help students to<br />
appreciate how therapists react to “interesting” cases. Therapists tend to spend more time thinking<br />
about these clients, consulting books and colleagues to better understand them, and paying<br />
attention to their subtle verbal and nonverbal messages. Like other people, clinicians become<br />
enthused by puzzles they have trouble solving. If nothing else, multiple personalities are puzzles<br />
that are hard to solve. In some ways, it may be a disappointment to find an interesting case<br />
becoming an ordinary case, so some clinicians may inadvertently influence clients to exaggerate<br />
the symptoms of multiple personality.<br />
The opposite of this effect may also occur with clients whose problems seem more pesky than<br />
interesting. Conversations with hypochondriacal clients are continuous battles to steer the topic<br />
away from their health concerns. (The worst thing a clinician can do is ask a hypochondriacal<br />
client, “How are you doing?”) Again, despite their training, clinicians are like other people and<br />
have a point at which they want to hear no more about somatic complaints. The therapist then<br />
works at reducing or discounting complaints—the opposite of what goes on in the iatrogenic<br />
process of fostering dissociative identity disorder.<br />
4. Dissociative identity disorder (DID) has largely been reported and researched in North America.<br />
Modestin’s (1992) research from Switzerland, cited in the text, suggests that DID is quite rare in<br />
Europe. The first large sample study of DID in Europe indicates that DID patients in the<br />
Netherlands are strikingly similar to those in North America (Boon & Draijer, 1993). Boon and<br />
Draijer (1993) gave the Structured Clinical Interview for Dissociative Disorders, the Structured<br />
Trauma Interview, and the Dissociative Experiences Scale to 71 patients being treated for<br />
dissociative identity disorder. The comparison with the Ross et al. (1990) sample of 102 cases<br />
from North America is noteworthy. The following table points out the similarities. For each item,<br />
the percentage of the sample reporting or qualifying for that item is given.<br />
Item Boon & Draijer (1993) Rosset al. (1990)<br />
Childhood physical or sexual abuse 94.4 95.1<br />
Sexual abuse 77.5 90.2<br />
Physical abuse 80.3 82.4<br />
Suicide attempts 62.9 72.5<br />
Drinking problem 32.4 33.3<br />
Street drugs 22.5 28.4<br />
Some form of amnesia 100.0 100.0<br />
Sources: Boon, S., & Draijer, N. (1993). Multiple personality disorder in The Netherlands: A<br />
clinical investigation of 71 patients. American Journal of Psychiatry, 150, 489–494.
92 Chapter 6: Dissociative Disorders and Somatoform Disorders<br />
Ross, C.A., Miller, S. D., Reagor, P., Bjornson, L., Fraser, G. A., & Anderson, G. (1990).<br />
Structured interview data on 102 cases of multiple personality disorder from four centers.<br />
American Journal of Psychiatry, 147, 596–601.<br />
Internet Site: http://www.sidran.org A non-profit education and advisory organization for<br />
traumatic life events.<br />
5. Rabinowicz (1989) describes a way of demonstrating dissociative identity disorder in the<br />
classroom. Students take the Imagination Potential Scale, and the top three scorers are given the<br />
task of playing a serial killer interviewed by a court-appointed clinician. The role play is based on<br />
the Hillside Strangler murder case and highlights the issues of differentiating multiple personality<br />
from faking, as discussed in the text.<br />
Source: Rabinowicz, F. E. (1989). Creating the multiple personality: An experiential<br />
demonstration for an undergraduate abnormal psychology class. Teaching of Psychology, 16,<br />
69-71.<br />
Internet Site: http://www.sidran.org A non-profit education and advisory organization for<br />
traumatic life events.<br />
6. The first controlled therapy outcome study on body dysmorphic disorder was published in 1995.<br />
Rosen, Reiter, and Orosan (1995) randomly assigned 54 body dysmorphic disorder subjects with<br />
to cognitive behavioral therapy or to a no-treatment control group. Patients met for eight two-hour<br />
sessions in small groups. Their beliefs concerning the importance of physical appearance were<br />
challenged, they monitored and modified their thoughts about body dissatisfaction, and they<br />
practiced techniques for eliminating body checking. An exposure/response prevention component<br />
of treatment put subjects in situations they normally avoided because of concern over their<br />
appearance. Checking and intrusive thoughts were significantly reduced in treated subjects, and in<br />
82 percent of cases the disorder was eliminated at posttreatment. In only one case was there<br />
relapse at follow-up.<br />
Clearly this study indicates that cognitive-behavioral therapy can be useful in the treatment of<br />
body dysmorphic disorder. However, further studies comparing different approaches to treatment<br />
are needed to see if more effective and efficient methods can be found.<br />
Source: Rosen, J. C., Reiter, J, & Orosan, P. (1995). Cognitive-behavioral body image therapy for<br />
body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63, 263–269.<br />
Internet Site:<br />
http://www.brown.edu/Administration/George_Street_Journal/v22/v22n5/dysmorph.html. Defines<br />
and discusses treating body dysmorphic disorder.<br />
7. When clinicians assume that somatic complaints are the result of somatoform disorders, they must<br />
be quite certain of their diagnosis. A false negative (failing to see an existing physiological<br />
condition) is a much more serious mistake than a false positive (claiming that a physiological<br />
condition exists when there is none). The wise psychologist makes sure that every conceivable<br />
medical test and specialist has been used prior to concluding that conversion disorder is the<br />
correct diagnosis. Consider this case presented by Fishbain and Goldberg (1991):<br />
A young man was in a fight when he was hit over the head with a bottle. He was arrested for<br />
assault and taken to the hospital. He never lost consciousness and x-rays of his skull showed<br />
no fracture. Neurological examinations were normal. However, the patient complained that<br />
he was unable to move his left arm and leg. He was reassured by hospital personnel and<br />
when given the direct suggestion that he was able to move the arm and leg, he moved them.<br />
Over a period of time, the patient continued to complain of an inability to move his left<br />
limbs, was reassured that he could, and showed movement. He was diagnosed with<br />
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Chapter 6: Dissociative Disorders and Somatoform Disorders 93<br />
conversion disorder. Only later, using CAT scans, which can detect damage better than xrays,<br />
did doctors discover that he had a hemotoma (bloody swelling) in the right<br />
frontoparietal area of the cortex, which accounted for his incomplete loss of movement on<br />
the left side.<br />
In a study of 30 patients diagnosed with conversion disorder, 80 percent were eventually found to<br />
have a medical disorder that was the cause or contributing factor of symptoms that were originally<br />
believed have a psychological origin (Gould et al., 1986). In many cases, current technology<br />
cannot detect physiological causes of neurological disorders in their earliest stages. To<br />
immediately assume that disorders are conversion disorders, with the social stigma attached, is to<br />
be reckless in diagnosis.<br />
Two key factors in separating conversion from physiological disorders are selective symptoms<br />
and la belle indifference. Selective symptoms are evident when, for instance, a paralyzed leg<br />
moves when the person is asleep or when blind individuals can see well enough to catch an object<br />
thrown unexpectedly. La belle indifference is a traditional sign of conversion: the individual’s<br />
way of discussing symptoms and their impact in a dispassionate, even unconcerned, manner.<br />
Patients with organic disorders, especially those whose impairment has been sudden and<br />
traumatic, are likely to be quite upset about their symptoms. However, this “beautiful<br />
indifference” is reported in only about one-third of individuals with conversion disorder so this is<br />
not a very strong means of differentiating psychological and physiological disorders either.<br />
Sources: Fishbain, D. A., & Goldberg, M. (1991). The misdiagnosis of conversion disorder in a<br />
psychiatric emergency service. General Hospital Psychiatry, 13, 177–181.<br />
Gould, R., Miller, B. L., Goldberg, M., & Benson, D. F. (1986). The validity of hysterical signs<br />
and symptoms. Journal of Nervous and Mental Disease, 174, 593–597.<br />
Internet Site: http://www.psyweb.com/Mdisord/somatd.html. This site consists of material on<br />
somatoform disorders, including statistics on the prevalence of theses disorders.<br />
CLASSROOM DEMONSTRATIONS<br />
1. A behavioral perspective on multiple personality stresses role playing and selective attention. To<br />
relate this concept to students’ everyday lives, ask them to report their behavior in widely<br />
different social situations. This kind of exercise underscores the extreme situationist viewpoint of<br />
some personality theorists—that traits are illusions. It is also possible to connect this exercise to<br />
research on self-monitoring. High self-monitors tend to change their behavior to meet the needs of<br />
social situations. They are “tuned in” to the reactions they create in others and shape their<br />
behavior to get the reactions that are socially valued. They are also more adept at playing roles<br />
and enjoying the theatrical aspects of interactions. It is not such a long step from this style to the<br />
development of dissociative identity disorder, especially if the disorder is seen as a response to the<br />
expectations of the therapist (iatrogenic). The 18-item Self-Monitoring Scale is provided as a<br />
handout. The following items answered True are scored in the direction of high self-monitoring:<br />
4, 5, 6, 8, 10, 12, 17, and 18. The following items answered False are also scored in the direction<br />
of high self-monitoring: 1, 2, 3, 7, 9, 11, 13, 14, 15, and 16.<br />
Have students report their scores anonymously. Compute the class mean. Gangestad and Snyder<br />
(1985) found that among college students, the median split for self-monitoring was between<br />
scores of 10 and 11. For greater purity of high- and low-self-monitoring groups, they suggest<br />
scores of 13 and over and 7 and under.<br />
As a further exploration of the topic of changing “personalities” in response to different social<br />
expectations, ask students to write down how they act in the following situations:
94 Chapter 6: Dissociative Disorders and Somatoform Disorders<br />
a. In the middle of a crowd at an exciting football game<br />
b. With their parents during Thanksgiving dinner<br />
c. After watching a sad movie by themselves<br />
d. When they walk into a party where they know no one<br />
e. When someone almost crashes into their car on the highway<br />
f. When they are in a silly mood and talk to a close friend<br />
g. When they are in a class taught by a boring professor (certainly not you!)<br />
Are they the same person in every situation? To what extent do they act the part that is expected<br />
of them? To what degree do they ignore aspects of themselves that do not fit the situation’s<br />
demands?<br />
At the extreme, this adaptive behavior does not represent much of a difference from the way<br />
multiple personalities react. However, it bears repeating that multiple personalities do not just<br />
ignore certain aspects of themselves. They have no information about certain aspects of<br />
themselves.<br />
Source: Gangestad, S., & Snyder, M. (1985). To carve nature at its joints?: On the existence of<br />
discrete classes in personality. Psychological Review, 92, 317–349.<br />
Internet Site: http://www.sidran.org A non-profit education and advisory organization for<br />
traumatic life events.<br />
2. The diagnosis of conversion disorder is something like a detective game. The following group<br />
exercise can give students some appreciation of the difficulties. Divide the class into groups of<br />
four or five and assign the groups the task of developing strategies for detecting conversion<br />
disorder as opposed to malingering or physiologically based disorders. Use the case study on the<br />
Handout for Demonstration 2 to get a discussion rolling. Then ask a reporter in each group to<br />
describe to the class the strategies group members thought of. List these on the board and then<br />
comment on or ask for ideas about the pros and cons of each.<br />
The detective issue is sometimes played out on a larger scale Kiesler & Finholt, (1988). An<br />
epidemic of painful arm, hand, and wrist conditions called repetitive strain injury or repetitive<br />
motion syndrome has overwhelmed Australian workers’ compensation funds. The article explores<br />
the explanations, including the possibility that the epidemic is related to job dissatisfaction.<br />
Sources: Kiesler & Finholt, (1988). The mystery of RSI. American Psychologist, 43, 1004–1015.<br />
Internet Site: http://www.nlm.nih.gov/medlineplus/ency/article/000954.htm . This site describes<br />
conversion disorder as a loss or change in bodily functioning that results from a psychological<br />
conflict or need.<br />
3. Cardena and Spiegel (1993) report that in a sample of graduate students the incidence of<br />
dissociative reactions immediately after the San Francisco Bay Area earthquake of October 1989<br />
was surprisingly high. Symptoms such as hypervigilance, difficulty concentrating, exaggerated<br />
startle response, and confusion were reported by more than half of the respondents one week after<br />
the quake. Four months after the event, fewer than one-third reported having these symptoms.<br />
Survey students for their experience of dissociative symptoms during “baseline” conditions and<br />
compare the percentages with those from Cardena and Spiegel (1993). A handout is provided.<br />
Another possibility is to ask students if they have experienced an extraordinary life event (for<br />
example, life-threatening car accident, violent crime, or natural disaster). The event should be<br />
stressful enough to have had an intense impact for a week or more. If a large enough sample<br />
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Chapter 6: Dissociative Disorders and Somatoform Disorders 95<br />
exists, ask these students to fill out the questionnaire using the week after their particular stressful<br />
event as the period for reporting their reactions. This exercise can spark discussion of several<br />
topics: how to decide the base rate of dissociative reactions, the reliability of retrospective<br />
symptom reporting, and why dissociative reactions occur in the wake of trauma.<br />
Here are the findings of Cardena and Spiegel showing the percentage of 100 graduate students<br />
reporting each dissociative symptom at one week and at four months after the Loma Prieta<br />
earthquake. In every case the symptom was less likely to be reported at four months, most with p<br />
< .001.<br />
1 Week 4 Months<br />
1. Difficulty taking in new information 55 26<br />
2. An exaggerated startle response 67 29<br />
3. Periods of confusion 55 16<br />
4. Hypervigilance (extreme alertness and being “on<br />
guard”)<br />
76 39<br />
5. Having your attention automatically drawn toward<br />
56 33<br />
thoughts of an unpleasant event<br />
6. Intrusive recollections of an unpleasant event 39 17<br />
7. Difficulties with everyday memory 29 14<br />
8. Recurrent dreams about an unpleasant event 22 11<br />
9. Distressful associations about an unpleasant event 39 18<br />
10. Detailed memories about an unpleasant event 55 23<br />
11. The reliving of an unpleasant event 29 14<br />
12. The sensation that time was expanding 51 19<br />
13. The sensation that your surroundings were unreal or 40 12<br />
dreamlike<br />
14. A lack of interest in usually interesting activities 40 12<br />
15. A tendency to avoid certain activities 26 10<br />
16. Withdrawal from other people 28 13<br />
17. A tendency to avoid thoughts about an unpleasant<br />
event<br />
30 15<br />
18. A sensation that your self is detached from your body 25 6<br />
19. A feeling that events are occurring at a distance 40 13<br />
20. A feeling that sensations (hearing and seeing) are<br />
17 3<br />
occurring at a distance<br />
21. Numbing or slowness 23 7<br />
22. Unusual body sensations 27 10<br />
23. A feeling that your thoughts are occurring at a distance 22 7<br />
24. A restricted range of emotions 23 9<br />
Note: The wording of the questionnaire items differs from that of the Cardena and Spiegel<br />
instrument and makes direct comparison impossible. The 24-item list above is a truncated version<br />
of the 98-item Standard Acute Stress Reaction Questionnaire (SASRQ) and focuses on<br />
dissociative reactions.<br />
Source: Cardena, E., & Spiegel, D., “Dissociative reactions to the San Francisco Bay Area<br />
earthquake.” American Journal of Psychiatry, 150, 474–478, 1993. Copyright 1993, the American<br />
Psychiatric Association. Reprinted by permission.<br />
4. Introduce your students to the idea that common conceptions of dissociative disorders are often<br />
incorrect. Have the students form small groups of 4-7 individuals depending on your class size
96 Chapter 6: Dissociative Disorders and Somatoform Disorders<br />
and space limitations. Ask group members to recall incidents of amnesia from movies, prime time<br />
television, or daytime television. The other group members are then asked to determine if the<br />
amnesia or fugue state meet DSM-IV criteria. They will find that most of these incidents are<br />
designed for the storyline but do not meet the definition of amnesia. Ask each group to develop<br />
this list with the most salient examples first. Each group could then have a spokesperson deliver a<br />
short talk about the best examples. You could provide a blank overhead transparency to each<br />
group at the beginning of this demonstration.<br />
Internet Site: http://www.sidran.org/didbr.html . A listing of information on dissociation disorders<br />
5. Invite a guest speaker who is a psychologist or psychiatrist specializing in the treatment of<br />
dissociative disorders. Have the students develop questions during the class period before the<br />
guest lecturer is scheduled. These professionals are usually very busy, but if you schedule early<br />
enough they will usually be happy to lecture to your class.<br />
6. Bring the DSM-IV-TR to class, and prepare an overhead transparency or PowerPoint slide ahead<br />
of time for your lecture on somatoform disorders. Describe the in-depth material from the DSM-<br />
IV-TR while using the transparency or PowerPoint slide as an outline. Lead a discussion on the<br />
differences between different anxiety disorders. Encourage student input about individuals they<br />
have known with these symptoms.<br />
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Chapter 6: Dissociative Disorders and Somatoform Disorders 97<br />
HANDOUT FOR DEMONSTRATION 1: SELF MONITORING SCALE<br />
This 18-item measure of self-monitoring can give you a general idea of whether you are a high or low<br />
self-monitor. Your instructor will explain the concept of self-monitoring and its relevance to such<br />
dissociative disorders as dissociative identity disorder. Please read each item carefully, consider how<br />
you typically act, and answer true or false. Your instructor will show you how to score and interpret<br />
your score on this scale.<br />
1. I find it hard to imitate the behavior of other people. true false<br />
2. At parties and social gatherings, I do not attempt to do or say things that<br />
others will like.<br />
true false<br />
3. I can only argue for ideas in which I already believe. true false<br />
4. I can make impromptu speeches even on topics about which I have almost<br />
no information.<br />
true false<br />
5. I guess I put on a show to impress or entertain others. true false<br />
6. I would probably make a good actor. true false<br />
7. In a group of people I am rarely the center of attention. true false<br />
8. In different situations and with different people, I often act like very<br />
different people.<br />
true false<br />
9. I am not particularly good at making other people like me. true false<br />
10. I’m not always the person I appear to be. true false<br />
11. I would not change my opinions (or the way I do things) in order to please<br />
someone or win their favor.<br />
true false<br />
12. I have considered being an entertainer. true false<br />
13. I have never been good at games like charades or improvisational acting. true false<br />
14. I have trouble changing my behavior to suit different people and different<br />
situations.<br />
true false<br />
15. At a party I let others keep the jokes and stories going. true false<br />
16. I feel a bit awkward in company and do not show up quite as well as I<br />
should.<br />
true false<br />
17. I can look anyone in the eye and tell a lie with a straight face (if for a right<br />
end).<br />
true false<br />
18. I may deceive people by being friendly when I really dislike them. true false<br />
Source: From Public appearance, private realities by Snyder. © 1987 by W. H. Freeman and<br />
Company. Used by permission.
98 Chapter 6: Dissociative Disorders and Somatoform Disorders<br />
HANDOUT FOR DEMONSTRATION 2:<br />
DIAGNOSING CONVERSION DISORDER<br />
1. Each group should choose a member who will be the reporter. The reporter keeps track of the<br />
ideas the group develops and reports those ideas to the rest of the class when everyone<br />
reconvenes.<br />
2. Everyone in the group should read the case below:<br />
Jane works as a word processor for a large insurance company. Her job, which she detests,<br />
involves inputting hundreds of numbers into a computer. She has gone to her family physician<br />
because she feels a constant tingling in her fingers and a sharp pain in her fingers, wrist, and<br />
forearm but only at certain times. Her doctor is not a neurological specialist but can see nothing<br />
obviously wrong with Jane’s hands or wrists. Jane is depressed and anxious about this condition.<br />
She says, “Here I am only 29 and already I have pains that are worse than my 76-year-old<br />
grandmother has. What will I be like in twenty years? Already it is agony for me to do my work.”<br />
3. Group members should list ways in which Jane’s condition could be evaluated. You cannot be<br />
expected to be experts in neurology, but you should think through ways of detecting malingering,<br />
voluntary inducement of symptoms, physical causes, and psychological causes. What information<br />
would you need to decide whether Jane<br />
• is malingering?<br />
• has a factitious disorder (is consciously inducing the symptoms)?<br />
• has a “real” physiological disorder?<br />
• has a somatoform disorder such as conversion disorder?<br />
4. After developing a list of assessment strategies, the group should think about the order in which<br />
these tests and evaluation strategies should be conducted. What makes sense to rule out first?<br />
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Chapter 6: Dissociative Disorders and Somatoform Disorders 99<br />
HANDOUT FOR DEMONSTRATION 3:<br />
INCIDENCE OF DISSOCIATIVE REACTIONS<br />
Please indicate whether any of the following reactions have occurred to you. Do not indicate your<br />
name. All information will be grouped, and individual data will not be used. Please answer as honestly<br />
as possible.<br />
During the past four months have you experienced<br />
Yes No<br />
1. difficulty taking in new information? _____ _____<br />
2. an exaggerated startle response? _____ _____<br />
3. periods of confusion? _____ _____<br />
4. hypervigilance (extreme alertness and being “on guard”)? _____ _____<br />
5. having your attention automatically drawn toward thoughts of an<br />
unpleasant event?<br />
_____ _____<br />
6. intrusive recollections of an unpleasant event? _____ _____<br />
7. difficulties with everyday memory? _____ _____<br />
8. recurrent dreams about an unpleasant event? _____ _____<br />
9. distressful associations about an unpleasant event? _____ _____<br />
10. detailed memories about an unpleasant event? _____ _____<br />
11. the reliving of an unpleasant event? _____ _____<br />
12. the sensation that time was expanding? _____ _____<br />
13. the sensation that your surroundings were unreal or dreamlike? _____ _____<br />
14. a lack of interest in usually interesting activities? _____ _____<br />
15. a tendency to avoid certain activities? _____ _____<br />
16. withdrawal from other people? _____ _____<br />
17. a tendency to avoid thoughts about an unpleasant event? _____ _____<br />
18. a sensation that your self is detached from your body? _____ _____<br />
19. a feeling that events are occurring at a distance? _____ _____<br />
20. a feeling that sensations (hearing and seeing) are occurring at a distance? _____ _____<br />
21. numbing or slowness? _____ _____<br />
22. unusual body sensations? _____ _____<br />
23. a feeling that your thoughts are occurring at a distance? _____ _____<br />
24. a restricted range of emotions? _____ _____
100 Chapter 6: Dissociative Disorders and Somatoform Disorders<br />
Source: Cardena, E., & Spiegel, D. “Dissociative reactions to the San Francisco Bay Area earthquake.”<br />
American Journal of Psychiatry, 150, 474–478, 1993. Copyright 1993, the American Psychiatric<br />
Association. Reprinted by permission.<br />
SELECTED READINGS<br />
Ford, C. V. (1995). Dimensions of somatization and hypochondriasis. Special issue: Malingering and<br />
conversion reactions. Neurological Clinics, 13, 241–253.<br />
Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger-Greenwood.<br />
Loewenstein, R. J. (l991). Psychogenic amnesia and psychogenic fugue: A comprehensive review. In<br />
A. Tasman & S. M. Goldfinger (Eds.) Annual review of psychiatry. Washington, DC: American<br />
Psychiatric Press, pp. 223–247.<br />
Phillips, K. A. (1991). Body dysmorphic disorder: The distress of imagined ugliness. American Journal<br />
of Psychiatry, 148, 1138–1149.<br />
Putnam, Frank W. et al. (1986). The clinical phenomenology of multiple personality disorder: A review<br />
of 100 recent cases. Journal of Clinical Psychiatry, 47, 285–293.<br />
VIDEO RESOURCES<br />
Case Study of Multiple Personality (16 mm, 30 min). The actual Eve (Chris Sizemore) interviewed by a<br />
psychiatrist during and after treatment. Background information also presented; poor sound quality.<br />
Psychological Cinema Register, Pennsylvania State University, University Park, PA 16802.<br />
Conversion Reaction—A Demonstration (16 mm, 20 min). A re-creation of an interview demonstrating<br />
conversion symptoms. U.S. National Audiovisual Center National Archives and Record Service,<br />
Washington, DC 20014.<br />
Hypnosis and healing (VHS, 54 min). Patients and physicians tell of success in using hypnosis: a rash<br />
developed thirty years prior during a wartime brush with death is eliminated; a mute individual is able<br />
to speak again while in a trance; a previously asthmatic youngster is cured with hypnosis. This 1982<br />
video was produced by the BBC. Psychological Cinema Register, Pennsylvania State University,<br />
University Park, PA 16802.<br />
Mind of a Murderer (VHS, 120 min). Interviews with psychologists and psychiatrists of Kenneth<br />
Bianchi, the "Hillside Strangler." Bianchi attempts to feign MPD in order to enter an insanity plea.<br />
Graphically demonstrates the ability of a clever psychopath to dupe experts into believing that he was a<br />
multiple personality. The Pennsylvania State Library.<br />
Multiple Personality Disorder: In the Shadows (VHS, color, 28 min.). Discusses the causes of and<br />
treatment for multiple personality disorder. Films for the Humanities. 1-800-257-5126.<br />
ON THE INTERNET<br />
http://www.sidran.org/ is the Web site for The Sidran Foundation, which focuses on trauma and traumarelated<br />
disorders. It provides a glossary of dissociative disorder terms, a brochure on dissociative<br />
identity disorder, as well as tips for survivors and an article on the effects of dissociative identity<br />
disorder on children of trauma survivors.<br />
http://mental-health-matters.com is the Mental Health Matters home page, which offers information and<br />
links for mental health, self-help, and psychology information and resources.<br />
http://www.psyweb.com/Mdisord/somatd.html includes material on somatoform disorders, including<br />
statistics on the prevalence of theses disorders, and references.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 6: Dissociative Disorders and Somatoform Disorders 101<br />
http://www.merck.com/pubs/mmanual/section15/chapter186/186a.htm This is chapter 186 of the<br />
Merck Manual of Diagnosis and Treatment that deals with somatoform disorders.<br />
http://www.brown.edu/Administration/George_Street_Journal/v22/v22n5/dysmorph.html is a text only<br />
site that defines and discusses treating body dysmorphic disorder.
CHAPTER 7<br />
Psychological Factors Affecting Medical<br />
Conditions<br />
CHAPTER OUTLINE<br />
I. Introduction<br />
A. Sudden death syndrome<br />
1. Most common cause of death in industrial societies (often coronary heart disease)<br />
2. Physiological changes include blood clotting more easily, increased blood pressure,<br />
and changes in heart rhythm (ventricular fibrillation, bradycardia, tachycardia, and<br />
arrhythmia)<br />
3. Among immigrants may result from severe culture shock<br />
B. Change from traditional separation of psychosomatic disorders from other illnesses<br />
1. In DSM-IV-TR, “psychological factors affecting medical condition” and listed on Axis<br />
III<br />
2. The term “psychosomatic disorder” has been replaced with psychophysiological<br />
disorder-any physical disorder with a strong psychological basis<br />
3. Separate from conversion: actual tissue damage in psychophysiological disorders<br />
4. DSM-IV-TR diagnosis requires presence of a medical condition plus one of the<br />
following: time relationship between psychological factors and onset of or recovery<br />
from medical condition, psychological factor interferes with treatment, and<br />
psychological factors are added health-risk factor<br />
II. Models for understanding stress<br />
A. Definitions<br />
1. Stressor: an external event that places physical or psychological demand on a person<br />
2. Stress: an internal response to stressor<br />
B. General adaptation model (Selye): Biological, psychological, and social stressors all produce<br />
three-stage response<br />
1. Alarm stage: immediate, short-term vulnerability to infection<br />
2. Resistance stage: mobilization to defend against threat<br />
3. Exhaustion stage: symptoms reappear, may lead to death<br />
4. Stress is known to affect immune system, heart function, hormone levels, nervous<br />
system, metabolic rates and leads to diseases (hypertension, chronic pain, heart attacks,<br />
cancer, and the common cold)<br />
C. Life change model (Holmes & Holmes): All changes affect person<br />
1. Greater life change units produce greater chance of illness, more severe form of illness<br />
a) Measured with Social Readjustment Rating Scale<br />
b) Stress potential values are called life change units (LCUs)<br />
2. Different cultures vary in the way they rank stressors<br />
3. Negative life changes are more detrimental than positive life changes<br />
4. Personal interpretations and characteristics matter<br />
D. Transaction model (Lazarus)<br />
1. Both stressor and person<br />
2. Complex interaction of psychosocial, physiological, and cognitive factors<br />
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Chapter 7: Psychological Factors Affecting Medical Conditions 103<br />
3. How situation is interpreted affects its impact<br />
III. Stress and the immune system<br />
A. Mechanisms by which cognitive/emotional state can influence the course or severity of<br />
disease:<br />
1. Biological: direct physiological reaction or changes in immune functioning<br />
2. <strong>Behavior</strong>al: response to stress by engaging in poor health practices<br />
3. Cognitive: feelings of hopelessness or optimism impact health decisions positively or<br />
negatively<br />
4. Social: stressor or emotional state may cause deterioration or increase in social support<br />
5. Conflicting evidence on the course of AIDS<br />
B. The immune system<br />
1. Components<br />
a) Lymphocytes (B-cells, T-cells, and NK cells)<br />
b) Phagocytes<br />
2. Stress-induced release of neurohormones may impair immune functioning<br />
a) Corticoseteroids: strong immunosuppressive actions<br />
b) Endorphins: decrease natural killer cells’ tumor-fighting ability<br />
C. Decreased immunological functioning as a function of stress<br />
1. Direct effects: spouses of dementia victims, divorced or bereaving individuals show<br />
weaker immune systems<br />
2. Indirect effects: stressed person eats poorly, gets less sleep<br />
D. Mediating the effects of stressors<br />
1. Helplessness or control<br />
a) Control increases lifespan of nursing home residents<br />
b) Control decreases epinephrine levels and feelings of tension and depression; aids<br />
rejection of cancer cells<br />
2. Hardiness: personality characteristics and mood state<br />
a) Openness to change, commitment, control<br />
b) Psychological factors are modest at best<br />
3. Self-efficacy and optimism (positive sense of self, of personal control, and optimism<br />
may help people cope with stress)<br />
E. Personality, mood states, and cancer (connection remains to be shown)<br />
IV. Psychological involvement in specific physical disorders<br />
A. Coronary heart disease<br />
1. Associated with cigarette smoking, obesity, high cholesterol, and other lifestyle issues<br />
2. Job stress and poor relations with boss increase blood clotting factor in women<br />
3. Anxiety symptoms predict death due to cardiac arrest<br />
4. Type A personality<br />
5. Questioning the Type A hypothesis (irritability and hostility are the risk factors)<br />
B. Stress and essential hypertension (high blood pressure with no known cause)<br />
1. Stressors related to hypertension<br />
2. Blood pressure higher when angry<br />
3. Gender differences in effect of anger suppression<br />
a) High job status and belief that success requires great effort increases blood<br />
pressure in women and African-American men<br />
4. Ethnic factors in hypertension: most prevalent in African Americans<br />
C. Migraine, tension, and cluster headaches<br />
1. Migraine: constriction and then dilation of cerebral blood vessels<br />
a) Classic: intense pain, neurological signs before throbbing pain<br />
b) Common: less pain and few neurological signs<br />
c) More hereditary than stress or personality based
104 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
2. Tension: not necessarily related to muscular tension; less severe than migraine<br />
3. Cluster: excruciating pain around the eye<br />
D. Asthma: chronic inflammatory disease of the airways in the lungs<br />
1. Characteristics: often worst at night and early morning, mostly in youngsters<br />
2. Psychological factors important in producing attacks (e.g., negative family<br />
environment)<br />
3. In most cases physical and psychological causes interact<br />
E. Perspectives on etiology<br />
1. Psychodynamic perspective: each physical ailment produced by specific unconscious<br />
conflict, related to aggression and dependency (Alexander)<br />
2. Biological perspective<br />
a) Evidence for genetic base<br />
b) Somatic weakness hypothesis and autonomic response specificity hypothesis<br />
c) General adaptation syndrome<br />
3. <strong>Behavior</strong>al perspective<br />
a) Classical conditioning explains generalization after physiological reaction first<br />
occurs<br />
b) Operant conditioning: autonomic responses can be influenced by reinforcement<br />
(attention)<br />
4. Sociocultural perspective<br />
a) Higher rates of cardiovascular disease in countries stressing individualism versus<br />
collectivism; the latter had higher rates of cerebrovascular disease<br />
b) Acculturated Japanese in California have higher heart disease rates than<br />
traditional Japanese<br />
V. Treatment of psychophysiological disorders<br />
A. <strong>Behavior</strong>al medicine merges a range of disciplines that study the social and psychological<br />
influences on health and provides approaches to medical conditions<br />
B. Relaxation training: tense and relax each muscle group<br />
C. Biofeedback: information (feedback) on internal changes gives patient a means of altering<br />
visceral response<br />
1. An operant technique<br />
2. Used for blood pressure, headache, muscle tensions, blood flow control<br />
D. Cognitive-behavioral interventions<br />
1. Self-instruction and cognitive restructuring<br />
2. When biological processes have primary influence and when psychological processes<br />
primary influence is not clear yet<br />
LEARNING OBJECTIVES<br />
1. Describe the sudden death syndrome and the factors related to it. Discuss how culture shock can<br />
lead to sudden death among Hmong immigrants. (pp. 203-204; Mental Health and Society)<br />
2. List the DSM-IV-TR criteria for diagnosis of psychological factors affecting medical conditions.<br />
Explain the rationale for changes in terminology from “psychosomatic” to “psychophysiological.”<br />
(pp. 204-206)<br />
3. Discuss the three models for understanding stress, including Selye’s general adaptation syndrome,<br />
the life change model, and Lazarus’s transaction model. (pp. 206-210)<br />
4. Discuss the research linking emotional states to vulnerability to infection. Discuss the evidence<br />
for and against the claim that stress influences the development of Acquired Immune Deficiency<br />
Syndrome (AIDS). (pp. 210-212)<br />
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Chapter 7: Psychological Factors Affecting Medical Conditions 105<br />
5. Describe the components of the immune system and evidence that stress decreases its functioning.<br />
(pp. 212-213)<br />
6. Describe the mediating effects of control and hardiness on stress. (pp. 213-215)<br />
7. Discuss the evidence linking personality, mood, and cancer. (pp. 215-217)<br />
8. Describe the relationship between stress and coronary heart disease and the influence of the Type<br />
A personality on CHD. (pp. 217-220)<br />
9. Describe the relationship between stress and essential hypertension, and the ethnic and social<br />
factors associated with it. (pp. 220-223)<br />
10. Describe the nature of migraine, tension, and cluster headaches. (pp. 223-225)<br />
11. Describe asthma and the psychological factors related to it. (pp. 225-226)<br />
12. Discuss the psychodynamic and biological perspectives on psychophysiological disorders,<br />
including the somatic weakness, autonomic response specificity, and the general adaptation<br />
hypotheses. (pp. 226-227)<br />
13. Discuss the behavioral perspective on psychophysiological disorders, including the influence of<br />
classical conditioning and operant conditioning. Describe how sociocultural factors influence<br />
coronary heart disease. (pp. 227-229)<br />
14. Define behavioral medicine and describe various interventions for psychophysiological disorders,<br />
including medical, relaxation training, biofeedback, and cognitive-behavior therapy. (pp. 229-232)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. The effects of stressors on physical and psychological health are influenced by the availability of<br />
social support. A good deal of research indicates that support has a main effect on health; people<br />
with support are healthier, and some findings also indicate an interaction (stress-buffering) effect.<br />
For more information on this topic, see Cohen, S., and Wills, T. A. (1985). Stress, social support,<br />
and the buffering hypothesis. Psychological Bulletin, 98, 310–357.<br />
Social support takes a variety of forms. Some support activities involve emotional validation and<br />
ventilation. Having someone to talk to about emotional experiences and problems appears to<br />
reduce stress reactions and lengthen life expectancy. Instrumental support includes helping that<br />
involves money, tools, babysitting, and other tangible resources. Another type of social support is<br />
providing information. Informational support can be especially beneficial in work settings and<br />
when a person is a newcomer to a situation.<br />
An important distinction in social support is between that which is received and that which is<br />
perceived. Many studies have shown that the expectation that support is available or its rating of<br />
utility is protective of our mental and physical health. It may be that the support we see is as<br />
important as the support we actually obtain. It is possible that perceived support develops out of<br />
an individual’s sense of optimism or pessimism, in which case support perception is more an<br />
individual personality variable than an environmental one. There is also the distinction between<br />
effective and ineffective supports. In some cases, people have such abrasive or dependent styles<br />
that interactions that might otherwise be mutually supportive become aversive. Excessive support<br />
can be seen as meddling or paternalism. On the other side of the coin, providing help can be such<br />
a draining and frustrating experience that the support provider may be extinguished by helping.<br />
Clearly, long-term support given by family members for those with Alzheimer’s disease has<br />
negative health and emotional effects on the support provider (Basic <strong>Behavior</strong>al Science Task<br />
Force, 1996).
106 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
In many ways, the topic of social support emphasizes that stress reactions are not merely the result<br />
of environmental demands or personality patterns. The availability of psychosocial resources<br />
surrounding a stressful situation and the individual’s capacity to make use of these resources<br />
influence the process as well.<br />
A handout is provided to get students thinking about the structure and quality of the support<br />
network around them. It can lead to some emotional moments, particularly for students who feel<br />
isolated or insufficiently supported. Be sure to provide individual time for those students who<br />
might want to discuss the problems they see in their own support system.<br />
Source: Basic <strong>Behavior</strong>al Science Task Force of the National Advisory Mental Health Council<br />
(1996). Basic behavioral science research for mental health: Family processes and social<br />
networks. American Psychologist, 51, 622–630.<br />
Internet Site: http://psychcentral.com/psyhelp/chap5/chap5d.htm This site defines stress in several<br />
different ways.<br />
2. The Type A personality pattern may be reinforced and modeled in work and school situations.<br />
Where Type A leaves off and “workaholism” begins is not clear. A good topic for discussion is<br />
the tendency for some managers, professors, and others to encourage time-pressured and highly<br />
competitive modes of behavior. You should point out to students that Type A personalities do not<br />
usually rise to the top of corporations for any of several plausible reasons: (1) Some hard-driving<br />
Type A’s may die prematurely and never reach the top; (2) Type A’s tend to irritate others,<br />
making it difficult for them to maintain friendships and win the support of the backers they need<br />
to achieve the highest levels of management; and (3) Type A’s tend to perform best at tasks that<br />
require little compromise and contemplation—not exactly the kinds of tasks that confront<br />
top-level managers.<br />
Internet Site: http://www.2h.com/Tests/personality.phtml. This site contains a large selection of<br />
personality tests that you can take on the Internet including type A personality.<br />
3. Many of the physiological changes that occur during stress involve the hypothalamus-pituitaryadrenal<br />
axis and are influenced by the hormone cortisol. Therefore, changes in cortisol levels<br />
reflect changes in stress responses. A well-documented sex difference in corticosterone levels<br />
exists in lab rats: females are higher at baseline and respond to stressors like restraint or shock<br />
with increased secretion. Kirschbaum et al. (1992) report the first studies of laboratory-induced<br />
psychological stress in humans during which repeated cortisol levels were assessed. In four<br />
experiments the researchers show a dramatic sex difference in stress (cortisol) response.<br />
Subjects experienced stress in a number of ways. Some were told to take the role of a job<br />
applicant and speak for five minutes before three strangers who acted as a selection committee.<br />
Some were asked to subtract, as quickly as possible, the number 13 from 1022 and start over if<br />
they made a mistake. Some pedaled stationary bicycles with the tension increased every two<br />
minutes until they were exhausted. Finally, others were given injections of corticotropin-releasing<br />
hormone. Cortisol levels were assessed by a recently developed saliva test every ten minutes<br />
during the fifty- to one hundred-minute test sessions.<br />
Men and women showed nearly identical baseline cortisol levels and very similar curves as<br />
cortisol levels increased and decreased in response to the biological stressor of muscle fatigue and<br />
the physiologically induced changes caused by the corticotropin-releasing hormone injection. This<br />
result indicates that men and women are similar in their biological reactivity. However, in the<br />
public speaking and arithmetic situations, both of which increased cortisol levels two to four times<br />
baseline levels, men showed much higher peaks than women. In fact, men averaged from 1.5 to 2<br />
times higher in cortisol than women did. Kirschbaum et al. (1993) argue that, although not<br />
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Chapter 7: Psychological Factors Affecting Medical Conditions 107<br />
conclusive, these sex differences stem from different interpretations of distressing psychosocial<br />
situations which, in turn, alter cortisol levels and perceived stress.<br />
Source: Kirschbaum, C., Wust, S., & Hellhammer, D. (1992). Consistent sex differences in<br />
cortisol responses to psychological stress. Psychosomatic Medicine, 54, 648–657.<br />
4. The text describes cluster headaches as excruciating. Indeed, sufferers often contemplate suicide.<br />
Fortunately, some European physicians have found some promising prevention and treatment<br />
techniques. A group of Spanish physicians (Pascual, Peralta, & Sanchez, 1995) report that of four<br />
patients with chronic cluster headache, two were dramatically helped with a two-week course of<br />
hyperbaric oxygen. However, the other two patients remained either unimproved or had the<br />
frequency of headaches reduced. Given the lack of a control group and the extremely small<br />
sample, this technique’s effectiveness is still in doubt. Another approach on larger samples has<br />
shown greater cause for optimism. A team in Italy reports that applying Caspian, the active<br />
ingredient in chili peppers, to the nasal passages can prevent the onset of cluster headaches<br />
(Fusco, Fiore, et al., 1994; Fusco, Marabini, et al., 1994). Cluster headaches occur on one side of<br />
the head (usually behind one eye) and cause the nose to become blocked. This team gave Caspian<br />
to either the same-side nostril as the headache or to the opposite side in fifty-one patients with<br />
episodic cluster headaches and nineteen with chronic cluster headaches. Same-side Caspian was<br />
significantly more effective and, among the episodic headache patients, 70 percent reported<br />
marked improvement. Although chronic patients obtained relief for no more than forty days,<br />
finding any preventative is a hopeful sign. Research with rats and humans has found that Caspian<br />
stimulates pain fibers in the nose and perhaps triggers changes in blood flow to the brain, which<br />
may explain the therapeutic effect. Internet Site: http://www.clusterheadaches.com/ is devoted<br />
to the understanding of cluster headaches.<br />
Sources: Fusco, B. M., Fiore, G., Gallo, F., Martelletti, P., et al. (1994). “Capsaicin-sensitivity”<br />
sensory neurons in cluster headache. Headache, 34, 132–137.<br />
Fusco, B. M., Marabini, S., Maggi, C. A., Fiore, G., et al. (1994). Preventative effect of repeated<br />
nasal applications of Capsaicin in cluster headache. Pain, 59, 321–325.<br />
Pascual, J., Peralta, G., & Sanchez, U. (1995). Preventive effect of hyperbaric oxygen in cluster<br />
headache. Headache, 35, 260–261.
108 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
HANDOUT FOR CLASSROOM TOPIC 1:<br />
MAPPING YOUR SOCIAL SUPPORT NETWORK<br />
All of us, to one degree or another, rely on others to cope with life stresses. This activity will help you<br />
see the structure and quality of the social support system that is around you. One way to do this<br />
experience is to focus on a specific, recent stressful event and the people who supported you. Another<br />
way is to think more generally about the helpful people in your life.<br />
Step 1<br />
On a separate sheet of paper (preferably unlined), draw three equally spaced concentric circles so that<br />
they take up the entire page. The inside ring will show the people in your support system to whom you<br />
feel closest, those who know you most intimately and provide the most crucial support. Those in the<br />
second ring have a somewhat less intimate relationship with you; those in the outer ring are still<br />
supportive but not as critically important to you. Now consider the major categories of people in your<br />
life: family, friends from high school, current friends, people you know from work, and so on. There<br />
may be three, four, or more such categories. By drawing lines from the middle of the inner most circle,<br />
divide the concentric circles into as many pie-shaped pieces as you have categories of support people.<br />
Step 2<br />
On the next page, list by initials the people you consider to be the major supportive individuals in your<br />
life. Some could be “specialists,” people to whom you go for help on specific problems; some will be<br />
“generalists.” Some people you may see virtually every day; some you may see only periodically. Some<br />
might provide emotional support (listening to your problems or letting you know you are important to<br />
them); some might provide informational support (how to do something); some might provide<br />
instrumental support (loaning you money when you are broke); and, of course, some will provide<br />
combinations of these types of support. Don’t worry if you don’t have twenty-six names, just stop when<br />
you run out of names. Finally, decide whether your relationship with each person is in the inner (most<br />
intimate and supportive), the second, or third ring. You may also want to rate the quality of the support<br />
each person provides.<br />
Step 3<br />
Now write the initials of each person on the diagram in the location that identifies his or her closeness<br />
to you and the category or sphere of your life where you interact (family, work, school, and so on).<br />
Draw a small circle around each of the initials (people). At this point you can do many things to depict<br />
the nature of your support system. One is to draw lines between all the people in the network who know<br />
or are friends with one another. This activity will reveal the density of the network (the number of<br />
connections out of the total possible). It can also reveal how integrated or isolated the various spheres<br />
of your life might be. For instance, if you draw many lines across boundaries of your life, you have a<br />
highly integrated network—people at school know your family, and people at work know friends you<br />
made in high school. You can use colors or other designations to indicate the kinds of support that<br />
people provide (one for emotional, one for information, one for instrumental). You could indicate<br />
whether the direction of support is usually from that individual toward you or is mutual—you provide<br />
as much support as he or she does. One more issue you could examine is the direction of the<br />
relationship: Is the person moving toward the inner ring, toward the outer ring, or staying at the same<br />
level of intimacy/support? You can also examine other aspects of the network, but this exercise should<br />
have made it messy enough!<br />
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Chapter 7: Psychological Factors Affecting Medical Conditions 109<br />
Supportive Individuals Supportive Individuals<br />
Initials Closeness (Ring) Initials Closeness (Ring)<br />
1. 14.<br />
2. 15.<br />
3. 16.<br />
4. 17.<br />
5. 18.<br />
6. 19.<br />
7. 20.<br />
8. 21.<br />
9. 22.<br />
10. 23.<br />
11. 24.<br />
12. 25.<br />
13. 26.<br />
CLASSROOM DEMONSTRATIONS<br />
1. If biofeedback equipment is available, an in-class demonstration is the best way to show how<br />
information about internal changes can make involuntary responses come under conscious<br />
control. Finger temperature indicators are relatively inexpensive and require no training to use. In<br />
addition, finger temperature feedback is a method of treating migraine headaches.<br />
Internet Site: http://www.aapb.org/. This site is the Association of Applied Psychophysiology<br />
and Biofeedback.<br />
2. Most stress models now accept the idea that individual differences in the perception of events and<br />
means of coping with them alter stress reactions. Furthermore, some stress and coping behaviors<br />
act as stressors themselves, keeping the person in distress, whereas others relieve stress. The<br />
following exercise can help students develop a cyclic model of stress that includes stressors,<br />
perceptions, physical and psychological reactions, and coping responses (some of which may<br />
produce new stressors).<br />
Divide the class into four groups. Handouts are provided for four groups of students. Rather than<br />
segregating students by topic, all students could complete the four sections of the handout. Group<br />
1 is assigned the task of brainstorming examples of stressors that are common among students<br />
they know (such as arguments with a roommate). After the group has developed a long list of such<br />
items, the group must decide on the half-dozen or so that occur most frequently. Group 2 is<br />
assigned the task of coming up with a list of perceptual statements or self-statements that they feel<br />
students commonly use when dealing with stressors (such as, “I can’t deal with this any more.”).<br />
They, too, must cull their list to the most commonly occurring statements in student populations.<br />
Group 3 is assigned the task of deciding, in similar fashion, what kinds of physical and<br />
psychological stress reactions they think are most common (such as headaches or restless<br />
walking). Group 4 should come up with a list of frequently used coping methods (such as<br />
shopping or talking with friends).<br />
On the board draw four large boxes in a diamond shape. Label the boxes Stressors, Perceptions,<br />
Physical and Psychological Reactions, and Coping Responses. Put an arrow to connect each box.<br />
Ask students to report the results of their deliberations and write the ideas in the appropriate boxes<br />
on the board. Explain to them that, at each step in the process, individuals exercise some control<br />
(even in the area of stressors). Changes at any point in the cycle can reduce stress. Also suggest<br />
that each coping response can have short-term positive consequences (which is why it is<br />
considered a coping response), but that some coping responses may have long-term negative
110 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
consequences that produce more stressors, not fewer. The key to stress management is finding<br />
methods of coping that produce positive consequences in both the short and long term.<br />
Internet Site: http://psychcentral.com/psyhelp/chap5/chap5d.htm . This site defines stress in<br />
several different ways.<br />
3. The cognitive perspective has had a major impact on our understanding of the stress-illness<br />
relationship. Where once psychologists viewed the sheer number of life events as the best way of<br />
measuring stress, current researchers emphasize the way those events are perceived. The first<br />
semester of college, for instance, can be a deeply threatening dislocation for one person and a<br />
delightful opportunity for another. The Perceived Stress Scale (PSS), developed by Cohen et al.<br />
(1983), is a fourteen-item tool that measures the stressfulness of recent experience. It asks about<br />
the degree to which recent situations have seemed overwhelming, uncontrollable, and<br />
unpredictable.<br />
Students can complete the questionnaire (see handout section) and score it themselves in class.<br />
Here is the scoring key: Items that are scored positively are 1, 2, 3, 8, 11, 12, and 14; items that<br />
are reverse-scored are 4, 5, 6, 7, 9, 10, and 13. For reverse-scored items, 0 = 4, 1 = 3, 2 = 2, 3 = 1,<br />
and 4 = 0. Mean scores for males, females, and overall, reported by Cohen et al. (1983), are as<br />
follows: males 22.1; females 24.7; overall 23.5. The difference between males and females is not<br />
statistically significant.<br />
The PSS is a good discussion starter. Students can be asked about the combinations of<br />
environmental and cognitive factors that account for their stresses, the impact on health-related<br />
behaviors such as eating and sleeping, and illness consequences. It is good to ask if any student<br />
has a high level of perceived stress but relatively good health. Ask him or her for explanations for<br />
what seems like a health-protective phenomenon. Mention such factors as low biological<br />
reactivity, strong social supports, and good health practices.<br />
Source: From “A Global Measure of Perceived Stress,” by S. Cohen, T. Kamarck, & R.<br />
Mermelstein, Journal of Health and Social <strong>Behavior</strong>, 24, pp. 385–396. Copyright © 1983. Used<br />
by permission.<br />
4. Stressful life events are key psychological factors in physical disorders, but there is controversy<br />
over how to measure life events. The original, and still widely used, instrument is the Social<br />
Readjustment Rating Scale (SRRS) (Holmes & Rahe, 1967). An alternative is the Life<br />
Experiences Survey (LES) (Sarason et al., 1978). It would take too long for students to fill out<br />
both surveys, but you can present shortened versions of them to illustrate their strengths and<br />
weaknesses.<br />
Holmes, Rahe, and their colleagues surveyed thousands of people in a variety of cultures and had<br />
them rate the impact of the SRRS items. By averaging these ratings, they give life change unit<br />
scores for each. The problem is that what is average for thousands of people may not be<br />
appropriate for an individual. Further, the SRRS implies that positive as well as negative events<br />
are stressful and linked to illness. However, a review of the literature finds that changes for the<br />
better are not correlated with distress (Thoits, 1983). See if your students note a glaring problem<br />
with the SRRS: personal illness is scored as both a stressor and the thing stressors are supposed to<br />
predict—illness!<br />
The LES gives the respondent control over rating the event’s impact, opening the door to denial,<br />
exaggeration, or other forms of bias. It, too, lists what are presumed to be common stressful<br />
events. It does have the advantage of leaving blanks for unlisted events that the respondent<br />
experienced. However, it, like the SRRS, leaves some events undefined (for example, “trouble<br />
with in-laws”). Ask students what life events they would add to such surveys and whether<br />
different populations require different lists of events. Finally, suggest that daily hassles may have<br />
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Chapter 7: Psychological Factors Affecting Medical Conditions 111<br />
as much or more relationship to physical and mental distress as the major, discrete events listed in<br />
these measures (Zarski, 1984). This partially explains the relatively weak correlations between<br />
stressful life event scores and near-term illness.<br />
Items from the Social Readjustment Rating Scale<br />
In the past six months, have you experienced any of the following?<br />
Event Life Change Units (LCUs)<br />
1. Death of a spouse 100<br />
2. Divorce 73<br />
3. Jail term 63<br />
4. Personal injury or illness 53<br />
5. Marriage 50<br />
6. Gain of new family member 39<br />
7. Change in responsibilities at work 29<br />
8. Begin or end school 26<br />
9. Change in recreation 19<br />
10. Christmas 12<br />
Items from the Life Experience Survey<br />
Please check the events you have experienced in the recent past and indicate the period during<br />
which you have experienced each event. Also, for each item checked, please indicate the extent to<br />
which you viewed the event as having either a positive or negative impact on your life at the time<br />
it occurred.<br />
Event Negative Positive<br />
0–6 mo 7–12 mo Extreme Moderate Some None Some Moderate Extreme<br />
1. Marriage –3 –2 –1 0 +1 +2 +3<br />
2. Major change in eating<br />
habits (much more or<br />
much less)<br />
–3 –2 –1 0 +1 +2 +3<br />
3. New job –3 –2 –1 0 +1 +2 +3<br />
4. Death of close friend –3 –2 –1 0 +1 +2 +3<br />
5. Trouble with in-laws –3 –2 –1 0 +1 +2 +3<br />
6. Breaking up with<br />
boyfriend/girlfriend<br />
–3 –2 –1 0 +1 +2 +3<br />
7. Failing a course in<br />
school<br />
–3 –2 –1 0 +1 +2 +3<br />
8. Borrowing for a major<br />
purchase (e.g., home)<br />
–3 –2 –1 0 +1 +2 +3<br />
Other recent experiences that have had an impact on your life<br />
Event Negative Positive<br />
____________________<br />
____________________<br />
0–6 mo 7–12 mo Extreme Moderate Some None Extreme Moderate Some<br />
Sources: Reprinted by permission of the publisher from “Items from the Social Readjustment<br />
Rating Scale,” by T. Holmes and R. Rahe, Journal of Psychosomatic Research, 11, 1967, pp.<br />
213–218. Copyright © 1967 by Elsevier Science Inc.
112 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
Life Experience Survey from “Assessing the Impact of Life Changes: Development of the Life<br />
Experiences Survey,” by I. G. Sarason, J. H. Johnson, & J. M. Siegel, Journal of Consulting and<br />
Clinical Psychology, 46, pp. 932–946. Copyright 1978 by the American Psychological<br />
Association. Reprinted by permission of the American Psychological Association and the author;<br />
Thoits, P. A. (1983). Dimensions of life events as influences upon the genesis of psychological<br />
distress and associated conditions: An evaluation and synthesis of the literature. In H. B. Kaplan<br />
(Ed.), Psychosocial stress: Trends in theory and research. New York: Academic Press; Zarski, J.<br />
J. (1984). Hassles and health: A replication. Health Psychology, 3, 243–251.<br />
5. A major stressor for students is finals week. The general adaptation and life-events models of<br />
stress-related illnesses suggest that large numbers of students should become sick during finals or<br />
just after they are over. On the other hand, the transaction model would emphasize the importance<br />
of thoughts and coping methods as mediators of a stressor-illness relationship. You can informally<br />
put these models to the test by asking students to recall the finals period in the semester or quarter<br />
prior to the one you are teaching. Ask them to recall the situation and give an overall rating of its<br />
stressfulness. Then have them list the physical symptoms they might have experienced during and<br />
after finals. A handout is provided. Compile their responses and cluster their responses into<br />
categories of high, medium, and low stressfulness. During class time, examine whether, on<br />
average, students in the high-stressful group were more likely than those in the low-stressful<br />
group to fall ill during or after finals. If the high-stressful group lists more symptoms than the<br />
low-stressful group, there is support for the general-adaptation and life-events approaches. If not,<br />
there may be mediating factors such as coping methods, beliefs, and health behaviors that might<br />
account for the results. These would support Lazarus’s transaction model. Ask students to<br />
describe what their lives were like during and after finals. What explanations do they offer for the<br />
results?<br />
Another element in this demonstration is to ask students to predict the stressfulness of finals week<br />
for the present semester or quarter and their estimated likelihood of becoming ill during it. When<br />
finals week arrives, you can survey students about their current health to see how well they<br />
predicted their own future. You can keep these predictions on file and share them with the next<br />
class you teach.<br />
Remind your students that the first activity’s retrospective research opens itself to several kinds of<br />
bias. Students may inaccurately recall the degree or number of stressors they faced in the previous<br />
finals period, they may fail to recall or inflate the recollection of illnesses, and they may<br />
inaccurately date their occurrence. The prospective design of the second activity avoids these<br />
problems but is vulnerable to a different bias: having made a personal prediction, students may<br />
alter their reporting of current circumstances to prove those predictions accurate.<br />
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Chapter 7: Psychological Factors Affecting Medical Conditions 113<br />
HANDOUT FOR DEMONSTRATION 1:<br />
STRESSORS, THOUGHTS STRES REACTIONS,<br />
AND COPING BY STUDENTS<br />
This activity is designed to get you thinking about the range of events, thoughts, stress reactions, and<br />
coping mechanisms you might see in college students. The activity requires you to brainstorm first and<br />
then reduce your list of ideas to the best three or four. Brainstorming means that each person in the<br />
group should come up with as many ideas as he or she can. Criticism is forbidden although requests for<br />
clarification are permitted. For each of the four topics in this exercise, the group should generate a<br />
minimum of ten ideas. When no more ideas are coming, the group should think about the three or four<br />
most commonly occurring examples from the original list. In other words, if group members came up<br />
with thirteen different coping methods that students use to deal with stress, they will need to decide on<br />
the three or four most commonly used methods they have seen in themselves, their friends, and others.<br />
Depending on how your instructor set up the activity, your group will either complete all four parts<br />
below or just the part that was assigned to you.<br />
I. Stressors<br />
List ten or more stressful situations that are common in the life of college students. These can include<br />
discrete life events such as taking final exams or breaking up with boyfriend/girlfriend or more<br />
prolonged situations such as not having enough money or driving an unreliable car.<br />
1. _________________________ 6. _________________________<br />
2. _________________________ 7. _________________________<br />
3. _________________________ 8. _________________________<br />
4. _________________________ 9. _________________________<br />
5. _________________________ 10. _________________________<br />
The most common stressors facing students<br />
1. ______________________________________________________________________________<br />
2. ______________________________________________________________________________<br />
3. ______________________________________________________________________________<br />
II. Stress-related thoughts<br />
List at least ten thoughts that you or others commonly think tend to inflate stress reactions. Sometimes<br />
called “catastrophic thoughts,” they can be about the event (This is the worst thing that ever happened.);<br />
about the expected consequences of the event (If I have to face her again, I’ll die of embarrassment.); or<br />
about the individual’s perceived capacity to deal with the event (I know I cannot deal with these<br />
situations.).<br />
1.<br />
2.<br />
3.<br />
4.<br />
_________________________ 6. _________________________<br />
_________________________ 7. _________________________<br />
_________________________ 8. _________________________<br />
_________________________ 9. _________________________
114 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
5.<br />
_________________________ 10. _________________________<br />
The most common stress-inflating thoughts<br />
1. ______________________________________________________________________________<br />
2. ______________________________________________________________________________<br />
3. ______________________________________________________________________________<br />
III. Stress Reactions<br />
List ten or more stress reactions that are common in the life of college students. These can include<br />
behaviors such as irritability or crying or medical conditions such as headache or nausea. Ask if the<br />
psychophysiological conditions listed in the book (asthma, ulcer, hypertension, migraine, and tension<br />
headaches) are commonplace.<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
_________________________ 6. _________________________<br />
_________________________ 7. _________________________<br />
_________________________ 8. _________________________<br />
_________________________ 9. _________________________<br />
_________________________ 10. _________________________<br />
The most common stress reactions<br />
1. ______________________________________________________________________________<br />
2. ______________________________________________________________________________<br />
3. ______________________________________________________________________________<br />
IV. Coping Methods<br />
List ten or more coping methods that college students use to respond to stress. These can include<br />
outward behaviors such as talking with friends and shopping or more internal reactions such as<br />
meditating or praying. Some coping mechanisms are focused on reducing bad feelings while others<br />
directly attack the problem at hand. Include both types in your first list.<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
_________________________ 6. _________________________<br />
_________________________ 7. _________________________<br />
_________________________ 8. _________________________<br />
_________________________ 9. _________________________<br />
_________________________ 10. _________________________<br />
The most common coping methods<br />
1. ______________________________________________________________________________<br />
2. ______________________________________________________________________________<br />
3. ______________________________________________________________________________<br />
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Chapter 7: Psychological Factors Affecting Medical Conditions 115<br />
HANDOUT FOR DEMONSTRATION 3:<br />
PERCEIVED LEVEL OF STRESS<br />
Instructions: The questions in this inventory ask you about your feelings and thoughts during the last<br />
month. In each case, you will be asked to indicate how often you felt or thought a certain way.<br />
Although some of the questions are similar, there are differences between them, and you should treat<br />
each one as a separate question. The best approach is to answer each question fairly quickly. That is,<br />
don’t try to count the number of times you felt a particular way, but rather indicate what seems like a<br />
reasonable estimate. For each question, choose from the following alternatives:<br />
0 = never 1 = almost never 2 = sometimes 3 = fairly often 4 = very often<br />
1. In the last month, how often have you been upset because of something that happened<br />
unexpectedly? ________<br />
2. In the last month, how often have you felt that you were unable to control the important things in<br />
your life? ________<br />
3. In the last month, how often have you felt nervous and stressed? ________<br />
4. In the last month, how often have you dealt with irritating life hassles? ________<br />
5. In the last month, how often have you felt that things were going your way? ________<br />
6. In the last month, how often have you felt confident about your ability to handle your personal<br />
problems? ________<br />
7. In the last month, how often have you felt that things were going the way you expected they<br />
would? ________<br />
8. In the last month, how often have you found that you could not cope with all the things that you<br />
had to do? ________<br />
9. In the last month, how often have you been able to control irritations in your life? ________<br />
10. In the last month, how often have you felt that you were on top of things? ________<br />
11. In the last month, how often have you been angered because of things that happened that were<br />
outside of your control? ________<br />
12. In the last month, how often have you found yourself thinking about things that you have to<br />
accomplish? ________<br />
13. In the last month, how often have you been able to control the way you spend your time?<br />
________<br />
14. In the last month, how often have you felt difficulties were piling up so high that you could not<br />
overcome them? ________<br />
Source: From “A Global Measure of Perceived Stress,” by S. Cohen, T. Kamarck, & R. Mermelstein,<br />
Journal of Health and Social <strong>Behavior</strong>, 24, pp. 385–396. Copyright © 1983. Used by permission.
116 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
HANDOUT FOR DEMONSTRATION 5:<br />
STRESS AND HEALTH DURING FINALS WEEK<br />
The following questions are designed to help you remember the last finals period you experienced so<br />
that you can give it an overall rating in terms of stressfulness.<br />
How many courses were you taking? ___________<br />
In how many courses did you take a final exam? ___________<br />
In how many courses did you have papers or other assignments due at the end of the semester or<br />
quarter? ___________<br />
On a scale from 1 to 10 (with 10 = extremely difficult) rate the difficulty level of each course you took.<br />
course 1 ___________ course 2 ___________ course 3 ___________ course 4 ___________<br />
course 5 ___________ course 6 ___________ course 7 ___________ course 8 ___________<br />
What other events were occurring during the finals period that might have added to its stressfulness?<br />
On a scale from 1 to 10 (10 = extremely stressful) give an overall rating to the stressfulness of the last<br />
finals period you experienced. __________<br />
During the last finals period you experienced, did you have any of the following symptoms?<br />
(Circle all that apply) sore throat runny nose fever fatigue<br />
skin rash headaches nausea diarrhea<br />
insomnia stomach pain weight loss cough<br />
sweating dizziness other (specify)<br />
In the week after the last finals period you have experienced did you have any of the following<br />
symptoms?<br />
(Circle all that apply) sore throat runny nose fever fatigue<br />
skin rash headaches nausea diarrhea<br />
insomnia stomach pain weight loss cough<br />
sweating dizziness other (specify)<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 7: Psychological Factors Affecting Medical Conditions 117<br />
SELECTED READINGS<br />
Booth-Kewley, S., & Friedman, H. S. (1987). Psychological predictors of heart disease: A quantitative<br />
review. Psychological Bulletin, 101, 342–362.<br />
Cohen, S., & Williamson, G. M. (1991). Stress and infectious disease in humans. Psychological<br />
Bulletin, 109, 5–24.<br />
Friedman, H. S. (Ed.) (1991). Hostility, coping, and health. Washington, DC: American Psychological<br />
Association.<br />
O’Leary, A. (1990). Stress, emotion, and human immune function. Psychological Bulletin, 108, 363–<br />
382.<br />
Rodin, J., & Salovey, P. (1989). Health psychology. Annual Review of Psychology, 40, 533–579.<br />
Sattler, D., Shabatay, V., and Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 6, Psychological Factors and Medical<br />
Conditions.<br />
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 8, Stress-Related Disorders.<br />
VIDEO RESOURCES<br />
Biofeedback: Listening to Your Head (16 mm, color, 22 min). Brain-wave biofeedback as a technique<br />
to control diseases and emotional problems and to open new avenues of communication. Ideal School<br />
Supply Company, 1100 S. Lavergne Avenue, Oak Lawn, IL 60453.<br />
Biofeedback and Self-Regulation (16 mm, color, 22 min). Interviews with Neal Miller and others<br />
illustrate how people can directly control a variety of physiological processes. Harper & Row Media, 10<br />
E. 53rd Street, New York, NY 10022.<br />
Headaches (16 mm, 15 min). This film differentiates the various forms of headache and their causes<br />
and describes symptoms that require medical attention. Journal Film, Inc., 930 Pitner Street, Evanston,<br />
IL 60202.<br />
Health, Mind, and <strong>Behavior</strong> (#23) from the Discovering Psychology series (video, color, 30 min). This<br />
segment reviews recent research on the relationship between mind and body, including<br />
psychoneuroimmunology and biofeedback. The Annenberg/CPB Collection, Dept. CA94, P.O. Box<br />
2345, S. Burlington, VT 05407-2345; to order, call 1-800-532-7637.<br />
Management of Asthmatic Children (16 mm, 30 min). The contribution of psychological factors to<br />
asthma in young children is illustrated by a lecturer who works with a child’s parents. Time-Life<br />
Multi-Media, 100 Eisenhower Drive, Paramus, NJ 07652.<br />
Stress (16 mm, 11 min). A very brief description of Selye’s work on the general adaptation syndrome<br />
and how that syndrome is related to psychophysiological disorders. Contemporary Films, McGraw-Hill,<br />
1221 Avenue of the Americas, New York, NY 10020.<br />
Stress: A Disease of Our Time (16 mm, color, 35 min). This film shows several experiments with<br />
disorders such as migraine headache, peptic ulcer, and asthma to relate the experience of stress to<br />
illness. Time-Life Multi-Media, 100 Eisenhower Drive, Paramus, NJ 07652.<br />
Emotion and Illness (VHS, color, 30 mm.). Looks at the immunology research that shows a link<br />
between emotional and physical health. Films for the Humanities and Science. 1-800-257-5126.
118 Chapter 7: Psychological Factors Affecting Medical Conditions<br />
Hypertension: The Relaxation Response (VHS, color, 50 mm.). Teaches the viewer to use relaxation<br />
techniques to manage stress and hypertension. Insight Media. 1-800-233-9910.<br />
Managing Stress, Anxiety, and Frustration (VHS, color, 60 min.). Looks at how stress is linked to<br />
many physiological disorders. Insight Media. 1-800-233-9910.<br />
The Nature of Stress (VHS, color, 60 mm.). Part of The World of <strong>Abnormal</strong> Psychology series.<br />
The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S. Burlington, VT 05407-2345; to order,<br />
call 1-800-532-7637.<br />
The Relaxation Response (VHS, color, 30 mm.). Looks at the relaxation response and shows exercises<br />
to elicit that response. Films for the Humanities and Science. 1-800-257-5126.<br />
ON THE INTERNET<br />
http://www.pslgroup.com/ is an organization based in Australia that has developed the “Doctor’s<br />
Guide to the Internet.”<br />
http://www.americanheart.org/ the home page for The American Heart Association, which has an<br />
extensive listing of materials on heart disease and stroke.<br />
http://www.takeheart.co.uk/ at this site individuals can check their own risk for developing coronary<br />
heart disease, and learn more about symptoms, course, risk factors, prevention, etc.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
CHAPTER 8<br />
Personality Disorders and Impulse Control<br />
Disorders<br />
CHAPTER OUTLINE<br />
I. Personality disorders<br />
A. Characteristics<br />
1. Inflexible and maladaptive behaviors<br />
2. Social difficulties, subjective distress, or problems in functioning<br />
3. Account for 5 to 15 percent of admissions to hospitals and outpatient clinics; overall<br />
lifetime prevalence between 10 and 13 percent<br />
4. Gender distribution: more men have paranoid, obsessive-compulsive, and antisocial;<br />
more women have borderline, dependent, and histrionic<br />
5. Problems in diagnosis<br />
a) Recorded on Axis II of DSM<br />
b) Extreme versions of normal personality traits; DSM requires either-or decision<br />
about disorder<br />
c) Overlap of symptoms with other disorders<br />
d) Clinicians do not adhere to diagnostic criteria<br />
e) Criteria: current and long-term personality pattern, either notably impairs<br />
functioning or causes distress<br />
B. Etiological and treatment considerations for personality disorders<br />
1. Use five-factor model (FFM) of personality and see disorders as extremes<br />
a) Neuroticism (emotional instability)<br />
b) Extraversion (prefer interaction)<br />
c) Openness to experience (curious and willing to entertain new ideas)<br />
d) Agreeableness (helpful and forgiving)<br />
e) Conscientiousness (organized)<br />
2. Causes<br />
a) Genetics<br />
b) Family environment<br />
3. Treatment<br />
a) Approaches vary<br />
b) Frequently not sought<br />
c) Research needed to verify efficacy of different approaches for different<br />
personality disorders<br />
4. Ten personality disorders in three clusters<br />
a) Odd or eccentric behaviors: paranoid, schizoid, schizotypal<br />
b) Dramatic, emotional, or erratic behaviors: histrionic, narcissistic, antisocial,<br />
borderline<br />
c) Anxious or fearful behaviors: avoidant, dependent, obsessive-compulsive<br />
C. Disorders characterized by odd or eccentric behaviors<br />
1. Paranoid personality disorder: unwarranted suspiciousness, lack of emotion, hypersensitivity<br />
Copyright © Houghton Mifflin Company. All rights reserved.
120 Chapter 8: Personality Disorders and Impulse Control Disorders<br />
a) DSM-IV-TR prevalence estimate is 0.5 to 2.5 percent; somewhat higher among<br />
males<br />
b) Psychoanalytic thinking emphasizes projection<br />
2. Schizoid personality disorder: desired social isolation; relationship to schizophrenia<br />
unclear<br />
3. Schizotypal personality disorder: oddities of thinking and behavior without loss of<br />
reality contact; social isolation secondary<br />
a) Occurs in approximately 3 percent of population<br />
b) Higher risk of schizotypal disorder among relatives of schizophrenics<br />
D. Disorders characterized by dramatic, emotional, or erratic behavior<br />
1. Histrionic personality disorder: self-dramatizing, attention seeking, and exaggerated<br />
emotions<br />
a) Prevalence between 1 and 3 percent<br />
b) Diagnosed more frequently among women<br />
2. Narcissistic personality disorder: exaggerated self-importance<br />
a) Denial and devaluation of others to prop up self-concept<br />
b) Prevalence about 1 percent; more prevalent in males<br />
3. Antisocial personality disorder: guiltless, little loyalty (more on this later)<br />
4. Borderline personality disorder: fluctuations in mood including angry outbursts;<br />
identity problems; feelings of emptiness; capricious behaviors<br />
a) Most commonly diagnosed personality disorder (DSM-IV-TR prevalence<br />
estimates prevalence at 2 percent; three times more common in females)<br />
b) Lack of purposefulness<br />
c) Etiological theories: psychodynamic (split objects into all good or all bad,<br />
including self); social learning (poor coping skills); cognitive (mistaken<br />
assumptions and attributions)<br />
E. Disorders characterized by anxious or fearful behaviors<br />
1. Avoidant personality disorder: desires attention from others but hypersensitive to<br />
disapproval; fantasies of intimacy; depression and inadequacy<br />
2. Dependent personality disorder: unwilling to assume responsibility; low selfconfidence;<br />
lets others decide<br />
a) Prevalence about 2.5 percent<br />
b) Cognitions: think they are inherently inadequate and need someone to take care<br />
of them<br />
3. Obsessive-compulsive personality disorder: perfectionistic; no expression of warmth,<br />
demanding of others; indecisive<br />
a) Prevalence about 1 percent; twice as common in males<br />
II. Antisocial personality disorder<br />
A. Views of ASP:<br />
1. Historically called moral insanity, moral imbecility, moral defect, and psychopathic<br />
inferiority<br />
2. Diagnosis of APD (also called sociopathic or psychopathic personality) has now lost<br />
some of the moralistic overtones despite disregard for society rules and morals.<br />
B. Cleckley’s checklist of characteristics<br />
1. Superficial charm and good intelligence<br />
2. Shallow emotions, lack of empathy<br />
3. Little life plan or order<br />
4. Failure to learn from experience, lack of anxiety<br />
5. Unreliability and dishonesty<br />
C. DSM-IV-TR symptoms<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 8: Personality Disorders and Impulse Control Disorders 121<br />
1. Do not include lack of anxiety, shallow emotions, failure to learn from punishment, or<br />
superficial charm<br />
2. Does include history of truancy/delinquency before age 15 (but diagnosis at or after 18<br />
years old)<br />
3. Revised psychopathy checklist has two factors: egocentricity and impulsivity/<br />
antisocial behavior; only second factor fades with age<br />
D. Incidence about 3 percent of American males; less than 1 percent females<br />
E. Two types: primary psychopath (lacks guilt) and secondary psychopath<br />
F. Explanations of antisocial personality disorder<br />
1. Psychodynamic perspective<br />
a) Faulty superego development<br />
b) Lack of parental identification<br />
2. Family and socialization perspectives<br />
a) Divorce and socioeconomic indicators weak predictors of disorder<br />
b) Poor parental involvement and prenatal hostility good predictors of disorder<br />
c) Antisocial father as model; use social skills to manipulate others<br />
3. Genetic influences<br />
a) Five times more common among first-degree biologic relatives of males<br />
b) MZ twins’ concordance rate higher than that of DZ twins<br />
c) Greater likelihood among adoptees whose biologic parents have APD, but does<br />
not preclude environmental factors<br />
4. Central nervous system abnormality<br />
5. Autonomic nervous system abnormalities: inability to learn from experiences, absence<br />
of anxiety, tendency to engage in thrill-seeking behaviors<br />
6. Fearlessness or lack of anxiety (Lykken, 1982): failure to learn avoidance because of<br />
underarousal; research supports hypothesis<br />
7. Arousal, sensation seeking, and behavioral perspectives<br />
a) Big T’s (thrill seekers): either constructive (test pilots) or destructive (antisocial<br />
personality)<br />
b) Type and certainty of punishment are important: physical, social, material<br />
punishment ineffective for APD, but loss of memory is effective and when<br />
punishment is highly certain<br />
G. Treatment of antisocial personality disorder<br />
1. Antisocial are poorly motivated to change themselves<br />
2. Successful treatment may require behavior controls<br />
3. <strong>Behavior</strong>al and cognitive approaches are not very effective<br />
4. Treatment strategies should focus on antisocial youth who seem amenable to treatment<br />
and should involve family and peers<br />
III. Disorders of impulse control<br />
A. Characteristics<br />
1. Failure to resist temptations resulting in harm<br />
2. Tension before committing act<br />
3. Release after committing act<br />
4. Guilt may or may not be felt<br />
B. Intermittent explosive disorder: discrete episodes of uncontrolled aggression<br />
C. Kleptomania: recurrent failure to resist impulses to steal; more common in women<br />
D. Pathological gambling: inability to resist gambling<br />
1. About 2 to 3 percent of adults; more common in males<br />
2. Manic while winning; depression follows<br />
3. Cognitive-behavioral approaches focus on erroneous beliefs about ability to influence<br />
outcomes governed by chance
122 Chapter 8: Personality Disorders and Impulse Control Disorders<br />
E. Pyromania: deliberate fire setting driven by fascination, not revenge<br />
1. Pleasure in observing fires<br />
2. Children are hostile and impulsive<br />
3. More common in males<br />
F. Trichotillomania: irresistible urge to pull out one’s own hair<br />
1. More common in women<br />
2. About 1 percent of college students report current or past history<br />
G. Etiology and treatment of impulse control disorders<br />
1. Little information on causes<br />
a) In some ways like obsessive-compulsive disorders, in other ways like substance<br />
abuse, in others like sexual deviance<br />
2. Psychoanalytic theory stresses sexual symbolism<br />
3. <strong>Behavior</strong>ists stress variable reinforcement schedule<br />
4. Lesieur (1989) notes two explanatory camps<br />
a) Impulse control problems on a continuum (behavioral, cognitive, and<br />
sociological perspectives)<br />
b) Impulse control disease (psychodynamic and physiological perspectives)<br />
5. Treatments often include behavioral and cognitive methods; can include family and<br />
self-help groups (such as Gamblers Anonymous)<br />
LEARNING OBJECTIVES<br />
1. Discuss the general characteristics of personality disorders, the factors involved in considering a<br />
personality pattern a disorder, how they are diagnosed in the DSM-IV-TR, and why they are<br />
difficult to diagnose. (pp. 235-237)<br />
2. Discuss the prevalence and gender distribution of personality disorders and possible reasons for<br />
gender differences. (pp. 237-238; Critical Thinking)<br />
3. Discuss the causal considerations for personality disorders, including the five-factor model and its<br />
relevance. Explain why we know little about treating personality disorders. (pp. 237-238)<br />
4. Describe the three clusters of personality disorders. (p. 238; Figure 8.1)<br />
5. Describe and differentiate among the characteristics of paranoid, schizoid, and schizotypal<br />
personality disorders. Discuss how schizoid and schizotypal personality disorders are<br />
differentiated from schizophrenia. (pp. 238-243)<br />
6. Describe and differentiate among the characteristics of histrionic, narcissistic, antisocial, and<br />
borderline personality disorders. (pp. 243-247)<br />
7. Describe and differentiate among the characteristics of avoidant, dependent, and obsessivecompulsive<br />
personality disorders. (pp. 247-250)<br />
8. Describe the characteristics and incidence of antisocial personality disorder and how it is<br />
differentiated from criminal behavior. Explain why it is a difficult population to study. (pp. 250-<br />
252)<br />
9. Describe and discuss the etiological theories of antisocial personality disorders, including<br />
psychodynamic, family and socialization, and genetic theories. (pp. 252-255)<br />
10. Discuss the relationship between central nervous system and autonomic nervous system<br />
abnormalities and antisocial personality disorder. Discuss the role of fearlessness, lack of anxiety,<br />
under-arousal, learning deficits, and thrill-seeking in the disorder. (pp. 256-259)<br />
11. Describe treatments for antisocial personality and their success. (pp. 259-260)<br />
Copyright © Houghton Mifflin Company. All rights reserved.
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Chapter 8: Personality Disorders and Impulse Control Disorders 123<br />
12. Define impulse control disorders. Describe and differentiate among the following impulse control<br />
disorders: intermittent explosive disorder, kleptomania, pathological gambling, pyromania, and<br />
trichotillomania. (pp. 260-265)<br />
13. Discuss how impulse control disorders overlap with other conditions. Describe the two<br />
explanatory “camps” for these disorders. Review the treatments for impulse control disorders and<br />
their success. (pp. 265-266)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. It should be easy to impress upon students the huge impact that a small number of antisocial<br />
personalities can have on our lives. Charles Manson and, perhaps, Jim Jones stand out as<br />
examples. Further, it is alarming that the number of antisocial personalities appears to be growing.<br />
Ask students whether the enormous increase in drug-related teenage murder can be considered a<br />
symptom of antisocial behavior. (News reporters claim that most of the 366 murders committed in<br />
Washington, D.C., in 1988 were by teenagers who, when their drug customers did not pay, simply<br />
killed them.) What makes the picture even grimmer is the fact that prison does not change<br />
antisocial personalities, and psychological treatment has hardly done much better.<br />
Prevention is the critical third option when treatment and punishment prove ineffective. Ask<br />
students what aspects of family and social life must change to prevent new cases of antisocial<br />
personality. Prod them to think about training for parenthood, the impact of television and movies,<br />
drug culture, and unemployment. If antisocial personality is actually genetically based, what<br />
should be done with high-risk groups such as the children of antisocial fathers? What hurdles do<br />
they see in the way of preventing new cases of the disorder?<br />
http://www.mentalhealth.com/dis/p20-pe04.html Search for the main characteristics of antisocial<br />
personality disorder.<br />
2. More than in many other chapters, students can come down with “medical student syndrome”<br />
while reading about personality and impulse control disorders. It is a good idea to acknowledge<br />
this. It is also valuable to point out how resisting forbidden behaviors is a part of everyone’s<br />
struggle to cope. Ask students to list (privately) behaviors that they have trouble resisting. These<br />
might include fingernail biting (if hair pulling is a disorder, can nail biting be far behind?), ice<br />
cream eating, television watching, shopping, and computer game playing or Internet surfing. Ask<br />
them what they are feeling before they engage in the “forbidden” behavior. What do they feel and<br />
think during and after? What separates their inability to resist from that of people with impulse<br />
control disorders? Point out the degree to which their behavior dominates their lives, the intensity<br />
of their feelings, and whether the behavior harms anyone else.<br />
In the end, it is impaired functioning and subjective distress that define disorders, one of the<br />
definitions used in Chapter 1.<br />
3. The Five-Factor Model (FFM) (Digman, 1990) has emerged as the dominant approach to<br />
personality patterns in the past ten years. A natural link occurs between this model and the<br />
personality disorders, but the use of the model’s assessment instrument, the NEO Personality<br />
Inventory (Costa & McCrae, 1985), as a diagnostic device has drawn both praise and criticism.<br />
Costa and McCrae (1990) report comparisons of their NEO Personality Inventory with the Millon<br />
Clinical Multiaxial Inventory-II (a highly regarded assessment instrument for diagnosing<br />
personality disorders). The correlation matrix for the two instruments over six personality<br />
disorders is as follows:
124 Chapter 8: Personality Disorders and Impulse Control Disorders<br />
Five-Factor Dimensions<br />
Personality<br />
Disorder Neuroticism Extraversion<br />
Openness to<br />
Experience Agreeableness<br />
Conscientiousness<br />
Borderline .46*** –.09 –.16 –.22 –.22<br />
Compulsive –.05 –.03 –.11 .15 .52***<br />
Narcissistic –.22* .42** .17 –.31* –.24<br />
Paranoid .04 .24 .12 –.07 .02<br />
Schizotypal .39** –.34** –.07 .06 .01<br />
Antisocial .15 .21 .08 –.42*** –.40***<br />
The most striking findings are that, with the exception of paranoid personality disorder, each<br />
disorder has at least one NEO-PI scale that strongly correlates with it. Most of the results are to be<br />
expected. Borderline personality disorder’s chief characteristic is fluctuation in moods, which is<br />
nearly identical to the meaning of the term neuroticism. Obsessive-compulsive personalities are<br />
highly organized and detail-oriented, so “conscientiousness” is likely to be high on their list of<br />
values. Narcissistic individuals distrust others and deride their abilities, so a negative correlation<br />
with “agreeableness” is understandable. Explaining the strong correlation between narcissistic<br />
personality disorder and extraversion is somewhat more difficult, although narcissistic individuals<br />
want others to notice them and their achievements. Schizotypal individuals, with their bizarre<br />
thoughts and interpersonal difficulties, are likely to be both emotionally intense (neuroticism) and<br />
withdrawn from others (introverted). One could also predict that people with antisocial personality<br />
disorder, who are impulsive and interpersonally predatory, would score low on both<br />
conscientiousness and agreeableness.<br />
Widiger and Trull (1992) conclude that while the FFM is a compelling model of personality<br />
disorders, it has serious methodological and conceptual limitations. In particular there has been<br />
little research on the less known factors (agreeableness, openness to experience, and<br />
conscientiousness) and it is difficult to sort out how depression can contribute to personality<br />
disorders. Coolidge et al. (1994) identify four reservations about using the FFM as a model for<br />
personality disorders. First, in their research comparing the NEO-PI and Millon scales, they found<br />
that neuroticism was involved in all of the personality disorders so that it did not help discriminate<br />
among them. Second, Coolidge et al. argue that the model implies that all five factors have equal<br />
weight when, in fact, neuroticism and extraversion do most of the predicting. Third, there is<br />
confusion on whether openness to experience is an intellect factor or not. Costa and McCrae<br />
themselves suggest that intelligence may be a needed sixth factor in explaining personality<br />
disorders. Finally, it is premature to use the NEO Personality Inventory as the only measure of the<br />
five factors; other, older measures have tapped many of the same personality factors.<br />
Sources: Coolidge, F. L., Becker, L. E., DiRito, D. C., Durham, R. L., Kinlaw, M. M., &<br />
Philbrick, P. B. (1994). On the relationship of the five-factor personality model to personality<br />
disorders: Four reservations. Psychological Reports, 75, 11–21.<br />
Costa, P., & McCrae, R. R. (1985). The NEO Personality Inventory Manual. Odessa, FL:<br />
Psychological Assessment Resources.<br />
Costa, P. & McCrae, R. R. (1990). Personality disorders and the five-factor model of personality.<br />
Journal of Personality Disorders, 4, 362–371.<br />
Digman, J. M. (1990). Personality structure: Emergence of the five-factor model. Annual Review<br />
of Psychology, 41, 417–440.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
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Chapter 8: Personality Disorders and Impulse Control Disorders 125<br />
Widiger, T. A., & Trull, T. J. (1992). Personality and psychopathology: An application of the fivefactor<br />
model. Journal of Personality, 60, 363–393.<br />
Internet Site: http://www.personalityresearch.org/bigfive.html . Site on the five factor model.<br />
4. The overlap between the impulse control disorders and obsessive-compulsive disorder is<br />
interesting. Trichotillomania is a difficult disorder to treat successfully and has many of the<br />
characteristics of obsessive-compulsive disorder. Individuals pull their hair out when they feel<br />
anxious, and they experience relief after they do so. Despite disfiguring effects, they continue to<br />
pull out their hair in a chronic, ritualistic way (Christenson et al., 1991). Interestingly,<br />
clomipramine, a drug that is increasingly used to treat obsessive-compulsive disorder, has, in<br />
several case studies, helped patients with trichotillomania (Black & Blum, 1992; Gupta &<br />
Freimer, 1993; Swedo et al., 1989). It also seems that itchy scalp is a problem for many patients,<br />
so the combined use of clomipramine and topical steroid medication may be more effective than<br />
either medication alone.<br />
Gupta and Freimer (1993) report on a 13-year-old girl with a 14-month history of hair pulling who<br />
had no hair longer than an inch in length and so many bald spots that she wore a wig. After taking<br />
150 mg of clomipramine for two weeks and using a topical steroid medication for itching, she had<br />
a complete remission in hair pulling.<br />
Sources: Black, B. W., & Blum, N. (1992). Trichotillomania treated with clomipramine and a<br />
topic steroid (letter). American Journal of Psychiatry, 149, 842–843.<br />
Christenson, G. A., Mackenzie, T. B., & Mitchell, J. E. (1991). Characteristics of 60 adult chronic<br />
hair pullers. American Journal of Psychiatry, 148, 365-370.<br />
Gupta, S., & Freimer, M. (1993). Trichotillomania, clomipramine, and topic steroids (letter).<br />
American Journal of Psychiatry, 150, 524.<br />
Swedo, S. E., Leonard, H. L., Rapoport, J. L., Lenane, M. C., Goldberger, E. L., & Cheslow, D. L.<br />
(1989). A double-blind comparison of clomipramine and desipramine in the treatment of<br />
trichotillomania (hair pulling). New England Journal of Medicine, 321, 497-501.<br />
Internet site: http://www.health-center.com/english/pharmacy/meds/anxiety.htm. Discusses<br />
antianxiety medications, which are often used to treat anxiety disorders such as obsessivecompulsive<br />
disorders.<br />
CLASSROOM DEMONSTRATIONS<br />
1. This exercise emphasizes speculation more than fact, which reflects our current state of<br />
knowledge about personality disorders. Have students pair off or form small groups. Present each<br />
group of students with two descriptions of hypothetical married couples with personality disorders<br />
(see the Handout for Demonstration 1). In their groups, students should first check to be sure they<br />
understand the features of each of these personality disorders. Then they should answer the<br />
questions on the handout sheet. These questions should help them understand the adaptive nature<br />
of personality disorders, the interpersonal conflicts they can engender, and the impact such<br />
marriages have on children. Some or all of the student groups should report their answers and<br />
speculations to the rest of the class. Examine how universal the impressions are.<br />
There is a danger that this exercise will spawn stereotypes, so you should point out that people are<br />
far more complex than mere labels might suggest.<br />
Internet Site: http://www.mentalhealth.com/p20-grp.html Search this site for discussions of all<br />
the personality disorders currently defined in the DSM-IV-TR.
126 Chapter 8: Personality Disorders and Impulse Control Disorders<br />
2. Parenting style is often assumed to be a cause of personality disorders. At the extremes, parenting<br />
styles can be exceptionally tolerant or authoritarian. At one end of the continuum, we might<br />
expect spoiled children, and at the other, brutalized children. In this demonstration, students are<br />
asked to consider whether particular personality disorders are the result of spoiling or brutalizing<br />
children. The possibility should also be raised that neither or both are true.<br />
After you introduce this exercise, write on the board the words Spoiled and Brutalized. List on the<br />
left side the following: Paranoid, Dependent, Histrionic, Narcissistic, Obsessive-Compulsive, and<br />
Schizoid. Have students describe the basic characteristics of each personality disorder as an inclass<br />
review. Ask students to speculate on whether each personality disorder is likely to develop<br />
in one of these extreme parenting conditions, in neither, or in both. It is likely that they will see<br />
low-self-confidence disorders, such as dependent personality disorder, as coming from<br />
authoritarian parents, and grandiose disorders, such as narcissistic personality disorder, coming<br />
from overly tolerant parents. You may agree or disagree with this, but you should point out the<br />
possibility that overt behavior may belie one’s underlying self-image (for example, narcissists<br />
who try to compensate for low self-confidence). Finally, it is well to note that empirical research<br />
on these questions is sorely lacking.<br />
3. There are so many personality disorders, it will be helpful to give students a handout (provided)<br />
that lists them and provides a brief description. The text also indicates current prevalence<br />
estimates and whether a gender difference occurs in the diagnosis of the disorder. Use the handout<br />
to have students discuss the reasons for gender differences (stereotyping, biased sampling,<br />
socialization, and so forth) and the reasons when no such differences occur.<br />
4. Many characters in television and cinema have extreme personalities, bordering on personality<br />
disorders. Ask students to nominate characters from situation comedies, dramas, and the like who<br />
they think illustrate the personality disorders. If they are stumped, consider Chrissy (Suzanne<br />
Somers’s character) on Three’s Company reruns as an example of the histrionic personality<br />
disorder. If students can recall Monica from Friends, you can use her as an example of the<br />
obsessive-compulsive personality disorder.<br />
5. A number of biographies about famous people with antisocial personality disorder are available.<br />
Reading excerpts can give students a nontextbook, nonclinical description of the remorseless,<br />
exploitative, thrill-seeking manner of these individuals. Examples of biographies are The<br />
Executioner’s Song (about murderer Gary Gilmore) by Norman Mailer, Helter Skelter (about<br />
Charles Manson) by Vincent Bugliosi, and more recent accounts of Ted Bundy, Jim Jones, and<br />
David Koresh.<br />
6. Antisocial personality disorder is associated with high levels of thrill seeking. Individuals with<br />
this disorder feel bored if not stimulated by risky situations, frequent change, and adventure.<br />
Perhaps because they are biologically programmed to have low arousal levels, antisocial<br />
personalities need to seek out additional sensations to reach an optimal level of arousal. Marvin<br />
Zuckerman (1978, 1979) has developed a measure to assess a general sensation-seeking trait.<br />
More than 10,000 people have taken this test. You can give a short version to your students and<br />
quickly score the results.<br />
Please caution students against making sweeping generalizations about their personalities and,<br />
especially, about whether they have antisocial personality tendencies. First, one test cannot be<br />
considered a reliable measure of anything about an individual. Second, college-age people tend to<br />
take a great many more risks than the general population. Third, antisocial personality disorder<br />
involves a good deal more than high sensation seeking. And finally, as Farley (1986) points out, a<br />
need for variety and arousal can take both a constructive and a destructive form. Here are the<br />
scoring key and norms. Count one point for each of the following items:<br />
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Chapter 8: Personality Disorders and Impulse Control Disorders 127<br />
1. A 4. B 7. A 10. B<br />
2. A 5. A 8. A 11. A<br />
3. A 6. B 9. B 12. A<br />
13. B<br />
1–3 points: very low on sensation seeking<br />
4–5 points: low<br />
6–9 points: average<br />
10–11 points: high<br />
12–13 points: very high<br />
Sources: Farley, F. (1986). World of the Type T personality. Psychology Today, 20, 45–52.<br />
Zuckerman, M. (1979). Sensation seeking: Beyond the optimal level of arousal. Hillsdale, NJ:<br />
Lawrence Erlbaum; test reprinted with permission from Psychology Today Magazine. Copyright<br />
© 1978 (Sussex Publishers, Inc.).<br />
7. The Internet Web site http://www.bpdcentral.com (Borderline Personality Disorder Central) has<br />
assembled first-person accounts of this disorder—what it is like for people, how their behaviors<br />
affect others and themselves—from posts to a newsgroup, from interviews, and from other<br />
sources. By reading these comments aloud you can help students become aware of the thinking<br />
and emotions that characterize borderline personality disorder. This demonstration should increase<br />
students' empathy for people who often get contempt from even well-meaning therapists.<br />
Person A. I think that borderliners are concerned of only one thing: losing love. When cornered, I<br />
get very scared and I show that by getting angry: anger is easier than fear and less vulnerable. I<br />
strike before being stricken. Real anger, the anger normal persons feel, by getting unjust treatment<br />
or being disappointed, I don’t feel at all, I don’t have that capability. It would require a self, a<br />
complete being, self conscience [sic] and self-confidence to get angry because people are treating<br />
you badly. Since I don’t have a self (or better said: since I put away my own self so deep that I<br />
can’t reach it myself anymore) I don’t have all those things and I can’t get angry.<br />
I think this goes for all borderliners; that no BP will admit they are really scared when they are<br />
angry. When I’m angry, I can’t be reasonable too. When I’m angry, I’m angry and telling myself<br />
doesn’t help. The only thing that helps is when my husband says to me, “I know you are scared<br />
and not angry.” At that moment, my anger melts away and I can feel my fear again. But that’s the<br />
only thing that works.<br />
Person B. It feels terribly lonely to be borderline. I am living in a castle, with very thick defensive<br />
walls and a very tightly closed draw-bridge and door. Outside is a crowd and they are having a<br />
party. But I can’t hear what it’s about and I can’t join them, although part of me wants to. So I<br />
stand at the window and look outside and I don’t understand what they are doing. Also I feel like<br />
they look at me all the time and laugh at me for not understanding and not belonging. I don’t<br />
know what I have to do to belong or to understand. The castle is empty. I am the only thing in it.<br />
Not only the only living thing, but really the only thing: the castle is completely empty. There is<br />
no furniture, no wallpaper, no carpets. The wooden floors are bare, the closets are empty, and the<br />
doors are standing ajar. The castle is huge, with many floors, and every floor has many rooms and<br />
everything is empty. Try imagining living like this and you can, just for a little bit, understand<br />
how we feel.<br />
Person C. We borderlines occasionally cut ourselves because we are hurting so bad, and no one<br />
knows how bad we hurt, that we cut ourselves just to somehow externalize how we feel. Like we<br />
could never communicate the pain we have (because it is too big and people don’t understand)
128 Chapter 8: Personality Disorders and Impulse Control Disorders<br />
and also because how could we feel so much without it somehow being visible from the outside.<br />
There are times when we have cut ourselves because we were really hurting and it comforted us,<br />
but then there were those times when we wanted to say, “See how bad I hurt!” like it is a way of<br />
communicating and expressing the extent of our pain. Words just are not powerful enough.<br />
Internet Site: http://www.bpdcentral.com. This site is Borderline Personality Disorder Central.<br />
8. Two films that depict excellent examples of personality disorders are Fatal Attraction and Misery.<br />
Ask for volunteers from the class to view the movies, then make a diagnosis of the lead characters<br />
in each. Many students will have seen these films. Alternately, you could rent the films and<br />
select short portions to show to the class. Glenn Close's character is identified by many as a<br />
classic borderline personality disorder, while the character portrayed by Kathy Bates in Misery<br />
could be paranoid or schizoid rather than psychotic.<br />
9. Have the student form small groups of between 4-7 individuals depending on your class size and<br />
space limitations. Assign students to collect pictures from magazines of people who seem to have<br />
the physical characteristics of some of the personality disorders described in the chapters, such as<br />
histrionic, narcissistic, and others. Ask each group to develop this list with the most salient<br />
examples first. Each group could then have a spokesperson deliver a short talk about the best<br />
examples. You could provide a blank overhead transparency to each group at the beginning of<br />
this demonstration.<br />
10. Bring the DSM-IV-TR to class, and prepare an overhead transparency or PowerPoint slide ahead<br />
of time for your lecture on personality disorders. Describe the in-depth material from the DSM-<br />
IV while using the transparency or PowerPoint slide as an outline. Lead a discussion on the<br />
differences between different personality disorders. Encourage student input about individuals<br />
they have known with these symptoms.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
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Chapter 8: Personality Disorders and Impulse Control Disorders 129<br />
HANDOUT FOR DEMONSTRATION 1:<br />
EFFECTS OF PARENTING STYLE<br />
For each couple described below, imagine that she is 31 and he is 33. They have been married for ten<br />
years, and they have two children—a boy (age 9) and a girl (age 5).<br />
The Case of Tom and Mindy<br />
Tom is a classic obsessive-compulsive. He is an engineer who must have everything perfectly orderly<br />
and clean at work and at home. Unable to express his emotions, he deals only in facts. In Tom’s mind,<br />
every action must be rational; all decisions must fit some master formula. Mindy is a classic histrionic<br />
personality. She is attractive and tends to be flirtatious and attention seeking. To her, life is a series of<br />
crises, but her feelings never seem to be more than superficial. She forgets facts quickly and uses only<br />
impressions to describe her world.<br />
Speculate on the answers to these questions:<br />
1. What did Tom see in Mindy that made him want to marry her?<br />
2. What did Mindy see in Tom that made her want to marry him?<br />
3. What are their major points of conflict concerning the house and the children?<br />
4. Who disciplines the children and how?<br />
5. Why do they stay married?<br />
The Case of John and Sarah<br />
John is a classic dependent personality. He tolerates everything his boss, mother, or wife demands. He<br />
considers himself a weak and generally incompetent man. Frightened of offending anyone, he keeps<br />
any opinions he might have to himself. Sarah is a classic narcissistic personality. She sees herself as the<br />
hottest real estate agent in the business and complains bitterly about the poor performance of others.<br />
Secretly, she worries that others will not value her, so she puts herself in a good light as much as she<br />
can.<br />
Speculate on the answers to these questions:<br />
1. What did John see in Sarah that made him want to marry her?<br />
2. What did Sarah see in John that made her want to marry him?<br />
3. What are their major points of conflict concerning the house and the children?<br />
4. Who disciplines the children and how?<br />
5. Why do they stay married?
130 Chapter 8: Personality Disorders and Impulse Control Disorders<br />
HANDOUT FOR DEMONSTRATION 3:<br />
PERSONALITY AND IMPULSE CONTROL DISORDERS:<br />
DESCRIPTIONS, PREVALENCE, AND GENDER DISTRIBUTIONS<br />
Disorder Category<br />
Odd or eccentric behaviors<br />
Estimated<br />
Prevalence (percent) Gender Difference<br />
Paranoid: unwarranted suspiciousness,<br />
hypersensitivity, controlled<br />
0.5 to 2.5 males somewhat more<br />
Schizoid: social isolation, indifference toward<br />
others<br />
uncommon males slightly more<br />
Schizotypal: peculiar thoughts and behaviors<br />
Dramatic, emotional, or erratic behaviors<br />
3.0 unclear<br />
Histrionic: attention seeking, exaggerated<br />
2.0 to 3.0 females more in some<br />
emotional expression, dramatic<br />
studies<br />
Narcissistic: exaggerated self-importance,<br />
lack of empathy<br />
1.0 males more<br />
Antisocial: break rules without remorse,<br />
impulsive, lack of anxiety<br />
2.0 males 3 times more<br />
Borderline: intense changes in mood, feelings<br />
of emptiness, stormy relationships<br />
Anxious or fearful behaviors<br />
2.0 females 3 times more<br />
Avoidant: fear of rejection and humiliation,<br />
hesitant interpersonal relations<br />
< 1.0 no differences<br />
Dependent: unwarranted reliance on others,<br />
unwillingness to take responsibility<br />
2.5 unclear<br />
Obsessive-compulsive: perfectionism,<br />
rigidity, attention to details<br />
Impulse control disorders<br />
1.0 males more<br />
Intermittent explosive: loss of control over<br />
aggressive impulses<br />
rare males more<br />
Kleptomania: failure to resist impulses to<br />
steal<br />
rare females more<br />
Pathological gambling: failure to resist<br />
impulses to gamble<br />
1.0 to 3.0 males more<br />
Pyromania: recurrent purposeful fire-setting probably rare males more<br />
Trichotillomania: failure to resist impulses to 1.0 to 2.0 (of college females more<br />
pull out one’s hair<br />
students)<br />
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Chapter 8: Personality Disorders and Impulse Control Disorders 131<br />
HANDOUT FOR DEMONSTRATION 6: SENSATION-SEEKING SCALE<br />
For each item, circle the letter corresponding to the statement that best describes your preference or<br />
opinion. There are no right or wrong answers. Be as honest as possible.<br />
1. A. I would like a job that requires a lot of traveling.<br />
B. I would prefer a job in one location.<br />
2. A. I am invigorated by a brisk, cold day.<br />
B. I can’t wait to get indoors on a cold day.<br />
3. A. I get bored seeing the same old faces.<br />
B. I like the comfortable familiarity of everyday friends.<br />
4. A. I would prefer living in an ideal society in which everyone is safe, secure, and happy.<br />
B. I would have preferred living in the unsettled days of our history.<br />
5. A. I sometimes like to do things that are a little frightening.<br />
B. A sensible person avoids activities that are dangerous.<br />
6. A. I would not like to be hypnotized.<br />
B. I would like to have the experience of being hypnotized.<br />
7. A. The most important goal of life is to live it to the fullest and experience as much as<br />
possible.<br />
B. The most important goal of life is to find peace and happiness.<br />
8. A. I would like to try parachute jumping.<br />
B. I would never want to try jumping out of a plane, with or without a parachute.<br />
9. A. I enter cold water gradually, giving myself time to get used to it.<br />
B. I like to dive or jump right into the ocean or a cold pool.<br />
10. A. When I go on vacation, I prefer the comfort of a good room and bed.<br />
B. When I go on vacation, I prefer the change of camping out.<br />
11. A. I prefer people who are emotionally expressive even if they are a bit unstable.<br />
B. I prefer people who are calm and even-tempered.<br />
12. A. A good painting should shock or jolt the senses.<br />
B. A good painting should give one a feeling of peace and security.<br />
13. A. People who ride motorcycles must have some kind of unconscious need to hurt themselves.<br />
B. I would like to drive or ride a motorcycle.<br />
Reprinted with permission from Psychology Today Magazine. Copyright © 1978 (Sussex Publishers,<br />
Inc.).
132 Chapter 8: Personality Disorders and Impulse Control Disorders<br />
SELECTED READINGS<br />
Adler, G. (1981). The borderline-narcissistic personality disorder continuum. American Journal of<br />
Psychiatry, 138, 46–50.<br />
Cowdry, R. W., & Gardner, D. L. (1988). Pharmacotherapy of borderline personality disorder:<br />
Alprazolam, canbumazepine, trifluoperazine, and tranylcypromine. Archives of General Psychiatry, 45,<br />
111–119.<br />
Eron, L. D., Gentry, J. H., & Schlegel, P. (Eds.) (1994). Reason to hope: A psychosocial perspective on<br />
violence and youth. Washington, DC: American Psychological Association.<br />
Hare, R. D. (1985). Comparison of procedures for the assessment of psychopathy. Journal of<br />
Consulting and Clinical Psychology, 53, 7–16.<br />
Lesieur, H. R., & Rosenthal, R. J. (1991). Pathological gambling: A review of the literature. Journal of<br />
Gambling Studies, 7, 5–39.<br />
Sattler, D., Shabatay, V., & Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 8, Personality Disorders and Impulse<br />
Control Disorders.<br />
Clipson, C., & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 12, Borderline Personality Disorder: One Side Wins, The Other Side Loses.<br />
Chapter 13, Antisocial Personality Disorder: Bad to the Bone.<br />
VIDEO RESOURCES<br />
A Psychopath (16 mm, 30 min). This case study examines the childhood and adolescent experiences of<br />
a psychopath through recollections and interviews with police and mental health professionals.<br />
McGraw-Hill Text-films, 1221 Avenue of the Americas, New York, NY 10020.<br />
Achievement Place (16 mm, 30 min). Illustrates the use of a token economy treatment at a residential<br />
setting for predelinquent boys. Achievement Place has been a model for residential treatment of<br />
antisocial personality. University of Kansas Audio Visual Center, 746 Massachusetts Avenue,<br />
Lawrence, KS 66044.<br />
Criminal Personality (VHS, 28 min). A psychiatrist explains how adult criminality can be traced to<br />
childhood experiences. The Center for Cassette Studies, 8110 Webb Avenue, North Hollywood, CA<br />
91605.<br />
“Personality Disorders” (#5) from The World of <strong>Abnormal</strong> Psychology series (video, color, 60 min).<br />
The hour is divided into four segments covering antisocial, narcissistic, borderline, and<br />
obsessive-compulsive personality disorders. The Annenberg/CPB Collection, Dept. CA94, P.O. Box<br />
2345, S. Burlington, VT 05407-2345; to order, call 1-800-532-7637.<br />
Shotgun Joe (16 mm, 25 min). Illustrates the characteristics of the antisocial personality, including the<br />
absence of remorse for socially unacceptable actions. Examines the antisocial personality’s<br />
relationships with parents and peers. Jason Films, 2621 Palisade Avenue, Riverdale, NY 10463.<br />
Violent Youth: The Unmet Challenge (16 mm, color, 26 min). Three incarcerated juveniles, a chief of<br />
police, a family court judge, and the head of a juvenile detention center are interviewed. Harper & Row<br />
Media, 10 East 53rd Street, New York, NY 10022.<br />
Personality Disorders (VHS, color, 60 mm.). The video looks at the different types of personality<br />
disorders. The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S. Burlington, VT 05407-<br />
2345; to order, call 1-800-532-7637.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 8: Personality Disorders and Impulse Control Disorders 133<br />
ON THE INTERNET<br />
http://www.nlm.nih.gov/ is the Web site of The National Library of Medicine<br />
http://huizen.dds.nl/~laura_d/ is the home page of a Dutch woman diagnosed with borderline<br />
personality disorder. She describes herself, her theory of the disorder.<br />
http://www.bpdcentral.com/ is Borderline Personality Disorder Central.<br />
http://mental-health-matters.com is the Mental Health Matters home page, which offers information and<br />
links for mental health, self-help, and psychology information and resources.<br />
http://www.mentalhealth.com/fr00.html has an index feature to explore all the personality disorders.
CHAPTER 9<br />
Substance-Related Disorders<br />
CHAPTER OUTLINE<br />
I. Introduction<br />
A. Substance-related disorders: when use of psychoactive drugs causes social, occupational, or<br />
physical problems<br />
1. Substance use: involving dependence and abuse<br />
2. Substance-induced disorders: intoxication, delirium, and withdrawal (discussed with<br />
cognitive disorders in Chapter 15)<br />
3. Substance abuse: recurrent use over 12 months leading to impairment or distress;<br />
continues despite social, physical, occupational, psychological, or safety problems<br />
4. Substance dependence: several symptoms over 12 months including tolerance or<br />
withdrawal<br />
5. Intoxication: a substance affecting the CNS has been ingested and maladaptive<br />
behaviors or psychological changes are evident<br />
6. Typical pattern from experimentation to abuse or dependence:<br />
a) Experimentation (usually with tobacco, alcohol, marijuana)<br />
b) Early regular use-actively seek substance & drug-induced state<br />
c) Plan daily activities around drug use; unpleasant states worsen and lead to more<br />
drug use and self-destructiveness<br />
d) Drugs (more potent) need to avoid constant dysphoria<br />
II. Substance-use disorders<br />
A. Most prevalent among youths and young adults<br />
1. Adult lifetime prevalence for controlled substances is 6.2 percent; greatest for<br />
marijuana<br />
2. Drug of choice varies for different ethnic groups abuse of OTC drugs anticipated to<br />
increase for elderly age “baby boomers” age<br />
3. Recent studies show alcohol use stable but high; cocaine, hallucinogens, and heroin<br />
increased in past several years<br />
4. Adult lifetime prevalence for drug abuse/dependence (excluding alcohol) is 6.2 percent<br />
B. Gender and ethnic differences<br />
1. Women less likely to take drugs than men<br />
2. White Americans have higher lifetime prevalence rates for drug problems than<br />
Hispanic Americans or African Americans<br />
C. Depressants or sedatives: depress central nervous system and slow responses, increase<br />
relaxation, lower inhibitions<br />
1. Alcohol-use disorders<br />
a) Need to use alcohol daily to function<br />
b) Person can abstain but binges when he or she drinks<br />
2. Alcohol consumption in the United States<br />
a) 11 percent of adults consume one ounce or more per day; 35 percent abstain<br />
b) 50 percent of alcohol consumed by 10 percent of drinkers; males drink two to<br />
five times more than females<br />
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Chapter 9: Substance-Related Disorders 135<br />
c) Cultural variations: in some cultures with meals; in most cultures, females<br />
usually consume less; at older ages, blacks and Hispanics have higher rate of<br />
dependence than whites<br />
3. The effects of alcohol<br />
a) Short-term physiological effects<br />
b) Specific effect related to dose, time, weight<br />
c) Short-term psychological effects<br />
d) Long-term psychological effects<br />
e) Long-term physiological effects<br />
4. Narcotics (opiates): opium and derivatives—morphine, heroin, codeine-depress CNS;<br />
provide relief from pain, anxiety, tension; are addictive: tolerance builds quickly,<br />
withdrawal symptoms are severe euphoria and sometimes nausea; tolerance builds<br />
quickly, withdrawal is serious<br />
a) Administered intravenously, causes spread of HIV when needles shared<br />
b) Lifetime prevalence is 0.7 percent; four times more common in men<br />
5. Barbiturates: “downers” induce sleep and relaxation<br />
a) Addicting, common in middle-aged and older people<br />
b) Accidental overdose leads to death; dangerous in combination with alcohol<br />
c) Polysubstance dependence (DSM-IV-TR diagnosis): at least three substances<br />
used (not including nicotine and caffeine) for twelve months and meets criteria<br />
for any drug<br />
6. Benzodiazepines (for example, Valium): used to relieve tension, but people can<br />
develop tolerance and become dependent<br />
D. Stimulants: CNS energizer producing elation, grandiosity, activity, appetite suppression<br />
1. Amphetamines: speed up CNS activity, reduce need for sleep, suppress appetite,<br />
increase confidence<br />
a) Increase dopamine concentrations<br />
b) Taken orally, intravenously, snorted, and recently smoked (“ice”)<br />
c) Overdose fatal; heavy users can become homicidal, suicidal<br />
d) Lifetime prevalence 2 percent; more men common in men and the poor<br />
2. Caffeine<br />
a) Effects: restlessness, usually transitory<br />
3. Nicotine<br />
a) Smoking is single most preventable cause of death in United States<br />
b) Signs of dependence: attempts to stop are unsuccessful, attempts to stop lead to<br />
withdrawal, use continues despite physical disorder such as emphysema<br />
4. Cocaine and crack<br />
a) Growing use: from one to three million cocaine abusers need treatment<br />
b) Effects: when snorted, increases heart rate, reduces fatigue, produces euphoria;<br />
when smoked (crack), produces quicker effects; physical as well as psychological<br />
dependence<br />
c) Addiction can develop, sometimes after short period of use; depression when<br />
high wears off<br />
d) Crack is a purified and potent form<br />
e) Concern to society for many reasons<br />
5. Hallucinogens—not considered physiologically addictive<br />
a) Marijuana: mildest, most common; 33 percent of United States population has<br />
used it; effects include passivity, tranquility, lung damage, memory problems;<br />
other risks seen as unsubstantiated<br />
b) LSD: reality distortions and hallucinations; “bad trips”; flashbacks;<br />
psychotomimetic
136 Chapter 9: Substance-Related Disorders<br />
c) Phencyclidine (PCP): very dangerous delusions, violence, perceptual distortions<br />
6. Other substance-use disorders include anabolic steroids and nitrous oxide<br />
III. Etiology of substance-use disorders<br />
A. Most integrate biological and psychological factors<br />
B. Biogenic explanations<br />
1. Genetic impact shown through adoption research and twin studies; incidence of<br />
alcoholism four times higher for male biological offspring of alcoholic fathers than for<br />
offspring of nonalcoholic fathers<br />
a) Familial and nonfamilial alcoholism<br />
b) Specific genes: quantitative trait loci (QTL) analysis used in breeding animals for<br />
alcohol preference<br />
c) Risk factors: neurotransmitters, sensitivity to alcohol, central nervous system<br />
differences, racial differences in response to drugs<br />
C. Psychodynamic explanations<br />
D. Explanations based on personality characteristics<br />
1. High activity level, emotionality, goal impersistence, and sociability (but not causal)<br />
2. Low frustration tolerance, high tolerance for deviance, antisocial behavior, depression<br />
3. Reviews conclude there is no single alcoholic personality<br />
4. Antisocial behavior and depression associated with drinking problems<br />
E. Sociocultural explanations<br />
1. Different patterns around the world (France and Italy high, Israel and China low)<br />
2. Cultural values concerning tolerance of alcohol abuse<br />
3. Ethnic variations in United States: drug abuse and dependence higher in whites than<br />
African Americans and Hispanic Americans; whites have lower alcoholism rates and<br />
heroin use<br />
4. Peer identification: good predictor of adolescent smoking is the group a young person<br />
identifies with<br />
F. <strong>Behavior</strong>al explanations<br />
1. Anxiety reduction<br />
a) Believed alcohol reduced anxiety of approach-avoidance conflict<br />
b) Anxiety reduction is reinforcing<br />
2. Learned expectations<br />
a) Marlatt, Deming, & Reid (1973): “told and given” alcohol or tonic water<br />
challenges disease concept of loss of control; expectation important<br />
b) Longitudinal study of adolescent drinking: those who expect social benefits drink<br />
more and endorse more positive social benefits to alcohol<br />
3. Cognitive influences<br />
a) Conflicting findings that alcohol is tension reducing<br />
b) Steele and Josephs find alcohol increases or decreases anxiety depending on how<br />
alcohol affects thought<br />
c) Different types of stress produce different results<br />
d) Coping styles<br />
4. Relapse: a source of evidence<br />
a) Risk factors: age at onset of drug use; more extensive involvement with<br />
substances; antisocial behavior; comorbid psychiatric disorder; less involvement<br />
in school or work; less support from drug-free family and peers; type of stressor<br />
is also important<br />
b) Risk greatest in first three months following treatment<br />
c) Negative emotional (not physical) states predict relapse<br />
d) Marlatt and Gordon: negative emotional feelings, social pressure to<br />
drink/temptation are high-risk situations; coping skills important<br />
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Chapter 9: Substance-Related Disorders 137<br />
e) Biological factors<br />
f) Most heroin-addicted Vietnam vets discontinued use after return to United States<br />
G. Overall theories of the addiction process<br />
1. Solomon (1980): opponent-process theory (acquired motivation to avoid aversiveness<br />
of craving)<br />
2. Wise (1988): two-factor model involves positive reinforcement and negative<br />
reinforcement<br />
3. Tiffany (1990): theory of automatic processes (rather than conscious) and changeresistant<br />
processes<br />
IV. Intervention and treatment of substance-use disorders<br />
A. Detoxification: removal of substance produces withdrawal; followed by intervention<br />
programs to prevent return to use<br />
B. Self-help groups<br />
1. Alcoholics Anonymous: based on disease concept; fellowship and self-revelations<br />
encouraged in group; many drop out<br />
2. Spin-offs include Al-Anon (for those who live with alcoholic) and Narcotics<br />
Anonymous<br />
C. Pharmacological approach<br />
1. Antabuse: to produce aversion to alcohol and stay abstinent<br />
2. Methadone: to ease heroin withdrawal but is addicting itself<br />
3. Nicotine replacement programs for cigarette smoking<br />
D. Cognitive and behavioral approaches<br />
1. Aversion therapy (shock and emetics)<br />
2. Covert sensitization (imagery of nausea paired with drug use)<br />
3. Skills training<br />
4. Reinforcing abstinence<br />
5. <strong>Behavior</strong>al treatment for cigarette smoking<br />
a) Rapid smoking and nicotine fading<br />
b) Nicotine fading<br />
6. Other cognitive-behavioral treatments: relaxation, systematic desensitization,<br />
extinction of relapse cues, thoughts restructured<br />
7. Controlled-drinking controversy<br />
E. Multimodal treatment: detoxification, inpatient, outpatient, family therapy<br />
F. Prevention programs<br />
1. Education campaigns<br />
2. Smoking prevention in junior high<br />
a) Resistance to social influence<br />
b) Information on social image of smokers<br />
c) Information on physical consequences of smoking<br />
d) Smoking less likely in those getting intervention than in controls<br />
G. Effectiveness of treatment<br />
1. Most heroin addicts and treated smokers are using within one year<br />
2. Some recover on their own<br />
3. Same factors predict outcome regardless of substance used<br />
LEARNING OBJECTIVES<br />
1. Distinguish substance-related disorders from substance-use cognitive disorders, substance abuse<br />
from substance dependence, and define the terms tolerance, withdrawal, and intoxication. Discuss<br />
the overlap in criteria for dependence and abuse. (pp. 269-272)
138 Chapter 9: Substance-Related Disorders<br />
2. Describe the nature and scope of substance use and describe the types and prevalence of<br />
substance-use disorders in the United States. (pp. 272-273; Figure 9.3)<br />
3. Categorize the psychoactive drugs according to their properties (sedative, stimulant, or<br />
hallucinogenic). (pp. 274-285; Table 9.1)<br />
4. Discuss the nature and magnitude of drinking problems in the United States and the short- and<br />
long-term physiological and psychological effects of alcohol. (pp. 274-277)<br />
5. Describe the effects of narcotics, barbiturates, and benzodiazepines. Define polysubstance use and<br />
explain why it causes special problems. (pp. 277-280)<br />
6. Describe and discuss the problems of stimulant-use disorders, including amphetamines, caffeine,<br />
nicotine, cocaine, and crack. Evaluate the controversy concerning nicotine addiction and its<br />
treatment. (pp. 280-282)<br />
7. Describe and discuss the problems of hallucinogen-use disorders, including marijuana, LSD,<br />
phencyclidine (PCP), and “other substance-use disorders.” Evaluate evidence concerning<br />
marijuana’s harmful effects. (pp. 282-285)<br />
8. Describe the two general types of etiological theories of substance-related disorders. Describe and<br />
evaluate the evidence for specific genes and risk factors related to alcoholism and other forms of<br />
substance dependence. (pp. 285-287)<br />
9. Describe and discuss the various explanations for alcoholism and other substance-related<br />
disorders, including psychodynamic, personality, and sociocultural explanations. Evaluate<br />
research evidence on the relation between drug use and maladjustment. (pp. 287-290)<br />
10. Describe and discuss behavioral explanations for alcohol abuse and dependence, including the<br />
anxiety-reduction hypothesis, learned expectations, and cognitive influences. (pp. 290-292)<br />
11. Discuss explanations for relapse among alcoholics and people who are dependent on other<br />
substances. Describe and distinguish opponent process, two-factor, and automatic processing<br />
theories of the addiction process. (pp. 292-295)<br />
12. Describe the nature and effectiveness of alcohol and drug treatment programs, including self-help<br />
groups, pharmacological approaches to substance-use treatment, and controlled-drinking. (pp.<br />
295-302)<br />
13. Describe and compare the cognitive and behavioral approaches to treating substance-related<br />
disorders, including aversion therapy, covert sensitization, rapid smoking, nicotine fading,<br />
relaxation and social learning methods, and cognitive-change treatments. (pp. 298-302; Mental<br />
Health and Society)<br />
14. Discuss what is meant by multimodal treatment. Describe and evaluate the evidence concerning<br />
treatment effectiveness for alcohol, smoking cessation, and other substance-related disorders. (pp.<br />
302-304)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. One of the mysteries of alcohol and drug abuse is that continued use occurs even when all the<br />
apparent consequences are negative. This seems to fly in the face of basic behavioral principles. It<br />
is useful to separate the short-term positive consequences of drug use from the more distant<br />
negative consequences. Develop a list on the blackboard of the short-term positive and negative<br />
consequences of drug use. Make another list of long-term positive and negative consequences. As<br />
abuse becomes physical addiction, the short-term consequences become positive indeed. The<br />
addict has a choice each day to either feel much better after one or two doses of the drug or wait<br />
through several very uncomfortable days (detoxification and withdrawal) before feeling human<br />
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Chapter 9: Substance-Related Disorders 139<br />
again. Some withdrawal syndromes, especially in poorly nourished individuals, can create<br />
medical emergencies.<br />
This discussion of the power of immediate consequences should lead into a discussion of<br />
treatment. <strong>Behavior</strong> therapy stresses the need to disentangle the drug from its positive effects and<br />
to find alternative, drug-free ways of deriving pleasure. Cognitive approaches also must<br />
restructure the expectations of the user, from seeing the benefits of continued use to understanding<br />
the benefits of cutting down or quitting.<br />
Internet Site: http://www.apa.org/divisions/div28. The Division of Psychopharmacology and<br />
Substance Abuse of the American Psychological Association.<br />
2. The text notes that there are cultural differences in alcohol use. These are also reflected in the<br />
guidelines that health care professionals give their patients concerning drinking. In Great Britain<br />
for the past five or six years, general practitioner physicians and other health care professionals<br />
have been educating the public about sensible alcohol consumption. They have taught the public<br />
how to count alcoholic drinks in “units”: one unit is equal to one-half pint of ordinary strength<br />
beer, a 125-ml glass of wine, or a single measure of 80-proof spirits. The Health Education<br />
Authority in conjunction with the British Medical Association has developed recommended<br />
separate “sensible” limits for men and women. For men it is 21 drinks per week with one or two<br />
drink-free days, for women 14 drinks per week with one or two drink-free days. A second range<br />
of drinking, described as “increasing risk,” is 22 to 50 units for men and 15 to 35 units for women.<br />
“Harmful” drinking for men is given as more than 50 units per week and more than 35 for women.<br />
The gender differences are due to the greater mass and water content in men, which dilutes the<br />
alcohol and reduces blood alcohol concentrations even if the same dose is taken. Surveys show<br />
that 27 percent of men and 11 percent of women in Britain drink beyond this sensible zone<br />
(Edwards, 1996).<br />
Ask students if they think these numbers of drinks would be considered “sensible” in the United<br />
States. They may be amazed to find out that in 1996, a British government agency (not the British<br />
Medical Association) decided to revise the guidelines upward! The revised sensible zone was up<br />
to 28 drinks for men and 21 for women. Some have doubted the motivations for making the<br />
change because it is not based on scientific evidence; in addition, two of the 13 members of the<br />
deciding group were employees of the British ministry that works closely with the distilling<br />
industry. Most physicians have refused to go along with the new guidelines (Edwards, 1996).<br />
Sources: British Health Education Authority (1994). That’s the limit: A guide to sensible drinking.<br />
Edwards, G. (1996). Sensible drinking: Doctors should stick with the independent medical advice.<br />
British Medical Journal, 312, 1.<br />
3. Although the text does not discuss the need for family treatment in most substance-abuse<br />
disorders, consider with students the following case:<br />
An alcoholic and Valium-abusing mother has been unable to meet her family responsibilities for<br />
several years. Her eldest daughter has taken over many of these but has missed out on her own<br />
adolescence. The woman’s husband no longer relies on her to meet intimacy needs. Mother goes<br />
off for inpatient treatment that does not include the rest of the family. She returns home sober and<br />
wanting her “rightful” place in the family.<br />
Ask students how the family adapted to the woman’s drug problem. Describe how the husband<br />
and daughter might react when the woman returns. Explain, in family system terms, the ways in<br />
which families can unconsciously promote relapse. Finally, discuss why family-oriented therapy<br />
should be more effective in the long run than traditional individual treatment.
140 Chapter 9: Substance-Related Disorders<br />
4. Miller and Rollnick (1991) provide a wealth of information on how professionals can help<br />
addicted individuals overcome their ambivalence about changing and consent to treatment. They<br />
use Prochaska and DiClemente’s (1986) model of the change process, which states that change is<br />
usually cyclic and involves the following stages: precontemplation, contemplation, determination,<br />
action, and maintenance. At each stage the professional must present appropriate information in a<br />
nonthreatening manner in order to help motivate clients. For example, during contemplation, the<br />
client is highly ambivalent. The professional should be empathic and voice the client’s<br />
reservations, help him or her to assess the costs and benefits of change, and subtly tip the balance<br />
in favor of change.<br />
Because the six stages of change occur in a cycle, draw a circle on the board and divide it into five<br />
sections (contemplation through maintenance), leaving precontemplation outside the circle of<br />
change. Draw arrows from contemplation to determination, from determination to action, from<br />
action to maintenance. Draw two arrows from maintenance—one to permanent exit and another to<br />
relapse. This points out the possibility of establishing a new habit on the first trip around the<br />
cycle, but the greater likelihood of relapse. Relapse often leads to precontemplation but also can<br />
return to contemplation (a part of the change process). Successfully conquering an addiction<br />
typically takes several journeys around the cycle.<br />
According to Miller and Rollnick (1991), five general principles for motivational interviewing<br />
(interacting with addicted individuals to foster change) are as follows:<br />
a. Express empathy: Your acceptance of the client facilitates change. Be a skillful reflective<br />
listener. Appreciate that ambivalence and fear about change is normal.<br />
b. Develop discrepancy: Provide information about the consequences of continued drug use. A<br />
discrepancy between present behavior and important personal goals motivates change.<br />
Orchestrate the interview so that the client presents the arguments for change.<br />
c. Avoid argumentation: Arguments are unproductive and breed defensiveness. Do not engage<br />
in labeling (for example, alcoholic or in denial).<br />
d. Roll with resistance: Use psychological judo to take the client’s momentum and shift<br />
perceptions. Turn problems back to the client so he or she can find solutions and avoid “yes,<br />
but...” games.<br />
e. Support self-efficacy: Foster a belief that change is possible. Help the client see that he or<br />
she is responsible for choosing and carrying out personal change. Give a range of ways to<br />
change; a series of failures is not cause to give up.<br />
Sources: Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to<br />
change addictive behavior. New York: Guilford Press.<br />
Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W.<br />
R. Miller & N. Heather (Eds.) Treating addictive behaviors: Processes of change. New York:<br />
Plenum Press, pp. 3–27.<br />
5. The text notes that treatment outcomes for heroin users are often disheartening, with more than<br />
half of addicts readdicted within a year of treatment. One reason for this depressing statistic is the<br />
fascinating phenomenon called “needle habit.” Before heroin addicts inject themselves, there are<br />
many preliminary behaviors. Injection equipment and drugs must be acquired and a suitable place<br />
found for injecting—often a bathroom. The drug is cooked, mixed with water, loaded into the<br />
syringe; a vein is found, tied off, and so on. All of these behaviors and the stimuli that are<br />
associated with them become conditioned stimuli paired with the unconditioned stimulus of the<br />
heroin itself. After many pairings, the ritual of injection takes on reinforcing properties by itself.<br />
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Chapter 9: Substance-Related Disorders 141<br />
A heroin user (Powell, 1973) is quoted as saying, “Once you decide to get off, it’s very exciting. It<br />
really is. Getting some friends together and some money, copping, deciding where you’re going to<br />
do it, getting the needles out and sterilizing them, cooking up the stuff, tying off, then the whole<br />
thing with the needle, booting, and the rush, that’s all part of it… Sometimes I think that if I just<br />
shot water I’d enjoy it as much.” (Italics added.)<br />
O’Brien (1974) reports a study in which heroin addicts were given Naloxone, a narcotic<br />
antagonist (a drug that stops the pharmacological effect of a drug). This drug ensured that none of<br />
the subjects were actually experiencing any physiological “high.” Addicts were then allowed to<br />
shoot up with their own equipment and use their own rituals in a special bathroom that simulated<br />
the usual setting for injection. Subjects either injected themselves with saline solution, a low dose<br />
of heroin, or a high dose. Since it was a double-blind study, no one but the experimenter (who was<br />
not present) knew what was being injected. Regardless of what they injected, the subjects reported<br />
experiencing pleasure after shooting up. Only after three to five injections did ratings come down<br />
to neutral, but one subject continued saying he felt a rush after 26 injections that could not have<br />
had a pharmacological effect! It turns out he was giving himself saline solution. So part of the<br />
relapse process in heroin addiction may be that the ritual of injection and its conditioned euphoria<br />
are missed—not just the physiological effects of the heroin.<br />
Sources: O’Brien, C. P. (1974). “Needle freaks”: Psychological dependence on shooting up. In<br />
Medical World News, Psychiatry Annual. New York: McGraw-Hill.<br />
Powell, D. H. (1973). A pilot study of occasional heroin users. Archives of General Psychiatry,<br />
28, 586–594.<br />
CLASSROOM DEMONSTRATIONS<br />
1. The following role-play can illuminate several issues in drug and alcohol treatment. First, it<br />
explores the role of denial in both the user and others in keeping people from getting help.<br />
Second, it points out the difficulties of confronting someone who denies that drugs are a problem.<br />
Third, it raises the issue of whether treatment can or should be forced on someone who does not<br />
want it. Finally, since the names in the main roles are sex-ambiguous, it examines whether<br />
identical behaviors are perceived as different depending on whether a male or a female is the drug<br />
abuser. Instructors can note many other issues as well.<br />
A good topic to touch on after the groups report is how to motivate people for treatment. One<br />
approach, called intervention by the Johnson Institute, uses pressure and the creation of a personal<br />
crisis to break down defenses. Family members and friends are instructed to monitor incidents in<br />
which the substance abuser has affected them and, after some coaching from a counselor, confront<br />
the abuser as a group. In the meeting, the target person cannot speak until all of the family<br />
members and friends have their say. They should convey the message that while they care about<br />
the abuser, they must let him/her know how they feel and how they have been affected by drugrelated<br />
behavior. The object is to cause such discomfort in the abuser that he or she becomes open<br />
to help. The group then provides support and, having already arranged it, rapid transition into<br />
treatment. A second approach emphasizes empathy and a kind of mental judo in which motivation<br />
comes not from direct confrontation but from subtle persuasion. The method, called motivational<br />
interviewing, is growing in popularity. It is founded on the transtheoretical model of change<br />
(Prochaska & DiClemente, 1986) that sees change as occurring in stages. If the user is ambivalent<br />
about changing, motivation comes by helping the person do a cost-benefit analysis of use and<br />
voicing the user’s own doubts about maintaining the status quo. More information on these ideas<br />
are presented in item 4 in “Topics for Classroom Lecture and Discussion” in this chapter.<br />
Divide the class into groups of six. (If class size is not a multiple of six, the character of Tracy can<br />
be dropped in enough groups to use all students.) Set the stage for the role play: Pat (the
142 Chapter 9: Substance-Related Disorders<br />
protagonist) has been called into a meeting convened by a psychologist (Dr. Dwight) because Kim<br />
and Terry have “had it” with Pat’s poor behavior. Pat is adamant about not having a drug problem.<br />
Karen is sure Pat is unhappy but does not see drugs or alcohol as the source. Kim and Terry are<br />
certain that drugs and alcohol are the basis of Pat’s problems, but they see different solutions to<br />
the problem. Tracy is ambivalent. Dr. Dwight plays the role of convener and facilitator.<br />
Each group is given a copy of the Handout for Demonstration 1, and members select the roles<br />
they wish to play. Emphasize that the demonstration works well only when students stay “in role”<br />
(although you can expect some giggling and laughter). Each group is to play out the<br />
meeting/confrontation and resolve what will happen to Pat (forced into treatment? convinced that<br />
treatment will help? successful in thwarting attempts at treatment?). Once the groups are formed<br />
and you have answered any questions, you should plan to leave the room for five minutes or so to<br />
allow acting to go on without the students feeling that you are looking over their shoulders.<br />
Let discussion go on until half of the groups seem to have come to some resolution (perhaps 15<br />
minutes). Reconvene the class and write on the board abbreviated descriptions of each group’s<br />
process and resolution. Be sure to ask about the ethics of confronting (and not confronting) drug<br />
abusers. Ask whether the students would have seen Pat and Kim differently if they were of the<br />
opposite sex.<br />
Source: Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model of change.<br />
In W. R. Miller & N. Heather (Eds.) Treating addictive behaviors: Processes of change. New<br />
York: Plenum Press, pp. 3–27.<br />
2. A thought-provoking topic for discussion is whether drug and alcohol use is perceived as<br />
pathological or “normal.” Present the following descriptions of drug use to students and ask them<br />
to rate each on a four-point scale (1 = no sign of abuse; 4 = a sure sign of abuse).<br />
A man who has been diagnosed with terminal cancer takes enough morphine to keep himself<br />
in a permanently drugged state.<br />
A college student with sleep problems drinks by himself or herself in the dormitory room<br />
until drunk enough to fall asleep.<br />
A fashion model uses amphetamines each day so that she can burn off enough calories and<br />
suppress her appetite to the point where she can stay as slim as the modeling agency<br />
requires.<br />
A middle-aged man with a history of heart disease continues to smoke cigarettes because<br />
after six attempts at stopping in the past, he feels he will die a smoker.<br />
A writer feels she cannot create significant poetry without being high on alcohol or<br />
marijuana.<br />
A college student uses up all her month’s spending money on cocaine within the first few<br />
days of the month.<br />
Using a show of hands, tally the number of people rating each behavior as 1, 2, 3, or 4. Ask those<br />
who rate the behaviors as “normal” what would have to change for them to see a problem. Ask<br />
those who give a rating of 4 to explain their perceptions.<br />
Some research (Leavy & Dunlosky, 1989) on undergraduate student and faculty perceptions of<br />
problem drinking indicates that heavier drinkers are less likely than light drinkers to perceive<br />
drinking problems and that students are less likely than faculty to perceive problems, even when<br />
differences in drinking habits are controlled.<br />
Source: Leavy, R. L., & Dunlosky, J. T. (1989). Undergraduate student and faculty perceptions of<br />
problem drinking. Journal of Studies on Alcohol, 50, 101–107.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 9: Substance-Related Disorders 143<br />
3. Legal restrictions have been placed on nearly all of the substances discussed in the current<br />
chapter. Ray and Ksir (1996) point out that, in many cases, crackdowns on drugs make some<br />
drugs less available but other, sometimes more dangerous drugs, more available. In 1644 the<br />
Emperor of China forbade tobacco smoking, an edict that was largely responsible for a surge in<br />
opium smoking. Opiate use in the United States was widespread in the late nineteenth and early<br />
twentieth century until the Harrison Act (1914), designed to tax the manufacture and sale of these<br />
drugs, became a way to make them illegal. The result was that opiate addicts switched to<br />
intravenous heroin.<br />
Another point of view is to accept the inevitability of drug use and encapsulate it or reduce its<br />
harm on users and others. One example is the idea of providing clean needles to intravenous drug<br />
users so that the incidence of HIV is reduced. The needle exchange program in Liverpool,<br />
England, succeeded in slowing the spread of HIV. However, many would suggest that such<br />
programs make drug abuse easier and more attractive (Ray & Ksir, 1996).<br />
The dilemma is this: Do we try to reduce the overall amount of drugs in society or to reduce the<br />
harm that drug use may inflict? Ask your students to examine their position on this critical issue.<br />
What do they think the goal of drug policy should be? Is drug policy a moral issue: Is it simply<br />
wrong to allow the spread of drug use?<br />
Source: Ray, O., & Ksir, C. (1996). Drugs, society, & human behavior (7th ed.). St. Louis:<br />
Mosby.<br />
4. Most students are interested in substance-abuse disorders, particularly as they affect adolescents.<br />
This demonstration conveys the most important risk factors for adolescent substance abuse and<br />
asks students to consider how much they feel these factors can be modified to reduce the<br />
incidence of abuse problems. The handout gives a consolidated list of factors taken from an<br />
exhaustive review by Hawkins et al. (1992). exhaustive review. For each risk factor, students<br />
should consider possible interventions to prevent adolescent substance abuse. You can also<br />
engage them in discussion of the costs to society for such interventions versus the costs of doing<br />
nothing. The full fifteen-page table of risk factors and research findings on successful and<br />
unsuccessful interventions in Hawkins et al. (1992) is well worth reading.<br />
Source: Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for<br />
alcohol and other drug problems in adolescence and early adulthood: Implications for substance<br />
abuse prevention. Psychological Bulletin, 112, 64–105.<br />
5. The early identification of a problem makes its solution easier than if the problem progresses to<br />
full flower. Several screening devices can help nip alcohol abuse and dependence in the bud. One<br />
such instrument, the Alcohol Use Disorder Identification Test (AUDIT) is provided (see handout)<br />
but should be given to students with caution. No screening instrument can provide a diagnosis of a<br />
condition, and this caveat is especially true of alcohol abuse. There is no “gold standard” by<br />
which alcoholism can be defined, because many of the criteria offered by DSM-IV are subjective.<br />
For instance, the degree to which alcohol use impairs social or occupational functioning—for how<br />
long and how intensely—is a personal judgment. Nevertheless, you should discuss with students<br />
these screening devices so they can see what physicians, counselors, and others use to identify<br />
drinkers who may require further assessment for problems. The screening devices can generate<br />
discussion about potential errors in the detection of substance-related disorders. Those who are<br />
concerned with their own drinking might speak with you privately and be referred to your college<br />
or university counseling service for a more extensive evaluation.<br />
The CAGE (Ewing, 1984) is a set of four questions that is widely used in clinical practice in the<br />
United States. Each question focuses on a lifetime problem that contributes to the acronym<br />
CAGE: Have you ever felt the need to Cut down on your drinking? Have you ever felt Annoyed
144 Chapter 9: Substance-Related Disorders<br />
by someone criticizing your drinking? Have you ever felt Guilty about your drinking? Have you<br />
ever felt the need for an Eye-opener (a drink first thing in the morning)? Two positive responses<br />
are considered the cutoff for making a fuller evaluation of the individual’s drinking and its<br />
consequences. The sensitivity (ability to identify all potential cases) and specificity (ability to<br />
disregard noncases) for the CAGE ranges from 60 to 95 percent and 40 to 95 percent,<br />
respectively. The large range probably results from using different cutoff scores, asking in<br />
different ways, and sampling different populations. The advantages of the CAGE are its brevity<br />
and the ease with which a clinician can remember the questions. The disadvantage is that it asks<br />
about lifetime problems and omits current consumption or concerns. As with all self-report<br />
instruments, it relies heavily on the respondent’s honesty.<br />
The Alcohol Use Disorder Identification Test (AUDIT) developed for the World Health<br />
Organization is somewhat longer, focuses on consumption and problems in the past year, and has<br />
been tested internationally (Babor & Grant, 1989). It is a two-part device including ten items that<br />
can be done in a structured interview or as paper-and-pencil measure and a series of laboratory<br />
tests and alcohol-related physical measures. The ten-item survey is given on the handout. The<br />
maximum score is 41, the minimum 0. Using a cutoff score of 8, its sensitivity (92 percent) and<br />
specificity (93 percent) seem superior to the CAGE. Fleming reports using a cutoff score of 11<br />
with college students.<br />
Sources: Babor, T. F., & Grant, M. (1989). From clinical research to secondary prevention:<br />
International collaboration in the development of the Alcohol Use Disorder Identification Test<br />
(AUDIT). Alcohol Health and Research World, 13, 371–374.<br />
Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American<br />
Medical Association, 252, 1905–1907.<br />
6. Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask them to rewrite either the DUI/DWI laws or the laws pertaining to possession of a<br />
controlled substance and the consequences for breaking those laws. Ask each group to develop<br />
this list with the most salient examples first. Each group could then have a spokesperson deliver a<br />
short talk about the best examples. You could provide a blank overhead transparency to each<br />
group at the beginning of this demonstration. The class should discuss whether the laws were<br />
written to be tougher or easier on those who break the law.<br />
7. Have the student form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask them how parents should talk to their children about drugs and alcohol. What<br />
would be effective? Would it change the parents' credibility if the child knows that the parents<br />
have used drugs and/or alcohol? Ask each group to develop this list with the most salient<br />
examples first. Each group could then have a spokesperson deliver a short talk about the best<br />
examples. You could provide a blank overhead transparency to each group at the beginning of<br />
this demonstration.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 9: Substance-Related Disorders 145<br />
HANDOUT FOR DEMONSTRATION 1: ROLE-PLAY<br />
Pat: A 26-year-old junior high social studies teacher, Pat has worked at the same school for four years.<br />
Pat usually gets to work, but never has a lesson plan and “wings it” using films and rambling<br />
conversations with students. Papers and tests are superficially graded. Pat has fallen well behind the<br />
planned curriculum. Performance has declined rapidly in the past three months.<br />
Pat smokes marijuana every morning before work and through the evening. On Friday nights, Pat<br />
drinks eight to ten drinks, and over the weekend, consumes three six-packs of beer. Pat has not gone<br />
more than two days without marijuana in the past two years.<br />
Pat will not talk about drug or alcohol use, but focuses exclusively on the “lousy kids I have to teach”<br />
and old hurts and dissatisfactions in love life.<br />
Kim: Pat’s roommate of two years and friend from college, Kim is now concerned about Pat’s<br />
increasing drug and alcohol use. Kim is angry at Pat’s lack of responsibility. Kim complains to Pat of<br />
Pat’s lack of professionalism at school and failure to help with shared costs and apartment clean-up. Pat<br />
gets verbally abusive when drunk, which scares and angers Kim. Kim has threatened to throw Pat out of<br />
the apartment unless there are changes. Kim called Dr. Dwight for help about Pat.<br />
Terry: Pat’s supervisor at the junior high (the social studies department head), Terry, is upset with the<br />
decline in Pat’s teaching performance. Pat used to be involved with the kids while being fairly<br />
disciplined, but now Terry thinks that “Pat has a mental problem or hates teaching or is on drugs.”<br />
Terry is very shy about confronting Pat, but will have to be honest when teacher evaluations are written<br />
in two weeks. Secretly, Terry wishes Pat would get out of the school and out of teaching.<br />
Karen: Pat’s 49-year-old divorced mother, Karen, left her alcoholic husband ten years before and has<br />
always considered Pat “my problem child.” She wants Pat to “grow up and stop leaning on me,” but<br />
denies that Pat has a drinking or drug problem. When Pat is in deep financial trouble, Karen always<br />
bails Pat out, although she feels angry about this afterward. While Karen isn’t thinking that Pat has<br />
mental problems, she thinks that Pat is the one who ruined the family.<br />
Dr. Dwight: A psychologist in private practice, Dr. Dwight, has convened this meeting and is taking no<br />
sides. Dr. Dwight believes that treatment works only when a client voluntarily asks for help. In this<br />
meeting, Dr. Dwight moves the conversation along and does not offer professional wisdom.<br />
Tracy: Pat’s 19-year-old brother, Tracy, has admired Pat for being the “wild one” in the family. Tracy<br />
is a highly responsible student and family helper. He has always been ambivalent about Pat, being<br />
sometimes jealous and sometimes furious.
146 Chapter 9: Substance-Related Disorders<br />
HANDOUT FOR DEMONSTRATION 4:<br />
RISK FACTORS FOR ADOLESCENT SUBSTANCE ABUSE<br />
Risk Factor Evidence<br />
What Could Be Done to Reduce<br />
Risk?<br />
1. Laws<br />
a. Taxation Increase in alcohol tax led to sharp<br />
decrease in consumption and cirrhosis<br />
mortality.<br />
Raise taxes<br />
b. Legal age Higher drinking age associated with<br />
fewer teen traffic fatalities.<br />
Raise and enforce age restrictions<br />
2. Availability Increased alcohol availability led to Enforce laws; teach peer resistance<br />
increased alcohol consumption. skills<br />
3. Neighborhood Drug trafficking associated with high Early family support for families in<br />
crime, mobility, low attachment in<br />
neighborhood.<br />
poverty<br />
4. Physiological<br />
a. Biochemical Low harm-avoidance predicts Target interventions with those<br />
early-onset alcoholism.<br />
having markers, especially boys<br />
b. Genetic Slow-wave EEGs in children of<br />
alcoholics.<br />
5. Family drug use Use by oldest brother and parents has Parent-skills training for drug-using<br />
independent effects on younger<br />
brother’s use.<br />
parents<br />
6. Family management Lack of or inconsistent parental Parents skills training; family<br />
discipline predicts initiation into drug<br />
use.<br />
therapy<br />
7. Family conflict Marital discord and divorce predictors<br />
of drug use.<br />
See 5 and 6<br />
8. Early and persistent Aggressiveness and hyperactivity in Social competence training for<br />
problem behavior boys age 5 to 7 predicts drug problems<br />
in adolescence.<br />
child; parent-skills training<br />
9. School failure Failure in school predicts adolescent Tutoring; parent involvement;<br />
drug abuse.<br />
alteration of classroom methods<br />
10. Low school<br />
Students expecting to attend college Cooperative<br />
commitment have lower rates of learning in druguse<br />
classroom.<br />
11. Peer rejection in Low social competency associated Social-competence training<br />
elementary grades with higher drug use.<br />
12. Association with Influence of peers on use stronger than Social-influence resistance training<br />
drug-using peers that of parents.<br />
13. Alienation and Alienation from dominant social Prosocial activities (for example,<br />
rebelliousness values; resistance to authority are<br />
related to drug use.<br />
sports)<br />
14. Early onset of drug Later onset predicts lower drug Educate at a young age<br />
use<br />
involvement.<br />
Source: Consolidated from “Risk and Protective Factors for Alcohol and Other Drug Problems in<br />
Adolescence and Early Adulthood: Implications for Substance Abuse Prevention,” by J. D. Hawkins,<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 9: Substance-Related Disorders 147<br />
R. F. Catalano, & J. Y. Miller, Psychological Bulletin, 112 (1), 1992, pp. 64–105. Copyright © 1992<br />
by the American Psychological Association. Reprinted with permission from the American Psychological<br />
Association and the author.
148 Chapter 9: Substance-Related Disorders<br />
HANDOUT FOR DEMONSTRATION 5:<br />
ALCOHOL USE DISORDER IDENTIFICATION TEST (AUDIT)<br />
The following are questions about your use of alcoholic beverages (beer, wine, liquor) during the past<br />
year.<br />
Record the score for each question in the box on the right side of the question [ ].<br />
1. How often do you have a drink containing alcohol?<br />
[ ] Never (0) [ ]<br />
[ ] Monthly or less (1)<br />
[ ] 2 to 4 times a month (2)<br />
[ ] 2 to 3 times a week (3)<br />
[ ] 4 or more times a week (4)<br />
2. How many drinks containing alcohol do you have on a typical day when you are drinking?<br />
[ ] None (0) [ ]<br />
[ ] 1 or 2 (1)<br />
[ ] 3 or 4 (2)<br />
[ ] 5 or 6 (3)<br />
[ ] 7 or 9 (4)<br />
[ ] 10 or more (5)<br />
3. How often do you have six or more drinks on one occasion?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
4. How often during the last year have you found that you were unable to stop drinking once you had<br />
started?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
5. How often during the last year have you failed to do what was normally expected of you because<br />
of drinking?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 9: Substance-Related Disorders 149<br />
6. How often during the last year have you needed a first drink in the morning to get yourself going<br />
after a heavy drinking session?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
7. How often during the last year have you had a feeling of guilt or remorse after drinking?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
8. How often during the last year have you been unable to remember what happened the night before<br />
because you had been drinking?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
9. Have you or someone else been injured as the result of your drinking?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
10. Has a relative, friend, or doctor or other health worker been concerned about your drinking or<br />
suggested that you cut down?<br />
[ ] Never (0) [ ]<br />
[ ] Less than monthly (1)<br />
[ ] Monthly (2)<br />
[ ] Weekly (3)<br />
[ ] Daily or almost daily (4)<br />
Record the total of the specific items. [ ]
150 Chapter 9: Substance-Related Disorders<br />
SELECTED READINGS<br />
Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in junior high: A multi-site longitudinal test.<br />
Science, 247, 1299–1305.<br />
Gallant, D. M. (1987). Alcoholism: A guide to diagnosis, intervention and treatment. New York: W. W.<br />
Norton.<br />
Glantz, M., & Pickens, R. (Eds.) (1991). Vulnerability to drug abuse. Washington, DC: American<br />
Psychological Association.<br />
Miller, W. R., & Hester, R. K. (1986). Inpatient alcoholism treatment: Who benefits? American<br />
Psychologist, 41, 794–805.<br />
Nathan, P. E. (1993). Alcoholism: Psychopathology, etiology, and treatment. In P. B. Sutker & H. E.<br />
Adams (Eds.) Comprehensive handbook of psychopathology. New York: Plenum Press, pp. 451–476.<br />
Sattler, D., Shabatay, V., & Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 9, Substance-Related Disorders.<br />
Clipson, C. , & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 9, Alcohol Dependence: The Web that Denial Weaves.<br />
VIDEO RESOURCES<br />
ACA Recovery: Meeting the Child Within (video, color, 25 min). Vignettes depict the childhood<br />
experiences of Adult Children of Alcoholics (ACAs) and the process of getting better by appreciating<br />
their unmet childhood needs and the covert messages they learned. University of Minnesota Film and<br />
Video Service, Suite 108, 1313 Fifth Street S.E., Minneapolis, MN 55414-1524.<br />
The Addictive Personality (slides and audio cassettes, 45 min). An examination of the addictive<br />
personality. Emotional needs that predispose an individual to drug use are described, as well as the<br />
effects of addiction and its treatment. IBIS Media, P.O. Box 308, Pleasantville, NY 10570.<br />
Alcohol and Drugs: How They Affect Your Body (16 mm, color, 20 min). A description of how the brain<br />
regulates functioning in the rest of the body and how drugs interfere with normal functioning, leading to<br />
long-term deterioration. Barr Films, P.O Box 5667, Pasadena, CA 91107.<br />
Alcoholism: Out of the Shadows (16mm, color, 30 min). An ABC-TV documentary giving first-hand<br />
accounts of individuals whose alcoholism seriously affected their own lives and those of others.<br />
American Broadcasting Corporation TV, 1330 Avenue of the Americas, New York, NY 10019.<br />
Fetal Alcohol Syndrome (16 mm, color, 13 min). Describes the effects of alcohol abuse by mothers<br />
during pregnancy. Shows physical abnormalities and retardation at birth and throughout the child’s<br />
development. Films, Inc., 1144 Wilmette Avenue, Wilmette, IL 60091.<br />
LSD: Insanity or Insight? (16 mm, color, 18 min). The film shows what is known about the<br />
psychological and physiological effects of LSD. Adverse effects such as chromosomal damage, brain<br />
chemistry changes, and the malformation of fetuses are emphasized. Interviews with users are also<br />
presented. Phoenix/BFA Films and Video, Inc., 470 Park Avenue South, New York, NY 10016.<br />
An Ounce of Prevention (16 mm, color, 26 min). The film assesses the individual and community<br />
damage wrought by alcohol abuse. Community treatment and prevention efforts are discussed. Harper<br />
& Row Media, 10 East 53rd Street, New York, NY 10022.<br />
Psychoactive (16 mm, 30 min). Through live action and animation, the film shows the physiological<br />
effects of barbiturates, opiates, hallucinogens, and stimulants. Emphasis is given to the development of<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 9: Substance-Related Disorders 151<br />
dependence, the effects of prolonged use, and programs to detoxify users. Pyramid Film Productions,<br />
P.O. Box 1048, Santa Monica, CA 90406.<br />
“The World of <strong>Abnormal</strong> Psychology” (#6) from the series Substance Use Disorders (VHS, 60 min).<br />
The focus is on alcohol, cocaine, and nicotine addiction—their effects on the individual and society.<br />
The film also discusses risk factors, AA policy, Native American approaches and has a strong segment<br />
on relapse prevention. The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S. Burlington, VT<br />
05407-2345; to order, call 1-800-532-7637.<br />
Substance Abuse Disorders (VHS, color, 60 mm.). From The World of <strong>Abnormal</strong> Psychology series.<br />
The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S. Burlington, VT 05407-2345; to order,<br />
call 1-800-532-7637.<br />
ON THE INTERNET<br />
http://www.health.org/ is the Web site for the National Clearinghouse for Alcohol and Drug<br />
Information (NCALI) a government agency that provides a wealth of information.<br />
http://www.nida.nih.gov is another government source, the National Institute on Drug Abuse (NIDA).<br />
http://www.jointogether.org/ has information on funding, public policy, community action programs, a<br />
national forum on drug abuse prevention and treatment (The Coffee House), and searches for<br />
documents on all the above.<br />
http://www.ca.org/ is a site for Cocaine Anonymous (CA) and http://www.alcoholics-anonymous.org/<br />
is for Alcoholics Anonymous.
CHAPTER 10<br />
Sexual and Gender Identity Disorders<br />
CHAPTER OUTLINE<br />
I. What is "normal" sexual behavior?<br />
A. President Clinton and "normal" sexual behavior<br />
1. Is oral sex normal?<br />
2. Does oral sex constitute "sex"?<br />
3. Does the use of a "cigar" in sex play constitute perversion?<br />
4. Is the former President a "sex addict"?<br />
5. Defining "perversion" is difficult; it is affected by changing perspectives over time and<br />
differences in cultural perspective<br />
B. The study of human sexuality<br />
1. Kinsey; first scientific studies; used self-report and questionnaire-interview methods<br />
2. Masters and Johnson observed sexual behavior in laboratory; dispelled myths of less<br />
sexuality in women and vaginal orgasm; described “normal” sexual response cycle<br />
3. Janus Report (1993): large cross-sectional survey (1,347 women; 1,418 men) including<br />
older populations<br />
C. The sexual response cycle<br />
1. Appetitive (desire for sexual activity)<br />
2. Excitement (physiological arousal)<br />
3. Orgasm (involuntary muscular contractions and release of sexual tension)<br />
4. Resolution (relaxation of body after orgasm)<br />
D. Homosexuality: DSM-III-R and DSM-IV-TR do not include homosexuality as a disorder<br />
1. Homophobia: the irrational fear of homosexuality<br />
2. Reasons homosexuality is not a disorder<br />
a) No physiological differences in arousal between homosexuals and heterosexuals<br />
b) No difference in psychological disturbance<br />
c) No gender identity confusion in homosexuals<br />
d) Because of homophobia, homosexual sexual concerns may differ significantly<br />
from heterosexuals’ concerns<br />
e) Not a lifestyle choice, but a naturally occurring biological phenomenon<br />
E. Aging and sexual activity<br />
1. Sexual frequency in older men reflects frequency at younger age<br />
2. Among most active, fewest dysfunctions<br />
3. Janus Report (1993)<br />
a) Sexual activity of people 65 and over declined little<br />
b) Ability to reach orgasm diminished little, desire unchanged<br />
4. Physiological changes only slow sexual response; more warmth and intimacy after sex<br />
II. Sexual dysfunctions<br />
A. Prevalence: range from 5 to 60 percent, depending on gender and specific problem<br />
B. DSM-IV-TR requires problem to be recurrent and persistent disruption for a diagnosis of<br />
sexual dysfunction; also considers: frequency, chronicity, subjective distress, and effect on<br />
other areas of functioning<br />
C. Sexual desire disorders: hypoactive sexual desire disorder and sexual aversion disorder<br />
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Chapter 10: Sexual and Gender Identity Disorders 153<br />
1. Questions about category when there are marital problems or job stress<br />
2. About 20 percent of adult population believed to suffer hypoactive sexual desire<br />
disorder<br />
3. Wide range of “normal” for sexual involvement<br />
D. Sexual arousal disorders<br />
1. Erectile dysfunction: inability of male to attain or maintain erection sufficient for<br />
sexual intercourse and/or psychological arousal during sexual activity<br />
a) Difficult to distinguish between primarily biological and primarily psychological<br />
even nocturnal penile tumescence (NPT) assessment is imprecise<br />
b) Primary erectile dysfunction: never able; secondary erectile dysfunction: previous<br />
success<br />
c) Prevalence difficult to estimate; prior to Viagra, perhaps 10-15 million American<br />
men; current estimates: 30 million (one reason may be greater comfort in<br />
reporting)<br />
2. Female sexual arousal disorder: inability to attain or maintain physiological response<br />
and/or psychological arousal during sexual activity<br />
a) Lack signs of excitement (e.g., lubrication)<br />
b) May be primary or secondary; often from learned negative attitudes<br />
c) Prevalence estimates: 10 to 50 percent of female population<br />
3. Differentiation between biological and psychological cause is difficult—even<br />
assessment by nocturnal penile tumescence (NPT) imprecise<br />
E. Orgasmic disorders (inability to achieve orgasm despite adequate stimulation)<br />
1. Female orgasmic disorder (inhibited female orgasm)<br />
a) Clinician judges whether stimulation is “sufficient”<br />
b) Need to reevaluate “necessity” for coital orgasm<br />
c) Primary and secondary forms<br />
d) Wakefield (1988): diagnosed only if women have had experiences conducive to<br />
orgasm (masturbation)<br />
2. Male orgasmic disorder (inhibited male orgasm): inability to ejaculate intravaginally;<br />
relatively rare<br />
3. Premature ejaculation:<br />
a) Common varied definitions of “too fast”<br />
b) A common problem (possibly 50 percent for women, 33 percent for men)<br />
F. Sexual pain disorders<br />
1. Dyspareunia: persistent pain in genitals before, during, or after intercourse<br />
2. Vaginismus: involuntary spasms of outer third of vagina restricting penile penetration<br />
G. Etiology and treatment of sexual dysfunctions<br />
1. Biological factors and medical treatment<br />
a) Sex hormones<br />
b) Prescribed medications can affect sex drive<br />
c) Constitutional hypersensitivity<br />
d) Insufficient blood flow into genital area<br />
e) Treatment (for men): vascular surgery (penile implants, injections of papaverine<br />
and phentolamine into penis, pumps) or medication (Viagra)<br />
2. Psychological factors and behavioral therapy<br />
a) Predisposing or historical factors )unconscious hostility, parentalattitudes, early<br />
conditioning)<br />
b) Current factors (relationship stress, performance anxiety, self-focus, guilt)<br />
3. Therapy usually includes education, anxiety reduction, structured behavioral exercises,<br />
communication training
154 Chapter 10: Sexual and Gender Identity Disorders<br />
a) Specific techniques for specific disorders: masturbation for female orgasmic<br />
disorder, start-stop and squeeze techniques for premature ejaculation, relaxation<br />
and successively larger dilators for vaginismus<br />
b) Evaluation of behavior therapy: questions about high success rate; relapse a<br />
concern<br />
III. Gender identity disorders: conflict between anatomical sex and self-identification<br />
A. Transsexualism: early sex role conflicts; cross-gender identification<br />
1. Asexual, heterosexual, and homosexual histories<br />
2. Mostly males; prevalence between 1 in 100,000 and 1 in 30,000 for males; 1 in<br />
400,000 to 1 in 100,000 in females<br />
B. Gender identity disorders not otherwise specified involve cross-dressing without identity<br />
problems or preoccupation with castration without desire for sex characteristics of other sex<br />
C. Etiology of gender identity disorders<br />
1. Biological perspective<br />
a) Animal studies support role of sex hormones<br />
b) Children in one study adopt gender identity imposed by parents regardless of<br />
genetic sex<br />
2. Some believe gender identity is malleable<br />
3. <strong>Behavior</strong>al perspective: parental encouragement of feminine behavior, lack of male<br />
playmates, peer ostracism<br />
D. Treatment of gender identity disorders<br />
1. Children get sex education and male therapist as role model<br />
2. Parents trained to reinforce sex-appropriate behavior<br />
3. <strong>Behavior</strong> therapy with adults<br />
4. Sex reassignment surgery<br />
IV. Paraphilias: for at least six months person has acted on or is severely distressed by recurrent urges<br />
or fantasies involving nonhuman objects, nonconsenting others, real or simulated suffering or<br />
humiliation<br />
A. Paraphilias involving nonhuman objects<br />
1. Fetishism: sexual attraction to inanimate objects (panties, shoes); rare among women<br />
2. Transvestic fetishism: arousal from cross-dressing; if cross-dressing only during course<br />
3. of gender identity disorder, rules out transvestic fetishism<br />
a) Majority are heterosexuals<br />
b) Feel they have alternating male and female personalities<br />
B. Paraphilias involving nonconsenting persons<br />
1. Exhibitionism: exposing genitals to strangers for shock effect<br />
a) Relatively common; men show sexual arousal to erotically neutral females<br />
b) Tend to be young married men<br />
c) Exposing has a compulsive quality<br />
2. Voyeurism: urges, acts, or fantasies of observing an unsuspecting person disrobing or<br />
engaging in sexual activity<br />
a) Risk of arrest; prefer victim is a stranger (95 percent)<br />
b) Because it is repetitive, arrest is predictable<br />
3. Frotteurism: recurrent fantasies and behavior of rubbing against nonconsenting person<br />
4. Pedophilia: sexual gratification from fantasies or sexual contact with children<br />
a) DSM-IV-TR criteria: at least 16 years old and five years older than victim; may<br />
include own children (incest)<br />
b) Child sexual abuse common (20 to 30 percent of women report being victims)<br />
c) Pedophile usually family member or friend<br />
d) In one study 25 percent of victims were under 6, 25 percent 6 to 10, 50 percent<br />
11 to 13 years<br />
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Chapter 10: Sexual and Gender Identity Disorders 155<br />
e) Highest recidivism rate among sex offenders<br />
f) Pedophile profile: passive, impulsive, alcoholic, low social skills, possible brain<br />
dysfunction<br />
g) Victims seriously affected: physical symptoms, nightmares, acting out, sexually<br />
focused behavior<br />
C. Paraphilias involving pain or humiliation<br />
1. Sadism and masochism: sexual gratification from pain (sadist inflicts; masochist<br />
receives); DSM-IV-TR requires acting on urges or being distressed by them<br />
a) Majority enjoy both roles; activity is planned<br />
b) Aggressive sex fantasies common in “normals”; sadism/masochism deviant<br />
because pain is necessary<br />
c) Possible brain dysfunction in right temporal area<br />
D. Etiology and treatment of paraphilias<br />
1. Biological perspective: too little known about neurohormones to make assertions<br />
2. Psychodynamic perspective: castration anxiety; actions symbolic of unconscious<br />
conflict<br />
3. <strong>Behavior</strong>al perspective: early conditioning<br />
a) Masturbation fantasies<br />
b) Preparedness accounts for normal sexual cues<br />
4. Treatments<br />
a) Extinction or aversive conditioning<br />
b) Strengthen appropriate behaviors<br />
c) Develop social skills<br />
d) Aversive behavior rehearsal (for exhibitionism)<br />
V. Sexual aggression<br />
A. Rape: intercourse accomplished through force or threat of force; seen as crime of violence<br />
1. Statutory rape: sexual intercourse with a girl younger than a certain age<br />
2. Prevalence: 102,000 cases reported in 1990 (large underestimate)<br />
3. Rape victims: mostly young; date rape common<br />
a) Characteristics of men who coerce women: create situation, interpret friendliness<br />
as provocation manipulate with drugs or alcohol attribute failures to negative<br />
features of woman<br />
4. Effects of rape<br />
a) Acute phase: disorganization<br />
b) Long-term phase: reorganization<br />
5. Etiology of rape<br />
a) Power rapists—to compensate for personal inadequacy<br />
b) Anger rapists—at women in general<br />
c) Sadism rapists—satisfaction from torture and pain<br />
d) More common in college men than expected<br />
e) Media portrayals of violent sex<br />
f) “Cultural spillover”—rape more common in cultures that encourage violence<br />
g) Sociocultural and sociobiological perspectives<br />
6. Etiology: sociobiological reasons<br />
B. Incest<br />
1. Wide range of incidence estimates (48,000 to 250,000 cases per year); 75 percent of<br />
sibling incest is consensual<br />
2. Daughter victims seriously affected<br />
3. Incestuous fathers more likely to have experienced child sexual abuse than<br />
nonincestuous, but rare<br />
C. Treatment for incest offenders and rapists
156 Chapter 10: Sexual and Gender Identity Disorders<br />
1. Conventional<br />
a) Imprisonment main form (but not treatment)<br />
b) <strong>Behavior</strong> therapies: some treatment programs effective with child molesters and<br />
exhibitionists, but treatment has not been effective for rapists<br />
2. Controversial treatments<br />
a) Surgical castration<br />
b) Chemical therapy (Depo-Provera)<br />
LEARNING OBJECTIVES<br />
1. Distinguish between sexual dysfunctions, paraphilias, and gender identity disorders. (p. 307)<br />
2. Discuss the problems of defining “normal” sexual behavior. (pp. 308-309)<br />
3. Indicate the contributions of Kinsey, Masters and Johnson, Kaplan, and the Janus Report in the<br />
history of studying human sexuality. (p. 309-310)<br />
4. Describe and discuss the four stages of the human sexual response cycle. (pp. 310-312)<br />
5. Explain why homosexuality is not considered a mental disorder. (pp. 312-315)<br />
6. Discuss the results of research on sexuality among those over age 60. (pp. 315-317)<br />
7. Describe and differentiate sexual desire disorders in men and women, sexual arousal disorder in<br />
men and women, and male and female orgasmic disorder. Describe and discuss the causes of<br />
sexual pain disorders. (pp. 317-323)<br />
8. Discuss the biological causes and treatments for psychosexual dysfunctions. (pp. 324-326)<br />
9. Discuss the psychological factors that cause, and the behavioral therapy techniques used to treat,<br />
sexual dysfunctions. (pp. 326-328)<br />
10. Define gender identity disorders and describe their symptoms. Discuss the biological,<br />
psychodynamic, and behavioral explanations for these disorders and how gender identity<br />
disorders are treated. (pp. 328-332)<br />
11. Define paraphilias and list the three categories of these disorders. Describe and differentiate<br />
fetishism, transvestic fetishism, exhibitionism, voyeurism, frotteurism, pedophilia, sadism, and<br />
masochism. (pp. 332-339; Figure 10.8)<br />
12. Discuss the problems of people who were childhood victims of sexual abuse. (pp. 337-338)<br />
13. Discuss the biological, psychodynamic, and behavioral etiological theories of paraphilia and how<br />
those theories lead to different forms of treatment. (pp. 339-341)<br />
14. Differentiate the terms sexual coercion, sexual aggression, rape, and incest. Describe the effects<br />
of rape on victims, including the acute and long-term phases of rape trauma syndrome. Discuss<br />
what is known about the cause of rape, including the three motivational types of rapists. (pp. 341-<br />
348)<br />
15. Discuss the effects of media portrayals of sexual violence and sociocultural variables. (pp. 347-<br />
348)<br />
16. Describe and evaluate the conventional and controversial treatments provided for incest offenders<br />
and rapists. (pp. 348-349)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. You can augment the information given in the text about the normal sexual response cycle for<br />
men and women by using Masters and Johnson’s Human Sexual Response (1966). On the board,<br />
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Chapter 10: Sexual and Gender Identity Disorders 157<br />
draw the generic curve of sexual arousal for males, showing that the process toward orgasm is<br />
typically more rapid for males than it is for females. The refractory period for males should also<br />
be described and discussed. In part, the related problems of female orgasmic difficulty and male<br />
premature ejaculation are linked to basic differences in the timing of sexual arousal and release.<br />
Further, it is useful to point out the need for relaxation plus arousal in order to have a male<br />
erection and female orgasm. If either relaxation is absent (and anxiety takes its place) or arousal is<br />
insufficient, sexual difficulties are more likely.<br />
2. Ask students to indicate their gender and nothing else at the top of a page. Assure them that, in the<br />
exercise to follow, only group data will be of interest. To further lower concern, let students know<br />
that they can refrain from participation by simply turning in blank sheets of paper.<br />
Ask students to write a description of a person that comes to mind when the following words are<br />
read: (1) impotent man, (2) lesbian, (3) flasher, (4) frigid woman, (5) AIDS victim.<br />
Have students fold their papers in half and pass them in. You can do a quick tally of positive,<br />
negative, and neutral adjectives for each hypothetical person. Put on the board some of the more<br />
commonly listed adjectives for each sex separately. Do male students show stronger negative<br />
reactions than female students? Discuss why this might be so (males are expected to be sexually<br />
dominant; women are socialized to be more nurturing). Ask students whether their responses<br />
might have been different if DSM-IV-TR language had been used, such as erectile dysfunction or<br />
exhibitionist. This should lead to a discussion of whether changes in names would effectively<br />
prevent stereotypic attitudes and discriminatory behavior.<br />
3. The sheer number of separate sexual deviances listed in this chapter may indicate that people in<br />
the United States are particularly concerned with what is “right” or “normal” sexual behavior.<br />
Challenge students to think of any other naturally occurring behavior that has as many<br />
emotionally charged and incorrect ways of being performed (some suggested behaviors are<br />
sleeping, eating, drinking, and walking).<br />
A related issue is the fact that the paraphilias are predominantly a male problem. Discuss with<br />
students why males are so much more likely to be plagued with these problems. One reason might<br />
be that women traditionally deny their sexuality and tend to be passive in their sexual behavior. If,<br />
in the future, women come to be as involved and explicit about their sexuality as men, will they<br />
develop paraphilias, too? Another reason might be the pressure placed on men to perform within a<br />
narrow range of sexually correct behaviors. When they are socially immature and unable to be<br />
sexually successful under stressful circumstances, they resort to extraordinary measures to feel<br />
competent and dominant. Note that exhibitionists and voyeurs, for example, tend to be socially<br />
immature men.<br />
Internet Site: http://www.goaskalice.columbia.edu/index.html. "Go Ask Alice" a sexual health<br />
question and answer service by Columbia University.<br />
4. There has been an explosion in the number of allegations of child sexual abuse stemming from the<br />
recovery of memories of such abuse. Clients, usually women, coming to therapy for problems as<br />
common and diverse as depression, sexual dysfunction, low self-esteem, or anxiety, recover<br />
memories of childhood abuse during treatment. Elizabeth Loftus, a highly respected researcher on<br />
memory, challenges the validity of many of these cases (Loftus, 1993).<br />
First, we are unclear what the base rate for repression may be. In one study of women treated for<br />
substance abuse, one-half reported sexual abuse in childhood, but only 18 percent claimed they<br />
forgot the abuse for a period of time and later remembered it. In another study, 38 percent of<br />
women known to have been abused were amnesic.
158 Chapter 10: Sexual and Gender Identity Disorders<br />
Second, some of the memories being recalled seem highly implausible. In some cases, richly<br />
detailed recollections of abuse during infancy are given. Research shows that our earliest<br />
recollections do not date back before age 3; most of our early memories are remembrances of<br />
things told to us by others.<br />
Third, therapists tend to be uncritical of recollections reported by clients. In one small study of<br />
clinicians who had had at least one repressed memory case, the great majority invariably believed<br />
whatever the client said. As one clinician reported, “If a woman says it happened, it happened.”<br />
(Loftus, 1993, p. 524)<br />
Popular magazine articles and books have flooded the media with reports of childhood abuse,<br />
such as revelations by Roseanne Barr Arnold and former Miss America Marilyn Van Derbur. The<br />
book The Courage to Heal (Bass & Davis, 1988) is very popular and gives victims a great deal of<br />
comfort. However, it also counsels readers to “assume that your feelings are valid. So far, no one<br />
we’ve talked to thought she might have been abused, and then later discovered that she hadn’t<br />
been... If you think you were abused, and your life shows the symptoms, then you were” (p. 22).<br />
The symptoms, however, are pervasive: depression, self-destructive thoughts, low self-esteem,<br />
and sexual dysfunction. In one book (Farmer, 1989) repression is the expected result of abuse:<br />
“The more severe the abuse, the more likely you were to repress any conscious recollection of it”<br />
(p. 52).<br />
Research with hypnosis and direct insertion of false information (Loftus & Coan, in press)<br />
demonstrates that therapists can take actual events or dreams and suggest that abuse occurred or<br />
can generate memories out of whole cloth. For example, children who lived in a neighborhood<br />
where a sniper attack occurred on a playground vividly remembered the attack even though they<br />
were not present.<br />
Repression probably does occur, but we do not know the base rate. It seems unlikely that recovery<br />
of repressed memories for child sexual abuse occurs with the frequency that is currently being<br />
reported. It is difficult to square the rate of abuse repression with the fact that, in a study of<br />
children who witnessed the murder of a parent, not a single child repressed the memory. To the<br />
contrary, they could not get the images and emotions out of their minds (Malmquist, 1986).<br />
Loftus (1993) argues that uncritical acceptance of even the most dubious allegations is a drain on<br />
society in interminable therapy, a source of unspeakable anguish for wrongly accused parents,<br />
and, perhaps most tragic, the “increased likelihood that society in general will disbelieve the<br />
genuine cases of childhood sexual abuse that truly deserve our sustained attention” (p. 534).<br />
Sources: Bass, E., & Davis, L. (1988). The courage to heal. New York: Harper & Row.<br />
Farmer, S. (1989). Adult children of abusive parents. New York: Ballantine.<br />
Loftus, E. F. (1993). The reality of repressed memories. American Psychologist, 48, 518–537.<br />
Loftus, E. F., & Coan, D. (in press). The construction of childhood memories. In D. Peters (Ed.)<br />
The child witness in context: Cognitive, social, and legal perspectives. New York: Kluwer.<br />
Malmquist, C. P. (1986). Children who witness parental murder: Post-traumatic stress. Journal of<br />
the American Academy of Child Psychiatry, 25, 320–325.<br />
Internet Site: http://www.qrd.org/QRD/orgs/NAMBLA/. Journal and research reports on<br />
pedophilia.<br />
5. The range of cultural norms about sexuality is extraordinary. Nevid, Rathus, and Greene (1994)<br />
offer these glimpses into the cultural anthropology of sex.<br />
• Among the Abkhasian people of the southern part of the former Soviet Union, men are<br />
sexually aroused by women’s armpits. Only a husband is permitted to see a wife’s armpits.<br />
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Chapter 10: Sexual and Gender Identity Disorders 159<br />
• Some societies believe that men and women eating together is a mild form of sexual<br />
behavior. Therefore, in such societies brothers and sisters are forbidden from eating meals<br />
together since this behavior approaches incestuous relations.<br />
• Kissing is unknown among the Siriono of Bolivia and the Thonga of Africa. The Thonga,<br />
upon learning that Europeans kiss, caused one man to say, “Look at them—they eat each<br />
others’ saliva and dirt!”<br />
• It is considered polite among the Native American Aleut people of Alaska for a husband to<br />
offer his wife to a visitor.<br />
• In Pakistan, where men’s testimony is considered more believable than women’s, women<br />
who accuse men of raping them have sometimes been imprisoned themselves. Some women<br />
who have charged men with rape have been prosecuted for adultery, but their assailants,<br />
claiming that if sex occurred it was consensual, have been acquitted.<br />
Internet Site: http://www.goaskalice.columbia.edu/index.html. "Go Ask Alice" a sexual health<br />
question and answer service by Columbia University.<br />
6. Masters and Johnson’s book (1970) on treating sexual dysfunctions made the case for fear as the<br />
cause of many problems. They suggested that tension caused by fear of failure created a selffulfilling<br />
prophesy in the form of erectile disorder and female orgasmic disorder. Helen Singer<br />
Kaplan (1979) claimed that all sexual dysfunctions were caused by anxiety. David Barlow and his<br />
colleagues (Barlow, Sackheim, & Beck, 1983; Abrahamson, Barlow, Sackheim, Beck, &<br />
Athanasiou, 1985; Barlow, 1986) have tested this hypothesis in the laboratory and found it only<br />
partially accurate. Fear, it seems, can lead to increased arousal and performance in some men,<br />
decreased arousal in others. The difference seems to be cognitive. The research went through the<br />
following steps.<br />
The initial study sought to simulate in the laboratory the fearfulness some experience in the<br />
bedroom. All subjects were sexually functional men, and all were given a harmless but somewhat<br />
painful electric shock before being put into one of three conditions. In condition one (control), the<br />
subjects were told they were going to watch an erotic movie and they should just enjoy it. In<br />
condition two, subjects were told that there was a 60 percent chance of receiving an electric shock<br />
while they were watching the erotic movie. Nothing they would do could alter the chances of<br />
getting the shock (a noncontingent condition). Condition three was contingent shock: Subjects<br />
were told that if they did not achieve an “average” erection, they had a 60 percent chance of<br />
receiving a shock. This condition was seen as most closely simulating performance anxiety in the<br />
bedroom. In no case did subjects receive a shock. The results were surprising. Subjects in both<br />
shock conditions showed more arousal than those who simply relaxed and the contingent shock<br />
group were significantly more aroused than the noncontingent group. Clearly, anxiety not only did<br />
not impair performance, it enhanced it. Incidentally, research on women (Palace & Garzalka,<br />
1990) produced similar findings.<br />
Later, the Barlow team found that although sexually functional men showed increased<br />
performance in the shock-demand condition, sexually dysfunctional men showed reduced sexual<br />
arousal. Further, although the functional men were significantly less aroused if distracted by<br />
nonsexual stimuli (listening to a nonerotic narrative over earphones), dysfunctional men’s arousal<br />
was not decreased by nonsexual distractions. Functional men were accurate in estimating their<br />
level of arousal, but dysfunctional men underestimated it. Barlow constructed a model that<br />
accounts for these puzzling findings and applies to sexual arousal disorders. In essence, functional<br />
men have a positive feedback loop that interprets both external and internal sexual stimuli in a<br />
way to increase arousal, whereas dysfunctional men have a negative feedback loop that does the<br />
opposite. Here are the components of the model:
160 Chapter 10: Sexual and Gender Identity Disorders<br />
For functional men: When there are explicit or implicit demands for sexual performance, they<br />
think of past positive experiences, perceive themselves to be in control, and maintain a positive<br />
mood. They focus their attention on the erotic stimuli, and when they feel increases in arousal, pay<br />
further attention to erotic cues. They approach the sexual situation and perform satisfactorily. For<br />
dysfunctional men: When there are similar demands for sexual performance, they think of past<br />
failures, perceive themselves to have little control, and maintain a negative mood. They focus<br />
their attention on the negative consequences of not performing adequately or on other nonerotic<br />
stimuli. They underestimate their level of autonomic arousal, focus greater attention on negative<br />
consequences and other distractions leading to avoidance of the sexual situation, and perform<br />
unsatisfactorily.<br />
Other factors account for sexual-arousal disorders, including physical causes, socialization, and<br />
interpersonal difficulties, but this model helps us understand that anxiety alone is not the cause. In<br />
fact, the model suggests that channeling performance concerns through certain cognitions leads to<br />
increased arousal and presumably enjoyment for some people.<br />
Sources: Abrahamson, D. J., Barlow, D. H., Sakheim, D. K., Beck, J. G., & Athanasiou, R.<br />
(1985). Effects of distraction on sexual responding in functional and dysfunctional men. <strong>Behavior</strong><br />
Therapy, 16, 503–515.<br />
Barlow, D. H., Sackheim, D. K., & Beck, J. G. (1983). Anxiety increases sexual arousal. Journal<br />
of <strong>Abnormal</strong> Psychology, 92, 49–54.<br />
Barlow, D. H. (1986). Causes of sexual dysfunction: The role of anxiety and cognitive<br />
interference. Journal of Consulting and Clinical Psychology, 54, 140–148.<br />
Kaplan, H. S. (1979). Disorders of sexual desire. New York: Brunner/Mazel.<br />
Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. Boston: Little, Brown.<br />
Palace, E. M., & Gorzalka, B. B. (1990). The enhancing effects of anxiety on arousal in sexually<br />
dysfunctional and functional women. Journal of <strong>Abnormal</strong> Psychology, 99, 403–411.<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. Presentations by professionals who come in contact with raped or sexually abused individuals can<br />
have a powerful and informative impact. Many police forces have special departments for rape<br />
and sexual abuse. Officers from these departments can provide information on the legal issues<br />
involved and the frustration of prosecuting these offenders. Rape counselors from mental health or<br />
freestanding service organizations can describe the psychological crisis of rape and the difficulties<br />
involved in sorting out which of several options the woman will take in dealing with the trauma.<br />
Hospital emergency room nurses can provide yet another vantage point, the immediate response<br />
to rape, whereas mental health professionals can describe the longer term reactions, which parallel<br />
posttraumatic stress syndrome. Finally, all these people can be included in a discussion of our<br />
society’s tendency to blame the victim. Ask them what the implications of this tendency are in<br />
terms of reporting rapes, prosecuting rapists, and getting adequate help to overcome the physical<br />
and psychological trauma of the event.<br />
2. Marcia Freer (1992) uses this exercise to give students a way to voice and compare their opinions<br />
about sexual behavior without being embarrassed. The exercise also provides data for keeping<br />
track of trends in sexual attitudes over the years. It is bound to generate discussion.<br />
Because students need to move around the classroom, this demonstration is probably feasible for<br />
classes with no more than 40 or 50 students. It works only if there is a 60/40 or a more even<br />
distribution of males and females in the class. Freer estimates that 30 minutes is an average time<br />
involved, including discussion.<br />
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Chapter 10: Sexual and Gender Identity Disorders 161<br />
Copy two versions of the Handout for Demonstration 2—one on pink paper, for females; one on<br />
blue paper, for males. Complaints about the colors and sex-role stereotyping will help you during<br />
discussions later. Students fill out the questionnaire anonymously. They are instructed to fold it in<br />
half and pass it up to you. Shuffle the questionnaires and redistribute. Caution anyone who gets<br />
his/her own questionnaire not to reveal this information to the rest of the class.<br />
Designate five locations around the room to correspond with the five possible ratings (strongly<br />
agree to strongly disagree) on the questionnaire. Tell students to move to the location<br />
corresponding to the answer given for the first question (about premarital sex) on the<br />
questionnaire they are holding. For each successive item, students move to the corresponding<br />
location.<br />
The exercise has several benefits. Students can register opinions anonymously, since the position<br />
they take around the room represents someone else’s attitude. The color of the paper the student<br />
holds indicates the gender of the respondent, so gender differences in attitudes are easily noted.<br />
Third, as the behaviors become more controversial, a physical shift of bodies around the room<br />
illustrates conservative and liberal attitudes, as well as points of consensus or controversy. At any<br />
point the instructor can ask why shifts in opinion are occurring. Finally, if an assistant keeps<br />
numerical track of the distribution of “votes” for each item, data can be fed back to the class and<br />
maintained for comparison with next year’s group.<br />
If time permits and the group is small, have students fill out the values clarification form (see<br />
handout) and turn in folded, completed forms. Shuffle them so they can be returned to other<br />
students. Have them silently read these comments and pass them to a second student, giving<br />
closure and a sense of validation at the end of the exercise.<br />
3. This chapter is a good one for confronting homophobia. The AIDS epidemic has added a new<br />
rationalization for discriminating against gays. The following exercise may become heated but can<br />
help identify some of the students’ blind spots and the reasons for them.<br />
Have students split up into small groups (four or five per group). Distribute the Handout for<br />
Demonstration 3 and ask each group member to answer the questions without consulting others.<br />
Then, for each situation, have each group member announce which way he or she “voted.” For<br />
each question, the individuals should discuss why they took the stand they did. Ask students<br />
whether their fears are based on anything even remotely rational or whether they are using<br />
unconscious defense mechanisms. What defenses might they be?<br />
Students may paint a more progressive and tolerant picture of themselves than their actual<br />
attitudes and behaviors suggest. One way to slice through some of this is to ask what would<br />
happen if they were told that, as a requirement of this course, they were to walk through campus<br />
hand in hand with a person of the same sex. How many would drop the course rather than do the<br />
assignment?<br />
4. Despite increased discussion of sexuality and more permissive attitudes in our society, many men<br />
and women still subscribe to sexual myths. These untrue beliefs seem to affect sexual functioning,<br />
and contribute to needless anxiety about sexual behavior. Baker and DeSilva (1988) presented a<br />
list of male sexuality myths constructed by Bernie Zilbergeld to groups of sexually dysfunctional<br />
and functional men. Those with dysfunctions reported significantly more beliefs in these myths<br />
than functional men did. It is not clear what is cause and what is effect, but a relationship seems to<br />
exist between beliefs, emotions, and behaviors. The Handout for Demonstration 4 has two lists of<br />
sexuality myths: one for women and one for men.<br />
Ask students to think about how strongly they agree or disagree with each item. Do not ask for<br />
them to reveal their responses, but ask them to discuss what they think the “average” person<br />
would say. They will feel less personally vulnerable in the discussion that ensues while still taking
162 Chapter 10: Sexual and Gender Identity Disorders<br />
something personal from the activity. Ask them the degree to which they think these beliefs have<br />
changed in the recent past. How do they predict their parents or grandparents would respond to<br />
them? How do they think their children will respond to them? This could spark a discussion of<br />
gender role stereotyping and the value of teaching children to be more psychologically<br />
androgynous.<br />
Internet Site: http://www.goaskalice.columbia.edu/index.html. "Go Ask Alice" a sexual health<br />
question and answer service by Columbia University.<br />
5. Sex is one of the ways advertisers get our attention and sell their products. You can use the<br />
Handouts for Demonstration 5 in one of two ways to increase student awareness of sexual themes<br />
in the media and spark class discussion about our culture’s sexual expectations. This subject, in<br />
turn, can be linked to sexual dysfunctions and sexual deviances. In the first, assign students to<br />
watch two or three hours of evening television before the next class period. Have them use the<br />
television handout to record advertisements and program content they believe have sexual content.<br />
They should indicate to whom they think these sexual messages are targeted and the degree to<br />
which they think such messages have an impact on thinking or behavior. In class, have students<br />
meet in small groups and compare their recordings, ratings, and comments. Ask them if they<br />
themselves have ever been influenced by advertisements or portrayals of reality in television<br />
programs. They will probably not say yes. Ask them who they think are influenced by television<br />
ads and programs. How might the equation of sexual attractiveness, sexual activity, and “the good<br />
life” affect heterosexual attitudes? Ask if any mention (direct or indirect) was made of making sex<br />
safer. Link this to our fight to prevent HIV infection and AIDS. Finally, ask them to imagine how<br />
the large minority of sexually dysfunctional individuals in society must respond to seeing such<br />
portrayals of sexual behavior.<br />
To take a second look at the media, buy (or ask students to buy) a range of magazines. Include<br />
magazines targeted at teens, middle-aged women, men, and general audiences. Students can page<br />
through the magazines in small groups and record advertisements and articles with sexual themes,<br />
rate them, and evaluate their impact on target audiences on the media handout. This exercise<br />
should also get into issues of being personally influenced, the role of the media in preventing<br />
HIV, and how those with dysfunctions might react to the portrayal of the sexual world in<br />
magazines.<br />
6. The main character on the television show, Ellen, revealed that she was gay, (the show was later<br />
canceled.) This episode was one of the highest-rated television shows of the year. What has<br />
changed in our society that makes now the time to have an openly lesbian lead character on a<br />
prime time television show? Do you see the gay lifestyle becoming more acceptable in the future?<br />
Additionally both ABC and NBC have launched top, rated sitcoms with openly gay men as main<br />
characters (Will and Grace is the NBC program). Lead the class in a discussion of this trend in<br />
the media. Do students think this trend will continue?<br />
7. Invite a guest speaker who is a psychologist or psychiatrist specializing in treatment of sexual<br />
disorders. Have the students develop questions during the class period before the guest lecturer is<br />
scheduled. These professionals are usually very busy but if you schedule early enough they will<br />
usually be happy to lecture to your class.<br />
8. Bring the DSM-IV-TR to class, and prepare an overhead transparency or PowerPoint slide ahead<br />
of time for your lecture on gender identity disorders. Describe the in-depth material from the<br />
DSM-IV while using the transparency or PowerPoint slide as an outline. Lead a discussion on the<br />
differences between different sexual disorders. Encourage student input about individuals they<br />
have known with these symptoms.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 10: Sexual and Gender Identity Disorders 163<br />
HANDOUT FOR DEMONSTRATION 2:<br />
ASSESSING SEXUAL ATTITUDES AND BEHAVIOR<br />
Instructions: On the line before each item, place the number representing one of these five responses to<br />
indicate how you feel about the sexual behavior.<br />
5 Strongly approve<br />
4 Approve somewhat<br />
3 Neutral<br />
2 Disapprove somewhat<br />
1 Strongly disapprove<br />
________ 1. Premarital sex when the couple is engaged<br />
________ 2. Premarital sex when the couple is only casually acquainted<br />
________ 3. Masturbation<br />
________ 4. Homosexuality<br />
________ 5. Extramarital sex (a married person having sex with someone other than his/her spouse)<br />
________ 6. Mouth-genital sex (or oral-genital sex—cunnilingus or fellatio)<br />
________ 7. Anal intercourse<br />
________ 8. Cross-dressing to become sexually aroused<br />
________ 9. Nonviolent pornographic films<br />
________ 10. Violent pornographic films<br />
Source: Adapted from “A Technique for Assessing Sexual Attitudes and <strong>Behavior</strong>,” by Dr. Marcia M.<br />
Freer, Presentation to Midwestern Psychological Association Convention, 1992. Used by permission of<br />
Dr. Marcia M. Freer.
164 Chapter 10: Sexual and Gender Identity Disorders<br />
HANDOUT FOR DEMONSTRATION 3:<br />
RESPONSES TO GAY MEN AND LESBIAN WOMEN<br />
For each situation described below, please respond as honestly as you can. Think of the reasons for<br />
your reaction.<br />
1. You and your spouse have decided that you want to build a house of your own. You hear that<br />
John Smith is an outstanding architect. After several weeks of talking with Mr. Smith, you<br />
discover that he has superb ideas for your new home. You also discover that Mr. Smith is gay and<br />
that his partner, Mr. Jones, is also his lover.<br />
In this situation, what is the likelihood that you would cancel any business dealings with Mr.<br />
Smith?<br />
Definitely Probably Probably Definitely<br />
Cancel Cancel Not Sure Not Cancel Not Cancel<br />
1 2 3 4 5<br />
2. You are the parent of a 14-year-old boy. One of his favorite teachers is Mr. Thomas, a brilliant<br />
English teacher. Your son has developed a flair for writing and a love of reading that stems from<br />
Mr. Thomas’s excellent teaching. One day, you pick your son up after school and see that Mr.<br />
Thomas is in his car with another man. They then hug and kiss each other.<br />
In this situation, what is the likelihood that you would forbid your son from talking with Mr.<br />
Thomas for the rest of the school year?<br />
Definitely Would Probably Would<br />
Probably Would Definitely Would<br />
Forbid<br />
Forbid Not Sure Not Forbid Not Forbid<br />
1 2 3 4 5<br />
3. [For female students] You have just had your third appointment with a new gynecologist, Dr.<br />
Holdon. She is exceptionally understanding and careful in her examinations, unlike the male<br />
gynecologists you have used or heard about in the past. Then you find out that Dr. Holdon is a<br />
lesbian.<br />
[For male students] You have just had your third appointment with a new general practice<br />
physician, Dr. Holdon. He is exceptionally understanding and careful in his examinations, unlike<br />
the other doctors you have had in the past. Then you find out that Dr. Holdon is a homosexual.<br />
In this situation, what is the likelihood that you would stop using Dr. Holdon as your physician?<br />
Definitely Probably Probably Definitely<br />
Stop Using Stop Using Not Sure Not Stop Using Not Stop Using<br />
1 2 3 4 5<br />
Copyright © Houghton Mifflin Company. All rights reserved.
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Chapter 10: Sexual and Gender Identity Disorders 165<br />
HANDOUT FOR DEMONSTRATION 4: MYTHS OF SEXUALITY<br />
SA = strongly agree A = agree SD = strongly disagree D = disagree<br />
Myths of female sexuality (Heiman & LoPiccolo, 1988)<br />
1. Sex is only for women under thirty. SA A D SD<br />
2. Normal women have an orgasm every time they have sex. SA A D SD<br />
3. All women can have multiple orgasms. SA A D SD<br />
4. Pregnancy and delivery reduce women’s sexual responsiveness. SA A D SD<br />
5. A woman’s sex life ends with menopause. SA A D SD<br />
6. Different kinds of orgasms are related to a woman’s personality.<br />
Vaginal orgasms are more feminine and mature than clitoral orgasms.<br />
SA A D SD<br />
7. A sexually responsive woman can always be turned on by her partner. SA A D SD<br />
8. Nice women aren’t aroused by erotic books or films. SA A D SD<br />
9. You are frigid if you don’t like the more exotic forms of sex. SA A D SD<br />
10. If you can’t have an orgasm quickly and easily, there is something<br />
wrong with you.<br />
SA A D SD<br />
11. Feminine women don’t initiate sex or become wild and unrestrained<br />
during sex.<br />
SA A D SD<br />
12. You are frigid if you don’t have sexual fantasies and wanton if you do. SA A D SD<br />
13. Contraception is a woman’s responsibility, and she’s just making<br />
excuses if she says contraceptive issues are inhibiting her sexually.<br />
SA A D SD<br />
Myths of male sexuality (Zilbergeld, 1992)<br />
1. We’re liberated folks who are very comfortable with sex. SA A D SD<br />
2. A real man isn’t into sissy stuff like feelings and communicating. SA A D SD<br />
3. All touching is sexual and should lead to sex. SA A D SD<br />
4. A man is always interested in and always ready for sex. SA A D SD<br />
5. A real man performs in sex. SA A D SD<br />
6. Sex is centered on a hard penis and what’s done with it. SA A D SD<br />
7. Sex equals intercourse. SA A D SD<br />
8. A man should be able to make the earth move for his partner, or at the<br />
very least knock her socks off.<br />
SA A D SD<br />
9. Good sex requires orgasm. SA A D SD<br />
10. Men don’t have to listen to women in sex. SA A D SD<br />
11. Good sex is spontaneous, with no planning and no talking. SA A D SD<br />
12. Real men don’t have sex problems. SA A D SD<br />
Sources: (lists) Barlow, D. H., & Durand, V. M. (1995). <strong>Abnormal</strong> psychology: An integrative<br />
approach. Pacific Grove, CA: Brooks/Cole; Baker, C. D., & DeSilva, P. (1988). The relationship<br />
between male sexual dysfunction and belief in Zilbergeld’s myths: An empirical investigation. Sexual<br />
and Marital Therapy, 3, 229–238; Heiman, J. R.,& LoPiccolo, J. (1988). Becoming orgasmic: A sexual<br />
and personal growth program for women (rev. ed.). New York: Prentice-Hall; Zilbergeld, B. (1992).<br />
The new male sexuality. New York: Bantam Books.
166 Chapter 10: Sexual and Gender Identity Disorders<br />
HANDOUT FOR DEMONSTRATION 5:<br />
SEXUAL THEMES IN THE MEDIA (TELEVISION)<br />
I am female ________ male ________.<br />
I watched television from ________P.M. until ________ P.M. on _____________________________.<br />
(date and day of the week)<br />
1. List the advertisements you saw that had a sexual theme; for example, in which a man or a woman<br />
is posed or dressed provocatively or there is the implication that using the product will lead to<br />
sexual success.<br />
Name of product: _______________________________________________________________<br />
Sex-related theme: ______________________________________________________________<br />
Name of product: _______________________________________________________________<br />
Sex-related theme: ______________________________________________________________<br />
Name of product: _______________________________________________________________<br />
Sex-related theme: ______________________________________________________________<br />
2. List sex-related themes or portrayals during television programs.<br />
Name of show: _________________________________________________________________<br />
Sex-related theme or portrayal: ____________________________________________________<br />
Name of show: _________________________________________________________________<br />
Sex-related theme or portrayal: ____________________________________________________<br />
To whom do you think these messages were directed?<br />
Do you think you are influenced by them? yes no<br />
Do you think other people are influenced by them? yes no If yes, who?<br />
Copyright © Houghton Mifflin Company. All rights reserved.
HANDOUT FOR DEMONSTRATION 5:<br />
SEXUAL THEMES IN THE MEDIA (MAGAZINES)<br />
I am female ________ male ________.<br />
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 10: Sexual and Gender Identity Disorders 167<br />
List the print advertisements you saw that had a sexual theme; for example, in which a man or a woman<br />
is posed or dressed provocatively or where there is the implication that using the product will lead to<br />
sexual success.<br />
Name of product: ____________________________________________________________________<br />
Sex-related theme: ___________________________________________________________________<br />
Magazine name and its target audience: __________________________________________________<br />
Name of product: ____________________________________________________________________<br />
Sex-related theme: ___________________________________________________________________<br />
Magazine name and its target audience: __________________________________________________<br />
Name of product: ____________________________________________________________________<br />
Sex-related theme: ___________________________________________________________________<br />
Magazine name and its target audience: __________________________________________________<br />
Sex-related magazine article content: ____________________________________________________<br />
Magazine name and its target audience: __________________________________________________<br />
Sex-related magazine article content: ____________________________________________________<br />
Magazine name and its target audience: __________________________________________________<br />
Do you think you are influenced by them? yes no<br />
Do you think other people are influenced by them? yes no If yes, who?
168 Chapter 10: Sexual and Gender Identity Disorders<br />
SELECTED READINGS<br />
Anderson, B. L. (1983). Primary orgasmic dysfunction: Diagnostic considerations and review of<br />
treatment. Psychological Bulletin, 93, 105–136.<br />
Barlow, D. H. (1986). Causes of sexual dysfunction: The role of anxiety and cognitive interference.<br />
Journal of Consulting and Clinical Psychology, 54, 140–148.<br />
Briere, J. (1992). Methodological issues in the study of sexual abuse effects. Journal of Consulting and<br />
Clinical Psychology, 60, 196–203.<br />
Heiman, J. R., & LoPiccolo, J. (1988). Becoming orgasmic: A sexual and personal growth program for<br />
women. New York: Prentice-Hall.<br />
Maletzky, B. M. (1991). Treating the sexual offender. Newbury Park, CA: Sage.<br />
Rosen, R. C., & Leiblum, S. (Eds.) (1991). Erectile failure: Diagnosis and treatment. New York:<br />
Guilford.<br />
Sattler, D., Shabatay, V., 7 Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 10, Sexual Dysfunctions and<br />
Disorders.<br />
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 10, Premature Ejaculation: Under Pressure to Perform. Chapter 11, Pedophilia:<br />
Predator of Youth.<br />
VIDEO RESOURCES<br />
Child Molesters: Facts and Fiction (16 mm, color, 30 min). This film uses a depiction based on actual<br />
case material to illustrate two different reactions: parents who overreact and terrorize the child, and<br />
those who react with more support. The effects on the child and the role of police and the courts are<br />
discussed. University of Kansas Audio Visual Center, 746 Massachusetts Street, Lawrence, KS 66044.<br />
I Am Not This Body (16 mm, 28 min). Two transsexuals are interviewed: a man who is preparing for<br />
sex-change surgery and a woman who has already had the surgery. Misconceptions about<br />
transsexualism and homosexuality are attacked. Erickson Educational Foundation, P.O. Box 185,<br />
Kendall Post Office, Miami, FL 33156.<br />
Michael: A Gay Son (16 mm, color, 27 min). An actual case; Michael works with a counselor to reveal<br />
his sexual orientation to his family. The film examines how society refuses to accept homosexuality and<br />
how this attitude affects the issue of “coming out.” Filmmakers Library, Inc., 133 E. 58th Street, Suite<br />
703A, New York, NY 10022.<br />
Overcoming Erection Problems (16 mm, color, 21 min). This film is an explicit look at one man’s<br />
erectile dysfunction. It traces Masters and Johnson therapy from initial assessment to sensate focus<br />
exercises and then to increasingly greater genital-to-genital contact. University of California, Los<br />
Angeles Instructional Media Library, Powell Library, Room 46, Los Angeles, CA 90024.<br />
Pedophile (Child Molester) (16 mm, color, 20 min). This film examines the underlying causes of<br />
pedophilia and the various types of molesters that exist. The material is augmented by an examination<br />
of methods molesters use to prevent being detected. AMS Media Inc., 626 Justin Avenue, Glendale, CA<br />
91201.<br />
Rape: A Preventive Inquiry (16 mm, color, 17 min). Presents information about reducing the chances of<br />
being raped by examining circumstances in which four women were victims. Police and convicted<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 10: Sexual and Gender Identity Disorders 169<br />
rapists discuss their experiences. Psychological Cinema Register, Pennsylvania State University,<br />
University Park, PA 16802.<br />
Dear Mom and Dad, I am Gay (VHS, color, 28 min.). This video looks at what happens when a family<br />
discovers they have a homosexual child or adolescent. Films for the Humanities and Sciences.<br />
1-800-257-5126.<br />
Gay Couples: The Nature of Relationships (VHS, color, 50 min.). This video looks at one gay and one<br />
lesbian couple and their lives. Films for the Humanities and Sciences. 1-800-257-5126.<br />
Recovery from Sexual Abuse (VHS, color, 47 min.). This video follows five teenagers as they work to<br />
recover and heal from sexual abuse. Films for the Humanities and Sciences. 1-800-257-5126.<br />
Scared Silent: Incest (VHS, color, 22 min.). Oprah Winfrey explores how sexual abuse moves through<br />
the generations. Fanlight Productions. 1-800-937-4113.<br />
Sexual Disorders (VHS, color, 60 min.). This video covers the various sexual disorders.<br />
Annenberg/CPB. 1-800-LEARNER.<br />
Pedophiles: Preying on Our Children (VHS, 45 min) This program looks at the cyclical nature of child<br />
abuse from the eyes of an abuser, as well as considering issues of false accusations and the effects on<br />
community. Films for the Humanities and Sciences, P.O. Box 2053, Princeton, NJ 08543-2053, 1-800-<br />
257-5126<br />
Multiple Genders: Mind and Body in Conflict (VHS, 40 min) This fascinating film looks at a range of<br />
human sexuality that includes not only homosexuality (and the right of gays and lesbians to adopt), but<br />
also transsexuals, hermaphrodites, and transvestites. An important discussion revolves around whether<br />
infants should have operations that make the physical body consistent with their chromosomal structure<br />
and who should make such decisions; a clergyman discusses his church's views that seem somewhat<br />
surrealistic in the context of these very talented people with multiple genders. Films for the Humanities<br />
and Sciences, P.O. Box 2053, Princeton, NJ 08543-2053, 1-800-257-5126<br />
ON THE INTERNET<br />
http://www.cdspub.com/ is the Creative Design Services (CDS) Transgender Forum and Resource<br />
Center.<br />
http://www.mcsp.com/smcop/toc.html is the sadomasochists’ home page, which provides information<br />
on sadomasochism.<br />
http://www.gmu.edu/facstaff/sexual/rapesas.html is the Rape and Sexual Assault Information Page,<br />
which has a large listing of links on rape and sexual assault<br />
http://www2.impotent.com/ is the Online Guide to Impotence, which provides an eight-item screening<br />
quiz, information about impotence and its treatment, and a physician’s referral list for evaluation and<br />
treatment.<br />
http://www.qrd.org/QRD/orgs/NAMBLA/journal.and.research.reports is a text-only site that includes<br />
an extensive longitudinal study on pedophilia in Germany.<br />
http://www.genderweb.org/medical/psych/ contains diagnostic information on transsexualism, gender<br />
identity disorder, and transvestic fetishism.<br />
This is http://www.goaskalice.columbia.edu/index.html "Go Ask Alice" a sexual health question and<br />
answer service by Columbia University.
CHAPTER 11<br />
Mood Disorders<br />
CHAPTER OUTLINE<br />
I. Mood disorders: Disturbances in emotion that cause discomfort or hinder functioning<br />
A. Prevalence<br />
1. Rank among the top ten causes of worldwide disability<br />
a) A leading cause of absenteeism and diminished productivity in workplace<br />
b) Prevalence for all mood disorders is 15 percent for males, 24 percent for females<br />
2. Depression (intense sadness, feelings of futility and worthlessness, withdrawal from<br />
others) is the most common complaint among those seeking help:<br />
a) Yearly prevalence in United States is 10 million people, 100 million worldwide;<br />
b) Lifetime prevalence: 10 to 25 percent for women, 5 to 12 percent for men<br />
3. Mania (characterized by elevated mood, expansiveness, or irritability, often resulting in<br />
hyperactivity)<br />
4. Likelihood of recurrence of depression is 50 percent after one episode, 70 percent after<br />
two, 90 percent after three<br />
II. Symptoms of depression and mania<br />
A. Symptoms of depression<br />
1. Affective symptoms<br />
a) Feelings of sadness, dejection, worthlessness<br />
b) Crying, not necessarily connected to specific situation<br />
c) Anxiety<br />
2. Cognitive symptoms<br />
a) Feelings of futility, self-denigration; loss of interest and energy<br />
b) Poor concentration; difficulty making decisions<br />
c) Cognitive triad (Beck): negative views of self, outside world, and future<br />
3. <strong>Behavior</strong>al symptoms<br />
a) Unkempt appearance, masklike face, slowed movements (psychomotor<br />
retardation)<br />
b) Social withdrawal<br />
c) Low energy is key symptom distinguishing between depressed and nondepressed<br />
4. Physiological symptoms<br />
a) Loss of appetite and weight (although some gain weight)<br />
b) Constipation<br />
c) Sleep disturbance (insomnia, early waking, nightmares)<br />
d) Disrupted menstrual cycle<br />
e) Aversion to sexual activity<br />
5. Culture influences experience and expression of symptoms<br />
6. Children more likely to express somatic complaints, irritability, social withdrawal;<br />
adolescents and adults more likely to have psychomotor retardation, hypersomnia, and<br />
delusions<br />
B. Symptoms of mania<br />
1. Affective symptoms<br />
a) Elevated, expansive, irritable mood<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 11: Mood Disorders 171<br />
b) Boundless energy and enthusiasm<br />
2. Cognitive symptoms<br />
a) Fast, disjointed speech<br />
b) Uncontrolled attention, poor judgment<br />
3. <strong>Behavior</strong>al symptoms<br />
a) Hypomania: overactive in behavior but no delusions<br />
b) Mania: more disruptive grandiosity, incoherent speech; hallucinations and<br />
delusions possible<br />
4. Physiological symptoms<br />
a) High arousal and decreased need for sleep<br />
b) Weight loss<br />
III. Classification of mood disorders<br />
A. Depressive disorders include major depressive disorder, dysthymic disorder, and depressive<br />
disorder not otherwise specified<br />
1. Major depression<br />
a) No history of mania<br />
b) Lasts two weeks or more and represents change from earlier functioning<br />
c) The earlier the onset, the more likely the recurrence<br />
2. Dysthymic disorder<br />
a) Impairment less than in major depression, but chronic condition of longer<br />
duration (most of the day, more days than not for two years or more)<br />
b) Each year 10 percent of those with dysthymic have a major depressive episode<br />
c) Lifetime prevalence 6 percent<br />
B. Bipolar disorders (one or more manic or hypomanic episodes)<br />
1. Mania must last one week; hypomania must last four days<br />
2. Bipolar I: mania episode (with or without depression); lifetime prevalence .8 percent<br />
3. Bipolar II: one or more major depressive episodes and at least one hypomanic (no<br />
mania); lifetime prevalence .5 percent<br />
4. Cyclothymic disorder: chronic mood swings but less than hypomania or depression<br />
a) Lasts more than two months<br />
b) Lifetime prevalence 0.4 to 1.0 percent (greater than bipolar, less than dysthymic)<br />
c) Risk of becoming bipolar is 15 to 50 percent<br />
C. Other mood disorders<br />
1. Due to general medical condition<br />
2. Substance induced<br />
D. Symptom features and specifiers<br />
1. Symptom features: accompany disorders but not criteria for diagnosis (melancholia<br />
and catatonia, for depression)<br />
2. Course specifiers: cyclic, seasonal, postpartum, or longitudinal pattern of disorder<br />
(rapid cycling bipolar, seasonal affective disorder, postpartum depression)<br />
E. Comparison between depressive and bipolar disorders<br />
1. Bipolar more genetically based<br />
2. Bipolar much less common<br />
3. Onset of bipolar earlier (late twenties) than unipolar (mid-thirties)<br />
4. Bipolar displays psychomotor retardation and more suicide attempts<br />
5. Bipolar responds to Lithium<br />
IV. The etiology of mood disorder<br />
A. Psychological or sociocultural approaches to depression<br />
1. Psychoanalytic explanations<br />
a) Loss (physical or symbolic) with anger and guilt<br />
b) Incomplete mourning; current rejection symbolic of earlier loss; anger turned
172 Chapter 11: Mood Disorders<br />
c) inward<br />
2. <strong>Behavior</strong>al explanations<br />
a) Reduced reinforcement reduces activity<br />
b) Sympathy reinforces depression (secondary gain)<br />
c) Drive others away and lose social reinforcement<br />
d) Lewinsohn et al.: number of reinforcing events, availability of reinforcers, low<br />
social skills, stress<br />
e) In bipolar, biogenic factors dominant but rewards for euphoria continue until<br />
negative reactions bring on depression<br />
3. Cognitive explanations<br />
a) Primary disturbance in depression is negative thinking and low self-esteem<br />
b) Beck: schema (cognitive set) predisposes depression<br />
c) Arbitrary inference<br />
d) Selected abstraction<br />
e) Overgeneralization<br />
f) Magnification/minimization<br />
g) Depressives remember negative events<br />
h) Pessimism may be result, not cause of depression<br />
4. Cognitive-learning approaches: learned helplessness and attributional style<br />
a) Learned helplessness: depressive believes skills no longer effective in reaching<br />
goals<br />
5. Pessimistic attributional style<br />
a) Explain negative events in terms of internal, global, and stable factors<br />
b) Measured with Attributional Style Questionnaire and CAVE (content analysis of<br />
verbal expression)<br />
c) Attributional style related to achievements, health, and depression<br />
d) Internality and externality may relate to different forms of depression<br />
6. Response style<br />
7. Sociocultural explanations<br />
a) Higher rates for Native Americans and Southeast Asians in United States;<br />
Chinese have more somatic complaints<br />
8. Stress and depression<br />
a) Diathesis (vulnerability) triggered by stress; one severe stress more likely to<br />
cause depression than several minor stressors; stress and depression have<br />
bidirectional relationship<br />
b) Gender and depression: women twice as likely as men to become depressed;<br />
differences may appear real or differences are real; Nolen-Hoeksema concludes<br />
women ruminate over moods; men minimize dysphoria<br />
B. Biological perspectives on mood disorders<br />
1. Role of heredity<br />
a) Twin studies: MZ concordance rate 72 percent for bipolar, 40 percent for<br />
unipolar; DZ concordance rate 14 percent for bipolar, 11 percent for unipolar<br />
b) One study finds specific area of chromosome (not replicated); probably<br />
polygenetic<br />
2. Neurotransmitters and mood disorders<br />
a) Catecholamines (norepinephrine, serotonin, dopamine) insufficient due to<br />
excessive enzyme breakdown or excessive reuptake<br />
b) May be problem in reception of neurotransmitter<br />
3. <strong>Abnormal</strong> cortisol levels<br />
a) Too-high level measured by dexamethasone suppression test<br />
b) Cortisol-depression relationship may be bidirectional<br />
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Chapter 11: Mood Disorders 173<br />
4. REM sleep disturbance: rapid onset and increased level in depressives<br />
C. Evaluating the causation theories<br />
1. Three developments added to understanding<br />
a) Prospective studies of events and depression<br />
b) Technological advances in psychophysiology<br />
c) Awareness that depression is heterogeneous<br />
2. Psychoanalytic difficult to test<br />
3. Cognitive has become more complex<br />
4. <strong>Behavior</strong>al and learned helplessness well-grounded in research<br />
5. Interaction of environment and biology<br />
V. The treatment of mood disorders<br />
A. Biomedical treatments for depressive disorders<br />
1. Medications<br />
a) Tricyclic antidepressants<br />
b) Monoamine oxidase (MAO) inhibitors<br />
c) Fluoxetine SSRI (Prozac)<br />
2. Electroconvulsive therapy (ECT)<br />
a) Voltage to brain for one-half second or less to induce convulsion and short coma<br />
b) Improvement after four treatments; one in a thousand chance of serious<br />
complications<br />
B. Psychotherapy and behavioral treatments for depressive disorders<br />
1. Interpersonal psychotherapy: short-term, psychodynamic eclectic<br />
a) Focus on conflicts in current relationships<br />
b) Linked to past life experiences and traumas<br />
2. Cognitive-behavioral therapy<br />
a) Identify negative thoughts<br />
b) Link to depression<br />
c) Examine negative thought and decide if it can be supported<br />
d) Replace distorted negative thoughts with realistic ones<br />
e) Steps: monitor thoughts and substitute logical interpretations; increase activity<br />
level; improve social skills<br />
f) Evaluation<br />
(1) Reduces risk of relapse compared to those treated with drugs<br />
(2) Both interpersonal psychotherapy and cognitive-behavioral effective<br />
(3) Cognitive therapy as effective as antidepressants<br />
(4) Cognitive-behavioral skills can prevent depression<br />
(5) Combination of medication and psychotherapy most advantageous<br />
C. Treatment for bipolar disorders<br />
1. Lithium<br />
a) Effective<br />
b) Side effects and compliance problems<br />
LEARNING OBJECTIVES<br />
1. Describe the mood disorders and distinguish them from normal mood changes. Recall prevalence<br />
rates for these disorders. (pp. 353-354; Figure 11.1)<br />
2. Describe the symptoms of depression, including the affective, cognitive, behavioral, and<br />
physiological domains. (pp. 354-357)<br />
3. Describe the symptoms of mania. Differentiate the two levels of manic intensity. (pp. 357-358)
174 Chapter 11: Mood Disorders<br />
4. Describe and differentiate among the following mood disorders and the symptom features that<br />
may accompany these disorders: major depressive disorder, dysthymic disorder, the bipolar<br />
disorders, cyclothymic disorder, and mood disorders associated with a medical condition or<br />
substance use. (pp. 358-359)<br />
5. Describe and differentiate course specifiers including cycling type, seasonal, postpartum, and<br />
longitudinal patterns of mood disorders. Compare unipolar and bipolar disorders. (pp. 359-363)<br />
6. Contrast the various theories of depression, including psychodynamic, behavioral, and<br />
Lewinsohn’s comprehensive view of depression. (pp. 363-366)<br />
7. Discuss the cognitive and cognitive-learning approaches to depression. Give examples of the<br />
logical errors depressives make and the pessimistic attributions they might use. (pp. 366-371)<br />
8. Describe various sociocultural explanations for mood disorders, including cross-cultural<br />
differences, the role of stress, and social support in depression. (pp. 371-373)<br />
9. Describe what is known about sex differences and depression and the explanations for any<br />
differences. (pp. 373-375).<br />
10. Describe the biological theories of mood disorders, including genetic and neurotransmitter<br />
theories, the role of cortisol and REM sleep in depression. (pp. 375-378)<br />
11. Evaluate the strengths and weaknesses of the various causal theories of depression. (pp. 378-379)<br />
12. Indicate the kinds of biological therapies that have been used to treat depression, including<br />
medication and electroconvulsive therapy (ECT). Discuss the effectiveness of these treatments<br />
and their side effects. (pp. 379-381)<br />
13. Describe psychological treatments for mood disorders, including interpersonal psychotherapy and<br />
cognitive-behavioral therapy. Evaluate the effectiveness of these treatments. (pp. 381-385)<br />
14. Describe the use of lithium and its problems in treating bipolar disorders. (pp. 385-386)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Exogenous depressions are related to the experience of stressful life events. Both Lewinsohn’s<br />
and Seligman’s theories assume that negative events play a role in the development of depression,<br />
and research supports this idea. However, the availability and quality of social support can<br />
provide a buffer against depression. Support appears to have two key aspects: intimacy and<br />
integration in the community. Marital relationships are particularly important for intimacy. Major<br />
depression occurs twice as often in those who live alone than those who live with someone else<br />
(Weissman et al., 1991). Those with poor marital relationships report more signs of depression<br />
than those with better ones (Menaghan & Lieberman, 1986). Wives who rated their husbands as<br />
more supportive were less likely to be depressed one year later than wives who rated their<br />
husbands as less supportive (Monroe et al., 1986). It is unclear, however, whether poor support<br />
causes depression or the other way around. A depressive spouse can contribute to the deterioration<br />
of marital relations (Beach, Sandeen, & O’Leary, 1990). These researchers suggest that marital<br />
counseling be a routine part of the treatment of depressives who are married.<br />
People who have few friends and who are involved in few social activities are more prone to<br />
being depressed (Barnett & Gotlib, 1988). Lack of social integration reduces the opportunities for<br />
engaging in pleasant events, reduces the number of sources of help, and allows people who<br />
ruminate on their distress to become further withdrawn and depressed.<br />
Discuss with students the circumstances that have surrounded depression in their own lives and<br />
the roles that family members, friends, and other help providers have played in reducing or<br />
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Chapter 11: Mood Disorders 175<br />
exacerbating depressive symptoms. How have their relationships been affected? What level of<br />
social integration did they experience before, during, and after the depressive episode?<br />
Sources: Barnett, P. A., & Gotlib, I. H. (1988). Psychosocial functioning and depression:<br />
Distinguishing among antecedents, concomitants and consequences. Psychological Bulletin, 104,<br />
97–126.<br />
Beach, S. R. H., Sandeen, E. E., & O’Leary, K. D. (1990). Depression in marriage: A model for<br />
etiology and treatment. In D. H. Barlow (Ed.) Treatment manuals for practitioners. New York:<br />
Guilford Press.<br />
Menaghan, E. G., & Lieberman, M. A. (1986). Changes in depression following divorce: A panel<br />
study. Journal of Marriage and the Family, 17, 319–328.<br />
Monroe, S. M., Bromet, E. J., Connell, M. M., & Stener, S. C. (1986). Social support, life events,<br />
and depressive symptoms: A 1-year prospective study. Journal of Consulting and Clinical<br />
Psychology, 54, 423–431.<br />
Weissman, M. M. et al. (1991). Affective disorders. In L. N. Robins & D. A. Regier (Eds.)<br />
Psychiatric disorders in America: The Epidemiological Catchment Area Study. New York: The<br />
Free Press, pp. 53–80.<br />
2. To indicate the spectrum of mood disorders, draw a long horizontal line on the blackboard and<br />
label the poles "Psychotic Depression" and "Delirious Mania". At this point, explain what<br />
psychosis means. Then indicate a region toward the middle of the continuum that represents<br />
normal fluctuations in mood. Make only dotted lines to indicate the hazy boundaries separating<br />
“normal” behaviors and clinical disorders. On the depression side, label neurotic depression and<br />
explain that this term, though useful, is no longer part of the DSM terminology. Ask students to<br />
describe mild to moderate depression and list the affective, cognitive, behavioral, and<br />
physiological symptoms they suggest. In this region of the diagram, note dysthymia (based on<br />
closeness to “normal” and duration) and both exogenous and endogenous major depressions.<br />
Further toward the psychotic end, list the symptoms of psychotic depression. On the mania side of<br />
normal, describe hypomania and then acute and delirious mania. The area from neurotic<br />
depression to hypomania can then be linked by a double-headed arrow to show cyclothymia.<br />
Finally, the bigger mood swings of bipolar disorder can be indicated by an even larger doubleheaded<br />
arrow.<br />
Many students don’t understand the difference between Bipolar I and Bipolar II disorders. The<br />
key difference is that in Bipolar II a hypomanic episode (never reaching manic proportions)<br />
alternates with major depression. Bipolar I accounts for all other kinds of manic episodes.<br />
Internet Site: http://www.mentalhealth.com/dis/p20-md01.html . Discusses mood symptoms.<br />
3. The mood disorders are divided into many subcategories. It may be helpful to students to organize<br />
these categories in the following way: First is the psychotic versus neurotic dimension. Unlike<br />
many other forms of disorders, the mood disorders raise the issue of continuity (from “neurotic”<br />
conditions to psychotic ones). Second is the unipolar versus bipolar dimension. Third, particularly<br />
with the depressions, are the exogenous and endogenous explanations. Fourth, some disorders are<br />
mild and prolonged (cyclothymia and dysthymia), whereas others are severe and perhaps more<br />
acute (major depression and bipolar disorders). Finally, some mood disorders are primary<br />
(unaccompanied by other mental disturbances), whereas many are secondary (the outgrowth or a<br />
concomitant feature of some other disorder). You should remind students that the categorization<br />
of disorders is often overly neat and tidy. Many people with drinking or other substance abuse<br />
problems experience serious depressive episodes. If a person is both depressed and drug
176 Chapter 11: Mood Disorders<br />
dependent, must the diagnostician decide which is the “real” problem? A diagnosis of secondary<br />
depression may be more accurate, but figuring out which came first is a very difficult proposition.<br />
4. You can illustrate Lewinsohn’s theory with a downward spiral drawn on the board. The spiral<br />
includes poor social skills, reduced reinforcement, lowered activity, and worsening depressive<br />
symptoms. Treatment argues that an upward spiral of increased activity, increased reinforcement,<br />
and increased social skill and mood is also possible. What appears to be missing are the cognitive<br />
components that Beck stresses. You can add to the Lewinsohn diagram the depressive’s illogical<br />
and negative thoughts, which help to explain why events such as reduced reinforcement produce<br />
lowered activity. This more integrated model of depression mirrors the work of most cognitive<br />
behavioral therapists to change both the client’s activity and his or her normal way of interpreting<br />
events.<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. The reasons for the reported sex differences in depression are many and controversial. One reason<br />
is that men and women are socialized to express emotions differently and are taught to expect<br />
different reactions from others when they are distressed. The following exercise may reveal to<br />
students norms for experiencing depression and coping with it.<br />
Set up small groups (six to eight per group) with even numbers of males and females. Then say<br />
the following:<br />
Think of a time when you were quite sad and depressed. Fix this time in your mind. Try to<br />
visualize where you were, what you were doing, and how others were responding to you.<br />
Using the incident you have in mind, answer the following questions as honestly as you can.<br />
Then ask each student to write down on the handout his or her honest responses to the following<br />
questions below:<br />
a. In what ways did you behave differently during this time than you usually do?<br />
b. In what ways were your patterns of thinking different during this time than they usually are?<br />
c. In what ways did your body react differently during this time than your body usually reacts?<br />
d. During this time, what things did you do to cope with your feelings?<br />
Finally, ask the students to write down how they think the average male and female student would<br />
answer the question about coping.<br />
Then ask group members to read aloud their expectations for the opposite sex and compare these<br />
with the actual experiences. Caution students that they need not reveal any more than they feel<br />
comfortable revealing. The aim of the exercise is to see whether real differences occur in the<br />
behavior and expectations of men and women when “depressed.” If Nolen-Hoeksema’s (1991)<br />
conclusions about the gender difference in depression are supported, women will be more likely to<br />
analyze and track their depressed moods; men will be more likely to distract themselves from such<br />
emotions. Whether members of the opposite sex will expect such differences in coping methods is<br />
unknown.<br />
If time permits, groups can report to the rest of the class whether they found actual sex differences<br />
in cognitive, behavioral, and affective symptoms and in predictions for the opposite sex. Students<br />
may discover that stereotypic differences in emotional expression and coping are exaggerated.<br />
2. Depression can be as exasperating as it is common. The responses of friends and family members<br />
to a depressed individual often range from sympathy to anger or avoidance. Some researchers<br />
even suggest that depression is a contagious disorder, since those who strive to alter the<br />
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Chapter 11: Mood Disorders 177<br />
depressive often wind up depressed themselves. The following role-play exercise may illustrate<br />
this.<br />
Have students pair off and ask each pair to decide who will play the role of a moderately<br />
depressed person first. This person is to talk negatively throughout the exercise. All suggestions<br />
from the “helper” are to be met with brief, “yes-but” responses or claims that the “depressed”<br />
person is too tired, too worthless, or not interested. The helper is assigned the role of the caring<br />
friend. This person should use the strategies that he or she has actually used with depressed<br />
friends or that he or she is expected to use. Ask each pair to imagine a series of encounters<br />
between the still-depressed individual and the helper-friend so that a condensed version of several<br />
days’ or a week’s contact is played out. You can assist by announcing to the class every three or<br />
four minutes that a day has gone by and the helper should try again to get the depressed person<br />
“undepressed.”<br />
After the students have role-played four or so encounters, have the partners exchange roles. Ask<br />
the new helpers to use what they have learned from the first set of interactions to do a better job of<br />
dealing with the depressive.<br />
After the second set of exchanges, ask partners to report to the class the sequence of strategies the<br />
first helpers tried. Write on the board whether the strategy was sympathy, questioning to<br />
determine the cause, cajoling and suggesting, anger and resentment, avoidance and defeat, or<br />
some other approach. Ask the helpers how they felt during the exercise and how they have felt in<br />
actual experiences dealing with depressives. How many of them feel defeated and depressed at the<br />
end? Link this to Lewinsohn’s idea that sometimes the “help” of friends and family unwittingly<br />
reinforces depression.<br />
Finally, ask whether they learned any lessons as to what are effective or self-protective ways of<br />
responding to depression. Discuss with students the need to educate the public about these<br />
strategies to prevent burnout and contagious depression in helpers.<br />
Internet Site: http://www.mentalhealth.com/dis/p20-md01.html A site that lists the DSM-IV-TR<br />
criteria for depression.<br />
3. This quick review will help students remember Beck’s four errors in logic, all of which typify the<br />
negative schema that keeps depressives depressed. Present the short vignettes below and ask<br />
students to decide whether each best illustrates selective abstraction, magnification/ minimization,<br />
arbitrary inference, or overgeneralization. The overlap in these errors is considerable, but it is<br />
worthwhile clarifying the differences.<br />
Tom is being interviewed for a job. He has seven years’ work experience in a related field. The<br />
interviewer asks him a standard set of questions, including: “What would you say are your<br />
strengths and weaknesses?” This is Tom’s answer:<br />
Well, it’s a lot easier for me to talk about my weaknesses than my strengths. I guess my<br />
strength is that I’m pretty old and experienced. My problem is that I don’t follow through on<br />
things, I make other people uncomfortable, I make silly mistakes, and I really don’t have<br />
many creative ideas.<br />
[Tom’s response best illustrates magnification/minimization: The depressive exaggerates his/her<br />
limitations while minimizing his/her strengths. In a job interview, this negative schema is a<br />
serious problem.]<br />
Gina handed in a 12-page term paper that included one page that was upside down. When her<br />
instructor flipped through the paper, he saw the upside-down one and said, “Oops.” This is what<br />
Gina thought to herself:
178 Chapter 11: Mood Disorders<br />
I’m such an incompetent, I can’t even get all the pages going in the right direction. I’m sure<br />
he thinks I’m a fool. If I can’t put 12 pages together and staple them correctly, how do I ever<br />
hope to be a lawyer? What a hopeless case I am.<br />
[Gina’s thinking best illustrates overgeneralization. She takes one mistake and generalizes it to<br />
mean that she is incompetent, foolish, and hopeless.]<br />
Barry is the father of a 3-year-old boy. On Halloween night, after the excitement of dressing up<br />
and eating candy, the boy cried and fussed about going to bed and, despite Barry’s best efforts,<br />
was still awake one hour after his bedtime. Barry’s explanation for his son’s crying is as follows:<br />
I must be an incompetent parent, and he hates me. He probably thinks I’m as evil as I think I<br />
am. I have no sensitivity, no skills. When his wife wonders, Don’t you think he might be<br />
crying for other reasons? Barry says flatly, No.<br />
[Although this vignette could illustrate generalization, it best illustrates arbitrary inference, since<br />
Barry is unable to think of any alternative explanation for why his son was crying and draws<br />
conclusions that are unsupported by evidence. It does not dawn on him that his son might have<br />
been overtired, too excited to wind down, or even that, as a father, he helped his child have an<br />
enjoyable evening.]<br />
Nancy painted her kitchen yesterday. She had picked out a very attractive color, bought the right<br />
brushes, and did an exceptionally neat job. However, a small dab of paint got on the tile floor<br />
despite her careful use of a drop cloth. When her husband saw the kitchen he was delighted and<br />
raved about how improved it looked. At one point he looked down, noticed the small dab of paint,<br />
and innocently tried to rub it off with the toe of his shoe. When he did this, Nancy said:<br />
I completely missed that spot. Why can’t I ever get things right? I’m sorry about the paint<br />
spill. I just can’t seem to be careful even when I try. People are going to see that mistake on<br />
the floor as soon as they come into the room. My carelessness ruined everything.<br />
[Nancy is taking one minor incident and blowing it up, while taking it out of context. Her husband<br />
was praising her, but she could only select out what she perceived as a negative and use it as proof<br />
that she “always ruins everything.” This example best illustrates selective abstraction.]<br />
4. In this classroom exercise, give students only the shortest of descriptions for a person who may be<br />
suffering from one of many disorders, but who most likely has unipolar or bipolar disorder. The<br />
students’ job is to think of the questions they would ask or the observations they would make as<br />
clinicians to decide which diagnosis is correct. Make clear to them that we do not know what the<br />
individual is really suffering from; the exercise is to get them thinking about the alternatives and<br />
introduce them to the process of ruling certain diagnoses in while ruling other diagnoses out.<br />
Tell students to take out a fresh sheet of paper. At the top of the page, have them write Bipolar<br />
disorder on the left side and Major depressive disorder on the right. Then read them this brief<br />
description of a new client to an outpatient treatment facility:<br />
Mrs. S. came to the clinic with her husband. Mrs. S. is 35, but looks much older. Her hair<br />
was unkempt, and she walked slowly and with a stooped posture, as though she were<br />
carrying a heavy burden. Her face showed little expression although there were tears in her<br />
eyes. Her answers to questions were given in a low voice in one- or two-word sentences.<br />
Clearly, Mrs. S. could have a mood disorder, but what kind? What information would rule in<br />
bipolar disorder? What information would rule it out? What would rule in unipolar<br />
depression? What would rule it out? What other disorders could Mrs. S. be suffering from?<br />
Have students write out the questions they would ask or the observations they would make and the<br />
answers that would rule in or rule out the diagnoses. This can take the form of a flowchart in<br />
which each question has a yes or no answer that serves to confirm or deny a particular diagnosis.<br />
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Chapter 11: Mood Disorders 179<br />
Here are some of the observations and answers to questions that would support a diagnosis of<br />
bipolar disorder.<br />
a. Does she experience mood swings including sudden periods of elation, grandiosity, or<br />
irritability? yes<br />
b. Has she had periods of high energy and sleeplessness before a period of depression? yes<br />
c. Has she had several of these mood swings? yes<br />
d. Is this the first episode of such a mood disorder? no<br />
e. Has she ever been successfully treated with lithium? Yes<br />
f. Did the mood disorder start without there being a clear precipitating event? yes<br />
g. Does anyone else in her family have a history of mood swings? yes<br />
h. Does she look especially anxious? no<br />
i. Does she worry constantly while in the depressed state? no<br />
j. When she is depressed, do her movement and speech slow down a great deal? yes<br />
Here are some of the observations and answers to questions that would support a diagnosis of<br />
unipolar disorder.<br />
a. Did an undesirable or uncontrollable event precede the onset of the depressive<br />
episode? yes<br />
b. Has she had mood swings involving sudden periods of elation, grandiosity, or irritability? no<br />
c. Is this the first episode of such a mood disorder? yes<br />
d. If she has been treated for this problem before, were antidepressants effective? yes<br />
e. Does she look especially anxious? yes<br />
f. Does she worry constantly while in the depressed state? yes<br />
g. Do these symptoms coincide with having recently given birth? yes (This answer suggests<br />
postpartum depression.)<br />
h. Do these symptoms coincide with a specific season of the year? yes (This answer<br />
suggests seasonal affective disorder.)<br />
Mrs. S. might be diagnosed as having other, nonmood disorders, such as a medical condition that<br />
leads to slowed movement (a thyroid condition, for example), a substance-related disorder<br />
involving depressants or withdrawal from stimulants, an organic brain dysfunction, or a<br />
schizoaffective or catatonic form of schizophrenia. To make matters even more confusing (just<br />
like real life!), many clients have two or more psychological or physiological conditions<br />
simultaneously. For example, the reported rates of personality disorders in depressed patients<br />
range from 30 to 40 percent; one study of a nonpatient sample found that 47 percent of those with<br />
a history of major depression had a personality disorder (Shea et al., 1992).<br />
Make clear to students that diagnosis is done over a period of time and observations. Additional,<br />
noninterview information, such as psychological testing and medical tests (the dexamethazone<br />
suppression test, for example) can be brought to bear so the clinician can adequately test his/her<br />
hypotheses about the client. However, the efficient diagnostician does not ask questions whose<br />
answers fail to discriminate among possible diagnoses. For instance, it would not be helpful to ask<br />
if Mrs. S. is feeling depressed, since both bipolar and unipolar clients would say yes. Considering<br />
her gender or socioeconomic status would not add any relevant information.
180 Chapter 11: Mood Disorders<br />
Source: Shea, M. T., Widiger, T. A., & Klein, M. H. (1992). Comorbidity of personality disorders<br />
and depression: Implications for treatment. Journal of Consulting and Clinical Psychology, 60,<br />
857–868.<br />
5. This activity helps students see how positive moods and reinforcing activities are related in their<br />
own lives. It illustrates the main point that Peter Lewinsohn and his colleague at the University of<br />
Oregon make about depression: If you are not engaged in reinforcing activities, your mood tends<br />
to become more depressed, and as you become more depressed you engage in fewer activities.<br />
One handout helps students monitor their daily moods; the other is a shortened version of the<br />
Pleasant Events Schedule Lewinsohn developed, listing reinforcing actions. Students should<br />
check off all the items on the schedule that are pleasant for them and add others that are missing<br />
from the list. Before going to bed each day for two weeks, students should fill out the daily mood<br />
form and list the number of pleasant activities in which they took part that day. At the end of two<br />
weeks, have students average their daily mood scores and the number of activities they took part<br />
in. You can then perform a correlational analysis of the data supplied (anonymously) by the class.<br />
If Lewinsohn’s work is supported, you should find a reasonably strong positive correlation. If not,<br />
consider with students other explanations. These might include ceiling effects on both mood and<br />
activities, cognitive factors that affect mood, ill health, and others.<br />
Source: The idea for this demonstration comes from Nevid, J. S., Rathus, S. A., & Greene, B.<br />
(1994). <strong>Abnormal</strong> psychology in a changing world (2nd ed.). Prentice-Hall. Reprinted by<br />
permission.<br />
6. The handout for this demonstration is a quick screening test for depression. It is taken from the<br />
Online Depression Screening Test developed by the New York University Department of<br />
Psychiatry http://www.med.nyu.edu/Psych/screens/depres.html. The cutoff scores are NOT<br />
PROVIDED. Therefore, this demonstration is mostly aimed at critiquing the screening device<br />
rather than doing a depression screening of students in the class. Remind students that any such<br />
screening device is incapable of diagnosing a condition and that a full, face-to-face evaluation is<br />
needed for diagnosing depression.<br />
Discuss the strengths and shortcomings of such self-report measures. Provide a list of the<br />
affective, cognitive, physiological, and behavior symptoms of depression from the text. Then ask<br />
students if they could improve on this measure. Are some symptoms overrepresented? are others<br />
underrepresented? Note with them that some questions cover multiple issues: Question 2, for<br />
instance, asks about both energy and inability to concentrate, so which symptom is the individual<br />
to rate? Discuss issues of social desirability, denial, and attention seeking. Finally, discuss the<br />
problem of finding an appropriate cutoff score. Remind students of the problems of false<br />
negatives (failing to detect real depressive symptoms) and false positives (seeing depressive<br />
symptoms when none exist). Which do they think is the more serious error?<br />
If students still want to have their responses to the screening device scored and evaluated, you can<br />
provide the Internet address above. It is wise to remind them again of the need for further<br />
evaluation even if results come back suggesting they show depressive symptoms. You may also<br />
want to make yourself available for consultation if you use this demonstration.<br />
Internet Site: http://www.med.nyu.edu/Psych/screens/depres.html. An online depression screening<br />
test developed by the New York University Department of Psychiatry.<br />
7. This demonstration is designed to introduce the students to depression and the media. Have each<br />
student watch one network news program, one local news program, one local newspaper and one<br />
major popular magazine. The student is to rate each news item as either negative or positive. Use<br />
an overhead transparency to track the individual responses from the students. Did the network<br />
news receive more negative or more positive ratings? Did any news medium receive more<br />
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Chapter 11: Mood Disorders 181<br />
negative or more positive ratings than the others? In large classes you can compare the ratings for<br />
ABC, CBS, CNN, FOX, and NBC by making columns on the overhead transparency. Discuss the<br />
effects of various news media on one's mood. Ask the students for examples of when the media<br />
has influenced their mood.<br />
8. Have the student form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask each group to develop a list of symptom of mood disorders with the most salient<br />
examples first. Each group could then have a spokesperson deliver a short talk about the best<br />
examples. You could provide a blank overhead transparency to each group at the beginning of<br />
this demonstration. Have each group conduct a discussion about why depression is so common in<br />
college and university environments. List reasons on an overhead transparency. Further, discuss<br />
which factors are the most common in the lives of college students.<br />
9. Invite a guest speaker who is a psychologist or psychiatrist specializing in treatment of mood<br />
disorders. Have the students develop questions during the class period before the guest lecturer is<br />
scheduled.<br />
10. Bring the DSM-IV-TR to class, and prepare an overhead transparency or PowerPoint slide ahead<br />
of time for your lecture on mood disorders. Describe the in-depth material from the DSM-IV<br />
while using the transparency or PowerPoint slide as an outline. Lead a discussion on the<br />
differences between different mood disorders. Encourage student input about individuals they<br />
have known with these symptoms.
182 Chapter 11: Mood Disorders<br />
HANDOUT FOR DEMONSTRATION 1:<br />
WAYS OF COPING WITH DEPRESSING SITUATIONS<br />
Think of a time when you were quite sad and depressed. Fix in your mind the situation, what led up to<br />
it, and how you coped. After you are clear on the circumstances, answer the following questions as<br />
honestly as you can. You need not reveal your answers to others if you do not wish to.<br />
1. In what ways, if any, did you behave differently during this time than you usually do?<br />
2. In what ways, if any, were your patterns of thinking different during this time than they usually<br />
are?<br />
3. In what ways, if any, did your body react differently during this time than your body usually<br />
reacts?<br />
4. During this time, what things did you do to cope with your feelings?<br />
How do you think the average female student would answer question 4?<br />
How do you think the average male student would answer question 4?<br />
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Chapter 11: Mood Disorders 183<br />
HANDOUT FOR DEMONSTRATION 5: DAILY MOOD RECORD<br />
For a two-week period you are to fill out this daily mood form. Make seven copies of this form and cut<br />
them in half. Be sure to complete it at the same time each day, preferably before you go to sleep.<br />
Review the day and your feelings. Rate your overall mood for the day on a scale from 1 to 10 (1 =<br />
severely depressed, very much down in the dumps; 10 = best possible mood, absolutely elated). Do not<br />
miss a day! Be honest!<br />
_________________________ Rating (from 1 to 10) for your overall mood for today: _____________<br />
Today’s date<br />
Any reasons for your mood today?<br />
__________________________________________________________________________________<br />
__________________________________________________________________________________<br />
__________________________________________________________________________________<br />
How many activities from the Pleasant Events Schedule did you do today? ______________________<br />
_________________________ Rating (from 1 to 10) for your overall mood for today: _____________<br />
Today’s date<br />
Any reasons for your mood today?<br />
__________________________________________________________________________________<br />
__________________________________________________________________________________<br />
__________________________________________________________________________________<br />
How many activities from the Pleasant Events Schedule did you do today? ______________________
184 Chapter 11: Mood Disorders<br />
HANDOUT FOR DEMONSTRATION 5:<br />
PLEASANT EVENTS SCHEDULE<br />
Put a check mark next to each of the items that you find pleasant. Add any that are not on this list.<br />
________ 1. Wearing expensive clothes<br />
________ 2. Talking about sports<br />
________ 3. Meeting someone new<br />
________ 4. Going to a rock concert<br />
________ 5. Playing baseball, football, or basketball<br />
________ 6. Buying things for yourself<br />
________ 7. Going to the beach<br />
________ 8. Doing artwork<br />
________ 9. Rock climbing<br />
________ 10. Reading the Scriptures<br />
________ 11. Playing golf<br />
________ 12. Redecorating a room<br />
________ 13. Going to a sports event<br />
________ 14. Going to the races<br />
________ 15. Reading novels, plays, magazines<br />
________ 16. Sailing or canoeing<br />
________ 17. Camping<br />
________ 18. Playing cards or board games<br />
________ 19. Doing puzzles<br />
________ 20. Having lunch with friends<br />
________ 21. Driving long distances<br />
________ 22. Being with animals<br />
________ 23. Ice skating or skiing<br />
________ 24. Going to a party<br />
________ 25. Playing pool or billiards<br />
________ 26. Gardening<br />
________ 27. Dancing<br />
________ 28. Shopping in the city<br />
________ 29. Lying in the sun<br />
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________ 30. Talking about philosophy<br />
________ 31. Having friends come to visit<br />
________ 32. Photography<br />
________ 33. Fishing<br />
________ 34. Writing a diary<br />
________ 35. Swimming<br />
________ 36. Making love<br />
________ 37. Knitting<br />
________ 38. Talking about politics<br />
________ 39. Doing yoga<br />
________ 40. Going to a restaurant<br />
________ 41. Attending a play<br />
________ 42. Going to a bar<br />
________ 43. Cooking meals<br />
________ 44. Getting a massage<br />
________ 45. Other ________________________________<br />
________ 46. Other ________________________________<br />
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Chapter 11: Mood Disorders 185
186 Chapter 11: Mood Disorders<br />
HANDOUT FOR DEMONSTRATION 6:<br />
DEPRESSION SCREENING TEST<br />
For more than two weeks:<br />
1. Do you feel sad, blue, unhappy, or “down in the dumps”?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
2. Do you feel tired, have little energy, unable to concentrate?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
3. Do you feel uneasy, restless, or irritable?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
4. Do you have trouble sleeping or eating (too little or too much)?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
5. Do you feel that you are not enjoying the activities that you used to?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
6. Do you feel that you have lost interest in sex or are experiencing sexual difficulties?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
7. Do you feel that it takes you longer than before to make decisions or that you are unable to<br />
concentrate?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
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8. Do you feel inadequate, like a failure, or that nobody likes you anymore?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
9. Do you feel guilty without a rational reason, or put yourself down?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
10. Do you feel that things always go or will go wrong no matter how hard you try?<br />
a. Never<br />
b. Rarely<br />
c. Sometimes<br />
d. Very often<br />
e. Most of the time<br />
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Chapter 11: Mood Disorders 187
188 Chapter 11: Mood Disorders<br />
SELECTED READINGS<br />
Barnett, P. A., & Gotlib, I. H. (1988). Psychosocial functioning and depression: Distinguishing among<br />
antecedents, concomitants, and consequences. Psychological Bulletin, 104, 97–126.<br />
Coyne, J. C., & Gotlib, I. H. (1983). The role of cognition in depression: A critical appraisal.<br />
Psychological Bulletin, 94, 472–505.<br />
Dobson, K. S . (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of<br />
Consulting and Clinical Psychology, 57, 414–419.<br />
Kolata, G. (1986). Manic-depression: Is it inherited? Science, 232, 575–576.<br />
Wender, P. H. et al. (1984). Psychiatric disorders in the biological and adoptive families of adopted<br />
individuals with affective disorders. Archives of General Psychiatry, 43, 923–929.<br />
Sattler, D., Shabatay, V., & Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 4 Mood Disorders.<br />
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 5, Major Depressive Disorder. Chapter 6, Bipolar Disorder.<br />
VIDEO RESOURCES<br />
Depression: Recognizing It, Treating It (filmstrip and audiocassette, 42 min). How depression differs<br />
from normal mood changes. Psychoanalytic and cognitive behavioral perspectives on depression as<br />
well as biological theories of cause and methods of treatment. Harper & Row Media, 10 East 53rd<br />
Street, New York, NY 10022.<br />
Depression: The Shadowed Valley (16 mm, color, 60 min). This film examines various forms of<br />
depression. Interviews with patients reveal the origins of problems and biological changes that occur<br />
during depression. A range of treatment methods is presented. Bristol-Myers Company, 345 Park<br />
Avenue, New York, NY 10022.<br />
Depression: A Study in <strong>Abnormal</strong> <strong>Behavior</strong> (16 mm, color, 26 min). The stages in the development of<br />
depression in a 29-year-old woman are presented, including the issue of suicide. Electroshock treatment<br />
and other methods are depicted. CRM Educational Films, 1011 Camino Del Mar, Del Mar, CA 92014.<br />
Four Lives: Portraits in Manic Depression (video, 60 min). Four individuals being treated for bipolar<br />
disorders are interviewed as well as their families. A segment showing a support group emphasizes the<br />
need for understanding and empathy from others. Fanlight Productions, 47 Halifax Street, Boston, MA<br />
02130.<br />
“Mood Disorders” (8) from The World of <strong>Abnormal</strong> Psychology series (video, 60 min). This segment<br />
describes major depression, bipolar disorder, the causal factors in depression and bipolar disorders, and<br />
both drug, ECT, and psychotherapies. Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345, S.<br />
Burlington, VT 05407-2345; to order, call 1-800-532-7637.<br />
One Man’s Madness (16 mm, color, 32 min). Nonfiction account of a manic-depressive writer’s<br />
symptoms and the effect on his family. Shows swings in mood from mania to severe depression. Time-<br />
Life Multi-Media, 100 Eisenhower Drive, Paramus, NJ 07652.<br />
Through Madness (video, 30 min). A documentary about three people who have either schizophrenia or<br />
bipolar disorder helps demystify students’ perceptions of these psychotic disorders. The man with<br />
bipolar disorder remains married, and the interview with him and his wife is especially relevant to this<br />
chapter’s material. Filmakers Library, 124 East 40th Street, Suite 901, New York, NY 10016.<br />
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Chapter 11: Mood Disorders 189<br />
Breaking the Dark Horse: A Family Copes with Manic Depression (VHS, color, 32 min.). The story of<br />
a woman with manic depression and how it affects her family and friends. Fanlight Productions.<br />
1-800-937-4113.<br />
Depression and Manic Depression (VHS, color, 28 min.). Covers depression and manic depression.<br />
Includes people such as Mike Wallace and Kay Red field James, author of An Unquiet Mind. Films for<br />
the Humanities.<br />
Four Lives: A Portrait of Manic Depression (VHS, color, 60 min.). Portrays the lives of four patients<br />
with manic depression and their families. Medical and psychotherapeutic treatments are discussed.<br />
Flight Productions. 1-800-937-4113.<br />
ON THE INTERNET<br />
http://www.psycom.net/depression.central.genetics.html is Depression Central an extremely thorough<br />
clearinghouse for information on all mood disorders.<br />
http://www.mentalhealth.com/dis/p20-md01.html describes a change in mood as a common complaint<br />
of many individuals. If your mood is interfering with your life, it may be due to one of the problems<br />
discussed at this site.<br />
http://www.med.nyu.edu/Psych/screens/depres.html is an online depression screening test.<br />
http://www.mentalhealth.com/p.html a site with information about mental health illnesses and issues.
CHAPTER 12<br />
Suicide<br />
CHAPTER OUTLINE<br />
I. Problems in the study of suicide<br />
A. Possible reasons: loss of family life, pressure to excel, perceived poor quality of life, for a<br />
greater good or cause (more than just depression)<br />
B. Suicide now recognized as serious threat to public health<br />
C. Reasons for separate chapter<br />
1. Psychiatric symptoms usually associated with suicidal person, but suicidal ideation<br />
may represent separate clinical entity<br />
2. Increasing interest in suicide, which is the eighth leading cause of death in the United<br />
States<br />
3. Society increasingly open about discussing death<br />
4. Suicide is irreversible, but suicidal person often ambivalent<br />
II. Correlates of suicide<br />
A. Cannot ask successful suicides about their motives<br />
B. Psychological autopsy: case records and survivor interviews to understand suicide<br />
C. Suicide notes rare (12 to 34 percent of cases)<br />
D. Attempters more likely to be white female housewives in 20s and 30s experiencing marital<br />
difficulties and use barbiturates; most likely to succeed are white males in 40s or older, who<br />
suffer ill health or depression and shoot or hang themselves<br />
E. Facts about suicide<br />
1. Frequency<br />
a) More than 31,000 in United States—yearly actual number of suicides may be 25<br />
to 30 percent higher)<br />
b) Eight to ten attempts for each completion<br />
2. Children and young people as victims<br />
a) Persons under age 25 accounted for 15 percent of suicides in 1997<br />
b) 12,000 children between ages 5 and 14 admitted to hospitals for suicidal behavior<br />
yearly<br />
c) Rate among 15 to 24 age group up 40 percent in past decade<br />
d) 20 percent of college students think of suicide during college career, but college<br />
students half as likely as non-college student age peers to attempt suicide<br />
3. Suicide publicity and identification with victims<br />
4. Gender: men succeed three to four times more often than women; women attempt three<br />
times more often than men<br />
5. Marital status: lowest incidence amongst married people, highest among divorced<br />
6. Occupation: high rates among physicians, lawyers, law-enforcement personnel, and<br />
dentists<br />
7. Socioeconomic level: across all groups, but loss of wealth related to suicide<br />
8. Choice of weapon<br />
a) Over 60 percent of suicides are with firearms, 70 percent of attempts are drug<br />
overdose<br />
b) Men choose firearms<br />
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Chapter 12: Suicide 191<br />
c) Women use poison and asphyxiation via barbiturates, but are increasingly using<br />
firearms and explosives<br />
d) Children jump from buildings or run into traffic<br />
e) Adolescents use hanging and drug overdoses<br />
9. Religious affiliation lowest among Catholics and Arabs where suicide is condemned;<br />
highest were religious sanctions regarding suicide are weak or absent (Scandinavia and<br />
Eastern Europe)<br />
10. Ethnic and cultural variables: highest among American Indians, lowest among Asian<br />
Americans<br />
11. Jails and prisons: suicide is most frequent cause of death in U.S. jails, ranging from 90<br />
to 230 per 1,000,000 (16 times higher than in general population)<br />
12. Historical period: decline during warfare and natural disasters; high during shifting<br />
norms<br />
13. Communication of intent: two-thirds of those who commit suicide signal intent<br />
14. Within three months of act; fewer than 5 percent unequivocally wish to die<br />
15. Other important facts<br />
a) Highest rate in spring and summer<br />
b) About one in six persons completing suicide leave notes<br />
c) Rates in U.S. highest in Western mountain states, especially Nevada<br />
F. Hopelessness and depression<br />
1. High correlation between suicide and depression, but not at depths of depression when<br />
too low in energy<br />
2. Hopelessness may be more catalyst than depression; supported with research<br />
G. Alcohol consumption<br />
1. Successful suicide without alcohol consumption is rare<br />
2. Alcohol-implicated suicide 27 times higher than rate in general population<br />
3. Alcohol foreshortens thinking and makes solution seem all-or-none<br />
H. Other psychological factors: many who commit suicide have DSM-IV-TR disorder; 15<br />
percent of those with mood disorders, schizophrenia, or substance abuse attempt to kill<br />
themselves; separation and divorce, academic pressures, unemployment, and serious illness<br />
contribute<br />
III. Theoretical perspectives<br />
A. Sociocultural (Durkheim) suggests three categories<br />
1. Egoistic suicide: inability to integrate with society<br />
2. Altruistic suicide: for group’s greater good<br />
3. Anomic suicide: sudden change in individual’s lifestyle<br />
4. Attributing suicide to a single sociological factor is simplistic and mechanistic, omit<br />
psychological dimension of person's struggle, don't explain why only certain group<br />
members commit suicide<br />
B. Psychodynamic explanations focus<br />
1. Self-destruction is hostility directed inward against interjected love object<br />
2. Freud proposed thanatos: death instinct antagonistic to life instinct<br />
C. Biological explanations<br />
1. Low-5HIAA (indicating low serotonin activity) related to violent suicide<br />
2. Low-5HIAA in suicidal individuals without history of depression<br />
3. Genetics also implicated<br />
IV. Victims of suicide<br />
A. Children and adolescents<br />
1. Prevalence<br />
a) Percent of suicides for age group 15-24 are by white males but most rapid rise in<br />
rates is black males
192 Chapter 12: Suicide<br />
b) Suicide is second leading cause of teenage deaths (accidents are number 1, but<br />
some of those may actually be suicides)<br />
c) Gallup poll of teens: 6 percent attempted suicide, 15 percent have come close to<br />
trying; estimate is that 8 to 9 percent of teens have engaged in self-harm behavior<br />
2. Characteristics of childhood suicides<br />
a) Attempters are female, fluctuating affect and hostile, occurs at home with parent<br />
nearby, during winter by drug overdose; families under economic stress; chaotic<br />
lives with parental chemical abuse<br />
b) Family instability significant correlate<br />
c) Need for early detection and treatment, including education of parents; teens<br />
using more lethal methods<br />
3. Copycat suicides<br />
a) Not common, but may be caused by colorful media portrayal<br />
b) Grief and mourning not the culprits inducing copycat behavior<br />
c) Need for suicide prevention program when suicide occurs in school; 41 percent<br />
of schools polled have suicide prevention programs<br />
B. Elderly people<br />
1. Stresses: physical changes, life events, and reduced income lead to depression<br />
associated with "feeling old"<br />
2. High-risk groups<br />
a) Elderly white males have highest rate of all<br />
b) Highest group for both genders is first generation Asian Americans<br />
V. Preventing suicide<br />
A. Assessing lethality<br />
1. Know factors correlated with suicide<br />
2. Determine probability of person acting on wish<br />
3. Implement appropriate actions<br />
B. Clues to suicidal intent<br />
1. Demographics and previous history<br />
2. Details about threat<br />
3. Verbal signals<br />
4. <strong>Behavior</strong>al clues (gestures)<br />
C. Crisis intervention<br />
1. Educate staff at mental health facilities and schools about signs<br />
2. Crisis intervention program may include hospitalization and intensive care followed by<br />
more traditional therapy<br />
D. Suicide prevention centers: first established in 1958 in Los Angeles, now widespread<br />
1. Telephone crisis intervention<br />
a) Staffed 24 hours per day by paraprofessionals<br />
b) Techniques used: maintain contact and establish rapport; obtain necessary<br />
information; evaluate suicidal potential; clarify nature of stressor; assess<br />
strengths; recommend and initiate action plan<br />
2. The effectiveness of suicide prevention centers<br />
a) 95 percent of callers to suicide prevention centers do not use service again: either<br />
it was helpful/no further treatment needed, or not helpful and useless to call again<br />
b) Only 2 percent who kill themselves contact a center<br />
c) Studies of effectiveness contradictory and inconclusive<br />
E. Community prevention programs<br />
1. Collaborative response by psychologists and others in community<br />
2. Methods (in case involving an elementary school teacher)<br />
a) Faculty meeting to share feelings<br />
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Chapter 12: Suicide 193<br />
b) Reassurance of children; individual sessions as needed<br />
c) Education of parents on suicide prevention<br />
F. The Surgeon General's call to action to prevent suicide: In 1999, Surgeon General David<br />
Satcher proposed the AIM program with three areas for reducing suicide: awareness,<br />
intervention, and methodology<br />
VI. The right to suicide: moral, ethical, and legal implications<br />
A. Suicide illegal and a sin (against Catholic canonical law)<br />
B. Some states provide for “living will” to protect physicians who comply with request to stop<br />
life support; California narrowly voted down Death With Dignity Act allowing physicians to<br />
end lives of terminally ill<br />
C. Thomas Szasz outspoken against suicide prevention centers; against coercive methods used<br />
by mental health professionals to stop client’s action<br />
D. Prolongation of life leads to prolonged dying<br />
1. Hemlock Society provides manual for successful suicide<br />
2. Dr. Jack Kevorkian uses “suicide machine” to assist suicide<br />
E. Problems with right to suicide<br />
1. Suicide not necessarily a rational act; patients may be coerced by relatives or others to<br />
choose to die<br />
a) Overburdening loved ones<br />
b) Medical cost control, particularly an issue for poor and disadvantaged<br />
F. Ethics of life quality versus preservation of life<br />
1. "Quality of life" and "quality of humanness" are subjective terms<br />
2. Therapist confronted with suicidal client must think through<br />
3. Werth summarized basic criteria for terminating life: hopeless condition, free of<br />
coercion, sound mind/rational decision, decision is consistent with patient's values<br />
4. Therapist has responsibility to prevent suicide if possible; failure to do so can result in<br />
legal liability<br />
LEARNING OBJECTIVES<br />
1. Explain why suicide is a serious concern in the United States and the problems involved in<br />
studying it. (pp. 391-397)<br />
2. Identify some of the possible reasons for suicide and discuss the relationships among<br />
hopelessness, depression, and suicide. (pp. 397-398)<br />
3. Discuss the relationship between suicide and other psychological factors, including alcohol abuse<br />
and other DSM-IV-TR disorders. (pp. 398-399)<br />
4. Describe the sociocultural factors in suicide, including egoistic, altruistic, and anomic suicide. (pp.<br />
399-401)<br />
5. Describe the psychodynamic and biological factors related to suicide and the different types of<br />
suicide notes. (pp. 401-402)<br />
6. Describe and discuss research on child and adolescent suicide, including characteristics of suicidal<br />
children, family issues, and copycat suicides. (pp. 402-404)<br />
7. Discuss suicide among special populations, including the elderly and among Asian Americans. (p.<br />
404)<br />
8. Describe clues to suicide intent and crisis intervention efforts to prevent it. (pp. 404-408)<br />
9. Describe the methods used by workers in suicide prevention centers and the effectiveness of these<br />
efforts. (pp. 408-411)
194 Chapter 12: Suicide<br />
10. Describe how community prevention programs may help to reduce the stress of suicide on<br />
survivors, with a focus on school-based interventions. (p. 411)<br />
11. Discuss the moral, ethical, and legal implications of the right to suicide. Clarify your own position<br />
on the legality of doctor-assisted suicide. (pp. 412-416)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. The question of whether suicide can be a rational act is a good one for discussion. On the board,<br />
draw a line indicating a continuum of “rationality.” At one end, give the reasons for committing<br />
suicide that could be expected if one were psychotic (I am cursed by Satan to bring evil to the<br />
world; I must die). At the other end, challenge students to describe the most rational suicide they<br />
can imagine. Now attempt to fill in the middle areas. As each suggestion is made, ask the student<br />
what aspects of the person’s decision to end his or her life represent rationality. Some of the issues<br />
you can highlight are the length of time for which suicide is contemplated, the person’s accuracy<br />
in predicting future happiness versus future sadness, and the impact of the suicide on survivors.<br />
Raise the issue that, if psychologists often have difficulty differentiating the psychologically<br />
disturbed from the “normal,” this decision is made even more difficult when it occurs in the<br />
context of such an emotionally charged issue as suicide.<br />
Internet Site: http://www.suicideinfo.ca The Suicide Information and Education Center, which is a<br />
good source for the topic of suicide and suicide prevention.<br />
2. Student suicide will produce a good deal of interest. A discussion of what to look for in a<br />
potentially suicidal peer can be extremely beneficial. Given the subtlety of many clues to suicide,<br />
it is important to caution students against a form of medical student syndrome. They should be<br />
encouraged to consult with student mental health service professionals if they are concerned about<br />
a peer’s behavior or comments.<br />
It is also worthwhile to discuss methods of unobtrusively monitoring friends who may be suicidal.<br />
Offering to study silently in the room with such a student is a good strategy. Maintaining contacts<br />
with the potentially suicidal individual’s social network is another. Reassure students that saying<br />
the word suicide to the person they are concerned about will not put a new idea into his or her<br />
head, and it may open the door to discussion of the person’s concerns and plans.<br />
Internet Site: http://www.suicideinfo.ca The Suicide Information and Education Center, which is a<br />
good source for the topic of suicide and suicide prevention.<br />
3. Elisabeth Kübler-Ross’s three-stage model of adjustment to suicide can be discussed at several<br />
levels. Challenge the data on which these ideas are based. Kübler-Ross’s ideas about death and<br />
dying have become very popular and are reported as “the truth” despite the fact that research fails<br />
to corroborate any such stage model. A second concern with Kübler-Ross’s model is that it<br />
implies that, once a letting-go occurs, the problem of adaptation is largely solved. Suggest to<br />
students that, to the contrary, future situations dredge up the suicide. When survivors are honest<br />
with others about the cause of their loved one’s death, they may suffer negative reactions.<br />
Anniversaries of the death often generate bouts of guilt and anger. The main points to make are<br />
that the accuracy of Kübler-Ross’s proposed stage model is still unclear and that adaptation<br />
probably continues for a long time.<br />
4. Clients who voice suicidal thoughts have a strong influence on psychotherapists. A recent survey<br />
of 750 psychologists (Pope & Tabachnik, 1993) found that the most widespread fear therapists<br />
have is that a client will commit suicide. 97 percent reported having this experience at least once.<br />
Over half reported feeling so afraid about a client that their own sleeping, eating, and<br />
concentration were affected. These findings should put to rest students’ impression that<br />
psychologists can compartmentalize their professional life so as to have no emotional response to<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 12: Suicide 195<br />
their clients. For trainees, the experience of a client suicide seems even more traumatic, leading to<br />
stress levels usually found in patients who are in the process of bereavement (Kleespies et al.,<br />
l990).<br />
Suicidal clients are an occupational hazard that students thinking about training in the helping<br />
professions should be aware of. Fears about suicide, and coping when it actually occurs, takes its<br />
toll.<br />
Sources: Kleespies, P. M., Smith, M. R., & Becker, B. R. (1990). Psychology interns as patient<br />
suicide survivors: Incidence, impact, and recovery. Professional Psychology: Research and<br />
Practice, 21, 257–263.<br />
Pope, K. S., & Tabachnik, B. G. (1993). Therapists’ anger, hate, fear, and sexual feelings:<br />
National survey of therapist responses, client characteristics, critical events, formal complaints,<br />
and training. Professional Psychology: Research and Practice, 24, 142–152.<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. You can effectively highlight the quality of life debate by dividing students into two groups: (1)<br />
the family members of a terminally ill person, who are fighting to terminate life support systems,<br />
and (2) the patient’s physicians and nurses, who argue that life must be sustained. Provide ten<br />
minutes or so for group members to develop arguments for their position. Then pass out the<br />
Handout for Demonstration 1, which depicts relevant characteristics of the patient, his or her<br />
illness, and the family. Continue by asking, “At what point does the quality of life override the<br />
need to prolong life?”<br />
2. Staff members of your community’s local suicide prevention center or hot line would be happy to<br />
make a presentation to your class. Invite both a professional staffer and a telephone volunteer to<br />
come to class. The speakers can give information about several important issues: recruiting<br />
volunteers (this can also lead to a request for student paraprofessionals), training telephone<br />
answerers, handling difficult calls, emotional effects of such work on the paraprofessional, and<br />
evidence for the center’s effectiveness.<br />
After the presenters leave, you can discuss with the class the degree to which the behavior of this<br />
center’s volunteers matches that suggested by Heilig (1970) and listed in the text. (Be sure to<br />
announce the telephone number of the local hot line to your class.)<br />
3. Hand out the Revised Facts on Suicide Quiz (Hubbard & McIntosh, 1992). Then have students<br />
score their responses. For the true-false section, correct answers alternate true and false; for<br />
multiple-choice, the correct answers alternate a, b, and c. If time permits, poll students to record<br />
the questions that were missed by the largest percentage. The quiz is reproduced below with the<br />
percentage of the original 331 undergraduates in an introductory psychology class who answered<br />
each question correctly given in brackets after each item. This test should start a discussion of the<br />
origins of misconceptions about suicide and the damage that such misconceptions can bring. The<br />
quiz also shows the multidisciplinary nature of the study of suicide, since there are issues touching<br />
psychiatry, social work, and public health, as well as psychology.<br />
1. T F The tendency toward suicide is not genetically (i.e., biologically) inherited and passed<br />
on from one generation to another. [46]<br />
2. T F People who talk about suicide rarely commit suicide. [73]<br />
3. T F The suicidal person neither wants to die nor is fully intent on dying. [38]<br />
4. T F If assessed by a psychiatrist, everyone who commits suicide would be diagnosed as<br />
depressed. [57]
196 Chapter 12: Suicide<br />
5. T F Suicide rarely happens without warning. [63]<br />
6. T F If you ask someone directly, “Do you feel like killing yourself?” it will likely lead that<br />
person to make a suicide attempt. [95]<br />
7. T F A time of high suicide risk in depression is when the person begins to improve. [47]<br />
8. T F A suicidal person will always be suicidal and entertain thoughts of suicide. [76]<br />
9. T F A person who has made a past suicide attempt is more likely to attempt suicide again<br />
than someone who has never attempted it. [80]<br />
10. T F A person who commits suicide is mentally ill. [70]<br />
11. T F Suicide is among the top ten causes of death in the United States. [83]<br />
12. T F Nothing can be done to stop people from making the attempt once they have made up<br />
their minds to kill themselves. [92]<br />
13. T F Most people who attempt suicide fail to kill themselves. [74]<br />
14. T F Motives and causes of suicide are readily established. [58]<br />
15. T F There is a strong correlation between alcoholism and suicide. [68]<br />
16. T F Those who attempt suicide do so only to manipulate others and attract attention to<br />
themselves. [64]<br />
17. T F Suicide seems unrelated to the phases of the moon. [49]<br />
18. T F Oppressive weather (e.g., rain) has been found to be very closely related to suicidal<br />
behavior. [26]<br />
19. What percentage of suicides leave a suicide note? [40]<br />
a. 15 to 25 percent<br />
b. 40 to 50 percent<br />
c. 65 to 75 percent<br />
20. With respect to sex differences in suicide attempts [65]<br />
a. males and females attempt at similar levels.<br />
b. females attempt more often than males.<br />
c. males attempt more often than females.<br />
21. Suicide rates for the United States as a whole are ______________ for the young. [8]<br />
a. lower than<br />
b. higher than<br />
c. the same as<br />
22. Suicide rates among the young are ______________ those for the old. [7]<br />
a. lower than<br />
b. higher than<br />
c. the same as<br />
23. Men kill themselves in numbers ______________ those for women. [67]<br />
a. similar to<br />
b. higher than<br />
c. lower than<br />
24. The season of highest suicide risk is [11]<br />
a. winter.<br />
b. fall.<br />
c. spring.<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 12: Suicide 197<br />
25. Suicide rates for the young since the 1950s have [97]<br />
a. increased.<br />
b. decreased.<br />
c. changed little.<br />
26. The most common method(s) employed to kill oneself in the United States is (are) [28]<br />
a. hanging.<br />
b. firearms.<br />
c. drugs and poison.<br />
27. Suicide rates for non-whites are ______________ those for whites. [35]<br />
a. higher than<br />
b. similar to<br />
c. lower than<br />
28. The day of the week on which most suicides occur is [60]<br />
a. Monday.<br />
b. Wednesday.<br />
c. Saturday.<br />
29. Compared to other western nations, the United States suicide rate is [21]<br />
a. among the highest.<br />
b. moderate.<br />
c. among the lowest.<br />
30. The ethnic/racial group with the highest suicide rate is [15]<br />
a. Whites.<br />
b. African Americans.<br />
c. Native Americans.<br />
31. Which marital status category has the lowest rates of suicide? [59]<br />
a. Married<br />
b. Widowed<br />
c. Single, never married<br />
32. The most common method(s) in attempted suicide is (are) [63]<br />
a. firearms.<br />
b. drugs and poison.<br />
c. cutting one’s wrists.<br />
33. The risk of death by suicide for a person who has attempted suicide in the past is<br />
______________ that for someone who has never attempted it. [80]<br />
a. lower than<br />
b. similar to<br />
c. higher than<br />
34. On the average, when young people make suicide attempts, they are ______________ to die<br />
compared to elderly persons. [41]<br />
a. less likely<br />
b. just as likely<br />
c. more likely<br />
35. As a cause of death, suicide ranks ______________ for the young when compared to the nation as<br />
a whole. [86]<br />
a. the same<br />
b. higher<br />
c. lower
198 Chapter 12: Suicide<br />
36. The region of the United States with the highest suicide rate is the [36]<br />
a. east.<br />
b. midwest.<br />
c. west.<br />
Source: From “Integrating Suicidology into <strong>Abnormal</strong> Psychology Classes: The Revised Facts on<br />
Suicide Quiz,” by R. W. Hubbard & J. L. McIntosh, Teaching of Psychology, 19, 1992, pp. 163–166.<br />
Copyright © 1992. Used with permission from Lawrence Erlbaum Associates, Inc., and the authors.<br />
4. Rich, Warstadt, and Nemiroff (1991) collected information from medical and police records as<br />
well as from interviews with the relatives and professionals who knew 204 suicide victims. The<br />
aim of the study was to find relationships concerning suicide among different age groups and the<br />
stressors that preceded the suicide. Over 95 percent of the suicides had one or more stressors prior<br />
to the suicide. Ask students what they think are the suicide-risk stressors for various ages in the<br />
life cycle. Conflict, separation, and rejection are the most common type of stressors in suicides<br />
until the age of 60. Legal difficulties are a primary cause for people in their twenties and thirties.<br />
Economic problems were commonly reported for those in their forties. Illness and bereavement<br />
are the key stressors for suicides in the 70 and 80 age groups. Illness influenced 48 percent of<br />
suicides in their seventies and 57 percent in their eighties.<br />
More recent research (Carney, Rich, Burke, & Fowler, 1994) indicates that suicides among those<br />
older than sixty are less likely to have financial problems as stressors than those under age 60.<br />
They also seem to talk about suicide less than the younger groups.<br />
An alternative to having students complete the handout in class is to have them survey one<br />
individual from each of the age groups. This task has the benefit of exposing traditional-age<br />
students to people from other age groups and registering their concerns. It also moves away from<br />
the students’ perceptions to those of others. A combination of both sets of data, student<br />
perceptions and reports from surveyed individuals, would be even more comprehensive and<br />
thought provoking.<br />
Sources: Carney, S. S., Rich, C. L., Burke, P. A., & Fowler, R. C. (1994). Suicide over 60: The<br />
San Diego study. Journal of the American Geriatrics Society, 42, 174–180.<br />
Rich, C. L., Wassradt, R. A., Nemiroff, R. A., et al. (1991). Suicide stressors and the life cycle.<br />
American Journal of Psychiatry, 148, 524–527.<br />
5. Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. You could provide a blank overhead transparency to each group at the beginning of<br />
this demonstration. Ask the groups to discuss several questions related to suicide and depression<br />
like the ones found below. Each group could then have a spokesperson deliver a short talk about<br />
the best examples.<br />
• What are some of the reasons why people who are depressed don't seek help?<br />
• Does society place stigma on a person with depression? If so, what could be done to change<br />
this idea?<br />
• Should doctor-assisted suicide be made legal? Why? Why not?<br />
6. Discuss the accuracy of statistics on suicide. Ask the class if some national statistics might be<br />
adjusted to account for cultural beliefs and values? Ask students for cultural or religious<br />
examples. You can develop a list on an overhead transparency. How often are deaths listed as<br />
accidents instead of suicides to spare mourners? Can the class provide examples of some<br />
accidents called intentional suicides?<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 12: Suicide 199<br />
7. Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. You could provide a blank overhead transparency to each group at the beginning of<br />
this demonstration. Ask the groups to discuss several questions related to suicide and depression<br />
like the ones found below. Each group could then have a spokesperson deliver a short talk about<br />
the best examples. Pose this question: "What is the role of rock lyrics in suicides among<br />
teenagers?" Do your students think that a rock group could be held responsible for a death that<br />
occurred after a young person had repeatedly listened to their morbid, suicide-praising lyrics?<br />
What role might video games play in suicides among children and adolescents? How has the film<br />
industry influenced younger children? Finally, ask how students would or should control the<br />
media.
200 Chapter 12: Suicide<br />
HANDOUT FOR DEMONSTRATION 1: QUALITY OF LIFE<br />
1. James is the patient. A devout Catholic, James always said that life was precious and something in<br />
God’s control. However, James is now in a coma that doctors are 90 percent sure is irreversible.<br />
He suffered for several years with a painful form of cancer that has now invaded his brain. His<br />
family has seen him suffer terribly, and they want to let him die now.<br />
2. Barbara is the patient. This 43-year-old woman suffered massive brain damage in a car accident,<br />
and doctors are 90 percent sure it is irreversible. She is unaware of her surroundings, but may live<br />
for many years. The family’s savings have already been used up to provide her with care; three<br />
children who were planning to attend college have had to forego their education and take jobs.<br />
Her family wants her to be allowed to die now.<br />
3. Verna, who is 77 years old, had always said she wanted to die if she were ever a burden to others.<br />
She has Alzheimer’s disease, a progressive and incurable brain disorder in which memory and<br />
personality gradually erode. It is a terminal illness, but death usually occurs three to five years<br />
after diagnosis. Verna was diagnosed one year ago and is already unable to remember where she<br />
is or to whom she is speaking. Her family wants her to be allowed to die to avoid becoming the<br />
burden she feared she would become.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
HANDOUT FOR DEMONSTRATION 3:<br />
THE REVISED FACTS ON SUICIDE QUIZ<br />
Circle the answer you believe is most correct for each question.<br />
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 12: Suicide 201<br />
T = true F = false ? = don’t know<br />
1. T F The tendency toward suicide is not genetically (i.e., biologically) inherited and passed<br />
on from one generation to another.<br />
2. T F People who talk about suicide rarely commit suicide.<br />
3. T F The suicidal person neither wants to die nor is fully intent on dying.<br />
4. T F If assessed by a psychiatrist, everyone who commits suicide would be diagnosed as<br />
depressed.<br />
5. T F Suicide rarely happens without warning.<br />
6. T F If you ask someone directly, “Do you feel like killing yourself?” it will likely lead that<br />
person to make a suicide attempt.<br />
7. T F A time of high suicide risk in depression is when the person begins to improve.<br />
8. T F A suicidal person will always be suicidal and entertain thoughts of suicide.<br />
9. T F A person who has made a past suicide attempt is more likely to attempt suicide again<br />
than someone who has never attempted it.<br />
10. T F A person who commits suicide is mentally ill.<br />
11. T F Suicide is among the top ten causes of death in the United States.<br />
12. T F Nothing can be done to stop people from making the attempt once they have made up<br />
their minds to kill themselves.<br />
13. T F Most people who attempt suicide fail to kill themselves.<br />
14. T F Motives and causes of suicide are readily established.<br />
15. T F There is a strong correlation between alcoholism and suicide.<br />
16. T F Those who attempt suicide do so only to manipulate others and attract attention to<br />
themselves.<br />
17. T F Suicide seems unrelated to the phases of the moon.<br />
18. T F Oppressive weather (e.g., rain) has been found to be very closely related to suicidal<br />
behavior.<br />
19. What percentage of suicides leave a suicide note?<br />
a. 15 to 25 percent<br />
b. 40 to 50 percent<br />
c. 65 to 75 percent<br />
20. With respect to sex differences in suicide attempts<br />
a. males and females attempt at similar levels.<br />
b. females attempt more often than males.<br />
c. males attempt more often than females.
202 Chapter 12: Suicide<br />
21. Suicide rates for the United States as a whole are ______________ for the young.<br />
a. lower than<br />
b. higher than<br />
c. the same as<br />
22. Suicide rates among the young are ______________ those for the old.<br />
a. lower than<br />
b. higher than<br />
c. the same as<br />
23. Men kill themselves in numbers ______________ those for women.<br />
a. similar to<br />
b. higher than<br />
c. lower than<br />
24. The season of highest suicide risk is<br />
a. winter.<br />
b. fall.<br />
c. spring.<br />
25. Suicide rates for the young since the 1950s have<br />
a. increased.<br />
b. decreased.<br />
c. changed little.<br />
26. The most common method(s) employed to kill oneself in the United States is (are)<br />
a. hanging.<br />
b. firearms.<br />
c. drugs and poison.<br />
27. Suicide rates for non-whites are ______________ those for whites.<br />
a. higher than<br />
b. similar to<br />
c. lower than<br />
28. The day of the week on which most suicides occur is<br />
a. Monday.<br />
b. Wednesday.<br />
c. Saturday.<br />
29. Compared to other western nations, the United States suicide rate is<br />
a. among the highest.<br />
b. moderate.<br />
c. among the lowest.<br />
30. The ethnic/racial group with the highest suicide rate is<br />
a. Whites.<br />
b. African Americans.<br />
c. Native Americans.<br />
31. Which marital status category has the lowest rates of suicide?<br />
a. Married<br />
b. Widowed<br />
c. Single, never married<br />
32. The most common method(s) in attempted suicide is (are)<br />
a. firearms.<br />
b. drugs and poison.<br />
c. cutting one’s wrists.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 12: Suicide 203<br />
33. The risk of death by suicide for a person who has attempted suicide in the past is<br />
______________ that for someone who has never attempted it.<br />
a. lower than<br />
b. similar to<br />
c. higher than<br />
34. On the average, when young people make suicide attempts, they are ______________ to die<br />
compared to elderly persons.<br />
a. less likely<br />
b. just as likely<br />
c. more likely<br />
35. As a cause of death, suicide ranks ______________ for the young when compared to the nation as<br />
a whole.<br />
a. the same<br />
b. higher<br />
c. lower<br />
36. The region of the United States with the highest suicide rate is the<br />
a. east.<br />
b. midwest.<br />
c. west.<br />
Source: From “Integrating Suicidology into <strong>Abnormal</strong> Psychology Classes: The Revised Facts on<br />
Suicide Quiz,” by R. W. Hubbard & J. L. McIntosh, Teaching of Psychology, 19, 1992, pp. 163–166.<br />
Copyright © 1992. Used with permission from Lawrence Erlbaum Associates, Inc., and the authors.
204 Chapter 12: Suicide<br />
HANDOUT FOR DEMONSTRATION 4:<br />
SUICIDE STRESSORS QUESTIONNAIRE<br />
For each age group indicate the stressors that would most commonly cause or trigger suicide.<br />
Ages 5 to 19 1. _________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Ages 20 to 29 1. ________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Ages 30 to 39 1. ________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Ages 40 to 49 1. ________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Ages 50 to 59 1. ________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Ages 60 to 69 1. ________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Ages 70 to 79 1. ________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Age 80 and over 1. ________________________ 2. ________________________<br />
3. ________________________ 4. ________________________<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 12: Suicide 205<br />
SELECTED READINGS<br />
Blumenthal, S. J., & Kupfer, D. J. (Eds.) (1988). Suicide over the life cycle: Risk factors, assessment<br />
and treatment of suicidal patients. Washington, DC: American Psychological Association.<br />
Bongar, M. (Ed.) (1992). Suicide: Guidelines for assessment, management, and treatment. New York:<br />
Oxford University Press.<br />
Colt, G. H. (1991). The enigma of suicide. Summit, NJ: Summit Books.<br />
Leenaars, A. A. et al. (Eds.). (1993). Suicidology: Essays in honor of Edwin S. Shneidman. Northvale,<br />
NJ: Jason Aronson, Inc.<br />
Lester, D., & Yang, B. (1992). Social and economic correlates of the elderly suicide rate. Special Issue:<br />
Suicide and the older adult. Suicide and Life-Threatening <strong>Behavior</strong>, 22, 36–47.<br />
Sattler, D., Shabatay, V., &Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 5, Suicide.<br />
VIDEO RESOURCES<br />
Born Dying (16 mm, color, 20 min). Presents the dilemma faced by parents of a newborn with multiple<br />
handicaps and examines the quality-of-life issue from several perspectives. Peter M. Robeck Company,<br />
Inc., 23 Park Avenue, New York, NY 10017.<br />
Do I Really Want to Die? (16 mm, 31 min). This film presents interviews with individuals who<br />
attempted suicide. They reveal their motivations for their attempts and their current feelings. Polymorph<br />
Films, 331 Newbury Street, Boston, MA 02115.<br />
Elderly Suicide (video, 28 min). Examines the reasons suicide is becoming an increasingly popular<br />
choice for the elderly. Psychology Video Catalogue, Fall, 1993.<br />
Fragile Time (VHS, color, 30 min). Three young people provide cases illustrating teen depression and<br />
suicide; shows the warning signs of suicide and intervention strategies for prevention. Perennial<br />
Education, 930 Pitner, Evanston, IL 60602.<br />
Suicide: A Teenage Crisis (16 mm, color, 10 min). Emphasizes the magnitude of the problem and<br />
community and school programs that can prevent suicide or reduce the impact on survivors. Film<br />
Rental Library, University of Kansas, Lawrence, KS 66045.<br />
Suicide: But Jack Was a Good Driver (16 mm, color, 14 min). Classmates of a boy who died in a car<br />
accident reflect on his activities and conversations before his death. <strong>Understanding</strong> motivations for<br />
suicide and detecting the subtle signs of suicidal intent are stressed. A good discussion starter. CRM<br />
Educational Films, 1011 Camino Del Mar, Del Mar, CA 92014.<br />
Teenage Suicide (VHS, color, 16 min). Points out warning signs of suicide attempts using lives and<br />
deaths of four teens who committed suicide. Emphasis placed on parents’ ability to listen. Also looks at<br />
suicide prevention centers. Audio-Visual Services, Pennsylvania State University, University Park, PA<br />
16802.<br />
Teenage Suicide: The Ultimate Dropout (VHS, color, 29 min). Explores feelings and circumstances that<br />
led a 14-year-old girl to attempt suicide. Looks at help-seeking by parents and provides advice to<br />
families facing a potential suicide crisis. Audio-Visual Services, Pennsylvania State University,<br />
University Park, PA 16802.
206 Chapter 12: Suicide<br />
ON THE INTERNET<br />
http://www.rochford.org/suicide/ is a general information page that answers some frequently asked<br />
questions about suicide.<br />
http://www.save.org/ is the Suicide Awareness/Voices of Education home page.<br />
http://crystal.palace.net/~llama/psych/ contains information about self-injury programs.<br />
http://www.helpline.org is a suicide help line on the Internet.<br />
http://www.psycom.net/depression.central.suicide.html provides an extensive listing of links for<br />
research information, help lines, bibliographies, and other resources concerning suicide<br />
Copyright © Houghton Mifflin Company. All rights reserved.
CHAPTER 13<br />
Schizophrenia: Diagnosis and Etiology<br />
CHAPTER OUTLINE<br />
I. Schizophrenia<br />
A. Group of disorders involving severely impaired cognitive processes, personality<br />
disintegration, and social withdrawal<br />
B. Lifetime prevalence in United States is 1 percent (males and females equally)<br />
1. Onset later in females probably due to protective factor of estrogen<br />
2. African American lifetime prevalence twice that of general population, probably due to<br />
lower socioeconomic status and higher divorce rates<br />
3. Hispanic American prevalence slightly lower, probably due to underreporting and less<br />
likely to seek help<br />
4. DSM-IV-TR presents unitary picture but evidence suggests heterogeneous syndrome<br />
with different etiologies and outcomes<br />
C. History of the diagnostic category and DSM-IV-TR<br />
1. Emil Kraepelin<br />
a) Names it “dementia praecox” (early insanity)<br />
b) Sees it as organic and incurable<br />
2. Eugen Bleuler suggests it is a group of disorders with different causes, including<br />
environment interacting with genetics; four A’s<br />
a) Autism (complete self-focus)<br />
b) Associations (unconnected ideas)<br />
c) Affect (inappropriate emotions)<br />
d) Ambivalence (uncertainty over actions)<br />
3. When diagnosed according to international standards, 50 percent of patients get other<br />
diagnoses<br />
4. DSM-IV-TR uses more restrictive definitions consistent with international standards;<br />
increases diagnostic reliability and validity of research, but makes comparison with<br />
previous research difficult<br />
D. DSM-IV-TR and the diagnosis of schizophrenia<br />
1. Delusions; hallucinations; or marked disturbances of speech, thinking, or affect<br />
2. Deterioration from previous functioning<br />
3. Disorder lasted six months at some point in life, currently present for one month<br />
4. Must rule out organic causes and affective disorders<br />
II. The symptoms of schizophrenia<br />
A. Types of symptoms<br />
1. Positive symptoms: hallucinations; delusions; and disorganization of speech, affect,<br />
behavior<br />
2. Negative symptoms: associated with poor premorbid functioning and prognosis<br />
a) Flat affect (little emotional expression)<br />
b) Alogia (lack of meaningful speech)<br />
c) Avolition (inability to take action or become goal-oriented)<br />
B. Positive symptoms<br />
1. Delusions: firmly held beliefs inconsistent with evidence or logic<br />
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208 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
a) Delusions of grandeur<br />
b) Delusions of control<br />
c) Delusions of thought broadcasting<br />
d) Delusions of persecution<br />
e) Delusions of reference<br />
f) Thought withdrawal<br />
g) Capgras’s syndrome: belief in existence of identical doubles who coexist or<br />
replace others or themselves<br />
h) Variability in how firmly delusions are held<br />
i) Develop beliefs on basis of too little information<br />
j) Therapists have some success challenging delusions and hallucinations<br />
2. Perceptual distortions: perceptions not directly attributable to environmental stimuli<br />
a) Hallucinations are sensory perceptions not directly attributable to environmental<br />
stimuli (differ from delusions, which are false intellectual experiences)<br />
b) Not pathognomonic (distinctive) to schizophrenia<br />
c) Auditory most common<br />
d) Schizophrenic attributes to sources outside self<br />
e) Delusions and hallucinations can be extremely distressing to schizophrenic<br />
f) Can be challenged by therapist<br />
g) Coping strategies include distraction, ignoring, selective listening, settling limits<br />
3. Disorganized thought and speech<br />
a) A primary characteristic of schizophrenia<br />
b) Found in deaf as well as hearing<br />
c) Loosening of associations? Cognitive slippage? Is continually shifting from topic<br />
to topic without apparent logical or meaningful connection between thought?<br />
d) Schizophrenic may respond to words or phrases in concrete manner, demonstrate<br />
difficulty with abstractions<br />
e) Inability to inhibit contextually irrelevant information<br />
4. Disorganized motor disturbances<br />
a) Hyperactive or inactive, odd postures, gestures, grimaces<br />
b) Maintaining odd position: sign of catatonic<br />
C. Negative symptoms: flat affect, avolition, alogia<br />
1. Primary (arise from schizophrenia itself)<br />
2. Secondary (response to medication or hospitalization)<br />
3. Associated with poor prognosis and may be related to structural abnormality in brain<br />
D. Associated features<br />
1. Anhedonia (inability to experience pleasure)<br />
2. Lack of insight<br />
3. Other comorbid disorders;<br />
4. Approximately 11 percent commit suicide: risk factors include severe depression,<br />
younger age, traumatic stress<br />
E. Cultural issues<br />
1. Culture may affect how symptoms are displayed or interpreted<br />
2. Ethnic group differences also found<br />
3. May cause problems with diagnostic errors and clinician bias; diagnostic system based<br />
on white middle-class norms<br />
III. Types of schizophrenia<br />
A. Paranoid schizophrenia: the most common form, persistent delusions, usually persecution or<br />
grandeur (or both)<br />
1. Differentiate from delusional disorder, where delusions are less bizarre and behavior<br />
is functional<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 209<br />
2. Delusional disorder often stems from suspicious personality exacerbated by lack of<br />
corrective feedback<br />
B. Disorganized schizophrenia (formerly called hebephrenic): severe regression, incoherence,<br />
and inappropriate affect without delusions; childish; bizarre<br />
C. Catatonic schizophrenia: quite rare; extreme excitement or profound withdrawal; waxy<br />
flexibility during withdrawal<br />
D. Undifferentiated and residual schizophrenia<br />
1. Undifferentiated: when the person's behavior shows prominent psychotic symptoms<br />
that do not meet criteria for the other three types<br />
2. Residual: those who have had at least one previous schizophrenic episode but currently<br />
have an absence of prominent psychotic features<br />
a) Continuing evidence of two or more symptoms (e.g., marked social isolation,<br />
peculiar behaviors)<br />
b) Symptoms not strong enough nor prominent enough to warrant classification as<br />
one of the other types<br />
E. Psychotic disorders once considered schizophrenia<br />
1. Brief psychotic disorder: duration under one month<br />
2. Schizophreniform disorder: duration between one and six months<br />
3. Both have better prognosis than schizophrenia<br />
4. Two-thirds of those with schizophreniform later diagnosed with schizophrenia<br />
F. Other psychotic disorders<br />
1. Shared psychotic disorder: person with close relationship with delusional individual<br />
comes to accept delusions<br />
2. Schizoaffective disorder: both mood disorder and psychotic symptoms for at least two<br />
weeks without prominent mood symptoms<br />
IV. The course of schizophrenia<br />
A. Premorbid personality usually impaired<br />
B. Prodromal phase: withdrawal and peculiar actions or talk<br />
C. Active phase: full-blown symptoms<br />
D. Residual phase: symptoms no longer prominent although full recovery rare<br />
E. Long-term outcome studies<br />
1. Newer definition requiring six months duration should reduce percentage with positive<br />
outcome<br />
2. Prognosis favorable in over 50 percent of cases in one study<br />
V. Etiology of schizophrenia<br />
VI. Heredity and schizophrenia<br />
A. Meehl (1962): identify schizophrenic by a finding person whose identical twin has been<br />
diagnosed<br />
B. Problems in interpreting genetic studies<br />
1. Several types of the disorder may have different causes and varying degrees of genetic<br />
influence<br />
2. Psychological condition of both parents must be considered<br />
3. Studies based on patients with severe and chronic cases may inflate estimates of<br />
genetic influence<br />
4. Researchers may use differing definitions of concordance<br />
5. Bias in interviewers of relatives<br />
C. Studies involving blood relatives<br />
1. General finding: the closer the blood relationship, the higher the risk among relatives<br />
of schizophrenics<br />
2. Environment confounded with genetics<br />
D. Twin studies
210 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
1. Concordance rates for schizophrenia should be higher for MZ twins than for DZ twins<br />
2. Discrepancy in concordance rates likely due to methodological differences in what is<br />
considered "concordant"<br />
a) Early studies included schizophrenia spectrum (those genetically related to<br />
schizophrenia): "latent or borderline" schizophrenia, acute schizophrenic<br />
reactions, schizoid an inadequate personality<br />
E. Adoption studies: still difficult to separate effects of heredity from effects of environment<br />
1. In Heston (1966) study, zero of fifty controls become schizophrenic, versus five of<br />
forty-seven in at-risk group<br />
a) Mother’s status and antipsychotic drug use may confound results<br />
b) At-risk group who do not get sick are more creative<br />
2. Families of adoptive parents whose children developed schizophrenia show no<br />
schizophrenia; only biological relatives of adoptive child who became schizophrenic<br />
show the disorder<br />
3. No increase in rate of disorder when adoptive family shows schizophrenic symptoms<br />
F. Studies of high-risk populations: developmental studies following children of schizophrenic<br />
parents<br />
1. Mednick’s study<br />
a) Fifteen of high-risk group (whose mothers had schizophrenia) diagnosed as<br />
schizophrenic<br />
b) Risk factors: severely disturbed mothers, more at-birth complications, aggression;<br />
slow to habituate to arousing stimuli<br />
2. The Israeli study<br />
a) High- and low-risk children raised either on kibbutz (collective farm) or in<br />
suburban home with biological parents<br />
b) When high-risk groups are in their thirties, diagnosis of schizophrenia in five<br />
people (no more in kibbutz than in town); none from control group were<br />
schizophrenic<br />
c) Most high-risk individuals do not show severe psychopathology<br />
d) Quality of parenting important; none of high-risk children with “adequate”<br />
parenting developed schizophrenia<br />
3. Conclusions and methodological problems<br />
a) Reasonably strong support for involvement of heredity<br />
b) Childhood and adolescence are especially vulnerable periods<br />
c) Schizophrenia is due to interaction of predisposition and environment<br />
d) Most high-risk children do not develop disorder<br />
e) Questions about control groups (should have other forms of psychopathology),<br />
choice of variables (should assess parent-child interaction), use of DSM-IV<br />
criteria<br />
VII. Physiological factors in schizophrenia<br />
A. Biochemistry: dopamine hypothesis (excess dopamine activity)<br />
1. Evidence<br />
a) Effective drugs (phenothiazines) reduce dopamine activity by blocking receptor<br />
sites<br />
b) L-dopa converts to dopamine and can produce schizophrenia-like symptoms<br />
c) Amphetamines produce or intensify schizophrenic symptoms<br />
2. Problems<br />
a) Minority (25 percent) of schizophrenics unresponsive to drugs<br />
b) Specific brain areas may be sensitive to either excess or deficiency of dopamine<br />
c) Effectiveness of Clozapine (works on serotonin) points to other neurotransmitters<br />
B. Neurological findings<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 211<br />
1. <strong>Abnormal</strong> neurological findings<br />
a) Neuronal loss (ventricles larger) related to negative-symptom schizophrenia<br />
b) Decreased frontal lobe functioning in schizophrenics<br />
c) Cerebral blood flow decreased only in identical twins with schizophrenia<br />
2. Conclusions<br />
a) Differences in neuronal loss too small to have significance in diagnosis<br />
b) Many contradictions in findings as summarized by Heinrichs (1993)<br />
VIII. Environmental factors in schizophrenia<br />
A. Infections during fetal period a possibility<br />
B. Stress related to schizophrenic diagnosis and relapse<br />
C. Family influences<br />
1. Theoretical constructs: negative family environments<br />
a) Schizophrenogenic mother (cold and overprotective)<br />
b) Double-bind theory (contradictory messages for which any response is<br />
punishing) produce thought disturbance<br />
2. Problems with earlier research<br />
a) Earlier research lacked control groups<br />
b) Observation made after diagnosis<br />
3. Expressed emotion: critical comments and emotional over involvement<br />
a) Predicts relapse<br />
b) May be effect rather than cause of disorder (bidirectional)<br />
c) Not pathognomic for schizophrenia; more evident in western societies<br />
D. Effect of social class<br />
1. Most prevalent in lower SES<br />
a) Stress of poverty causes (breeder hypothesis)<br />
b) Those with disorder cannot work (downward-drift hypothesis)<br />
c) Evidence for both<br />
E. Cross-cultural comparisons<br />
1. Many cultures have discrepancies in the perception of symptoms and treatments.<br />
2. Symptoms often mirror culture’s norms (Japanese more rigid, compulsive, passive)<br />
3. U.S. African Americans show more severe symptoms than Whites<br />
a) Race-related misdiagnosis another explanation<br />
IX. The treatment of schizophrenia<br />
A. Early warehousing has been replaced<br />
B. Antipsychotic medications (neuroleptics such as Thorazine and Clozapine)<br />
1. Highly effective with positive symptoms, not very good for negative symptoms, and<br />
not a cure<br />
2. Side effects seem like neurological disorders<br />
3. Relatively large group does not benefit from medication<br />
4. Need for monitoring drugs<br />
5. Clinicians unaware of motor and psychological side effects (tardive dyskinesia)<br />
6. The right to refuse medication<br />
7. Reduced dosage decreases side effects but increases relapse rate<br />
C. Psychosocial therapy: both medication and therapy<br />
1. Institutional approaches<br />
a) Milieu therapy: patients involved in ward decision-making<br />
2. Cognitive-behavioral therapy<br />
a) Positive and negative symptoms targeted to reduce frequency and severity;<br />
coping skills enhanced to allow patient management of symptoms<br />
b) Help patients critically evaluate irrational beliefs<br />
c) Social skills training emphasizes communication skills and assertiveness
212 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
d) Cultural sensitivity incorporates cultural values, may include family and other<br />
social support networks<br />
D. Interventions focusing on family communications and education (over 50 percent of<br />
recovering patients live with families)<br />
1. Normalizing the family experience<br />
2. Educating family about schizophrenia<br />
3. Identifying strength of family and patient<br />
4. Developing skills in problem solving<br />
5. <strong>Learning</strong> to cope with symptoms<br />
6. Recognizing early signs of relapse<br />
7. Creating a supportive family environment<br />
8. Meeting needs of all family members<br />
9. Family approaches and social skills training more effective in preventing relapse than<br />
drug treatment alone<br />
LEARNING OBJECTIVES<br />
1. Discuss the general characteristics of schizophrenia (pp. 419-420).<br />
2. Discuss the history of the diagnostic category known as schizophrenia and the current DSM-IV-<br />
TR criteria. (pp. 420-4211)<br />
3. Describe the symptoms of schizophrenia, including positive and negative symptoms, delusions,<br />
and perceptual distortions. (pp. 421-427)<br />
4. Describe the problems of communication and thought disturbance seen in schizophrenia,<br />
including loosening of associations. (pp. 425-426)<br />
5. Describe the motoric disturbances and negative symptoms, and associated features seen in<br />
schizophrenia, as well as the role of culture in interpreting symptoms. (pp. 426-429)<br />
6. Differentiate between the various subtypes of schizophrenia, including the paranoid, disorganized,<br />
catatonic, undifferentiated, and residual types of schizophrenia. (pp. 429-431)<br />
7. Describe the psychotic disorders once considered schizophrenia including delusional disorder,<br />
brief psychotic disorder and schizophreniform disorder, and differentiate them from<br />
schizophrenia. Differentiate delusional disorder from paranoid schizophrenia. Describe shared<br />
psychotic disorder and schizoaffective disorder. (pp. 431-433)<br />
8. Describe the three phases of schizophrenia, then discuss research on long-term outcomes of<br />
schizophrenia, including studies in developing and developed countries (pp. 433-434)<br />
9. Consider the usefulness of combining hereditary and environmental influences for understanding<br />
the origins of schizophrenia, then discuss and evaluate the genetic studies, including blood<br />
relatives, twin research, adoption and high-risk population studies, and the methodological issues<br />
involved with each type of study. (pp. 434-441)<br />
10. Describe the biochemical theories of schizophrenia, including the dopamine hypothesis of<br />
schizophrenia and research results that strengthen and weaken this hypothesis. (pp. 441-443)<br />
11. Describe the neurological impairments, cognitive, and information-processing deficits believed to<br />
be associated with schizophrenia. Evaluate the usefulness of a neurological explanation of<br />
schizophrenia. (pp. 443-445)<br />
12. Discuss environmental factors in the development of schizophrenic symptoms, including the<br />
family environment theories, methodological problems with this research, and the role pf<br />
expressed emotion in schizophrenia. (pp. 445-448)<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 213<br />
13. Discuss the social class and cross-cultural aspects of schizophrenia (pp. 448-450)<br />
14. Discuss the use of antipsychotic medications in the treatment of schizophrenia and the problems<br />
in using these drugs in treatment. Discuss changes in patients’ rights to refuse medication. (pp.<br />
450-452)<br />
15. Describe the psychosocial therapies including institutional approaches, cognitive-behavioral<br />
therapy, Integrated Psychological Therapy, and interventions targeted at relapse prevention by<br />
reducing expressed emotion. Discuss the effectiveness of these treatments. (pp. 452-456)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Schizophrenia is a difficult disorder to treat successfully when it occurs alone, but when it is<br />
accompanied by substance abuse, patients are frequently condemned to lives of instability, terror,<br />
and treatment without effect. Unfortunately, the prevalence of “dual diagnosed” schizophrenics<br />
with substance-related disorders is very high. Mueser, Bellack, and Blanchard (1992) thoroughly<br />
tell the grim story. The range of lifetime prevalence of comorbid schizophrenia and drug abuse is<br />
enormous—from 10 percent to 65 percent, the differences probably due to sampling and<br />
diagnostic criteria. However, in the large-scale, national Epidemiological Catchment Area<br />
program lifetime prevalence of alcohol diagnosis in the schizophrenic population was 33.7 percent<br />
(compared to 13.5 percent in the general population); drug diagnosis in the schizophrenic<br />
population was 27.5 percent (compared to 6.1 percent in the general population).<br />
The high-risk groups for dual diagnosis are males, young adults, those with low education, and<br />
those with early hospitalization and poor treatment compliance. In inner city psychiatric hospitals,<br />
dual diagnosis is so common that clinicians seeing young male schizophrenics assume there is an<br />
alcohol or drug problem unless evidence contradicts them. Unfortunately, once dual diagnosed,<br />
these patients usually receive less outpatient care, since mental health workers see them as less<br />
desirable and more difficult to treat (Solomon, 1986).<br />
Why should schizophrenics be so likely to have alcohol and drug problems, too? The most<br />
prominent explanation is that individuals suffering from auditory hallucinations and anxiety<br />
self-medicate, and they use alcohol because it is so available. But there is no consistent evidence<br />
that those with the most symptoms or the most pronounced symptoms are most likely to use<br />
drugs. An alternative reason is that drug use is largely a social phenomenon and develops out of<br />
social reinforcement or peer pressure. Further, genetics and/or parenting may play a role, since<br />
schizophrenics who abuse drugs are more likely to come from families in which there is a history<br />
of substance abuse.<br />
The effects of combining alcohol or other drugs with schizophrenia are devastating. Chronic drug<br />
use amplifies the cognitive deficits of schizophrenia. Substance abuse generates the kind of family<br />
arguments that heighten the schizophrenic’s arousal level (a kind of drug-induced expressed<br />
emotion), making relapse more likely.<br />
However, the substance-abuse and psychiatric camps have different treatment philosophies.<br />
Substance-abuse treatment in the United States usually subscribes to a 12-step (Alcoholics<br />
Anonymous) approach that stresses confrontation, assumed personal responsibility, and<br />
abstinence from all drugs (often including psychotropic ones). This orientation is a poor match<br />
with a schizophrenic patient who is vulnerable to heightened arousal and who may need<br />
medication to think straight. Psychiatric treatment tends to be more tolerant and accepting. This<br />
approach may be a poor match with the substance abuser, who is expert at distorting the truth and<br />
hiding symptoms. Despite a huge need for coordinated treatment, most communities treat dualdiagnosed<br />
schizophrenic/substance abusers separately, with contradictory treatment messages and<br />
poor relapse prevention (Minkoff, 1991).
214 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
Sources: Minkoff, K. (1991). Program components of a comprehensive integrated care system for<br />
seriously mentally ill patients with substance disorders. In K. Minkoff & R. E. Drake (Eds.) Dual<br />
diagnosis of major mental illness and substance disorder. San Francisco: Jossey-Bass, pp. 13–28.<br />
Mueser, K. T., Bellack, A. S., & Blanchard, J. J. (1992). Comorbidity of schizophrenia and<br />
substance abuse: Implications for treatment. Journal of Consulting and Clinical Psychology, 60,<br />
845–856.<br />
Solomon, P. (1986). Receipt of aftercare services by problem types: Psychiatric,<br />
psychiatric/substance abuse, and substance abuse. Psychiatric Quarterly, 87, 180–188.<br />
Internet Site: http://www.erols.com/ksciacca/. A site on dual diagnosis.<br />
2. The word schizophrenia is so widely misused that you should spend some time differentiating<br />
schizophrenia from multiple personality disorder. A short history of terminology, from<br />
Kraepelin’s dementia praecox to Bleuler’s schizophrenia, would be useful. It is important to<br />
convey that the split in schizophrenia is within a personality—between emotion and thinking—<br />
rather than between complete personalities. Finally, a listing of Bleuler’s four A’s (what he<br />
considered to be the fundamental symptoms of the schizophrenic spectrum disorders) helps to<br />
dispel the idea that schizophrenics are anything like the three faces of Eve. The four A’s are<br />
association (thought disorder), affect (inappropriate or blunted), ambivalence (indecisive in<br />
carrying out daily activities), and autism (withdrawal into self).<br />
Internet Site: http://www.health-center.com/mentalhealth A major site for the diagnosis and<br />
treatment of psychological disorders: link to schizophrenia for in-depth information and resources.<br />
3. Many students have difficulty imagining what a psychotic existence might be like. This inability<br />
to empathize makes intolerance more likely. You can link psychotic experiences to more everyday<br />
ones while discussing the symptoms of schizophrenia. Most people have experienced problems in<br />
thinking clearly during times of great stress; when severely fatigued; when drugged, intoxicated,<br />
or suffering from a fever; or even when first awakening. Hallucinations occur every night in our<br />
dreams and, for some people, every day during daydreams. Furthermore, we have all experienced<br />
auditory hallucinations, hearing music or our parents’ voices when there is no actual source for<br />
the sounds. In fact, musicians train themselves to hear the music written on the paper before them.<br />
(Beethoven could not have composed most of his symphonies without this ability to hallucinate.)<br />
Finally, most of us have had odd and disturbing (and incorrect) thoughts at one time or another<br />
that we were unwilling to relinquish.<br />
What best differentiates the schizophrenic’s subjective experience from ours is the degree of<br />
control we have over these states and our understanding of what causes them. Ask students to<br />
think about how they would feel if their problems in thinking were not transitory and were not<br />
easily explainable by, for instance, intoxication. Students may see that even the most bizarre<br />
forms of abnormal behavior occur on a continuum of human experience.<br />
Internet Site: http://www.health-center.com/mentalhealth A major site for the diagnosis and<br />
treatment of psychological disorders: link to symptoms for a discussion of the positive symptoms<br />
of schizophrenia.<br />
4. An intriguing experiment by Cohen, Nachmani, and Rosenberg (1974) gives students an<br />
appreciation of when loosening of associations occurs and what it looks like. A group of normal<br />
subjects and a group of people with schizophrenia were given the task of looking at two colored<br />
disks and then describing one of them in such a way that a person looking at the two disks would<br />
be able to pick out the one being described.<br />
This task requires the speaker to find accurately descriptive words or associations to convey the<br />
right color. When the colors were quite dissimilar, the descriptive ability of normals and people<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 215<br />
with schizophrenia was the same. For instance, when one disk was blue and the other was purple,<br />
both normals and schizophrenic people said “purple” or “violet.”<br />
However, when the discrimination task became more difficult, the normal speakers refined their<br />
first efforts and found a way to convey the color they meant. The schizophrenic subjects “fell<br />
apart” and a torrent of loose associations came forth. Here are the verbatim comments made by<br />
two normal subjects and two people with schizophrenia when the two colors were very similar<br />
hues of pinkish-red.<br />
Normal subject: My God this is hard. They are both about the same, except that this one<br />
might be a little redder.<br />
Normal subject: They both are either the color of canned salmon or clay. This one here is the<br />
pinker one.<br />
Schizophrenic subject: This is a stupid color of a shit ass bowl of salmon. Mix it with<br />
mayonnaise. Then it gets tasty. Leave it alone and puke all over the fuckin’ place. Puke fish.<br />
Schizophrenic subject: Make-up. Pancake make-up. You put it on our face and they think<br />
guys run after you. Wait a second! I don’t put it on my face and guys don’t run after me.<br />
Girls put it on them.<br />
When the task is difficult, the schizophrenic subjects seem to become confused and the first<br />
association they make, even if it is not helpful in identifying the color, becomes the starting point<br />
for chains of associations that they cannot control. Make-up becomes pancake make-up, which<br />
leads to personal references to women, guys, and, perhaps, fears of being thought of as a<br />
homosexual.<br />
Source: Cohen, B. D., Nachmani, G., & Rosenberg, S. (1974). Referent communication<br />
disturbances in acute schizophrenia. Journal of <strong>Abnormal</strong> Psychology, 83, 1–13.<br />
Internet site: http://www.health-center.com/mentalhealth A major site for the diagnosis and<br />
treatment of psychological disorders: link to negative symptoms for exercise.<br />
5. The DSM-IV-TR gives the impression that schizophrenia is a single disorder and that, despite its<br />
many forms, it represents a syndrome. Your text suggests that schizophrenia stems from both<br />
biogenic and psychogenic factors. Heinrichs (1993) asserts that schizophrenia is a brain disease,<br />
but one that is very hard to understand.<br />
Heinrichs argues that three criteria must be met in order to understand the neuropsychology of<br />
schizophrenia: (1) a core set of features that makes the disorder distinct from others and internally<br />
consistent; (2) evidence of brain damage that is consistently associated with the behavioral<br />
dysfunction; and (3) linkages between the brain damage and behavior that make neurological<br />
sense. Unfortunately, present evidence fails to meet any of the three criteria, although the problem<br />
of heterogeneity (standard 1) is the biggest obstacle.<br />
Heinrichs notes that people with schizophrenia show positive symptoms at some points in the<br />
illness and negative symptoms at others. Some schizophrenics have neurological abnormalities,<br />
whereas others do not. A large minority of patients do not respond to antipsychotic medication.<br />
These factors make researching schizophrenia as a singular entity quite difficult, but subdivision<br />
into separate disorders is not warranted either.<br />
Curiously, neuropsychological testing (for example, Halstead-Reitan) results usually indicate that<br />
people with schizophrenia have signs of brain damage, but only one-half of patients show<br />
abnormality on common imaging techniques (for example, CAT scans). The type of abnormality<br />
is not consistent among schizophrenics nor is it strongly related to behavior. Some schizophrenics<br />
have enlarged ventricles, but many do not. Some schizophrenics have decreased metabolic
216 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
activity in the prefrontal lobes, others have increased activity, and others show no difference from<br />
normals. What’s worse is that the relationships between schizophrenic behavioral deficits<br />
(memory, language, and perceptual distortions) do not match up with behavioral deficits seen in<br />
traditional neurological patients. In short, schizophrenia—devastating and life-long for many—<br />
remains a difficult scientific puzzle.<br />
For there to be progress, Heinrichs suggests that the heterogeneity issue be faced. “To make<br />
progress in reducing heterogeneity, neurobiologists need to join forces with behavioral<br />
researchers: thus it will be possible for some researchers to work ‘up’ from the neurobiological<br />
level, while others work ‘down’ from behavior to the brain” (p. 230).<br />
Source: Heinrichs, R. W. (1993). Schizophrenia and the brain: Conditions for a neuropsychology<br />
of madness. American Psychologist, 48, 221–233.<br />
6. Schizophrenia is as much a social problem as it is a psychological one. The revolution in<br />
antipsychotic medication has helped people function well enough to be discharged quickly. The<br />
problem is that adequate support for these people is not available. A frequent consequence of this<br />
is the revolving-door syndrome of treatment and relapse. In discussion, you can take this issue in<br />
at least three directions.<br />
First, the financial and social costs of “dumped” mental patients in cities and other communities<br />
create problems. Although the percentage of homeless people who are mentally disturbed has<br />
been inflated in the media, far too many people who are released become impoverished,<br />
abandoned, and abused. Students can be challenged to devise alternative plans for dealing with<br />
discharged schizophrenic patients in an era of shrinking budgets.<br />
Second, discuss what it feels like to be on the staff of a mental hospital where patients repeatedly<br />
return for treatment. Burnout and frustration are significant contributors to staff apathy and<br />
turnover. These facts make treatment less effective, so the cycle perpetuates itself.<br />
Third, the family of the schizophrenic needs support and education. Falloon et al.’s (1984) method<br />
of intervention to reduce expressed emotion is being used to slow or stop the revolving door. Less<br />
extensive intervention efforts may also be helpful. For instance, concerned family members can<br />
learn strategies to ensure that discharged patients continue taking medication (slipping Thorazine<br />
concentrate in the patient’s morning orange juice). The role of social support in the recovery of<br />
schizophrenics is detailed in several articles in a 1981 issue of Schizophrenia Bulletin (Vol. 7, No.<br />
1).<br />
Source: Falloon, I. R. H., Boyd, J. L., & McGill, C. W. (1984). Family care of schizophrenia.<br />
New York: Guilford Press.<br />
7. Token economies are a key treatment method in inpatient and halfway house environments. In<br />
explaining token economies, show how operant theory is applied to treatment. Token economies<br />
require clear communication of expectations, consistency, and constant monitoring.<br />
Unfortunately, most hospital staffs are not equipped to provide such attention to detail. Further,<br />
there is a tendency to be softhearted with some patients and, in that way, undermine the system.<br />
Share with students the difficulties of being a helper while simultaneously withholding the tokens<br />
that might lead to the patient’s happiness.<br />
Two related issues are also good discussion topics. Although token economies are very effective<br />
in shaping desirable behaviors and reducing or eliminating undesirable ones, the problem of<br />
generalization of behavior to unstructured environments is a significant one. Clinicians who use<br />
token economies should fade reinforcements prior to discharge so that desirable behaviors are<br />
more resistant to extinction. (This concept is another way of applying operant theory to a<br />
treatment method.) A second way of improving generalization is to use cognitive behavioral<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 217<br />
methods so that rewarding self-statements are given along with physical tokens and social<br />
reinforcements. If a discharged patient is equipped with a new set of self-statements that reinforce<br />
appropriate behavior, he or she is better able to cope in a hostile or uncaring world outside.<br />
Internet Site: http://www.health-center.com/mentalhealth A major site for the diagnosis and<br />
treatment of psychological disorders: link to section on therapy.<br />
8. In about 75 percent of cases, the symptoms of schizophrenia are greatly reduced with neuroleptic<br />
medication. However, for 25 percent of schizophrenic clients, major symptoms such as<br />
hallucinations, delusions, and social withdrawal remain despite trials with different types and<br />
doses of medication. The clinician and the client both seek relief. What else is available?<br />
Christison et al. (1991) provide a review of alternative somatic treatments for these refractory<br />
cases. They list eight alternatives:<br />
a. Clozapine (Clozaril)<br />
b. Lithium<br />
c. Benzodiazepines (Valium, Xanax)<br />
d. Reserpine<br />
e. Carbamazepine<br />
f. Propanolol<br />
g. Electroconvulsive therapy (ECT)<br />
h. L-dopa<br />
Based on double-blind, placebo studies, Christison et al. (1991) suggest that Clozapine, Lithium,<br />
and benzodiazepines be tried on refractory patients, and in that order. Clozapine is the drug of first<br />
resort because it can have such dramatic effects on otherwise refractory patients. Evidence for<br />
Lithium is the next-most promising.<br />
For clients whose symptoms are most negative (amotivational, mutism), L-dopa is the only<br />
treatment that has even weak evidence of being helpful. L-dopa exacerbates positive symptoms. In<br />
patients with the opposite form of symptoms—impulsive aggressiveness—Clozapine and Lithium<br />
are better medications than benzodiazepines because sometimes the benzodiazepines increase<br />
outbursts by disinhibiting behavior. Carbamazepine has been useful in reducing aggressiveness,<br />
but in only one controlled trial to date (Neppe, 1983).<br />
The other treatments, Reserpine, Propanolol, and ECT have been largely ineffective, usually after<br />
an initial burst of enthusiasm for their benefits in treating schizophrenia.<br />
Sources: Christison, G. W., Kirch, D. G., & Wyatt, R. J. (1991). When symptoms persist:<br />
Choosing among alternative somatic treatments for schizophrenia. Schizophrenia Bulletin, 17,<br />
217–245.<br />
Neppe, V. (1983). Carbamazepine as adjunctive treatment in nonepileptic chronic inpatients with<br />
EEG temporal lobe abnormalities. Journal of Clinical Psychiatry, 44, 326–331.<br />
Internet Site: http://www.health-center.com/mentalhealth. A major site for the diagnosis and<br />
treatment of psychological disorders: link to medications.<br />
9. Is schizophrenia related to viral infection? Present students with this puzzling finding: More<br />
people with schizophrenia are born in the late winter and early spring than in any other time of the<br />
year (although the difference in timing is rather small). Why might this be? Evidence is growing<br />
that influenza or other viral infections contracted during pregnancy may account for the disorder.
218 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
Rather than seeing a virus as directly causing schizophrenia, researchers hypothesize that a virus<br />
either interferes with neural development late in the fetal period or induces a deficiency in the<br />
immune system. A review of this work is provided in O’Reilly (1994).<br />
Source: O’Reilly, R. L. (1994). Viruses and schizophrenia. Australian and New Zealand Journal<br />
of Psychiatry, 28, 222–228.<br />
10. Could we spot early signs of schizophrenic deterioration in home movies? Research suggests we<br />
could (Walker & Lewine, 1990). The researchers collected home movies from four families in<br />
which one of the siblings developed schizophrenia and others did not. Experienced clinicians and<br />
graduate students in psychology, blind as to which child later developed schizophrenia, viewed<br />
segments of children interacting and were asked to identify the “preschizophrenic” individual. The<br />
viewers’ judgments were correct 80 percent of the time, significantly better than chance (50<br />
percent). The criteria the viewers used were atypical emotional expressions and movements,<br />
especially poor eye contact, poor motor coordination, and less facial responsiveness. However, it<br />
is not at all clear these differences are pathognomonic for schizophrenia; they may be precursors<br />
of other disorders. Replication with larger samples is certainly needed.<br />
The prospects of using home videos to investigate the cognitive, emotional, and behavioral<br />
markers of schizophrenia are quite impressive. This method also allows, over time, a way of<br />
seeing how family interaction styles may cause or be caused by schizophrenic symptoms. With<br />
the increased availability and use of camcorders, larger and larger samples of adult-onset cases<br />
can be investigated for early signs.<br />
Source: Walker, E., & Lewine, R. J. (1990). Prediction of adult-onset schizophrenia from<br />
childhood home movies of the patients. American Journal of Psychiatry, 147, 1052–1056.<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. Most students believe that they can detect “craziness” rather easily. To test this belief, you can<br />
read aloud excerpts from works by several twentieth-century writers, such as e. e. cummings,<br />
James Joyce, and Gertrude Stein, that illustrate a writing style called stream of consciousness.<br />
Among these writings, intersperse recitations of case transcripts that illustrate loosened<br />
associations in schizophrenics. (Transcripts can be obtained from several of the sources in the<br />
“Selected Readings” section.) Tell students that some of the sources represent published authors<br />
(presumably not schizophrenics) and some represent chronic schizophrenics. Ask students to<br />
judge which is which. Poll the class to see how accurate their judgments are. Then ask what<br />
factors influenced their decisions.<br />
2. The diagnosis of paranoid schizophrenia and delusional disorder is much more difficult than<br />
students might suspect. To demonstrate the problem, relate the following vignettes and ask<br />
whether these beliefs are signs of a disorder. If students conclude that they are not, ask them at<br />
what point the belief would go “over the line” into the realm of delusion.<br />
A 13-year-old girl is convinced that her English teacher is trying to embarrass her in front of<br />
the class. She claims the teacher calls on her to read a passage out loud even though the<br />
teacher knows she has a speech impediment. Each time she recites, her classmates snicker.<br />
A 50-year-old man is devoutly religious and claims that he was chosen by God to form a<br />
new church. He hears the voice of God when he goes for walks in the woods and believes<br />
his mission is to cleanse others of wickedness and heal them of both psychological and<br />
physical illness.<br />
A policeman is certain that drug dealers in the city where he works have developed a<br />
conspiracy to burn his house down and kidnap his children for ransom. He claims that<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 219<br />
several drug dealers he has arrested have threatened to get even, and he has seen the same<br />
car repeatedly driven in front of his house at night.<br />
Internet Site http://www.mentalhealth.com/book/p45-para.html. This site discusses paranoia.<br />
3. Osberg (1992) suggests reading (or, better yet, memorizing and delivering) a monologue that<br />
contains examples of the key qualities of schizophrenic thought, according to the DSM-IV-TR.<br />
Osberg argues that such a monologue has more impact if given without warning. Students may be<br />
distressed, depending on your acting ability, but the monologue will break up the routine, generate<br />
lively discussion, and give a concrete example of schizophrenic symptoms. Then distribute the<br />
handout that lists the types of schizophrenic thought disturbances and the portions of the<br />
monologue that illustrate each. Osberg reports that 100 percent of his students have recommended<br />
he use the demonstration in future classes. It takes about ten to fifteen minutes of class time. The<br />
monologue follows:<br />
Okay, class, we’ve finished our discussion of mood disorders. Before I go on, I’d like to tell<br />
you about some personal experiences I’ve been having lately. You see I’ve (pause) been<br />
involved in highly abstract (pause) type of contract (pause) which I might try to distract<br />
(pause) from your gaze (pause) if it were a new craze (pause) but the sun god has put me<br />
into it (pause) the planet of the lost star (pause) is before you now (pause) and so you’d<br />
better not try to be as if you were one with him (pause) because no one is one with him<br />
(pause) always fails because one and one makes three (pause) and that is the word for thee<br />
(pause) which must be like the tiger after his prey (pause) and the zommon is not common<br />
(pause) it is a zommon’s zommon.<br />
But really, class, (holding your head and pausing) what do you think about what I’m<br />
thinking right now? You can hear my thoughts, can’t you? I’m thinking I’m crazy and I<br />
know you (point to one student) put that thought in my mind. You put that thought there! Or<br />
could it be that the dentist did as I thought? She did! I thought she put that radio transmitter<br />
in my brain when I had the novocaine! She’s making me think this way and she’s stealing<br />
my thoughts! (Osberg, 1992, p. 47).<br />
Source: From “The Disordered Monologue: A Classroom Demonstration of the Symptoms of<br />
Schizophrenia” by T. M. Osberg, Teaching of Psychology, 19, 1992, pp. 47–48. Copyright ©<br />
1992. Used with permission from Lawrence Erlbaum Associates, Inc., and the author.<br />
4. An important goal of Chapter 13 is to convey the humanity of people who suffer from<br />
schizophrenia. Nothing accomplishes this goal better than first-person accounts of what the<br />
disorder is like. The National Institute of Mental Health publication Schizophrenia Bulletin has a<br />
continuing series called “First Person Accounts” at the back of every issue. The accounts are from<br />
people with schizophrenia as well as their siblings, parents, and other family members. If you read<br />
excerpts aloud to your class, students may be surprised by the articulateness of the authors, by the<br />
continuing struggle they face, and by their successes in the world despite their psychological<br />
impediments. Finally, their pleas for understanding may touch your students and increase their<br />
tolerance for people who have severe mental illness.<br />
The handout for this demonstration contains an abbreviated first-person description of<br />
schizophrenia and recovery. Have students read the account and see how many behaviors relate to<br />
the DSM-IV criteria for schizophrenia (also supplied in a handout). They might also make links to<br />
depression. In fact, an argument can be made that Alison is misdiagnosed; psychotic depression or<br />
schizoaffective disorder are at least as reasonable diagnoses as schizophrenia. This real case will<br />
show the complexities of diagnosis and the inadequacy of contemporary care for psychotic<br />
disturbances. Ask students what they think led most to Alison’s recovery. Do they think she will<br />
relapse?
220 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
Internet Site: http://www.schizophrenia.com/. The Schizophrenia Home Page. This site contains<br />
links to chat rooms and sites for families of affected individuals and for individuals with<br />
schizophrenia.<br />
5. Schizophrenia is such a devastating and mysterious disorder that it has an especially strong and<br />
negative effect on siblings of the person with the disorder. The National Alliance for the Mentally<br />
Ill has a Sibling and Adult Children Network for discussion of the disorder’s impact on other<br />
children in the family. A handout provides an abbreviated list of the common concerns siblings<br />
experience, the things parents can do, and the things parents cannot do. Ask students to comment<br />
on whether the issues listed seem specific to schizophrenia or general to other forms of<br />
psychopathology. You might want to distribute the handout to students at the end of one class and<br />
ask if any students who have dealt with a sibling having a chronic mental or physical condition are<br />
willing to discuss their experience with the class. This activity will show students that such<br />
difficulties happen in their peers’ lives and that material in the book “lives.”<br />
Internet Site: http://www.nami.org/. The home page for the National Alliance for the Mentally Ill.<br />
6. Perhaps no other psychological term is so misused as schizophrenic. Even well-educated people<br />
mistake the term for what psychologists call multiple personality disorder or dissociative identity<br />
disorder. An out-of-class data-gathering project can quantify the degree to which the term<br />
schizophrenic is misunderstood. Have each student survey two or three people who are not in the<br />
class and who have not taken a class in abnormal psychology. Students can use the Handout for<br />
Demonstration 6.<br />
You can modify the handout questions to test a number of hypotheses. The current version tests<br />
whether taking a course in introductory psychology or abnormal psychology affects the way<br />
people understand certain terminology. Other testable hypotheses are that respondents who have<br />
had experience in the social service field (paid or volunteer work) or people who have had family<br />
members in psychological care are more accurate in their use of the terms.<br />
Have students return the survey data and, in front of the class, read off some of the responses. You<br />
or the students can classify answers (right, mostly right, mostly wrong, wrong) and use chi-square<br />
analyses to informally test your hypotheses.<br />
7. This would be a good opportunity to invite mental health personnel from the local community<br />
mental health center to guest-lecture in class about day-treatment programs and other services<br />
available for individuals diagnosed with schizophrenia and other chronic mental illnesses.<br />
8. Have the students form small groups of between 4-7 individuals depending on your class size and<br />
space limitations. Ask each group to develop a list of symptom of schizophrenic disorders with<br />
the most salient examples first. Each group could then have a spokesperson deliver a short talk<br />
about the best examples. You could provide a blank overhead transparency to each group at the<br />
beginning of this demonstration.<br />
Then ask each groups to discuss the term "nervous breakdown" as it is sometimes used to describe<br />
an individual who has experienced a psychotic episode. Many times this term is used for affluent<br />
individuals who are in private mental hospitals. Ask each group to define a nervous breakdown in<br />
their own terms. Summarize the results to see if most responses include schizophrenic symptoms.<br />
Ask each group to discuss the question, "Why do affluent individuals have a nervous breakdown<br />
while poor individuals are classified as schizophrenic?"<br />
9. Communication problems are a major etiological component in schizophrenia. To get students to<br />
appreciate how chaotic such communications can be, ask them to write out several double-bind<br />
statements. Have one or two students read or act out what they have written. You can exaggerate<br />
some of these and point out the mixed nonverbal signals that make double-bind communications<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 221<br />
so emotional. A second feature of the communications in dysfunctional families is the tendency to<br />
speak tangentially and over another person (failing to take turns listening). An impromptu roleplay<br />
of such a family conversation can illustrate how frustrating this would be for a child. Finally,<br />
explain that in these families the child cannot escape from the confusion (nor does the child know<br />
that any other existence is possible). Verbatim transcripts of such poor communication are<br />
available in Susan Sheehan’s brilliant nonfiction account of a schizophrenic woman’s life, Is<br />
There No Place on Earth for Me?<br />
Make clear that faulty communications may not be the cause of the disorder. Emphasize the<br />
bidirectionality of confusing communications. Studies with the families of schizophrenic children<br />
have shown that parents communicate poorly only with the schizophrenic child, not the<br />
nonschizophrenic children. Engage students in a discussion of how the odd behaviors and<br />
thoughts of schizophrenic children could influence the communication patterns of others and how<br />
their frustration and emotional responses might exacerbate symptoms.<br />
Internet site: http://www.health-center.com/mentalhealth link to schizophrenia, then to symptoms,<br />
then to negative symptoms for a discussion of the negative symptoms associated with<br />
schizophrenia<br />
10. A major stumbling block to long-term recovery from schizophrenia is the general public’s<br />
intolerance and fear. This obstacle is particularly crucial in work settings, because discharged<br />
patients must have some way of keeping busy as well as supporting themselves. The following<br />
exercise might sensitize students to the need to improve work environments for treated<br />
schizophrenics.<br />
Divide the class into small groups (four or five per group) and assign each group the task of<br />
developing methods of changing the work climate of a small business (perhaps a fast-food<br />
restaurant or gift shop) so that coworkers and customers would be more accepting of newly<br />
discharged schizophrenic patients. Ask them to brainstorm what skills the former patient needs,<br />
what information the coworkers need, and how the work roles can be designed so that former<br />
patients can experience success.<br />
Have each group report the results of their brainstorming to the whole class. After you list the<br />
ideas on the board, ask the students what keeps business people from being more involved in the<br />
rehabilitation of mental patients. Suggest that greater exposure to the information made available<br />
through your course may increase tolerance and decrease the fears of the general public,<br />
especially of powerful people like employers.<br />
11. This classroom exercise is suitable for both Chapters 13 and 14. Give students the briefest<br />
possible descriptions of people who may be suffering from one of the schizophrenic-spectrum<br />
disorders. The students’ job is to think of the questions they would ask or the observations they<br />
would make as clinicians to decide which diagnosis is correct. Make clear that we do not know<br />
what the individual is really suffering from; the exercise is to get them thinking about the<br />
alternatives and introduce them to the process of ruling certain diagnoses in while ruling other<br />
diagnoses out. A secondary goal is to have them formulate a treatment plan for the person they<br />
have “diagnosed.”<br />
Distribute the Handout for Demonstration 3. Then read aloud this brief description of a new client<br />
in an outpatient treatment facility:<br />
Wendy is in her mid twenties and has become less and less able to perform her work at a<br />
local bank. She complains that her thoughts are unconnected and uncontrollable. She hears<br />
things that other people do not hear. She looks confused.
222 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
Instruct students to list questions or observations that, when answered, would support a diagnosis<br />
for each of the three schizophrenia-spectrum disorders.<br />
Students should consider Wendy’s behavior brief reactive psychosis if she has had thought<br />
disturbance that has interfered with social or other functioning for less than one month. The only<br />
difference between brief reactive psychosis and the others is duration. A diagnosis of positive<br />
symptom schizophrenia requires evidence of hallucinations (is she hearing voices that no one else<br />
can?), delusions, bizarre behavior, and loose associations. Negative symptom schizophrenia<br />
involves an absence of facial expression, speaking in very short sentences, and an inability to feel<br />
pleasure or motivation to do anything. In both positive and negative symptom schizophrenia, the<br />
symptoms must have lasted for six months. Questions should be asked to rule out<br />
substance-related disorders and mood disorders.<br />
You could follow up this exercise by giving more information about Wendy, suggesting that she<br />
is in the active stage of paranoid schizophrenia (she believes her parents are trying to poison her<br />
and that she is Christ). Tell students that she has come to their mental hospital and have them<br />
write down a treatment plan for Wendy on the handout. Encourage students to think of a treatment<br />
plan involving several components—medication, cognitive therapy, social skills training, family<br />
therapy, and so forth.<br />
12. Depending on your acting skills, you can demonstrate the side effects of excessive or prolonged<br />
neuroleptic medication. The extrapyramidal and Parkinsonian side effects of phenothiazines<br />
makes clients walk with a slow shuffle, rub their thumbs and forefingers against each other in<br />
what is termed pill rolling, keep their arms rigidly at their sides while shuffling, and, because of<br />
dry mouth, swallow frequently. Tardive dyskinesia involves thrusting out the tongue, smacking<br />
the lips, or making facial grimaces. In more extreme cases, the head is jerked to one side or arms<br />
and shoulders have tic like movements. About 20 percent of patients receiving antipsychotic<br />
medications over a long time develop tardive dyskinesia, especially elderly women who have<br />
been institutionalized many times (for whom the prevalence may be 50 percent).<br />
13. The deinstitutionalization of schizophrenics was seen as a major breakthrough made possible by<br />
the introduction of antipsychotic medications. Unfortunately, this breakthrough has not been a<br />
success. Many patients are admitted and discharged from state hospitals over and over again,<br />
some going through this process more than a hundred times.<br />
Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask each group to develop a list of problems associated with deinstitutionalization<br />
with the most salient examples first. Each group could then have a spokesperson deliver a short<br />
talk about the best examples. You could provide a blank overhead transparency to each group at<br />
the beginning of this demonstration.<br />
Then ask the groups to discuss:<br />
Who is responsible to care for the mentally ill who are allowed to leave state mental<br />
hospitals without outside support?<br />
Is the United States in a crisis with regard to the homeless mentally ill? What can be done?<br />
Source: From Celler, J. L. (1992). A historical perspective on the role of state hospitals viewed<br />
from the era of the 'revolving Door.' American Journal of Psychiatry, 149, 1526-1533.<br />
Internet Site: http://www.rwjf.org/publications/publicationsPdfs/anthology2000/chapt6.htm This<br />
site discusses the trend of deinstitutionalization and the effects on the mental health field.<br />
14. Bring the DSM-IV-TR to class, and prepare an overhead transparency or PowerPoint slide ahead<br />
of time for your lecture on schizophrenic disorders. Describe the in-depth material from the<br />
DSM-IV while using the transparency or PowerPoint slide as an outline. Lead a discussion on the<br />
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Chapter 13: Schizophrenia: Diagnosis and Etiology 223<br />
differences between different schizophrenic disorders. Encourage student input about individuals<br />
they have known with these symptoms.
224 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
HANDOUT FOR DEMONSTRATION 3:<br />
SYMPTOMS OF SCHIZOPHRENIA<br />
Clang associations:<br />
“abstract/contract/distract”<br />
“gaze/craze”<br />
“makes three and that is the word for thee”<br />
Perseveration:<br />
“no one is one”<br />
“and any one who tries to be one”<br />
“fails because one and one”<br />
Neologism:<br />
“zommon”<br />
Loose associations:<br />
throughout the monologue<br />
Thought broadcasting:<br />
“You can hear my thoughts, can’t you?”<br />
Thought insertion:<br />
“You put that thought in my mind. You put that thought there!”<br />
Thought withdrawal:<br />
“She’s stealing my thoughts.”<br />
Delusions of being controlled:<br />
“She put a radio transmitter in my brain.”<br />
Source: From “The Disordered Monologue: A Classroom Demonstration of the Symptoms of<br />
Schizophrenia” by T. M. Osberg, Teaching of Psychology, 19, 1992, pp. 47–48. Copyright © 1992.<br />
Used with permission from Lawrence Erlbaum Associates, Inc., and the author.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
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Chapter 13: Schizophrenia: Diagnosis and Etiology 225<br />
HANDOUT FOR DEMONSTRATION 4:<br />
ALISON’S STORY OF RECOVERY<br />
My illness became apparent when I was about 19 years old. I was depressed as a teenager but didn’t<br />
have any really psychotic symptoms until I was in my second year at university; then I stopped going to<br />
classes and started daydreaming all the time and sleeping all day, just waking up for meals. I was living<br />
in a fantasy world where I was a super-special person, and yet I was depressed because I couldn’t fulfill<br />
this role as a super-special person. One of my girlfriends suggested that, since I was missing classes, I<br />
speak to the women’s counselor. So I spoke to her and told her my symptoms, and she told me to see a<br />
psychiatrist at the university. I went to see him, and I told him all my symptoms: I felt like people<br />
started looking like robots to me, my body seemed to be alien matter to myself, I seemed to be like<br />
from outer space somehow. He gave me some pills, some antidepressant pills and some antipsychotic<br />
pills, but he didn’t give me any diagnosis at the time. He just wanted to see how my illness went on.<br />
This lasted about two years, and I was quite suicidal for that period . . . because I didn’t know what was<br />
going on and I was becoming more and more depressed as I could see my career slipping away . . . and<br />
living in this world that I had created and not having any idea what I was supposed to do with my life at<br />
that time, and I was very discouraged because nobody gave me any hope.<br />
I ended up in the hospital twice while I was actively suicidal and I finally decided that some of the<br />
medications weren’t working and I thought I would try another approach. I went to an orthomolecular<br />
psychiatrist. He started me on niacin and vitamin C, and it’s either coincidence or it really worked, but<br />
for some reason or other I got better within a month or two and I was no longer depressed . . . I don’t<br />
know to this day if they work, but I still take them.<br />
I graduated in 1988, and then the following year I started to notice my depression coming back slowly.<br />
I couldn’t find a job and I was hanging around my apartment all day. I did find a job and started<br />
working at it part-time, but then I started hearing screaming and becoming very agitated for no apparent<br />
reason . . . I couldn’t go to work any longer . . . I went back to a psychiatrist, and he put me on Prozac<br />
and that helped a little bit but didn’t help the psychosis part until I ended up in the hospital another<br />
time. I sort of became catatonic and they started me on Haldol. I was on Haldol for several months but<br />
had several bad side effects so I started on Loxapine after that. I was still a bit suicidal and not really<br />
depressed at being suicidal, but it was more of an elated feeling where I wanted to become an angel or<br />
something very special again. The doctor said, “Are you depressed?” and I said, “Not really, but I still<br />
want to die and I wish God would let me die by some natural cause.”<br />
I went to another day program and that helped me quite a bit. I was in that for four months and they<br />
taught me how to live on a budget . . . and social assertiveness techniques and I found that very helpful<br />
because that gave me a reason to get up in the morning. . . . I was in the hospital a few more times<br />
because I was suicidal again. My doctor . . . tried Risperidone for a few months. That seemed to work,<br />
but I seemed to be a bit flat on that so I went back on Loxapine and vitamins and I feel fairly good<br />
today. I’m not ready to look for a job . . . but at least I have the hope element in my life. I know that all<br />
my suffering was for a reason . . . I have since moved home with my parents because I became too<br />
lonely but I look forward to moving out again when I feel a lot better.<br />
DSM-IV-TR criteria for diagnosis of schizophrenia:<br />
1. At least two of the following, lasting for at least one month in the active phase (exception: only<br />
one symptom if it involves bizarre delusions or if hallucinations involve a running commentary on<br />
the person or two or more voices talking with each other)<br />
a. Delusions<br />
b. Hallucinations<br />
c. Disorganized speech (incoherence or frequent derailment)
226 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
d. Grossly disorganized or catatonic behavior<br />
e. Negative symptoms (flat affect, avolition, alogia, or anhedonia)<br />
2. During the course of the disturbance, functioning in one or more areas such as work, social<br />
relations, and self-care has deteriorated markedly from premorbid levels (in the case of a child or<br />
adolescent, failure to reach expected level of social or academic development)<br />
3. Signs of the disorder must be present for at least six months<br />
4. Schizoaffective and mood disorders with psychotic features must be ruled out<br />
5. The disturbance is not substance induced or caused by organic factors<br />
Reprinted with permission from Internet Mental Health (www.mentalhealth.com)<br />
Copyright © Houghton Mifflin Company. All rights reserved.
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Chapter 13: Schizophrenia: Diagnosis and Etiology 227<br />
HANDOUT FOR DEMONSTRATION 5:<br />
WHEN A SIBLING HAS A SEVERE MENTAL DISORDER<br />
The are common concerns and reactions of siblings of the mentally ill. The following are some of the<br />
things the sibling of someone with mental illness may be thinking. By understanding these thoughts,<br />
you will be better able to deal with them.<br />
1. He/she may try to escape, physically or emotionally, from the family. May establish rigid<br />
boundaries or barriers to separate self from others.<br />
2. The healthy sibling may take sides with one or both parents or with the ill sibling. She/he may try<br />
to act as a mediator and may have conflicting feelings of feeling sorry for and angry with parents<br />
and the ill sibling.<br />
3. The healthy sibling may feel the need to make up for the ill sibling’s failings or to avoid creating<br />
more problems.<br />
4. The healthy sibling may feel more “serious” about life. The atmosphere at home may be more<br />
serious and intense.<br />
5. The healthy sibling may establish a more critical, realistic view of parents earlier; may also<br />
become closer to parents.<br />
6. The healthy sibling may feel guilt because he/she is angry at the ill sibling.<br />
7. The healthy sibling may feel embarrassment over the ill sibling’s behavior and the reaction of the<br />
general public who know little about mental illness.<br />
8. The healthy sibling may feel grief because of the loss of the sister or brother they once knew.<br />
9. The healthy sibling may have concerns about whether or not to have children; worried about the<br />
genetics of mental illness.<br />
10. The healthy sibling may have concern about becoming mentally ill, too.<br />
What parents CAN do:<br />
1. Be aware that all family members are profoundly affected.<br />
2. Be aware of the coping stance the siblings adopt (for example, isolation and overinvolvement).<br />
3. Talk about your feelings and encourage them to do the same.<br />
4. Learn about mental illness to reduce family anxiety.<br />
5. Do not make the ill family member the axis around which the family revolves.<br />
What parents CANNOT do:<br />
1. Take away the fact that the mental illness affects other siblings.<br />
2. Lessen the impact by not talking about it.<br />
3. Shield the siblings from their own feelings about the ill sibling.<br />
4. Determine the coping style siblings may adopt.<br />
5. Do the grieving and mourning for them.
228 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
6. Take away peer and social stigma.<br />
From a handout prepared by Rex Dickens on behalf of the Alliance for the Mentally Ill/Friends and<br />
Advocates of the Mentally Ill, 432 Park Avenue South, New York, NY 10016. Phone: 212-684-3264.<br />
Reprinted by permission of the author.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 13: Schizophrenia: Diagnosis and Etiology 229<br />
HANDOUT FOR DEMONSTRATION 6:<br />
SURVEY ON PSYCHOLOGICAL TERMS<br />
First, make another copy of this form since you will be surveying two people.<br />
The purpose of this exercise is to see how accurately people can define psychological terms. You<br />
should pick one male and one female respondent whom you do not know. Pick people from different<br />
age groups. Introduce yourself by saying, “May I have a moment of your time? I am doing a research<br />
project for a college class. We are interested in people’s understanding of certain psychological terms.<br />
Are you willing to participate?” If the person says no, thank them for their time and find another<br />
person. If they say yes, mark down their gender.<br />
________ female ________ male<br />
Ask the following questions:<br />
What is your age? _____________<br />
Have you ever taken a high school or college-level introduction to psychology course?<br />
________ yes ________ no<br />
If yes, how many psychology courses after introduction to psychology did you take?<br />
_____ none (only introduction) _____ one _____ two _____ three _____ more than three<br />
Were any of the psychology courses you took about abnormal psychology? ______ yes ______ no<br />
Introduce the next section by saying, “I will now name some psychological terms. Please define each of<br />
them to the best of your ability. This is not a quiz; I simply want to find out how people understand the<br />
meaning of these words.” [Write down, word for word, the definition the respondent provides.]<br />
1. phobia<br />
2. psychopath<br />
3. schizophrenic<br />
You should supply the correct answers for those who get the definitions wrong and want to hear the<br />
right ones. Here are the definitions from your textbook:<br />
phobia: an intense fear of some object or situation and its avoidance that causes great distress
230 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
psychopath: a person with antisocial personality disorder (also called a sociopath) who chronically<br />
violates the rights of others without feeling remorse or shame<br />
schizophrenic: a person who has schizophrenia, a psychotic disorder marked by severe distortion<br />
and disorganization of thought, perception, emotions, and behavior and by social withdrawal (not<br />
a split personality)<br />
Be sure to thank your respondents for their help in the research.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 13: Schizophrenia: Diagnosis and Etiology 231<br />
HANDOUT FOR DEMONSTRATION 11:<br />
DIAGNOSIS AND TREATMENT OF SCHIZOPHRENIC-<br />
SPECTRUM DISORDERS<br />
You have just listened to your instructor’s description of a person who exhibits psychotic symptoms.<br />
Your job is to identify which type of psychosis it MIGHT be. No one, not even your instructor, knows<br />
what the correct diagnosis is because this is an incomplete and hypothetical case. For the purposes of<br />
this activity, we limit the potential diagnoses to three: Brief Psychotic Disorder, Paranoid<br />
Schizophrenia, and Schizophrenia (negative symptom). For each potential diagnosis, indicate the<br />
questions you would ask, the information you would gather, and the tests you would run to determine<br />
that the diagnosis was correct.<br />
Brief Psychotic Disorder Information you need to choose this diagnosis<br />
Paranoid Schizophrenia Information you need to choose this diagnosis<br />
Schizophrenia (negative symptom) Information you need to choose this diagnosis
232 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
Your instructor has given you additional information about the person in the hypothetical case and has<br />
provided a diagnosis. Imagine that you are a psychologist or psychiatrist in a treatment facility that can<br />
offer comprehensive services for people with this form of mental disorder. Think about and write a<br />
treatment plan for your hypothetical person. You need to identify what you think are important<br />
treatment goals so you can choose therapeutic approaches to reach those goals. Consider in your<br />
treatment plan all the methods that might be effective with this person. What specific forms should<br />
these therapies take? What are the potential drawbacks of each?<br />
Your treatment plan<br />
Treatment goals<br />
1.<br />
2.<br />
3.<br />
Specific treatment methods<br />
1.<br />
2.<br />
3.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Potential drawbacks<br />
1.<br />
2.<br />
3.<br />
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 13: Schizophrenia: Diagnosis and Etiology 233
234 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
SELECTED READINGS<br />
Andreasen, N. C., & Flaum, M. (1991). Schizophrenia: The characteristic symptoms. Schizophrenia<br />
Bulletin, 17, 27–48.<br />
Chapman, L. J., & Chapman, J. P. (1980). Scales for rating psychotic and psychotic-like experiences as<br />
continua. Schizophrenia Bulletin, 6, 476–489.<br />
Fowles, D. C. (1992). Schizophrenia: Diathesis-stress revisited. Annual Review of Psychology, 43, 303–<br />
336.<br />
Gray, J. A., Feldon, J., Rawlins, J. N. P., Hemsley, D. R., & Smith, A. D. (1991). The neuropsychology<br />
of schizophrenia. <strong>Behavior</strong>al and Brain Sciences, 14, 1–84.<br />
Nicholson, I. R., & Neufeld, R. W. J. (1993). Classification of the schizophrenias according to<br />
symptomatology: A two-factor model. Journal of <strong>Abnormal</strong> Psychology, 102, 259–270.<br />
Robbins, M. (1993). Experiences of schizophrenia: An integration of the personal, scientific, and<br />
therapeutic. New York: Guilford Press.<br />
Sattler, D., Shabatay, V., & Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 7, Schizophrenia.<br />
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 7, Schizophrenia.<br />
VIDEO RESOURCES<br />
Anne (16 mm, color, 40 min). A portrayal of a woman in her mid-fifties who has spent most of the last<br />
twenty years in mental hospitals. The film presents her mental and physical illnesses, her perceptions of<br />
her situation, and the world both inside and outside the hospital. Psychological Cinema Register,<br />
Pennsylvania State University, University Park, PA 16802.<br />
“Madness” (7) from The Brain series (VHS or 16 mm, color, 60 min). Actual case studies of acute and<br />
chronic schizophrenic individuals illustrate thought and behavior problems. Brain researchers discuss<br />
neurotransmitters and brain anomalies. WNET-TV, 356 W. 58th Street, New York, NY 10019.<br />
Dialogues with Madwomen (video, 90 min). Seven women including the filmmaker describe their<br />
experiences with schizophrenia, bipolar disorder, and multiple personality disorder. They emphasize the<br />
creativity and symbolism of madness as well as their individual paths to recovery. Women Make<br />
Movies, 462 Broadway, 5th floor, New York, NY 10013.<br />
Full of Sound & Fury: Living With Schizophrenia (video, color, 60 min). Three people with<br />
schizophrenia are interviewed. The video shows the daily struggle of living with mental illness,<br />
delusions, and social isolation. It examines the effectiveness of drugs and the need for compassion from<br />
others. Filmakers Library, 124 E. 40th Street, Suite 901, New York, NY 10016.<br />
Interview with a Schizophrenic (video, color, 50 min). The interview explores the subjective experience<br />
of the schizophrenic: thought disturbance, hallucinations, and social withdrawal. Media Guild, 118<br />
South Acacia, Box 881, Solana Beach, CA 92075.<br />
“In Two Minds” from the Madness series (video, color, 60 min). This segment addresses the degree to<br />
which schizophrenia is a brain disease. Clients’ behavior gives a good idea of what the schizophrenic<br />
experience entails and how the disorder can be treated in a variety of ways. PBS Video; to order, call 1-<br />
800-424-7963.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 13: Schizophrenia: Diagnosis and Etiology 235<br />
Jupiter’s Wife (video, color, 78 min). This drama and documentary describes the life of a homeless and<br />
delusional woman who says she is Jupiter’s wife. Over a two-year period, she is shown in and around<br />
New York’s Central Park. We learn that she lost custody of her two children due to her mental illness.<br />
The video puts a human face on the issue of the psychotic homeless. Blackbridge Productions, 169<br />
Mercer Street, New York, NY 10012.<br />
Losing the Thread: The Experience of Psychosis (video, color, 54 min). This video is a portrait of a<br />
woman, Rachel Corday, who has had intermittent episodes of psychosis for twenty-five years. She<br />
explains how she feels before and during a psychotic episode, why simple objects become menacing,<br />
and how she loses her ability to recognize even close friends. The tape increases student understanding<br />
and empathy. Insight Media, 2162 Broadway, New York, NY 10024.<br />
Mental Illness: Awareness and Hope (video, color, 14 min). Parents of mentally ill children and<br />
recovered victims discuss their lives and struggles. Mental health professionals describe how research<br />
efforts may lead to better understanding and reduced stigma concerning schizophrenia. American<br />
Mental Health Fund, 3299 Woodburn Road, Suite 334, Annandale, VA 22003.<br />
Schizophrenia: The Shattered Mirror (16 mm, 60 min). The film presents the chief characteristics of<br />
schizophrenia through the examination of a young girl’s behavior and feelings. Research on different<br />
treatment methods (drugs, psychotherapy, and ECT) are also described. Audio-Visual Center, Indiana<br />
University, Bloomington, IN 47401.<br />
“The Schizophrenias” (video, color, 25 min) from The Brain series. This segment explores the case of a<br />
man with undifferentiated schizophrenia. The Annenberg/CPB Collection, Dept. CA94, P.O. Box 2345,<br />
S. Burlington, VT 05407-2345; to order, call 1-800-532-7637.<br />
“The Schizophrenias” (9) from The World of <strong>Abnormal</strong> Psychology (video, color, 60 min). This tape<br />
shows patients suffering from chronic and acute schizophrenia, illustrates both positive and negative<br />
symptoms, and discusses current knowledge on causes and treatment. The Annenberg/CPB Collection,<br />
Dept. CA94, P.O. Box 2345, S. Burlington, VT 05407-2345; to order, call 1-800-532-7637.<br />
Back from Madness: The Struggle for Sanity (VHS, color, 53 min.). This video follows four psychiatric<br />
patients for up to two years as they deal with severe mental illness, including manic-depression,<br />
schizophrenia, obsessive-compulsive disorder, and major depression. Films for the Humanities and<br />
Sciences. 1-800-257-5126.<br />
Inside Schizophrenia (VHS, color, 33 min.). This video focuses on how the family of a schizophrenic is<br />
affected by the disorder. Fanlight Productions.<br />
Pharmacotherapy of Schizophrenia (VHS, color, 75 min.). This video covers the current state of<br />
psychopharmacotherapy, including side effects. Insight Media. 1-800-233-9910.<br />
Schizophrenia (VHS, color, 28 min.). Phil Donahue interviews Dr. E. Fuller Torrey, the author of<br />
Surviving Schizophrenia: A Family Manual. Films for the Humanities and Sciences.<br />
The Schizophrenias (VHS, color, 60 min.). Interviews are conducted with individuals diagnosed with<br />
schizophrenia. One of The World #<strong>Abnormal</strong> Psychology series. Annenberg/CPB. 1-800-LEARNER.
236 Chapter 13: Schizophrenia: Diagnosis and Etiology<br />
ON THE INTERNET<br />
http://www.mentalhealth.com/fr20.html is a major site for the understanding of schizophrenia. This site<br />
contains many links on this topic.<br />
http://www.health-center.com/mentalhealth a web site that consists of a thorough listing of offerings on<br />
mental health issues; check out those that apply to schizophrenia (antipsychotic medications, diagnosis<br />
and treatment, positive and negative symptoms, etc.) by linking as appropriate.<br />
http://www.schizophrenia.com is a massive site with many links to all aspects of schizophrenia.<br />
http://members.aol.com/leonardjk/USA.htm contains a listing of support organizations in the U.S. for<br />
people with schizophrenia and their families.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
CHAPTER 14<br />
Cognitive Disorders<br />
CHAPTER OUTLINE<br />
I. Cognitive disorders: behavioral disturbances resulting from transient or permanent brain damage;<br />
Mohammed Ali is a contemporary example<br />
A. DSM-IV-TR major classifications<br />
1. Delirium<br />
2. Dementia<br />
3. Amnestic disorders<br />
4. Cognitive disorders not otherwise specified<br />
B. Prevalence<br />
1. Severe disorders: 1 percent; mild disorders: 6 percent<br />
2. 22 times more likely in people over age 75 than in those 18 to 24<br />
3. No gender difference<br />
4. More African Americans than Whites or Hispanics<br />
II. The assessment of brain damage<br />
A. Neuropsychological tests assess memory, dexterity, and other functions<br />
B. Neurological tests: more direct monitoring of brain functioning and structure<br />
1. Electroencephalogram (EEG) measures electrical activity<br />
2. Computerized axial tomography (CAT) scan assesses brain damage via x-rays and<br />
computer technology<br />
3. Cerebral blood flow measurement<br />
4. Positron emission tomography (PET) monitors metabolism of glucose in brain<br />
5. Magnetic resonance imaging (MRI) radio waves produce pictures of brain<br />
C. Localization of brain damage<br />
1. Four lobes of cerebral cortex associated with certain functions<br />
2. Diaschisis: damage in one area disrupts distant, anatomically intact areas<br />
3. Redundancy (“unused” areas of brain) and plasticity (undeveloped areas) account for<br />
recovery<br />
D. Dimensions of brain damage<br />
1. Mild to moderate to severe<br />
2. Endogenous (within person) versus exogenous (outside agent)<br />
3. Diffuse versus specific<br />
4. Acute (not permanent) versus chronic (permanent)<br />
E. Diagnostic problems: similarity of functional and cognitive symptoms<br />
1. Depressed and schizophrenic individuals misdiagnosed<br />
2. Older people particularly vulnerable to inaccurate diagnosis<br />
3. Look for external cause or evidence of brain damage<br />
III. Types of cognitive disorders<br />
A. Four major categories, then subdivided by causal agent (for example, delirium due to<br />
substance induced conditions)<br />
B. Dementia: deterioration of memory, language (aphasia), motor function (apraxia), failure to<br />
recognize or identify objects (agnosia), judgment affecting social functioning, and<br />
significant decline from prior level<br />
Copyright © Houghton Mifflin Company. All rights reserved.
238 Chapter 14: Cognitive Disorders<br />
1. Major etiological categories<br />
a) General medical condition (Alzheimer’s, stroke, Parkinson’s, brain trauma)<br />
b) Substance induced<br />
c) Multiple etiologies (for example, medical condition and substance use)<br />
d) Not otherwise specified<br />
2. Prevalence<br />
a) Severe: 1.5 million Americans; mild to moderate: another 1 to 5 million<br />
b) Those over age 65: 5 to 7 percent have dementia, 2 to 4 percent have Alzheimer's<br />
c) Those over age 85: more than 20 percent have dementia<br />
3. Associated with range of causes (Alzheimer’s, vascular disease, alcoholism,<br />
intracranial masses)<br />
C. Delirium: rapid-onset reduction in ability to attend, memory deficit, disorientation<br />
1. Sometimes reduced consciousness; sleep-wake cycle disturbed<br />
2. Those over age 65 who are hospitalized: about 10 percent have delirium on admission<br />
D. Amnestic disorders<br />
1. Inability to learn new or recall old information<br />
2. Most common causes include head trauma, stroke, and Wernicke's encephalopathy<br />
(alcohol-induced thiamine deficiency)<br />
IV. Etiology of cognitive disorders<br />
A. Brain trauma: case of Phineas Gage; physical injury to brain (affects more than 1.9 million<br />
Americans per year)<br />
1. Concussion: mild injury caused by blow to head<br />
a) Dazed, headache, disoriented, temporary memory loss, nausea<br />
b) Symptoms usually persist for days; can persist for years<br />
2. Contusion: bruising of brain<br />
a) Symptoms similar, but more severe than those of concussion<br />
b) Lose consciousness for hours or days<br />
3. Laceration: tearing of brain tissue<br />
a) Usually due to object penetrating brain<br />
b) Most severe impact on functioning<br />
4. Consequences of serious brain trauma<br />
a) Permanent disability or death<br />
b) Closed-head injuries most common form<br />
c) Epilepsy develops in about 5 percent of closed-head injuries and in more than 30<br />
percent of open-head injuries in which train tissue is penetrated<br />
d) One-third with severe injury return to employment, although new treatment<br />
shows higher success rate<br />
B. Aging and disorders associated with aging<br />
1. Aged a growing group in United States; predicted 20 percent of Americans over age 65<br />
by 2030<br />
2. Cerebrovascular accidents or strokes: sudden stoppage of blood flow to portion of<br />
brain, leading to lost function<br />
a) Afflict more than 400,000 Americans per year (third leading cause of death);<br />
one-fourth develop major depression<br />
b) Strokes caused by narrowing of blood vessels due to atherosclerosis (buildup of<br />
fatty material on interior walls) or block of blood vessels, resulting in cerebral<br />
infarction, death of brain tissue from decreased supply of blood<br />
c) A series of infarctions may lead to vascular dementia, characterized by uneven<br />
deterioration of intellectual abilities (some remain intact)<br />
3. Memory loss in older people<br />
a) May mistake side effects of prescribed drugs for senile dementia<br />
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Chapter 14: Cognitive Disorders 239<br />
b) Overlap between normal aging and disorders makes diagnosis difficult<br />
c) Fear of cognitive decline common concern, but only performance and fluid<br />
(problem-solving) intelligence diminishes with age in most<br />
d) Determine age-related cognitive deficit based on comparison with general<br />
population, age group, similar individuals, and previous functioning<br />
C. Alzheimer's disease: brain tissue atrophies, leading to marked deterioration of intellectual<br />
and emotional functioning; accounts for 80 percent of dementia in older persons<br />
1. Characteristics of Alzheimer’s: irritability, cognitive impairment (memory loss), social<br />
withdrawal, neglect of personal hygiene, delusions<br />
2. Alzheimer's disease and the brain: neurofibrillary tangles and senile plaques<br />
(degenerated nerve endings) in brain<br />
3. Etiology of Alzheimer’s: unknown but speculation about reduced acetylcholine,<br />
aluminum exposure, head injuries, infection, decreased blood flow; diet, perhaps<br />
genetic (chromosome 21), especially in early onset<br />
D. Other diseases and infections of the brain<br />
1. Parkinson’s disease: progressive tremors, stiff gait, flat affect, social withdrawal,<br />
depression, dementia<br />
a) Lesion in motor area of brain stem; low dopamine<br />
b) Treated with L-dopa<br />
2. AIDS (acquired immunodeficiency syndrome)<br />
a) AIDS virus reaches brain and affects mental processes<br />
b) AIDS reduces immune function, allowing infection that causes<br />
neuropsychological problems<br />
c) Confusion and depression arise from knowing one has AIDS<br />
3. Neurosyphilis (general paresis): delayed brain damage resulting from syphilis; occurs<br />
in 10 percent of untreated cases of syphilis<br />
a) Symptoms: euphoria, simple dementia, apathy, paralysis; then death<br />
b) If syphilis treated early, clinical remission occurs; after five years of treatment<br />
more than half of patients with serious symptoms lose those symptoms<br />
4. Encephalitis: viral infection causes brain inflammation<br />
a) Symptoms: rapidly developing headache, sleep, delirium; agitated when awake<br />
5. Meningitis: inflammation of brain membrane by bacteria, virus, or fungus<br />
a) Symptoms: high fever, lethargy, stiff neck<br />
b) Residual effects: hearing loss, mental retardation<br />
6. Huntington’s disease: genetic disorder producing twitching, dementia, and death<br />
a) Onset at between 25 and 55; death within 16 years of onset<br />
b) Gene now identified, but no treatment<br />
E. Cerebral tumors: abnormal tissue growing in brain (faster growing produce most mental<br />
symptoms)<br />
1. Symptoms: diminished attention; mild dementia<br />
2. Removal can produce dramatic results<br />
F. Epilepsy: general term for set of symptoms (intermittent and short periods of altered<br />
consciousness, sometimes seizures and excessive electrical discharge in brain), no specific<br />
cause<br />
1. Prevalence<br />
a) Most common neurological problem<br />
b) 1 to 2 percent of population at some point in lifespan<br />
c) Most frequently diagnosed in childhood<br />
2. Causes: alcohol, lack of sleep, fever, low blood sugar, brain injury, hyperventilation,<br />
flickering lights<br />
3. Controlled but not cured by medication
240 Chapter 14: Cognitive Disorders<br />
a) 30 to 50 percent of people with epilepsy have psychological problems<br />
4. Types<br />
a) Tonic-clonic: aura before loss of consciousness; tonic (falls to ground), clonic<br />
(jerking movements), then coma<br />
5. Etiological factors: genetics, stress, personality, biochemical imbalances, head injury<br />
and physical illness<br />
G. Use of psychoactive substances<br />
V. Treatment considerations<br />
A. Surgery<br />
B. Medication: drugs to control symptoms<br />
C. Cognitive and behavioral approaches<br />
1. Memory improvement techniques<br />
2. Stress inoculation<br />
3. Classical conditioning to prevent seizures<br />
D. Environmental interventions and caregiver support<br />
1. Preserve patient’s sense of control<br />
2. Continued, short social contacts<br />
3. Diversions in low-arousal settings<br />
4. Tasks assigned to increase self-worth<br />
5. Caregivers need support (worry, guilt, parent-child role reversal)<br />
VI. Mental retardation<br />
A. Association for Retarded Citizens estimates that 75 percent of children with retardation can<br />
become self-supporting if given appropriate education and training<br />
1. Decrease of people with mental retardation in institutions from 200,000 in 1967 to<br />
110,000 by 1984<br />
B. Diagnosing mental retardation<br />
1. Prevalence: seven million or more in United States; have IQs of about 70 or less<br />
2. Criteria<br />
a) IQ of 70 or less<br />
b) Deficiencies in adaptive behavior<br />
c) Onset before 18<br />
3. Characteristics: dependency, passivity, low self-esteem, depression, self-injurious<br />
behavior<br />
C. Issues involved in diagnosing mental retardation<br />
1. Validity of IQ tests: IQ predicts scholastic achievement in Whites but not in minorities<br />
a) Issue has resurfaced<br />
b) Alternative explanations for lower African American IQ scores<br />
2. Larry P. v. Riles case<br />
D. Levels of retardation<br />
1. Mild (IQ 50–55 to 70)<br />
2. Moderate (IQ 35–40 to 50–53)<br />
3. Severe (IQ 20–25 to 35–40)<br />
4. Profound (IQ below 20 or 25)<br />
5. American Association on Mental Retardation no longer uses classification based on IQ<br />
scores; classifies the level of support needed<br />
E. Etiology of mental retardation<br />
1. Environmental factors<br />
a) Absence of stimulation<br />
b) Chronic stress and poverty<br />
2. Genetic factors<br />
a) Normal variation in genetics related to intelligence<br />
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Chapter 14: Cognitive Disorders 241<br />
b) Genetic anomalies (rare) leading to significant physical and intellectual<br />
impairment<br />
3. Down syndrome (extra chromosome on 21(superscript: st) pair: trisomy 21)<br />
a) physical characteristics: short incurving finger, short broad hands, slanted eyes,<br />
protruding tongue, flat broad face, harsh voice, incomplete or delayed sexual<br />
development (cosmetic surgery for tongue can help physical appearance and<br />
speaking/eating)<br />
b) those who live past 40 are at risk for Alzheimer's because of the 21 (superscript:<br />
st) chromosome anomaly; also, greater intellectual decline than with other types<br />
of mental retardation<br />
c) prenatal assessment via amniocentesis or chronic villus sampling; older mothers<br />
(older than 35) at higher risk for Down syndrome children<br />
d) other genetic anomalies that produce mental retardation: Turner's syndrome,<br />
Klinefelter's syndrome, phenylketonuria (PKU), Tay-Sachs disease, and cretinism<br />
4. Nongenetic biogenic facts<br />
a) Prenatal: German measles, drugs, radiation, poor nutrition.<br />
b) fetal alcohol syndrome (FAS): consumption of alcohol during pregnancy: small<br />
body size, microcephaly, mild retardation, academic and attentional difficulties,<br />
hyperactivity, behavioral deficits; exacerbated risk with smoking and poor<br />
nutrition; especially high among Native Americans<br />
c) Perinatal (during birth) factors: birth trauma or asphyxiation<br />
d) postnatal: head injuries, infections, tumors, malnutrition, ingesting toxic<br />
substance (e.g., lead), child abuse; small proportion of organically caused mental<br />
retardation<br />
F. Programs for people with mental retardation<br />
1. Early intervention: Head Start<br />
2. School services<br />
3. Employment programs<br />
4. Living arrangements (“least restrictive environment”)<br />
a) Group homes<br />
b) “Normalized” homes<br />
LEARNING OBJECTIVES<br />
1. Define cognitive disorders and discuss their possible causes. Compare the prevalence rate for<br />
different population groups. List the DSM-IV-TR categories of cognitive disorders and<br />
differentiate these disorders from other disorders involving cognitive problems that are not part of<br />
the cognitive disorders group. (pp. 459-462)<br />
2. Describe the methods for assessing brain damage and the problem of linking functional loss to a<br />
specific brain location. (pp. 462-464)<br />
3. Describe the dimensions by which brain damage is categorized. (p. 465)<br />
4. Describe how cognitive disorders are categorized by cause and the problems in diagnosing<br />
cognitive disorders. (pp. 465-466)<br />
5. Describe and differentiate dementia and delirium and discuss the possible causes of these<br />
disorders. (pp. 466-468)<br />
6. Describe the amnestic disorders and differentiate them from dementia and delirium. (pp. 468-469)<br />
7. List and differentiate the types of brain traumas, their symptoms and aftereffects. (pp. 469-471)
242 Chapter 14: Cognitive Disorders<br />
8. Describe the health conditions that accompany old age, including the nature and effects of, and<br />
risk factors for cerebrovascular accidents (strokes) and vascular dementia. (pp. 471-472)<br />
9. Discuss the extent and reasons for memory loss in older people. Discuss the characteristics of<br />
Alzheimer’s disease, brain abnormalities, and what is known about its cause. (pp. 474-476)<br />
10. Describe and differentiate among the following: Parkinson’s disease, AIDS-related dementia,<br />
neurosyphilis (general paresis), encephalitis, meningitis, Huntington’s chorea, cerebral tumors,<br />
and epilepsy. (pp. 477-482)<br />
11. Describe methods of treating cognitive disorders, including medication and cognitive and<br />
behavioral approaches. (pp. 482-484)<br />
12. Discuss the need for environmental interventions and methods of supporting the caregivers of<br />
individuals with cognitive disorders. (p. 484)<br />
13. Discuss the class of disorders known as mental retardation, including different forms of<br />
retardation, how mental retardation is diagnosed, the four levels of retardation, and the<br />
predisposing factors associated with mental retardation. (pp. 484-487)<br />
14. Explain the causes of mental retardation, including how environmental factors and nongenetic<br />
biogenic factors may be involved. (pp. 487-490)<br />
15. Describe and discuss early intervention and employment programs and living arrangements for<br />
people with mental retardation. (pp. 490-492)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. There are so many different cognitive disorders and the names of some are so unfamiliar to<br />
students that they will appreciate a handout that lists the categories of disorders, their names, and<br />
their major symptoms. Students will quickly recognize a major problem for diagnosticians: the<br />
similarity of symptoms despite widely different causes. The Handout for Classroom Topic 1<br />
organizes the various brain disorders by type and symptoms.<br />
Internet Site: http://www.merck.com/pubs/mmanual. Consists of the DSM criteria.<br />
2. In most cases, stroke survivors leave the structured environment of the hospital and return home,<br />
often without much preparation given to the family. In Leeds, England, a transitional program is<br />
in place that seems to improve the psychological and physical adjustment of stroke survivors<br />
(Geddes & Chamberlain, 1989; Geddes et al. 1991). The Leeds Family Placement Scheme (FPS)<br />
is a community-based rehabilitation program in which stroke patients and their families get<br />
intensive support for about eight weeks after the patient is stabilized after the stroke. Substitute<br />
careers help the patient, and the rest of the family devises rehabilitation plans and provides<br />
information and assistance in the recovery process. Apparently, patients who learn to cope soon<br />
after the stroke develop greater motivation to continue their rehabilitation and have greater<br />
acceptance of their changed lifestyles. A comparison of ten stroke patients placed in the FPS with<br />
61 controls showed no overall improvement in functioning among controls but significant<br />
improvements between three and twelve months poststroke for those in the FPS intervention.<br />
Sources: Geddes, J. M., & Chamberlain, M. A. (1989). The Leeds Family Placement Scheme: An<br />
evaluation of its use as a rehabilitation resource. Clinical Rehabilitation, 3, 189–197.<br />
Geddes, J. M., Chamberlain, M. A., & Bonsall, M. (1991). The Leeds Family Placement Scheme:<br />
Principles, participants, and postscript. Clinical Rehabilitation, 5, 53–64.<br />
Internet Site: http://neurosurgery.mgh.harvard.edu. Provides an extensive list of national<br />
associations involved with stroke, paralysis, spinal cord injury, and other neurological conditions.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 14: Cognitive Disorders 243<br />
3. Alzheimer’s disease is a cruel disorder because it robs people of their memory so that they know<br />
that it is being stolen. Both the individual with the disorder and the family member who is<br />
caregiver experience an extended grieving process for the person who used to be. Even if the<br />
individual fights hard to retain memories and tantalizingly, on good days, recovers functioning,<br />
there is the inevitability of loss long before death itself occurs. The emotions this situation<br />
engenders are difficult to express. For some, writing about the experience is therapeutic.<br />
Below is a poem written by a professional writer, Cris Cassidy, who is watching her highly<br />
educated mother lose her battle with Alzheimer’s. It is taken from an Internet site (see “On the<br />
Internet” at the end of this chapter) where people can submit poetry concerned with neurological<br />
disorders. Read this poem and ask students to respond. Expect a discussion of the quantity versus<br />
the quality of life and a return to issues of suicide or family-assisted suicide. Ask if grief can be<br />
experienced while a person is still alive.<br />
Death Before Dying<br />
It isn’t fair<br />
that a woman who spoke four languages<br />
and knew every word in Webster’s dictionary<br />
should be brought to this . . .<br />
this death before dying.<br />
She still remembers words<br />
but strings them all together wrong.<br />
On night wanderings she babbles in four languages.<br />
“I can remember everything!” she cries,<br />
and then she cries<br />
because somewhere she knows<br />
that everything does not remember her.<br />
Source: The Neurology Web Forum run by Massachusetts General Hospital, Department of<br />
Neurology Ms. Cassidy can be contacted by email at raycris@erols.com The poem by Cris<br />
Cassidy is reprinted by permission of the author.<br />
Internet Site: http://www.sfcrc.com/html/alzheimers.htm . The San Francisco Alzheimer's and<br />
Dementia Clinic.
244 Chapter 14: Cognitive Disorders<br />
HANDOUT FOR CLASSROOM TOPIC 1:<br />
REVIEW OF THE COGNITIVE DISORDERS<br />
DEMENTIAS<br />
Deterioration of brain tissue resulting in impaired intellectual ability including memory function and<br />
decreased judgment; impairs social and occupational functioning<br />
Types Key Symptoms<br />
Caused by cerebrovascular accident<br />
Stroke (blood vessels rupture or Paralysis, aphasias, memory impairments, depression,<br />
narrowing of blood vessels)<br />
Multi-infarct dementia (series of<br />
small strokes)<br />
and anxiety<br />
Uneven deterioration in intellectual functions, especially<br />
memory<br />
Caused by Alzheimer’s disease Worsening short-term memory loss, delusions, poor<br />
judgment, eventual death<br />
Caused by infection<br />
Neurosyphilis (general paresis) Ten to fifteen years after syphilis infection, memory<br />
loss, delusions of grandeur, apathy<br />
Caused by deteriorating conditions<br />
Parkinson’s disease Muscle tremors, shuffling walk, expressionless face,<br />
response to L-dopa<br />
Huntington’s chorea Onset when 25 to 50 years old; twitches become jerky<br />
movements, dementia, irritability<br />
Caused by brain trauma<br />
Concussion Dazed, temporary loss of consciousness, confusion<br />
Contusion Similar to concussion but more severe<br />
Laceration Coma, followed by minor to major impairments or<br />
death<br />
DELIRIUM<br />
Types Key Symptoms<br />
Caused by infection<br />
Encephalitis (sleeping sickness) Rapidly developing headache, prolonged sleep, fever,<br />
delirium, irritability<br />
Meningitis Great variance, but stiff neck, headache, seizures<br />
common<br />
Types Key Symptoms<br />
Caused by substance use<br />
Amphetamine psychosis Paranoia, restlessness, thought disturbance<br />
Intoxication from alcohol, narcotics, Stuporous, confused, uncontrolled emotions<br />
hallucinogens, and so on<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
AMNESTIC DISORDERS<br />
Chapter 14: Cognitive Disorders 245<br />
Types Key Symptoms<br />
Wernicke’s encephalopathy Inability to remember recent information; thiamine<br />
deficiency<br />
THE EPILEPSIES<br />
Types Key Symptoms<br />
Petit mal Momentary dimming or loss of consciousness<br />
Grand mal Aura followed by intense muscular contractions and<br />
spasms, then coma<br />
Jacksonian Seizures spread from one area of body to another<br />
Psychomotor During spell, behavior appears normal, but no recollection<br />
when spell is over
246 Chapter 14: Cognitive Disorders<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. Neuropsychological tests have had a great impact on the field of cognitive assessment. The<br />
Halstead-Reitan and Luria-Nebraska tests, in particular, are frequently used. The following<br />
demonstrations can give students a window into the kinds of tasks that are used in such<br />
assessments without invalidating the tests.<br />
A subtest of the Halstead-Reitan that screens for aphasia can be simulated in the following way.<br />
Cut out of cardboard several shapes, such as a triangle, square, and circle. Without allowing<br />
students to observe, place one shape in a brown bag. Ask a student volunteer to come forward<br />
and, without looking, place a hand into the bag. After allowing the volunteer to feel the shape, ask<br />
him or her to name it. Then ask the volunteer to draw the shape on the board. Finally, place all<br />
three shapes in the bag and ask the volunteer to take the correct shape out of the bag when the<br />
word for it is written on the board or said aloud. This test examines the comprehension of written<br />
and spoken words as well as the association between touch and language.<br />
A second subtest, trail making, asks the test taker to link labeled circles in a certain sequence.<br />
Draw two sets of ten circles on separate areas of the board. Inside one set, write the Roman<br />
numerals I, II, III, and so on. In the first test, the volunteer must, as quickly as possible, draw lines<br />
linking the circles in the order labeled. In the second set, label some circles with the sequence 1, 2,<br />
3, and so on, and the rest with A, B, C, and so on. Now instruct the volunteer to link the 1 to A,<br />
the A to 2, the 2 to B, and so on as quickly as possible. This tests both dexterity and the ability to<br />
shift categories.<br />
Finally, ask students to tap their desk surfaces with their dominant-hand index fingers as rapidly<br />
as possible and count the number of taps over ten seconds. Repeat the task. Then ask them to tap<br />
with the index fingers of their nondominant hands for ten seconds. Repeat. Explain that the test<br />
indicates not only the speed of responding, but also whether there is a difference between<br />
dominant and nondominant brain hemispheres. A normal number of finger taps for the dominant<br />
hand is roughly 50. This subtest, more than others, can show how elderly, high-functioning<br />
individuals might perform poorly on neuropsychological tests.<br />
Internet Site: http://www.cps.nova.edu/~cpphelp/HRNTB. This site describes the Halstead-Reitan<br />
Neuropsychological Battery<br />
2. Recent research suggests that it may be possible to identify early in life those individuals who will<br />
develop Huntington’s disease in midlife. Given the fact that the disorder cannot be treated or<br />
cured, and that developing it represents a ten-year deterioration into psychosis and death, would<br />
people want to know their fate ahead of time? What are the implications for genetic counseling if<br />
more commonly occurring degenerative and incurable cognitive disorders such as Alzheimer’s<br />
disease could be predicted?<br />
To get students thinking about these issues, split the class into groups of four to five students each.<br />
Ask the students to discuss in the groups whether they themselves would want to know whether<br />
they would develop such a disorder. Ask them to discuss the advantages and disadvantages to the<br />
wider society of the ability to predict the development of incurable disorders. Finally, discuss the<br />
psychological counseling that might be necessary for both those who “learn of their fate” and their<br />
close family members. Have them report their deliberations to the whole class.<br />
Internet Site: http://www.lib.uchicago.edu/~rd13/hd/index.html. This site has information on<br />
Huntington’s chorea.<br />
3. The odds are good that at least 10 percent of your students have a relative who suffers from<br />
dementia. Ask for a show of hands of those who are willing to describe the impact that this<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 14: Cognitive Disorders 247<br />
relative’s dementia has had on them, their parents, or other caregivers. Students who have had<br />
contact with dementia can give others an appreciation of the specific forms the symptoms take,<br />
the degree to which symptoms come and go, and the physical and emotional toll on caregivers.<br />
Internet Site: http://www.merck.com/pubs/mmanual. This site defines and discusses dementia,<br />
delirium, and depression in elderly populations.<br />
4. Traditional-age college students (18 to 22) often have difficulty empathizing with the situations<br />
older people face. Although it is important to underscore the fact that most older people remain in<br />
good health and do not face cognitive deterioration or depression, the reality is that life is often<br />
more trying for older individuals. With increasing age comes decreasing sensory and motor<br />
functions. If one has impaired eyesight, hearing, and flexibility of movement, many activities<br />
become more difficult to perform. Interpersonal life is strained and self-esteem can deteriorate.<br />
These problems may make depression, anxiety, and even disorientation more likely.<br />
The following demonstration can increase students’ awareness of the impact of sensory and motor<br />
impairments on behavior, emotion, and thought. You will need the following equipment: several<br />
pairs of the inexpensive reading glasses available at pharmacies, a jar of Vaseline petroleum jelly,<br />
a box of absorbent cotton, a roll of transparent tape, at least four unsharpened pencils, and four<br />
rolls of elastic (Ace) bandages. You will also want to have some water, dishwashing liquid, and<br />
tissues available.<br />
Ask for at least two volunteers from the class to participate in an exercise to mimic some of the<br />
impairments experienced in older age. If the students wear glasses, ask if they are willing to have<br />
the lenses smeared with Vaseline, promising that they will be cleaned later. If they say no or do<br />
not wear glasses, supply them with reading glasses that you have already smeared with the jelly.<br />
This visual impairment will mimic that of cataracts, a common eye disorder of older people. Have<br />
the volunteers stuff their ears with absorbent cotton until quiet speech is muffled. Now put strips<br />
of tape on the second knuckle of each finger on their dominant hand and the thumb joint. This<br />
should give them some appreciation for joint stiffness experienced by those with arthritis,<br />
although we cannot convey the pain that is involved. To reduce mobility, you can put one pencil<br />
on each side of the knee joint when the leg is straight and wrap tightly with the Ace bandage.<br />
Repeat with the other leg.<br />
Have the volunteers talk with each other in quiet voices while the rest of the class engages in<br />
normal conversation. In about a minute the volunteers will appreciate how little of their<br />
conversation they can understand and how much they ordinarily use visual cues to assist in their<br />
interactions. Because of the smeared lenses, they have few visual cues and may experience some<br />
of the frustration that older people feel when, in loud restaurants or other social settings, they<br />
cannot maintain interactions with others. After this portion of the demonstration, give the<br />
volunteers some lined paper and pens. Ask them to copy information from the course textbook in<br />
their best handwriting. They will struggle to see the words on the page, will not be able to<br />
manipulate the pen well, and will gain some empathy for those who suffer from arthritis. Finally,<br />
have them walk around the room, out into the hallway, and, preferably up and down a flight of<br />
stairs. For this last one, make sure an able-bodied person is close by to protect the volunteers from<br />
falling. You may want to create an obstacle course of sorts in the classroom, too. As the<br />
volunteers stumble or just feel unsure of themselves, they will begin to appreciate how<br />
disorienting, depressing, and isolating some of the physical disorders of the aged can be.<br />
Encourage the volunteers to voice their awareness, emotions, and thoughts to the rest of the class.<br />
Help them understand that cognitive disorders that occur on this background of sensory and motor<br />
impairment are more difficult to treat. You could also indicate on the board how a vicious cycle<br />
can evolve: Physical impairments increase the likelihood of depression and isolation, which<br />
increase the likelihood of cognitive disorders. Ask if any of their relatives have gone through this
248 Chapter 14: Cognitive Disorders<br />
progression. Finally, encourage the rest of the class to try some of these activities on their own<br />
and report their experiences to the class.<br />
Remember to leave time at the end to clean up the glasses of volunteers. That’s what the water,<br />
dishwashing liquid, and tissues are for.<br />
5. The fact that many cognitive disorders have similar symptoms and that these overlap with<br />
symptoms of noncognitive disorders presents problems for the diagnostician. Show students the<br />
thought processes that diagnosticians use to rule in or rule out various cognitive and affective<br />
disorders. Present this very sketchy portrait of a person who may have a cognitive disorder:<br />
Mrs. W. is 68 years old and lives alone. She moves very slowly and does not respond<br />
verbally to what others say. She sometimes mumbles to herself. Her face is expressionless.<br />
She seems confused by her surroundings. She is accompanied by her daughter, who is highly<br />
observant and an accurate reporter of Mrs. W.’s past medical and psychosocial history.<br />
First, provide students with the handout so they can think through the potential cognitive and<br />
affective disorders that might be appropriate for Mrs. W. Assure them that no one, not even you,<br />
knows what disorder Mrs. W. really has. The object is to brainstorm for legitimate, likely<br />
cognitive and noncognitive disorders. These include Parkinson’s disease, Alzheimer’s disease,<br />
multi-infarct dementia, stroke, depression, and possibly negative symptom schizophrenia. Ask<br />
students to report the disorders they wrote down and put a list on the board.<br />
Next, ask students what information they need to make a firm, differentiating diagnosis. Their first<br />
decision should be whether the disorder is cognitive or noncognitive. Have them write down the<br />
information they would want. If they need assistance, suggest that interviews, psychological<br />
testing, and neurological assessments might help. Observations and a medical and social history<br />
supplied by Mrs. W.’s daughter should be considered highly accurate information. When they<br />
have worked on the cognitive-noncognitive issue, ask them to refine their diagnoses to<br />
differentiate among the cognitive disorders. You can help by reminding them that some cognitive<br />
disorders involve dementia and that others involve delirium. Some are chronic, whereas others are<br />
acute. Have them think about the potential causes of the cognitive impairment, too. When they<br />
have finished this portion of the activity, ask for the information they listed for each of the<br />
disorders you have listed on the board. Correct any mistaken impressions and add your own<br />
thoughts on how to perform a differential diagnosis. Remember to mention that this task is<br />
extremely complex and difficult and that misdiagnosis is all too common.<br />
As an example, ask how they would differentiate Alzheimer’s disease from vascular dementia..<br />
Alert them to the fact that many professionals are stumped by this question. Finally, discuss the<br />
value of making a specific diagnosis. In some cases (such as Alzheimer’s disease versus<br />
multi-infarct dementia), there is little difference in treatment of the condition. In others (such as<br />
Alzheimer’s versus depression), differential diagnosis makes a huge difference in appropriate<br />
treatment.<br />
Internet Site: http://www.merck.com/pubs/mmanual. This site defines and discusses dementia,<br />
delirium, and depression in elderly populations.<br />
6. Screening for dementia can involve asking patients and their relatives for information on their<br />
recent cognitive, emotional, and behavioral functioning. A more standardized procedure is to ask<br />
questions from a mental status examination. A brief mental status exam developed by Glasko et<br />
al. (1990) is provided in the Handout for Demonstration 6. It will give students an idea of how to<br />
define orientation and the kind of short-term memory that is impaired by dementia. Caution<br />
students not to see this as a definitive diagnostic instrument. Further, since no cutoff scores or<br />
norms are provided, there is no way to evaluate responses. However, this screening device is<br />
available on the Internet at http://teri.bio.uci.edu/forms/short.html. Responses are scored and<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 14: Cognitive Disorders 249<br />
given in the form of probability that the patient is “normal.” These results are not explained:<br />
“normal” goes undefined, there are no age-graded norms used, and the normative sample is not<br />
described. You can use this opportunity to discuss (again) the need for critical thinking when<br />
people are consumers of mental health materials.<br />
Source: Glasko, D., Klauber, M. R., Hofstetter, C. R., Salmon, D. P., Lasker, B., & Thal, L. J.<br />
(1990). The mini-mental state examination in the early diagnosis of Alzheimer’s disease. Archives<br />
of Neurology, 47, 49–52. Copyright © 1990, American Medical Association. Reprinted by<br />
permission.<br />
Internet Site: http://www.merck./com/pubs/mm_geriatrics/figures/38fl.htm. A screen for<br />
dementia.<br />
7. The Alzheimer’s Association developed a list of warning signs for the disease. Because normal<br />
forgetfulness and early dementia are not easily distinguished, mistaken worry about Alzheimer’s<br />
is commonplace. Also common is ignoring the early signs of the disease. A handout is provided<br />
with the association’s warning signs for Alzheimer’s disease. Caution students that this<br />
information does not qualify them to engage in amateur diagnostics. Nevertheless, it can help<br />
them determine whether an impairment is of potential concern or not.<br />
Source: The Alzheimer’s Association, Inc., Chicago, Illinois. Reprinted by permission.<br />
Internet Site: http://www5.biostat.wustl.edu/alzheimer/. The site is an educational service created<br />
and sponsored by the Washington University Alzheimer's Disease Research Center.<br />
8. Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. The task of the group is to develop suggested policies or laws related to doctorassisted<br />
suicide. There should be at least one policy in favor of doctor-assisted suicide and one<br />
policy against doctor-assisted suicide. The students need to discuss whether there is a difference<br />
between doctor-assisted suicide and turning off life support systems. Should spouses who help<br />
their loved one commit suicide be prosecuted? In the process of developing the policies or laws,<br />
the students have to debate many issues related to doctor-assisted suicide.<br />
9. Invite an official from your local Council on Aging organization or Alzheimer's support group to<br />
talk to the class about the many problems that face the elderly in the areas of health and mental<br />
health. The speaker should also discuss the kinds of services available in your area for individuals<br />
with Alzheimer's and their families, as well as other services for the elderly.<br />
Internet Site: http://www.sfcrc.com/html/alzheimers.htm. The San Francisco Alzheimer's and<br />
Dementia Clinic.<br />
10. The treatment of mental retardation usually involves some combination of psychoactive<br />
medication (phenothiazines and antidepressants, for the most part) and behavior therapy. <strong>Behavior</strong><br />
therapy techniques have become widely used (and misused) in public institutions, group homes,<br />
sheltered workshops, and home environments. When used consistently and ethically, contingent<br />
positive reinforcement and modeling can help people with mental retardation control their<br />
emotions, learn self-care and daily living skills, and acquire job-related skills. Time out from<br />
reinforcement is the most common method of reducing inappropriate behavior, but it can be used<br />
inappropriately. Explain that behavioral principles are neutral—in the hands of staff members who<br />
want to work less or who have disdain for people with retardation, they can be abused. Capricious<br />
use of point systems, excessive time outs, and even the use of physical punishment are considered<br />
behavior therapy by those who do not truly value their patients. Unfortunately, behavior therapy,<br />
undoubtedly the most effective means of helping people with retardation when correctly<br />
employed, has acquired a bad reputation in some circles because it is so easily misused.
250 Chapter 14: Cognitive Disorders<br />
Internet Sites: http://www.cet.fsu.edu/tree/NICHCY/MR/MR.html. This site includes links to<br />
organizations and resources on mental retardation.<br />
http://TheArc.org/. The Association for Retarded Citizens home page has a search engine that<br />
allows the user to ask for information on any topic related to retardation.<br />
11. Mental retardation can serve as an excellent illustration of the social and political implications of<br />
incorrect diagnosis. Nowhere can we see the tragic effects of self-fulfilling prophecies more<br />
clearly than when a child is misdiagnosed as “retarded.” An appropriate topic for discussion is the<br />
reliability and validity of assessment methods used to make these diagnoses. Remind students of<br />
the concepts of test-retest and interrater reliability and of both concurrent and predictive validity.<br />
Point out that although the psychometrics indicate that IQ tests have strong test-retest reliability<br />
for scores in the middle range of the distribution, reliability drops dramatically for extreme scores.<br />
Therefore, as retardation becomes more severe, the value of such numbers decreases. Ask students<br />
whether school performance (that which IQ scores predict) should be the sole (or even most<br />
important) criterion for intellectual ability. Finally, the accuracy and interrater reliability of social<br />
adaptation measures are rather weak. You can ask students what factors make the parents of a<br />
child suspected of having mental retardation somewhat unreliable reporters of their child’s<br />
adaptive behavior. A final point to make: Diagnoses as important as mental retardation require<br />
multiple assessment methods reported by multiple sources over multiple points in time.<br />
Internet Sites: http://www.cet.fsu.edu/tree/NICHCY/MR/MR.html. This site includes links to<br />
organizations and resources on mental retardation.<br />
http://TheArc.org/. The Association for Retarded Citizens home page has a search engine that<br />
allows the user to ask for information on any topic related to retardation.<br />
12. The DSM-IV-TR has included in its definition of mental retardation the idea that other diagnoses<br />
are not excluded from consideration. This point confronts the common perception of those with<br />
mental retardation: that their intellectual impairment so overshadows other problems that the<br />
existence of other, independent disorders can be ignored or discounted. People with mental<br />
retardation can be expected to be depressed, for example. This may be a secondary depression<br />
stemming from their treatment by others. However, the depression could be a separate disorder.<br />
Whether primary or secondary, such problems as depression, alcohol or drug abuse, and anxiety<br />
disorders are quite prevalent in people with mental retardation, and they need to be acknowledged.<br />
This situation is what we mean by the term dual diagnosis. These problems, often overlooked,<br />
deserve treatment just as much as the symptoms of retardation. However, many treatment<br />
administrators and therapists feel constrained to place people either in institutions or programs<br />
that are focused on intellectual impairments or in institutions or programs that are focused on<br />
emotional problems. Instead, dual diagnosis should result in dual treatment.<br />
Internet Sites: http://www.cet.fsu.edu/tree/NICHCY/MR/MR.html. This site includes links to<br />
organizations and resources on mental retardation.<br />
http://TheArc.org/. The Association for Retarded Citizens home page has a search engine that<br />
allows the user to ask for information on any topic related to retardation.<br />
13. Invite an employee of the local developmental disabilities and rehabilitation services to class to<br />
discuss services available in the community for developmentally delayed adults.<br />
14. <strong>Learning</strong> disabilities present significant difficulties for students. Some, by incredible hard work,<br />
do well enough to be considered by selective colleges; even so, they must deal with timed tests,<br />
such as the SAT and ACT. Students with dyslexia have an extremely difficult time completing<br />
these tests in the required amount of time. The College Board and the American College Testing<br />
Program do allow students to take un-timed, special administrations of these tests, which<br />
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Chapter 14: Cognitive Disorders 251<br />
supposedly reflect more accurately the student's real academic achievement. It is possible for<br />
some students to be able to take the un-timed version of the tests by producing documentation of a<br />
diagnosis of a learning disability.<br />
Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask each group to develop this list with the most salient examples first. Each group<br />
could then have a spokesperson deliver a short talk about the best examples. You could provide a<br />
blank overhead transparency to each group at the beginning of this demonstration.<br />
How do your students in each group feel about learning-disabled students taking un-timed tests? If<br />
the student cannot compete for admission on the same basis as everyone else, how can he or she<br />
compete in the classroom without enormous amounts of assistance? Do your students know of<br />
anyone who took the un-timed versions? Is it fair to have resources made available to them that<br />
are not available to other students? What kind of services are available on campus for students<br />
with disabilities? Ask the students to discuss these issues keeping in mind that they may have a<br />
learning-disabled classmate in the group with them.
252 Chapter 14: Cognitive Disorders<br />
HANDOUT FOR DEMONSTRATION 5:<br />
THINKING CLINICALLY: DIFFERENTIATING COGNITIVE<br />
AND NONCOGNITIVE DISORDERS<br />
You have heard a brief description of an older woman and her symptoms. Using only this information,<br />
indicate the potential cognitive and noncognitive disorders she might have and the reasons you think<br />
they might be accurate diagnoses. Then list the assessment information (interview questions for the<br />
woman or her daughter, psychological and neurological test results, observations, etc.) that would help<br />
differentiate one disorder from another.<br />
Potential Cognitive Disorders Reasons for Initial Diagnosis<br />
1.<br />
2.<br />
3.<br />
Potential Noncognitive Disorders<br />
1.<br />
2.<br />
Additional Information Needed to Ensure<br />
This Is the Correct Diagnosis<br />
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Chapter 14: Cognitive Disorders 253<br />
HANDOUT FOR DEMONSTRATION 6:<br />
SCREENING TEST FOR DEMENTIA<br />
This is a short-form mental-state examination developed to screen for Alzheimer’s disease. Your<br />
instructor has purposefully not provided cutoff scores, so this test cannot be used to evaluate anyone.<br />
The point of this demonstration is to show you the questions used to identify dementia in its early<br />
stages.<br />
Instructions:<br />
1. Say: “I am going to ask you to repeat three words, and in a minute or two, I will ask you to recall<br />
those words on your own.”<br />
2. Say: “Repeat these three words: Apple, Table, Penny.”<br />
• If needed, correct the patient until he/she has correctly said all the words without assistance.<br />
• Then say, “Repeat those three words again.”<br />
3.<br />
Score: # of tries to obtain two correct repetitions of the three words ______________<br />
Say, “Recite the months of the year in reverse order, from December down to January.”<br />
December November October September August July June May April March February January<br />
Score: # failed __________ # self-corrected___________ # completely correct __________<br />
4. Say: “What state is this?” correct incorrect<br />
5. Say: “What county is this?” correct incorrect<br />
6. Say: “What city is this?” correct incorrect<br />
7. Say: “What is the name of this place?” correct Incorrect<br />
8. Say: “What floor are we on?” response ___________ actual floor ___________<br />
9. Say: “What were the three words I asked you to remember?”<br />
Apple Table Penny<br />
Source: Glasko, D., Klauber, M. R., Hofstetter, C. R., Salmon, D. P., Lasker, B., & Thal, L. J. (1990).<br />
The mini-mental state examination in the early diagnosis of Alzheimer’s disease. Archives of<br />
Neurology, 47, 49–52. Copyright © 1990, American Medical Association. Reprinted by permission.
254 Chapter 14: Cognitive Disorders<br />
HANDOUT FOR DEMONSTRATION 7:<br />
WARNING SIGNS YOU SHOULD KNOW FOR ALZHEIMER’S DISEASE<br />
To help you know what warning signs to look for, the Alzheimer’s Association has developed a<br />
checklist of common symptoms of Alzheimer’s disease. (Some of them also may apply to other<br />
dementing illnesses.) Review the list and check the symptoms that concern you. If you notice several<br />
symptoms, the individual with the symptoms should see a physician for a complete examination.<br />
1. Memory loss that affects job skills: It is normal to occasionally forget assignments, colleagues’<br />
names, or a business associate’s telephone number and to remember them later. Those with<br />
dementia, such as Alzheimer’s disease, may forget things more often and not remember them at<br />
all.<br />
2. Difficulty performing familiar tasks: Busy people can be so distracted from time to time that<br />
they may leave the carrots on the stove and only remember to serve them at the end of the meal.<br />
People with Alzheimer’s disease could prepare a meal and not only forget to serve it, but also<br />
forget they made it.<br />
3. Problems with language: Everyone has trouble finding the right word sometimes, but a person<br />
with Alzheimer’s disease may forget simple words or substitute inappropriate words, making his<br />
or her sentence incomprehensible.<br />
4. Disorientation of time and place: It is normal to forget the day of the week or your destination<br />
for a moment. But people with Alzheimer’s disease can become lost on their own street, not<br />
knowing where they are, how they got there, or how to get back home.<br />
5. Poor or decreased judgment: People can become so immersed in an activity that they<br />
temporarily forget the child they are watching. People with Alzheimer’s disease could forget<br />
entirely the child under their care. They may also dress inappropriately, wearing several shirts or<br />
blouses.<br />
6. Problems with abstract thinking: Balancing a checkbook may be disconcerting when the task is<br />
more complicated than usual. Someone with Alzheimer’s disease could forget completely what<br />
the numbers are and what needs to be done with them.<br />
7. Misplacing things: Anyone can temporarily misplace a wallet or keys. A person with<br />
Alzheimer’s disease may put things in inappropriate places: an iron in the freezer or a wristwatch<br />
in the sugar bowl.<br />
8. Changes in mood or behavior: Everyone becomes sad or moody from time to time. Someone<br />
with Alzheimer’s disease can exhibit rapid mood swings—from calm to fear to anger—for no<br />
apparent reason.<br />
9. Changes in personality: People’s personalities ordinarily change somewhat with age. But a<br />
person with Alzheimer’s disease can change drastically, becoming extremely confused,<br />
suspicious, or fearful.<br />
10. Loss of initiative: It is normal to tire of housework, business activities, or social obligations, but<br />
most people regain their initiative. The person with Alzheimer’s disease may become very passive<br />
and require cues and prompting to become involved.<br />
Source: The Alzheimer’s Association, Inc. Taken from its Internet site at http://www.alz.org./.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 14: Cognitive Disorders 255<br />
SELECTED READINGS<br />
Gatz, M., & Smyer, M. A. (1992). The mental health system and older adults in the 1990s. American<br />
Psychologist, 47, 741–751.<br />
Hantz, P., Caradoc-Davies, G., Caradoc-Davies, T., Weatherall, M., & Dixon, G. (1994). Depression in<br />
Parkinson’s disease. American Journal of Psychiatry, 151, 1010–1014.<br />
Mace, N. L., & Rabins, P. (1981). The 36-hour day: A family guide to caring for persons with<br />
Alzheimer’s disease, related dementing illnesses, and memory loss in later life. Baltimore: Johns<br />
Hopkins University Press.<br />
Sacks, O. (1985). The man who mistook his wife for a hat and other clinical tales. New York: Summit.<br />
This is a must read.<br />
Weiner, M. F. (Ed.) (1995). The dementias: Diagnosis, management, and research (2nd ed.).<br />
Washington, DC: American Psychiatric Press.<br />
Sattler, D., Shabatay, V., & Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 11, Cognitive Disorders.<br />
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 16, Dementia of the Alzheimer's Type: Descent into Darkness.<br />
Zigler, E., & Hodapp, R. M. (1991). <strong>Behavior</strong>al functioning in individuals with mental retardation.<br />
Annual Review of Psychology, 42, 29–50.<br />
Dorris, M., & Erdrich, L. (1990). The Broken Cord. Harper Collins Publishers. This poignant book, coauthored<br />
by Michael Dorris, his wife Louise Erdrich, with input from his adopted son, talks about the<br />
trials and tribulations of adopting and raising an FAS child. Michael Dorris, an anthropologist, became<br />
a single father when he adopted a Native American boy, not knowing the child's mother was an<br />
alcoholic and the child would encounter lifelong difficulties that ultimately led to his early death. The<br />
story is made sadder by knowing that Dorris himself later committed suicide.<br />
VIDEO RESOURCES<br />
“Aging” from The Mind series (video, color, 60 min). This tape debunks the idea that impairing<br />
diseases are the normal outcome of aging. Alzheimer’s disease is given prominent discussion, as is the<br />
need for research on prevention and cure for this disease. PBS; to order, call 1-800-424-7963.<br />
Alzheimer’s Disease: The Long Nightmare (video, color, 19 min). The tape shows the limitations of<br />
current Alzheimer’s research and points out recent advances in understanding protein production in the<br />
brain. Also discussed are the medical, financial, and emotional aspects of caring for those with<br />
Alzheimer’s. Films for the Humanities and Sciences, New York, NY.<br />
Brain and <strong>Behavior</strong> (16 mm, 22 min). Parts of the brain and their relationship to physical and<br />
psychological functioning. The film also shows patients with brain injuries. McGraw-Hill Films, 1221<br />
Avenue of the Americas, New York, NY 10020.<br />
Divided Brain and Consciousness (16 mm, 22 min). Illustrates the different effects of damage to the left<br />
and right hemispheres of the brain; split-brain research. Harcourt Brace Jovanovich, 7555 Cardwell<br />
Avenue, Chicago, IL 60648.<br />
“Organic Mental Disorders” from The World of <strong>Abnormal</strong> Psychology series (video, color, 60 min).<br />
This comprehensive tape shows the biological, psychological, and social aspects of cognitive disorders<br />
as well as their treatment and current topics in research.
256 Chapter 14: Cognitive Disorders<br />
Somebody Waiting (16 mm, color, 24 min). This film shows hospitalized children with severe cerebral<br />
dysfunctions who, as a result, are physically, emotionally, and mentally handicapped. The film includes<br />
a discussion and description of hospital staff experiences and personal growth amidst these tragic cases<br />
and a discussion of the need for environmental stimulation. University of California Extension Media<br />
Center, 2223 Fulton Street, Berkeley, CA 94720.<br />
“The Two Brains” from The Brain series (video, color, 60 min). This tape focuses on split-brain<br />
research and the relationships between the hemispheres. Topics relevant to cognitive disorders include<br />
language and its relation to thought, and gender differences in brain function. PBS; to order, call 1-800-<br />
424-7963.<br />
When the Brain Goes Wrong (video, color, 45 min). This video covers people with epilepsy, stroke, and<br />
closed-head injury as well as those with alcohol dependence, schizophrenia, and bipolar disorder. All<br />
are seen as having brain dysfunctions, so the differentiation of cognitive disorders may be blurred.<br />
However, the exploration of available treatments is good. Insight Media, 2162 Broadway, New York,<br />
NY 10024.<br />
Maturing and Aging (VHS, color, 30 min.). Part of the Essential Themes in Psychology: Discovering<br />
Psychology series. Annenberg/CPB1-800-LEARNER.<br />
Organic Mental Disorders (VHS, color, 60 min.). Part of The World of <strong>Abnormal</strong> Psychology series.<br />
Locks at organic and neurological disorders that affect the brain and its functioning. Annenberg/CPB.<br />
1-800-LEARNER.<br />
<strong>Behavior</strong> Modification: Teaching Language to Psychotic Children (16 mm, color, 15 min). This short<br />
film shows how mentally retarded individuals can be taught self-care and independent living skills<br />
through the application of operant conditioning techniques. Sensory Systems, 4314 Abbott Avenue,<br />
Minneapolis, MN 55459<br />
David: A Portrait of a Retarded Youth (16 mm, 28 min). The case history of a Down syndrome<br />
adolescent is the focus of this film, which gives a balanced view of the challenges and successes in<br />
dealing with the disorder. Filmmakers Library, 124 E. 40th Street, Suite 901, New York, NY 10016<br />
PKU: Preventable Mental Retardation (16 mm, color, 16 min). Preventable Mental Retardation (16<br />
mm, 16 min) This film shows how mental retardation resulting from phenylketonuria can be prevented<br />
through early detection and diagnosis in infancy and through restricted diet. International Film Bureau,<br />
332 South Michigan Avenue, Chicago, IL 60604<br />
Through Different Eyes (16 mm, color, 15 min). This short film shows how training programs must<br />
match the method of training to the specific handicap of individual children with mental retardation.<br />
Media Sales, Pennsylvania State University, 118 Wagner Building, University Park, PA 16802.<br />
When the Mind Fails: A Guide to Alzheimer's Disease. (VHS, 59 min). A guide for caregivers and<br />
Alzheimer's patients that discusses the first signs, diagnosis, middle stages, getting organized, coping,<br />
dealing with the day-to-day struggles, last stages, and hope for the future, which talks about the latest<br />
genetic research. Films for the Humanities & Sciences, P.O. Box 2053, Princeton, NJ 08543-2053. 1-<br />
800-257-5126.<br />
Fetal Alcohol Syndrome: Life Sentence (VHS, 24 min). Consumption of alcohol during pregnancy can<br />
cause permanent brain damage for the child that results in learning disabilities, poor judgment,<br />
antisocial behavior, and alcohol addiction. Focus on early intervention is critical. Films for the<br />
Humanities & Sciences, P.O. Box 2053, Princeton, NJ 08543-2053. 1-800-257-5126.<br />
ON THE INTERNET<br />
http://www.alz.org./ is the official home page of the Alzheimer's association.<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 14: Cognitive Disorders 257<br />
http://neurosurgery.mgh.harvard.edu provides an extensive list of national associations involved with<br />
stroke, paralysis, spinal cord injury, and other neurological conditions from The National Stroke<br />
Association.<br />
http://www.stroke.org/ has a five-item quiz on the facts and risk factors involved in stroke.<br />
http://teri.alz.uci.edu is the Institute for Brain Aging and Dementia, a collaborative effort of the<br />
University of Southern California and the University of California, Irvine.<br />
http://www.mentalhealth.com/fr20.html includes descriptions, treatments, research references, books,<br />
magazine articles, and other links to the topic of dementia of the Alzheimer type.<br />
http://www.sfcrc.com/html/alzheimers.htm is The San Francisco Alzheimer's and Dementia Clinic one<br />
of the institutions in the United States devoted to the investigation, diagnosis, treatment, and<br />
management of Alzheimer's.
CHAPTER 15<br />
Disorders of Childhood and Adolescence<br />
CHAPTER OUTLINE<br />
I. Range of childhood and adolescent disorders<br />
A. Almost 21 percent of children in the U.S. between ages nine and seventeen have a<br />
diagnosable mental or addictive disorder with at least minimal impairment; 11 percent have<br />
significant impairment; 5 percent has extreme impairment<br />
B. The disorders range from severe disturbance to those that are less severe<br />
II. Pervasive developmental disorders: Severe disorders with qualitative impairments in verbal and<br />
nonverbal communications and social interaction; do not include hallucinations or delusions<br />
A. Autistic disorder: Kanner identified three behaviors of "infantile autism": extreme<br />
isolation/inability to relate to people; psychological need for sameness; significant<br />
difficulties with communication<br />
1. DSM-IV-TR: qualitative impairment in social interaction and/or communication;<br />
restricted, stereotyped interest and activities; delays or abnormal functioning in major<br />
area before age 3<br />
2. Prevalence: about two to twenty cases in 10,000 children; four to five times more<br />
common in boys than girls<br />
3. Impairments<br />
a) Social interactions (lack of interest in others is primary aspect of disorder);<br />
appear unaware of other people’s identity; treat people as objects<br />
b) Verbal and nonverbal communication; half develop no speech; echolalia common<br />
in those who speak<br />
c) Activities and interests few; unusual repetitive habits (spinning things); minor<br />
changes produce rage<br />
d) Intellectual functioning; up to 75 percent have IQs below 70 (mental retardation);<br />
splinter skills (drawing, rote memory of calendars, song lyrics, math calculation);<br />
“autistic savants” as portrayed in the movie Rain Man<br />
4. Diagnosis<br />
a) Many different medical conditions can produce symptoms of autism<br />
b) Autistic profile found in those with and without neurological problems<br />
c) Shares communication and social problems with other disorders<br />
d) Wide range of symptoms<br />
e) Coexistence of mental retardation<br />
5. Research on autism<br />
a) Autistic children more interested in inanimate objects than in people<br />
b) Can match sound and drawing of nonhuman stimuli but not human<br />
c) Lack a “theory of mind”: cannot recognize others’ beliefs as mistaken, cannot<br />
appreciate others’ mental states<br />
B. Other pervasive developmental disorders<br />
1. Prevalence: about 22 in 10,000<br />
2. Controversy about overlap with autistic disorder and neurological conditions<br />
3. Asperger's disorder: severe social and emotional impairments but no language deficits<br />
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Chapter 15: Disorders of Childhood and Adolescence 259<br />
4. Childhood disintegrative disorder: normal development for at least two years followed<br />
by deterioration of social and language skills<br />
5. Rett's disorder: normal development between five and forty-eight months followed by<br />
deterioration of social and language skills; diagnosed only in females<br />
6. Pervasive developmental disorder not otherwise specified<br />
C. Etiology<br />
1. Rett’s, Asperger’s, and childhood disintegrative too new to have been researched<br />
2. Four etiological groups for autistic: familial, medical, nonspecific brain dysfunction,<br />
without family history or brain dysfunction<br />
3. Psychodynamic theories<br />
a) Kanner blamed cold, unresponsive parenting; described parents as cold,<br />
humorless perfectionists; later came to see autism as innate<br />
b) Psychological factors no longer implicated in autism<br />
4. Family and genetic studies<br />
a) Increased risk in siblings<br />
b) 36 percent concordance in MZ twins, 0 percent in DZ; some of discordant twins<br />
have language impairment<br />
5. Central nervous system impairment<br />
a) Inherited brain dysfunction<br />
b) Left hemisphere (language)<br />
c) Smaller brainstem and cerebellum<br />
d) Inconsistent findings<br />
6. Biochemical studies: high serotonin and dopamine in some patients<br />
D. Prognosis: mixed (some show highly significant improvement; those with severe mental<br />
retardation have poorer outcomes)<br />
E. Treatment<br />
1. Drug therapy: results are mixed<br />
a) Haloperidol: modest reduction in withdrawal and movements<br />
b) SSRIs: decreases in anxiety and repetitive behaviors<br />
c) Secretin: decreased evidence<br />
2. <strong>Behavior</strong> modification: used effectively<br />
a) Eliminates echolalia, self-destructiveness<br />
b) Increases attention, language, social play<br />
c) Intensive program had positive effect on IQ<br />
d) Social impairments harder to alter<br />
III. Other developmental disorders<br />
A. Overview<br />
1. What constitutes a disorder is vague<br />
2. Cultural differences in childhood problems<br />
B. Problems with diagnosis<br />
1. Controversy over guidelines<br />
2. Clinicians must decide if problems behaviors are present, excessive, maladaptive, or<br />
inappropriate for developmental level; such judgments are difficult to make<br />
IV. Attention deficit/hyperactivity disorders and disruptive behavior disorders<br />
A. Prognosis: without intervention, they tend to persist<br />
B. Attention deficit/hyperactivity disorder (ADHD)<br />
1. Symptoms<br />
a) Short attention span<br />
b) Low self-control and greater motor activity in two or more situations<br />
c) Academic impairment<br />
d) Poor peer relations
260 Chapter 15: Disorders of Childhood and Adolescence<br />
e) Present before age 7 and persists at least six months<br />
2. Three forms: predominantly hyperactive-impulsive; predominantly inattentive;<br />
combined<br />
3. Prevalence: 3 to 7 percent of school-age children; boys much more likely to receive<br />
diagnosis<br />
4. Prognosis: continues into adolescence, fewer problems if attention deficit only;<br />
increased likelihood of delinquency in adolescence, but not in adulthood; require<br />
structured situations; worse prognosis if other disruptive disorders<br />
5. Etiology<br />
a) Inconsistent findings on neurological cause<br />
b) No evidence for food additives or sugar as cause<br />
c) Family variables<br />
6. Treatment<br />
a) 75 to 90 percent of children with ADHD respond positive to stimulant medication<br />
b) Concerns about overmedicating<br />
c) Combine drugs and behavior therapy<br />
d) interventions based on functional behavior assessment almost completely<br />
eliminate aggressive behavior in those with high activity levels<br />
C. Oppositional defiant disorder (ODD): negativistic, hostile<br />
1. Controversial: not in International Classification of Diseases and may be normal<br />
variation in child behavior<br />
2. DSM-IV-TR: the problem causes "significant impairment in social or academic<br />
functioning"<br />
3. Associated with parent-child conflict, espousing unreasonable beliefs, negative family<br />
interactions<br />
D. Conduct disorders: consistent antisocial behavior over six months; prevalence from three to<br />
ten percent, four to five times more often in boys<br />
1. Two subtypes: childhood onset (prior to age ten); adolescent onset (after age ten)<br />
2. 83,000 juveniles in American correctional institutions; 1.75 million arrested in 1990;<br />
coexists with ODD and ADHD; prognosis poor, particularly with sexually aggressive<br />
behaviors, prognosis better for high IQ males whose parents do not have antisocial<br />
personalities and for females<br />
3. Etiology<br />
a) Psychodynamic perspective—underlying anxiety<br />
b) Biological perspective/genetic factors; little actually known about genetic<br />
influences<br />
c) Parental failure and lack of supervision<br />
4. Treatment<br />
a) Resist traditional psychotherapy<br />
b) Cognitive behavioral self-control treatment for child, role-playing<br />
c) Parent management training; greatest success combines skill training and parent<br />
training<br />
V. Anxiety disorders: exaggerated autonomic responses; internalizing or over controlled<br />
A. Prognosis is promising even without treatment<br />
B. Separation anxiety disorder: excessive anxiety when separated from parents or home [then<br />
continue with A ("constantly seek parents' company..."; 1-4 fine]<br />
1. Early temperament (shyness) interacts with parenting skill deficits<br />
2. School phobia subtype: 6 percent of females; 2.5 percent of males during lifetime<br />
3. Etiology: overdependence (psychodynamic); parental reinforcement (learning)<br />
4. Prognosis: for young children, very good; worse when symptoms develop in<br />
adolescence<br />
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Chapter 15: Disorders of Childhood and Adolescence 261<br />
VI. Reactive attachment disorder: extreme disturbance in relating to others socially<br />
A. Develops in infancy or early childhood from extreme abuse, neglect, institutional<br />
upbringing, or repeated changes in primary caregiver<br />
1. Result in inability to meet the child's physical or emotional needs that affect<br />
attachment formation.<br />
B. Therapy<br />
1. Rebirthing therapy ineffective; may put vulnerable children at risk<br />
2. These children need to feel they are in a safe and nurturing environment<br />
3. Caretakers should learn parenting skills, and children need to learn to set goals related<br />
to their specific symptoms.<br />
VII. Mood disorders<br />
A. DSM-IV-TR does not list childhood depression under childhood disorders, but children and<br />
adolescents may suffer from any form of mood disorder<br />
1. Bipolar: children cycle more rapidly; hyperactive, irritable, shifting moods<br />
2. Most common form of depression: reactive, which lasts a limited period of time in<br />
response to specific stressful situation<br />
B. Prevalence: 2 to 7 percent of children; common in adolescents, especially girls<br />
C. Treatments include cognitive behavioral and skills training<br />
VIII. Tic disorders<br />
A. Chronic tic disorder (lasts more than one year)<br />
1. Most common: eye blinks, jerking movements of head<br />
2. Transient tic disorder (lasts four weeks but less than one year)<br />
a) 15 to 23 percent of children have transient tics<br />
b) Can only be diagnosed in retrospect<br />
B. Tourette’s syndrome: facial tics, grunting and barking, coprolalia (compulsion to shout<br />
obscenities)<br />
1. Prevalence: 5 to 30 cases per 10,000 children; three to five times more frequent in boys<br />
than girls; 1 to 2 children per 10,000 continue to have symptoms in adulthood<br />
2. Course: varies from individual to individual; many suffer no significant distress and do<br />
not seek treatment<br />
3. Etiology and treatment<br />
a) Anxiety plays central role<br />
b) Avoidance response<br />
c) Nearly 50 percent meet criteria for ADHD<br />
d) Involves dopamine; some treatment success with Haloperidol, but there is a risk<br />
of negative side effects, such as tardive dyskinesia; fewer risks with clonodine<br />
IX. Elimination disorders<br />
A. Toilet training is a major focus of conflict<br />
B. Enuresis<br />
1. Commonly seen in children as bed wetting<br />
2. Significant distress in social, academic everyday life for children with enuresis<br />
3. Both psychological and biological explanations<br />
4. Interventions involve medication to decrease depth of sleep or volume of urine; most<br />
successful psychological procedure is behavioral<br />
a) Constant reinforcement form parents<br />
b) Wake child to use toilet<br />
c) Give child responsibility for making bed if accident occurs<br />
d) Bedtime urine alarm treatment<br />
C. Encopresis<br />
1. Less common that enuresis<br />
2. Defecating in clothes, on the floor or other inappropriate places
262 Chapter 15: Disorders of Childhood and Adolescence<br />
a) Occurs in 1 percent of grade school children, boys far outnumbering girls; can<br />
persist for years<br />
b) Seen with functional constipation; usually involuntary<br />
3. Amount of psychosocial impairment is in direct proportion to its effects on child's selfesteem:<br />
problems arise through shame, embarrassment, attempts to conceal disorder;<br />
ostracism by peers, anger from caregivers, rejection; but most children with encopresis<br />
do not have serious psychological or behavior problems<br />
4. Treatment: medical evaluation, behavioral and family therapy, parent and child<br />
education re toileting regimens<br />
LEARNING OBJECTIVES<br />
1. Describe the characteristics of pervasive developmental disorders and identify the prevalence of<br />
behavior problems in children and adolescents. (pp. 496-498)<br />
2. Indicate the prevalence of autistic disorder and describe the main impairments it entails. Describe<br />
diagnostic difficulties and research findings related to autism. Discuss the relation autistic disorder<br />
has to retardation and splinter skills. (pp. 498-501)<br />
3. Differentiate between autism and Rett’s disorder, childhood disintegrative disorder, Asperger’s<br />
disorder, and pervasive developmental disorder not otherwise specified. (pp. 501-504)<br />
4. Discuss the etiology of autistic disorder, including psychodynamic, family, genetic, central<br />
nervous system impairment, and biochemical theories. (pp. 504-505)<br />
5. Describe the prognosis and treatment for children with pervasive developmental disorders.<br />
Discuss drug therapy and behavior modification for these children. (pp. 505-506)<br />
6. Discuss the problems with the diagnosis and classification of other developmental disorders. (pp.<br />
506-508)<br />
7. Describe the symptoms, etiology, and treatment of the attention deficit/hyperactivity disorders.<br />
Discuss the difficulty involved in making an ADHD diagnosis accurately. (pp. 508-512)<br />
8. Define and differentiate oppositional defiant disorder and conduct disorder and discuss the<br />
prevalence, etiology, and treatment of conduct disorders. (pp. 512-516)<br />
9. Consider the question of whether school violence is a “sign of the times.” (p. 514; Critical<br />
Thinking)<br />
10. Contrast the anxiety-related disorders of childhood, including separation anxiety disorder and<br />
school phobia. Discuss how they can be treated. (pp. 516-518)<br />
11. Describe reactive attachment disorder and how to deal with it. (p. 518)<br />
12. Describe the prevalence, symptoms, and treatment of childhood depression. (pp. 518-519)<br />
13. Describe the symptoms, etiology, and treatment of chronic and transient tic disorders, including<br />
Tourette’s syndrome. (pp. 519-523)<br />
14. Discuss the various elimination disorders, including enuresis and encopresis. (pp. 523-524)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Recent research and clinical interest has focused on the children of dysfunctional families. Much<br />
has been written in the popular press about children of alcoholics and children of divorced<br />
parents. Some research (see Judith Wallerstein’s longitudinal research on children of divorce)<br />
indicates the likelihood of both immediate and long-delayed effects of growing up with conflict,<br />
parental absence, and emotional tension related to the noncustodial parent. Clinicians who work<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 15: Disorders of Childhood and Adolescence 263<br />
with alcoholic families assert the existence of designated roles for children from these homes: the<br />
overachieving mini-parent (the “hero”), the black sheep who is the psychological lightning rod<br />
(the “scapegoat”), the tension-breaking comedian (the “mascot”), and the depressed invisible child<br />
(the “lost child”). Unfortunately, this assertion is based on scant evidence. Furthermore, there is<br />
every reason to believe that some of these roles are played by children in any dysfunctional family<br />
in which parents fail to act responsibly. You can use this topic to stress the need for skepticism<br />
and replicable findings based on well-designed research before accepting sweeping assertions<br />
about the effects of alcoholism on children.<br />
2. Most students are eager to know about the prognosis for treated autistic children. McEachin et al.<br />
(1993) present follow-up results of an extremely comprehensive and well-controlled comparison<br />
of intensive behavior therapy with a control group getting less intensive behavior therapy. The<br />
original intervention occurred when most of the children were about 3½ years old or less. The<br />
experimental group (N = l9) received forty or more hours of one-to-one behavior therapy per<br />
week for two or more years. Controls (N = 19) got ten hours per week or less. Lovaas (1987)<br />
provides details about this treatment and the first evaluation of it.<br />
At a mean age of eleven and one-half, the children getting the intensive program (out of treatment<br />
for an average of five years) showed substantially better adjustment than the controls (who<br />
averaged three years, posttreatment). Average IQ scores for those getting intensive treatment was<br />
84.5; average for the controls was 54.9. Vineland Adaptive <strong>Behavior</strong> scores averaged 71.6 for<br />
experimentals, 45.7 for the controls. Furthermore, the nine experimental subjects with the best<br />
outcomes were, on the basis of IQ (average score = 108), indistinguishable from normal children.<br />
The best-outcome subjects also had Personality Inventory for Children scores that were within the<br />
normal range for all scales.<br />
Despite the limitations of small samples and the absence of replication by other researchers, these<br />
results are heartening. Given early and intensive work with children having autistic disorder,<br />
long-term outcome can be quite positive.<br />
Sources: Lovaas, O. I. (1987). <strong>Behavior</strong>al treatment and normal educational and intellectual<br />
functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3–9.<br />
McEachlin, J. J., Smith, T., & Lovaas, O. I. (1993). Long-term outcome for children with autism<br />
who received early intensive behavioral treatment. American Journal on Mental Retardation, 97,<br />
359–372.<br />
Internet Site: http://www.autism-society.org the web site from the Autism Society of America.<br />
3. As the United States becomes a more culturally diverse country, teachers, nurses, pediatricians,<br />
and mental health professionals who come in contact with children will have to be increasingly<br />
aware of cultural differences in parental expectations. Childhood psychopathology is defined not<br />
by children, but by the adult authorities in their lives. Those authorities can hold quite different<br />
views about the acceptability of such childhood behaviors as opposition to parents and fighting<br />
with peers. As defined by parents, what is deviant in one culture is normative in another (Lambert<br />
et al., 1992).<br />
Weisz et al. (1988) investigated the impact of cultural norms on perceptions of children’s<br />
problems. Vignettes of children were shown to parents, teachers, and psychologists in Thailand<br />
and the United States. Each person viewed two videos, one depicting a child who was disobedient<br />
and aggressive, the other showing a fearful, shy youngster. Viewers then rated how worrisome<br />
and serious they thought the children's behavior was, and whether they thought the children's<br />
behavior would improve without professional help. Ask students what they think the results would<br />
be. You can help here by putting a graph on the board with “average problem perception” on the
264 Chapter 15: Disorders of Childhood and Adolescence<br />
vertical axis and, on the horizontal axis, six places indicating Thai parents, teachers, and<br />
psychologists and U.S. parents, teachers, and psychologists.<br />
The results show that psychologists from both cultures gave quite similar ratings (4.72 and 4.82<br />
on a seven-point scale for the Thai and U.S. psychologists, respectively). The Thai parents and<br />
teachers gave much lower ratings of problems (4.43 and 4.25) than did U.S. parents and teachers<br />
(5.63 and 5.82). Now ask students why they think such dramatic differences exist. Weisz et al.<br />
(1988) suggest that Buddhist values tolerate a wide range of childhood behaviors and assume that<br />
behavior will change for the better. Parents are socialized to relax about their children’s behavior<br />
and expect that, with time, they will mature out of their foolishness. Americans are socialized to<br />
believe that childhood patterns are signposts of future behavior and that there is a relatively<br />
narrow range of acceptable behavior for children. What other explanations might there be?<br />
In addition, Weisz and his colleagues looked at the types of problems that parents typically see in<br />
children in the two countries. Problems of overcontrol—anxiety, sleeplessness, somatic<br />
complaints including headaches and stomachaches—were more common than problems of<br />
undercontrol in Thai society; American children tended to have the opposite kinds of problems.<br />
Even among the “undercontrolled” children in Thailand, children showed more control than in the<br />
United States. Rather than hitting other children undercontrolled Thai children tend to harm<br />
animals or simply not pay attention to parents’ requests. (Weisz, et al., 1993). These results<br />
suggest that sociocultural norms dictate not only how problems are seen but also the nature of the<br />
symptoms involved. Thailand is like many other Asian nations where a high premium is put on<br />
the individual’s ability to control selfish desires in favor of the group. Harmony is more important<br />
than individuality. One could argue that Americans place more emphasis on independence and<br />
creativity than they do on group cohesion and collaboration. As it is argued for adult disorder, so<br />
it is for childhood disorders: Symptoms are mirrors of the culture’s norms.<br />
Sources: (The first portion of this discussion is taken from Nevid, J. S., Rathus, S. A., & Greene,<br />
B. (1994). <strong>Abnormal</strong> psychology in a changing world (2nd ed.). Englewood Cliffs, NJ: Prentice-<br />
Hall).<br />
Lambert, M. C., et al. (1992). Jamaican and American adult perspectives on child<br />
psychopathology. Further exploration of the threshold model. Journal of Consulting and Clinical<br />
Psychology, 60, 64–72.<br />
Weisz, J. R., et al. (1988). Thai and American perspectives on over- and undercontrolled child<br />
behavior problems: Exploring the threshold model among parents, teachers, and psychologists.<br />
Journal of Consulting and Clinical Psychology, 56, 601–609.<br />
Weisz, J. R., et al. (1993). <strong>Behavior</strong>al and emotional problems among Thai and American<br />
adolescents: Parent reports for ages 12–16. Journal of <strong>Abnormal</strong> Psychology, 102, 395–403.<br />
4. Bedwetting is a common occurrence for young children, especially before age five, and is not<br />
really considered a problem unless it continues page age six or seven. Some issues to explore with<br />
your students might be: what are the appropriate steps for toilet training a child and how early<br />
should this start? what problems might a child encounter if she or he has not acquired bladder<br />
control by age five or six? what causes enuresis (psychological and physiological causes)? what<br />
would be the differences between the etiology of voluntary versus involuntary enuresis? what are<br />
the different ways that enuresis is treated, and which seems to have the best outcome?<br />
More of a problem, particularly emotionally, is encopresis, or defecating at inappropriate times in<br />
inappropriate places. Explore the following with your students: how does encopresis differ in<br />
severity from enuresis? what causes encopresis? how would parents know if their child has<br />
encopresis? why is encopresis a concern? in terms of behavior, how might voluntary encopresis<br />
differ from involuntary encopresis? what are the best treatments for encopresis?<br />
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Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 15: Disorders of Childhood and Adolescence 265<br />
Based on what the students have learned from the text and by using other resources, have them<br />
develop a community plan to educate parents and children about the elimination disorders.<br />
Internet sites: http://www.aafp.org/afp/990415ap/2171.html Treatment Guidelines for Primary<br />
Nonretentive Encopresis and Stool Toileting Refusal, on the American Family Physician website<br />
http://www.bedwetting.ferring.ca is a web site sponsored by Ferring Pharmaceuticals, a Canadian<br />
company that produces DDAVP (desmopressin), a drug used to treat enuresis<br />
http://www.healthcare.uiowa.edu/cdd is the University of Iowa's Health Care Center for<br />
Disabilities and Development, which offers information about the causes and treatment of<br />
encopresis<br />
http://www.wetbuster.com a site for parents and children (as well as adults with enuresis) who<br />
experience problems with bedwetting<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. <strong>Behavior</strong>s that are considered disorders in childhood change with the age of the child and the<br />
norms of the wider culture. Distribute the handout for this demonstration and ask students to rate<br />
each short description on a five-point scale, with l indicating no indication of a problem and 5<br />
being a strong indication of a problem. Remind students that in each case a 10-year-old child is<br />
engaging in the behavior today. Ask students to re-rate the items while imagining that the child is<br />
15 years old. Have them turn in their handouts; before the next class period, tabulate and average<br />
their ratings for the 10-year old and the 14-year-old. If you can, calculate the standard deviations<br />
as well. Display the averages on the board and ask if students are surprised by any of the ratings.<br />
Ask people who were tolerant (mostly gave 1s and 2s) to explain their thinking. Compare and<br />
contrast this attitude with the opinions of those who gave mostly 4s and 5s. Also ask students<br />
whether the same behaviors would have been seen as problematic if they themselves had engaged<br />
in them as 10- and 14-year-olds.<br />
This exercise illustrates how diverse our standards may be and how expectations of normative<br />
development influence definitions of abnormality. If your students represent a diverse set of<br />
cultures (international students, rural versus urban, white versus people of color), ask if social<br />
expectations influenced their ratings. Finally, you will get a rousing discussion of differences in<br />
the behaviors parents allow from first-born and last-born children. Birth order is yet another factor<br />
that muddies the waters when childhood behavior is rated as problematic or not.<br />
Internet Site: http://www.aacap.org/publications/factsfam The American Academy of Child and<br />
Adolescent Psychiatry provides up-to-date information on issues that affect youngsters<br />
2. Many students have strong opinions about how parents should interact with their children in order<br />
to foster self-esteem and open communication. Divide the class into small groups or engage in a<br />
round table discussion of the following themes:<br />
a. What methods did your parents use in rearing you that you are going to use in raising your<br />
own children?<br />
b. What child-rearing methods will you use as a parent that your parents failed to use?<br />
c. How much is the person you are today the direct result of the way your parents<br />
communicated with you?<br />
d. To what extent should a parent be a child’s “best friend”?<br />
This topic can spark heated discussion about the do's and don’ts of parenting. It is a good idea to<br />
interject questions about how research can evaluate assertions of the “right” method. You can also
266 Chapter 15: Disorders of Childhood and Adolescence<br />
note that different subcultures may have different right ways of being parents and that there are<br />
many parenting styles, all (none?) of which can be effective.<br />
3. Although the text did not include a section on learning disorders (there is a limit to how much can<br />
be included in any textbook!), they present significant difficulties for students that extend into<br />
adulthood. Some, by incredible hard work, do well enough to be considered by selective colleges;<br />
even so, they must deal with timed tests, such as the SAT and ACT. Students with dyslexia have<br />
an extremely difficult time completing these tests in the required amount of time. The College<br />
Board and the American College Testing Program do allow students to take un-timed, special<br />
administrations of these tests, which supposedly reflect more accurately the student's real<br />
academic achievement. It is possible for some students to be able to take the un-timed version of<br />
the tests by producing documentation of a diagnosis of a learning disability.<br />
Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask each group to develop this list with the most salient examples first. Each group<br />
could then have a spokesperson deliver a short talk about the best examples. You could provide a<br />
blank overhead transparency to each group at the beginning of this demonstration.<br />
How do your students in each group feel about learning-disabled students taking un-timed tests? If<br />
the student cannot compete for admission on the same basis as everyone else, how can he or she<br />
compete in the classroom without enormous amounts of assistance? Do your students know of<br />
anyone who took the un-timed versions? Is it fair to have resources made available to them that<br />
are not available to other students? What kind of services are available on campus for students<br />
with disabilities? Ask the students to discuss these issues keeping in mind that they may have a<br />
learning-disabled classmate in the group with them.<br />
4. Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask your students in the groups to discuss the difference between the laws related to<br />
special education in the public schools and the Americans with Disabilities Act, which affects<br />
higher education. Have the students develop a list of similarities and a list of differences.<br />
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Chapter 15: Disorders of Childhood and Adolescence 267<br />
HANDOUT FOR DEMONSTRATION 1:<br />
WHEN IS CHILDHOOD BEHAVIOR A SIGN OF A PROBLEM?<br />
For each of the following descriptions, imagine that the child involved is 10 years old and lives in your<br />
hometown. Rate each behavior from 1 to 5, with 1 indicating no behavior problem and 5 indicating a<br />
definite problem.<br />
<strong>Behavior</strong> No Problem Definite Problem<br />
1. The child stays up until 10:30 P.M. watching<br />
PG-13-rated video rentals on school nights.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
1 2 3 4 5<br />
2. The child sometimes goes into stores in the mall and<br />
shoplifts shirts, jewelry, or other items.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
3. The child spends the summertime sitting alone in his<br />
or her room reading books rather than playing outside<br />
or interacting with other children.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
4. The child is so nervous before taking a test in school<br />
that he or she gets only three hours of sleep the night<br />
before and throws up after breakfast.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
5. During a party thrown by adults, the child sneaks<br />
three or four drinks of beer.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
6. Whenever the child’s parents want to go out for the<br />
evening, the child begs the parents to stay.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
7. Afraid of being embarrassed by the teacher, the child<br />
fakes being ill in order to stay home from school.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
8. Whenever a parent asks the child to help with<br />
household chores, the child screams and refuses.<br />
Suppose the child was 14 years old. How, if at all,<br />
would your rating change?<br />
1 2 3 4 5<br />
1 2 3 4 5<br />
1 2 3 4 5<br />
1 2 3 4 5<br />
1 2 3 4 5<br />
1 2 3 4 5<br />
1 2 3 4 5
268 Chapter 15: Disorders of Childhood and Adolescence<br />
SELECTED READINGS<br />
Dodge, K. A. (1993). Social-cognitive mechanisms in the development of conduct disorder and<br />
depression. Annual Review of Psychology, 44, 559–584.<br />
Kazdin, A. E. (1990). Psychotherapy for children and adolescents. Annual Review of Psychology, 41,<br />
21–54.<br />
Meisels, S. J., & Shonkoff, J. P. (Eds.) (1990). Handbook of early childhood interventions. New York:<br />
Cambridge University Press.<br />
Quay, H. C., Routh, D. K., & Shapiro, S. K. (1988). Psychopathology of childhood: From description to<br />
validation. Annual Review of Psychology, 38, 491–532.<br />
Sattler, D., Shabatay, V.,& Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 12, Disorders of Childhood and<br />
Adolescence, Mental Retardation, and Eating Disorders.<br />
Clipson, C., &Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 14, Attention-Deficit Hyperactivity Disorder: All Wound Up and Out of Control.<br />
Christophersen, E. R., & Mortweet, S. L. (2001). Treatments that work with children. Washington, DC:<br />
American Psychological Association.<br />
VIDEO RESOURCES<br />
<strong>Behavior</strong> Modification: Teaching Language to Psychotic Children (16 mm, color, 43 min). This classic<br />
film shows the self-destructive behavior of psychotic children and how contingent punishment can<br />
suppress it. The step-by-step operant conditioning methods developed by Ivar Lovaas to increase<br />
attending behavior and vocalization and to teach the functional use of speech are illustrated.<br />
Prentice-Hall Media, Inc., 150 White Plains Road, Tarrytown, NY 10591.<br />
A Boy Named Terry Egan (16 mm, color, 53 min). The case study of a 9-year-old autistic boy who<br />
progresses in language use and social interaction through the efforts of his parents, doctor, and teachers.<br />
Interviews with parents illustrate the doubts, confusion, and guilt of parents who wonder how their<br />
child could have such desperate problems. Carousel Films, 1501 Broadway, New York, NY 10036.<br />
Chrysalis ’86 (video, color, 32 min). This video follows the process of a therapy group of adolescent<br />
girls at a summer residential camp for disturbed children. The focus is on three girls with problems<br />
ranging from cerebral palsy to depression following years of sexual abuse. It shows how an intensive<br />
group experience helps change behavior and self-perception. Penn State Audio-Visual Services, Special<br />
Services Building, University Park, PA 16802.<br />
Edge of Awareness (16 mm, 27 min). This film illustrates procedures that can help autistic children<br />
develop greater awareness of other people and open the door for greater communication. Cognitive<br />
Development Designs, Inc., 25 Huntington Avenue, Boston, MA 02116.<br />
Genetic Defects: The Broken Code (16 mm, 87 min). This film shows how genetic diseases are passed<br />
on to future generations and discusses genetic counseling and the moral questions this counseling<br />
raises. Indiana University, Audio Visual Center, Bloomington, IN 47401.<br />
Harry: <strong>Behavior</strong>al Treatment of Self-Abuse (16 mm, 38 min). This award-winning documentary film<br />
illustrates behavioral techniques used in helping a year old develop self-control skills. Research Press,<br />
Box 317740, Champaign, IL 61820.<br />
Headbangers (16 mm, color, 30 min). This film unflinchingly examines the self-destructive behavior of<br />
severely retarded individuals and treatment programs to protect them from themselves. The persistent,<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 15: Disorders of Childhood and Adolescence 269<br />
cooperative efforts of the staff and the therapist are viewed as the primary treatment mode. U.S.<br />
National Audio-Visual Center, Audiovisual Archives Division National Archives and Records Service,<br />
7th and Pennsylvania, NW, Washington, DC 20408.<br />
Hyperactive Child (16 mm, color, 14 min). Part of a CBS news report on the symptoms of attention<br />
deficit hyperactivity disorder, its effects on parents and teachers, and the use of drug therapy. The<br />
Feingold diet is also discussed. Carousel Films, Inc., 1501 Broadway, New York, NY 10036.<br />
<strong>Behavior</strong> Disorders of Childhood (VHS, color, 60 mm.). Explores the DSM-IV disorders first found in<br />
childhood. Annenberg/CPB. 1-800-LEARNFR.<br />
Secret Shame: Bullied to Death (VHS, color, 28 mm.). Looks at how aggressive bullies embarrass and<br />
torment other children. Films for the Humanities and Sciences. 1-800-257-5126<br />
Teen and Child Depression (VHS, color, 19 mm.). Looks at depression and bipolar disorders in<br />
children and adolescents. Films for the Humanities and Sciences. 1-800-257-5126.<br />
Childhood Depression (VHS, 28 min) This program discusses the prevalence of depression, especially<br />
among adolescent girls, and emphasizes the importance of early diagnosis and treatment.<br />
Silence of the Heart is an excellent, moving movie (now on video) starring a young Charlie Sheen and<br />
Chad Lowe dealing with issues of suicide and its effects on family and friends; delves into copycat<br />
suicides. Check it out on Amazon.com.<br />
ON THE INTERNET<br />
http://www.chadd.org/ is the web page of Children and Adults with Attention Deficit Disorder<br />
(CHADD).<br />
http://www.autism-society.org is the web site for the Autism Society of America.<br />
http://www.bedwetting.ferring.ca is a web site sponsored by Ferring Pharmaceuticals, a Canadian<br />
company that produces DDAVP (desmopressin), a drug used to treat enuresis.<br />
http://www.healthcare.uiowa.edu/cdd is the University of Iowa's Health Care Center for Disabilities and<br />
Development, which offers information about the causes and treatment of encopresis.<br />
http://www.wetbuster.com a site for parents and children (as well as adults with enuresis) who<br />
experience problems with bedwetting.
CHAPTER 16<br />
Eating Disorders and Sleep Disorders<br />
CHAPTER OUTLINE<br />
I. Eating disorders<br />
A. Prevalence:<br />
1. 13.4 percent of girls and 7.1 percent of boys have engaged in disordered eating patterns<br />
2. More than 5 million Americans have eating disorders, characterized by physically<br />
and/or psychologically harmful eating patterns<br />
3. 15 percent of young women having “substantially disordered” eating attitudes and<br />
behaviors<br />
B. Anorexia nervosa: refusal to maintain a body weight above the minimum normal weight for<br />
one's age and height; an intense fear of becoming obese that does not diminish with weight<br />
loss; body image distortion; and (in females) the absence of at least three consecutive<br />
menstrual cycles otherwise expected to occur.<br />
1. Prevalence<br />
a) Ranges from 0.5 to 1 percent of females<br />
b) Peak years: 15 to 19<br />
c) Increase in early onset (ages 8 to 13)<br />
2. Subtypes:<br />
a) Restricting type loses weight through dieting or exercising;<br />
b) Binge-eating/purging type loses weight through self-induced vomiting, laxatives,<br />
or diuretics.<br />
3. Physical complications: cardiac arrhythmias, low blood pressure, lethargy, and<br />
irreversible osteoporosis<br />
4. Associated characteristics: obsessive-compulsive behaviors and certain personality<br />
characteristics<br />
5. Course and outcome<br />
a) Approximately 44 to 50 percent of individuals treated for anorexia recover<br />
completely<br />
b) Mortality rate primarily from cardiac arrest or suicide ranges from 5 to 20 percent<br />
C. Bulimia nervosa: recurrent episodes of binge eating high caloric foods at least twice a week<br />
for three months, during which the person loses control over eating.<br />
1. Differs from binge-eating/purging anorexia: for anorexia, weight is under minimally<br />
expected levels<br />
2. Subtypes<br />
a) Purging type: individual regularly vomits or uses laxatives, diuretics, or enemas<br />
b) Nonpurging type: excessive exercise or fasting are used to compensate for<br />
binges.<br />
3. Prevalence rate is 3 percent of women in the United States; few males exhibit the<br />
disorder.<br />
4. Physical complications: erosion of tooth enamel, dehydration, swollen parotid glands,<br />
and lowered potassium, which can weaken the heart and cause arrhythmia and cardiac<br />
arrest<br />
5. Associated features<br />
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Chapter 16: Eating Disorders and Sleep Disorders 271<br />
a) Comorbid mood disorders are common<br />
b) Characteristics of borderline personality.<br />
6. Course and outcome<br />
a) Onset generally later than for anorexia (late adolescence or early adulthood)<br />
b) Follow-up studies tend to find almost 70 to 75 percent remission<br />
D. Binge-eating disorder (BED): a diagnostic category "provided for further study" in DSM-IV-<br />
TR; consumption of large amounts of food over a short period of time, accompanying<br />
feeling of loss of control, and marked distress over the binges; lacks the compensatory<br />
behaviors of bulimia (e.g., vomiting).<br />
1. Prevalence<br />
a) One and one-half times more likely for females than males<br />
b) Range estimated at from 0.5 to 5 percent<br />
c) African American women are as likely as European American women to have the<br />
disorder, but have fewer attitudinal concerns<br />
d) Prevalence rates for American Indian women are as high as 10 percent<br />
2. Associated characteristics: comorbid features include major depression, obsessivecompulsive<br />
personality disorder, and avoidant personality disorder.<br />
3. Course and outcome<br />
a) Onset typically late adolescence or early adulthood<br />
b) Most individuals make a full recovery even without treatment, but weight is<br />
likely to remain high<br />
E. Eating disorder not otherwise specified: DSM-IV-TR includes the category for those that do<br />
not meet all the criteria for anorexia or bulimia nervosa.<br />
II. Etiology of eating disorders<br />
A. Determined by social, gender, psychological, familial, cultural, and biological factors.<br />
B. Societal influences: social desirability of thinness in women in western culture<br />
C. Family and peer influences<br />
1. Family influences:<br />
a) Family interactions characterized by parental control, emotional enmeshment,<br />
and conflicts and tensions not openly expressed<br />
b) Maternal over-protectiveness, parental rejection<br />
c) These findings problematic: case studies, and may be reaction to eating problem,<br />
not its cause<br />
2. Peers or family members criticize weight, encourage dieting, glorify ultra-slim models<br />
3. Peer relationships can serve as buffer to eating disorders or produce pressure to lose<br />
weight<br />
D. Cultural factors<br />
1. Culture-bound syndrome<br />
2. Eating disorders are rare in Asia<br />
3. African Americans ignore white media messages equating thinness with beauty, more<br />
likely than white American women to be satisfied with their body shape and to feel that<br />
beauty stems from personality not thinness<br />
4. White women in their twenties have especially high standards of thinness<br />
E. Other suggested etiological factors in eating disorders<br />
1. Poor self-esteem, depression, and feelings of helplessness<br />
2. Anorexics are often described as perfectionistic, obedient, good students, excellent<br />
athletes, and model children; emphasis on weight allows them to have control over an<br />
aspect of their lives.<br />
3. Sexual abuse may be indirectly related to eating disorders<br />
F. Genetic influences: concordance rates were 22.9 for MZ twins and 8.7 percent for DZ twins<br />
for bulimia
272 Chapter 16: Eating Disorders and Sleep Disorders<br />
III. Treatment of eating disorders<br />
A. Prevention programs in schools: aimed at reducing the incidence of eating disorders and<br />
disordered eating patterns.<br />
B. Anorexia nervosa<br />
1. Focus on weight gain (by feeding tube, contingent reinforcement for weight gain, or<br />
both<br />
2. Family therapy may also be useful<br />
3. Cognitive-behavioral and family therapy sessions common after weight gain, but<br />
relapse and continued obsession with weight are common.<br />
C. Bulimia nervosa<br />
1. Initially assessed for conditions that may have resulted from purging, including cardiac<br />
and gastrointestinal problems.<br />
2. Treatment: psychotherapy, cognitive-behavioral treatment, and antidepressant<br />
medications<br />
3. Combination of cognitive-behavioral therapy and medications most effective<br />
4. Even with treatment, only about 50 percent recover fully<br />
5. Treatments for anorexia and bulimia involve interdisciplinary teams that include<br />
physicians and psychotherapists<br />
D. Binge-eating disorder<br />
1. Similar to those for bulimia, including weight reduction strategies<br />
2. Fewer physical complications for BED<br />
3. Cognitive therapy: clients identify impact of societal messages regarding thinness,<br />
encourage development of healthier goals and values, develop normal eating patterns, a<br />
more positive body image, and healthier ways to deal with stress learning objectives<br />
IV. Primary sleep disorders<br />
A. Dyssominas<br />
1. Involve difficulties in getting to or maintaining sleep<br />
2. Can involve primary insomnia, primary hypersomnia, narcolepsy or breathe related<br />
disorders<br />
3. Circadian rhythm sleep disorder is a pattern of sleep disruption caused by the<br />
disruption of the biological sleep-wake cycle<br />
B. Parasomnias<br />
1. Nightmare disorder<br />
2. Sleep terror disorder<br />
3. Sleepwalking disorder<br />
4. Parasomnias not otherwise specified<br />
V. Etiology and treatment of sleep disorders<br />
A. Etiology of dyssominas<br />
1. Subclinical anxiety<br />
2. Subclinical depression,<br />
3. Environmental changes due to noise, light or other stimuli<br />
4. Health and behavioral habits, in many cases the etiology is unknown.<br />
B. Etiology of parasomnias such as nightmare disorder, sleep terror and sleepwalking disorders<br />
is unknown.<br />
C. Treatments for dyssomnias<br />
1. Stimulant medications<br />
2. Psychological techniques such as relaxation or stimulus control and change in habits<br />
D. Treatment of parasomnias<br />
1. They tend to resolve in adolescence or early adulthood<br />
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Chapter 16: Eating Disorders and Sleep Disorders 273<br />
LEARNING OBJECTIVES<br />
1. Describe the prevalence and characteristics of eating disorders. (pp. 527-530)<br />
2. Discuss the symptoms and subtypes of anorexia nervosa. (pp. 531-532)<br />
3. Consider the physical complications that can arise from anorexia nervosa and why it is difficult to<br />
overcome. (pp. 532-533; Mental Health and Society)<br />
4. Delineate other characteristics and mental disorders that are associated with anorexia nervosa. (pp.<br />
533-534)<br />
5. Describe the course and outcome of anorexia nervosa. (p. 534)<br />
6. Discuss the characteristics of bulimia nervosa, as well as its physical complications, associated<br />
features, and course and outcome. (pp. 534-536)<br />
7. Discuss the characteristics of binge-eating disorder, as well as its associated features, and course<br />
and outcome; briefly describe the eating disorders not otherwise specified that are categorized in<br />
DSM-IV-TR. (pp. 536-537<br />
8. Describe the risk factors for and etiology of eating disorders and evaluate the degree to which<br />
society creates eating disorders. (pp. 537-542)<br />
9. Compare the attitudes toward weight of European American and African American females. (pp.<br />
542-545)<br />
10. Compare the treatments for anorexia nervosa, bulimia nervosa, and binge-eating disorder. (pp.<br />
546-548)<br />
11. Discuss the characteristics, etiology, and treatment of primary sleep disorders (pp. 548-556)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. A major irony of anorexia nervosa and bulimia nervosa are that they occur in times and places of<br />
relative affluence (consider the "vomitoria" of ancient Rome where wealthy Romans would go to<br />
purge after binging on lavish feasts). Such a pattern would logically suggest that these eating<br />
disorders are socially and culturally influenced. However, research on rats suggests that two<br />
hormones influence appetite. A team of investigators at the Howard Hughes Medical Institute and<br />
the University of Texas Southwestern Medical Center isolated the hormones, which they call<br />
orexin A and orexin B (orexis means "appetite" in Greek). Although the researchers aren't sure<br />
that these hormones act the same way in humans as they do in rats, they are exploring how orexins<br />
interact with other appetite-related hormones in an attempt to develop treatments both to increase<br />
hunger in anorexics and to reduce cravings in binge-eaters and the obese.<br />
Leutwyler, K. (1998, March 2). Treating eating disorders. Scientific American.<br />
2. What happens when you encounter a friend or relative who clearly has a problem, such as an<br />
eating disorder, and clearly doesn't want to talk about it? Do you back off? Do you push ahead<br />
and offer advice? Do you offer to listen and wait for the person to come to you for help? How<br />
would you feel if you "just waited" and the person died? Anorexia and bulimia are difficult<br />
disorders to deal with, even for professionals; typically waiting it out is not an option, while<br />
insisting that the person get help is likely to result in withdrawal. You're stuck between that<br />
proverbial "rock and a hard place."<br />
The National Association of Anorexia Nervosa and Associated Disorders provides some<br />
guidelines on how to confront someone with anorexia or bulimia, which they call:<br />
The Plan: "CONFRONT"
274 Chapter 16: Eating Disorders and Sleep Disorders<br />
Concern: The reason you are doing the confronting. You care about the mental, physical, and<br />
nutritional needs of the person.<br />
Organize: Decide WHO is involved, WHERE to confront, WHY concern, HOW to talk, WHEN is<br />
a convenient time.<br />
Face: The actual confrontation. Be empathetic, but direct. Do not back down if the problem is<br />
initially denied.<br />
Respond: By listening carefully.<br />
Offer help and suggestions. You may want to encourage the person to contact you when there is<br />
the need to talk to someone.<br />
Negotiate: Another time to talk and a time span to seek professional help.<br />
Time: Remember to stress that recovery takes time and patience. However, there is a lot to gain by<br />
the process and a lot to lose if the choice is made to continue the existing behaviors.<br />
What type of response would you expect with this plan? What factors would be relevant in terms<br />
of how effective this might be? What plan could you come up with?<br />
Internet Site: http://www.anad.org/site/anadweb/ is the web site for ANAD National Association<br />
of Anorexia Nervosa and Associated Disorders<br />
3. Chapter 18 discusses legal and ethical issues involved in providing therapy to persons who do not<br />
want to accept treatment. This is a critical issue for someone with anorexia nervosa (and often<br />
bulimia nervosa) when the individual's life may be threatened by the disease. As discussed in the<br />
chapter, the first step in treating anorexia is weight gain, and often this means use of a feeding<br />
tube to force feed the patient. The insidious nature of anorexia creates strong resistance to weight<br />
gain and all strategies to promote weight gain, even in the face of permanent, lifelong physical<br />
ailments and even death.<br />
Considering this dilemma (and perhaps jumping ahead to Chapter 18 to look at the issues involved<br />
in a patient's right to refuse treatment), do you believe that someone has the right to refuse forcefeeding?<br />
What issues are involved? How would you go about dealing with a situation like this? If<br />
you were the anorexic patient, how would you react? If you were that patient's parent, what would<br />
you do? What role do you believe a physician or therapist should play? What other options might<br />
be available?<br />
4. Have each student write on a piece of paper any sleep problems they have had in the recent past<br />
with sleep. Be sure not to identify the student by name. Collect the papers and shuffle them to<br />
assure students cannot be identified. Lead a discussion based on the types of problems each<br />
student has identified. At the end of lecture give names and contact information of professionals<br />
at your school or in the community who specialize in sleep disorders.<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. One of the major influences on body image in the U.S. and other western nations are the media,<br />
particularly television and movies, but also magazines, music videos, and various forms of<br />
advertising. In small groups, have students put together presentations that demonstrate the effect<br />
of the media on body image and eating disorders, then have them present a plan to counteract<br />
these powerful forces. After completing the presentations, the class as a whole, could design an<br />
intervention to present to junior high school and high school classes to educate students about the<br />
problem and prevention.<br />
2. Have your students develop and administer a weight satisfaction survey in which they collect data<br />
from males and females ranging in age from preteen to early adulthood, from different<br />
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Chapter 16: Eating Disorders and Sleep Disorders 275<br />
ethnic/cultural groups. Referring to information in the text, they should include questions<br />
concerning respondents' views of "ideal weight for males," "ideal weight for females,"<br />
respondents' self-perceptions concerning their own weight, body image, how they feel about<br />
themselves when looking in the mirror at their faces and in the nude, what they consider to be<br />
their "best" feature and their "worst" feature, how they feel about themselves in comparison to<br />
others (and whether/how often they compare themselves with others), and other questions that<br />
seem relevant.<br />
Responses from the entire class can be analyzed statistically and compared with research<br />
presented in the text. The results of the survey and data analysis can be used to develop<br />
presentations for local schools and other community organizations.<br />
3. Eating disorders are always a topic of strong interest and concern. A large-scale (N = 3,175)<br />
survey of middle-school children found that more than 40 percent reported feeling fat and wishing<br />
to lose weight. Among girls, whose average age was 12, 43 percent had dieted, 11 percent had<br />
fasted, and 6 percent had made themselves vomit to lose weight (Childress et al., 1993).<br />
Restrained eating (Herman & Polivy, 1975) is an associated concept. It involves a tendency to<br />
restrain oneself from eating for fear of gaining weight. People with clinical eating disorders and<br />
“normal” people can be restrained eaters. They diet frequently and, when feeling susceptible to<br />
stress or negative emotions, binge rather than eat normally. The 10-item Eating Restraint Scale is<br />
presented as a handout. Scoring instructions are on the handout. A high score (14 points or more)<br />
indicates a tendency to restrain eating. Let students know that the Eating Restraint Scale is not a<br />
clinical indicator. It is useful in helping students look at their attitudes and behaviors relevant to<br />
eating, but many other sources of information are needed before concluding that high scorers have<br />
a problem. Students may approach you for additional information. If a student become distressed<br />
about his or her eating patterns, you should make a referral to your school’s counseling center.<br />
Sources: Childress, A. C., Brewerton, T. D., Hodges, E. L., & Jarrell, M. P. (1993). The kid’s<br />
eating disorders survey (KEDS): A study of middle school students. Journal of the American<br />
Academy of Child and Adolescent Psychiatry, 32, 843–850.<br />
Eating Restraint Scale from “Anxiety, Restraint, and Eating <strong>Behavior</strong>” by C. P. Herman, & J.<br />
Polivy, Journal of <strong>Abnormal</strong> Psychology, 84, pp. 666–672. Copyright © 1975 by the American<br />
Psychological Association. Reprinted with permission from the American Psychological<br />
Association and the author.<br />
Internet Site: http://www.mentalhealth.com/p20-grp.html This site discusses the major categories<br />
of eating disorders.
276 Chapter 16: Eating Disorders and Sleep Disorders<br />
HANDOUT FOR DEMONSTRATION 3: EATING RESTRAINT SCALE<br />
Circle one response for each item.<br />
Item (Points) Scoring<br />
1. How often are you dieting?<br />
Never 0<br />
Rarely 1<br />
Sometimes 2<br />
Often 3<br />
Always 4<br />
2. What is the maximum amount of weight (in pounds) that you have ever lost within one month?<br />
0 to 4 pounds 0<br />
5 to 9 pounds 1<br />
10 to 14 pounds 2<br />
15 to 19 pounds 3<br />
20 pounds or more 4<br />
3. What is your maximum weight gain within a week?<br />
0 to 1 pounds 0<br />
1.1 to 2.0 pounds 1<br />
2.1 to 3.0 pounds 2<br />
3.1 to 5.0 pounds 3<br />
5.1 pounds or more 4<br />
4. In a typical week, how much does your weight fluctuate?<br />
0 to 1 pounds 0<br />
1.1 to 2.0 pounds 1<br />
2.1 to 3.0 pounds 2<br />
3.1 to 5.0 pounds 3<br />
5.1 pounds or more 4<br />
5. Would a weight fluctuation of five pounds affect the way you live your life?<br />
Not at all 0<br />
Slightly 1<br />
Moderately 2<br />
Very much 3<br />
6. Do you eat sensibly in front of others and splurge alone?<br />
Never 0<br />
Rarely 1<br />
Often 2<br />
Always 3<br />
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Chapter 16: Eating Disorders and Sleep Disorders 277<br />
7. Do you give too much time and thought to food?<br />
Never 0<br />
Rarely 1<br />
Often 2<br />
Always 3<br />
8. Do you have feelings of guilt after overeating?<br />
Never 0<br />
Rarely 1<br />
Often 2<br />
Always 3<br />
9. How conscious are you of what you are eating?<br />
Not at all 0<br />
Slightly 1<br />
Moderately 2<br />
Extremely 3<br />
10. How many pounds over your desired weight were you at your maximum weight?<br />
0 to 1 pounds 0<br />
2 to 5 pounds 1<br />
6 to 10 pounds 2<br />
11 to 20 pounds 3<br />
21 pounds or more 4<br />
Scoring instructions. Add your total points: If your total score is 14 or more points, you have a<br />
tendency to be a restrained eater.<br />
From “Anxiety, Restraint, and Eating <strong>Behavior</strong>” by C. P. Herman & J. Polivy, Journal of <strong>Abnormal</strong><br />
Psychology, 84, pp. 666–672. Copyright 1975 by the American Psychological Association. Reprinted<br />
with permission from the American Psychological Association and the author.
278 Chapter 16: Eating Disorders and Sleep Disorders<br />
SELECTED READINGS<br />
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin<br />
Company. Chapter 15, Bulimia Nervosa: The Self-Destructive Diet.<br />
Hall, L., & Ostroff, M. (1998). Anorexia nervosa: A guide to recovery. Gurze Designs & Books.<br />
Kazdin, A. E. (1990). Psychotherapy for children and adolescents. Annual Review of Psychology, 41,<br />
21–54.<br />
Meisels, S. J., & Shonkoff, J. P. (Eds.) (1990). Handbook of early childhood interventions. New York:<br />
Cambridge University Press.<br />
Porter, T. (2002). A dance of sisters. Joanna Cotler Books.<br />
Sattler, D., Shabatay, V.,& Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 12, Disorders of Childhood and<br />
Adolescence, Mental Retardation, and Eating Disorders.<br />
William D., & Christopher, V. (1999) Happiness and a Good Night's Sleep. New York, NY, Delacorte<br />
Press.<br />
VIDEO RESOURCES<br />
Diet unto Death: Anorexia Nervosa (VHS, color, 50 min). This documentary shows interviews with<br />
four anorexic adolescent girls who describe their self-starvation and their attempts to overcome their<br />
obsession with thinness. MTI Teleprograms, 3710 Commercial Avenue, Northbrook, IL 60062.<br />
Dying to Be Thin (VHS, color, 28 mm.). Provides information about anorexia and follows a young<br />
women as she battles anorexia. Films for the Humanities and Sciences. 1-800-257-5126.<br />
Eating Disorders (VHS, 15 min) Explains anorexia nervosa and bulimia nervosa through the eyes of<br />
two women suffering from these eating disorders and an expert who discusses treatment. Shows the<br />
devastating effect on the women and their families. Films for the Humanities & Sciences, P.O. Box<br />
2053, Princeton, NJ 08543-2053. 1-800-257-5126.<br />
Media Impact (VHS, 28 min) Looks at the seductive nature of visual media that constantly impact us,<br />
whether actual reality or manufactured reality, and how the media popularize unhealthy or antisocial<br />
behaviors. Films for the Humanities & Sciences, P.O. Box 2053, Princeton, NJ 08543-2053. 1-800-257-<br />
5126.<br />
Dreams: Theater of the night (VHS, 28 min) Discusses dreaming. Films for the Humanities &<br />
Sciences, P.O. Box 2053, Princeton, NJ 08543-2053. 1-800-257-5126.<br />
Dream voyage (VHS, 15 min). Discusses dreaming. Films for the Humanities & Sciences, P.O. Box<br />
2053, Princeton, NJ 08543-2053. 1-800-257-5126.<br />
Sleep disorders (VHS 30 min)). Discusses sleep disorders. Films for the Humanities & Sciences, P.O.<br />
Box 2053, Princeton, NJ 08543-2053. 1-800-257-5126.<br />
ON THE INTERNET<br />
http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=337 is the web site for the National Eating<br />
Disorders Association, which among other things offers advice on "listening to your body" and links to<br />
other resources<br />
http://www.apa.org is the web site for the American Psychological Association, where a search can be<br />
performed for the various eating disorders<br />
Copyright © Houghton Mifflin Company. All rights reserved.
Copyright © Houghton Mifflin Company. All rights reserved.<br />
Chapter 16: Eating Disorders and Sleep Disorders 279<br />
http://www.edauk.com is the web site for the Eating Disorders Association (EDA) in the United<br />
Kingdom; it presents a great deal of information as well as how to get help and poetry written by young<br />
people with eating disorders<br />
http://www.mentalhealth.org is the web site for The Center for Mental Health Services; this site, which<br />
is under the United States Department of Health and Human Services, offers a variety of resources,<br />
including search capability to learn about eating disorders<br />
http://www.raderprograms.com overtureindex.htm discusses the eating disorders presented in the text,<br />
as well as other related issues and solutions (the site is sponsored by Rader Programs, which specializes<br />
in treating eating disorders)<br />
http://www.cloud9.net:80/~thorpy/ A listing of resources regarding all aspects of sleep including the<br />
physiology of sleep, clinical sleep medicine, sleep research<br />
http://www.sleepfoundation.org/ The National Sleep Foundation is a nonprofit organization devoted<br />
to raising funds and awareness of the importance of sleep for health<br />
http://www.doctorsforum.com/oct96/articles/apnea.html Provides information on the symptoms,<br />
impact on daily living and treatment for sleep apnea.<br />
http://www.Sleepnet.com/ Contains links to other sleep-related web pages.
CHAPTER 17<br />
Therapeutic Interventions<br />
CHAPTER OUTLINE<br />
I. Biology-based treatment techniques<br />
A. Electroconvulsive therapy<br />
1. History: first use of shock was insulin shock; Meduna (1930s) believed that<br />
schizophrenia could be reduced through seizures; Cerletti and Bini (1938) introduced<br />
ECT<br />
2. Procedure: 65 to 140 volts for 0.1 to 0.5 seconds, now applied to one hemisphere<br />
3. Effective with depression; may alter cortisol levels; concern over side effects; drugs<br />
used instead<br />
B. Psychosurgery: brain surgery performed to correct severe mental disorder<br />
1. Moniz (1930s): destroying certain brain connections (particularly in frontal lobes)<br />
could disrupt psychotic thought patterns and behaviors<br />
2. Procedures include prefrontal and transorbital lobotomy, lobectomy (removal of<br />
portions of frontal lobe), electrical cauterization; videolaserscopy operates on<br />
extremely small areas<br />
3. Scientific and ethical objections; abandoned except for tumors; drugs used instead<br />
C. Psychopharmacology: study of drug effects on mind and behavior<br />
1. Antianxiety drugs (minor tranquilizers)<br />
a) Barbiturates: serious side effects, addiction<br />
b) Meprobamate (Propanediol) and benzodiazepines (Librium, Valium): block<br />
synaptic transmission; safer, but still cause addiction, overreliance<br />
2. Antipsychotic drugs (major tranquilizers)<br />
a) Chlorpromazine (Thorazine) and other drugs reduce schizophrenic symptoms,<br />
increase interactions<br />
b) Drugs allow release of thousands of chronic patients<br />
c) Concern about side effects (Parkinson-like symptoms, sensitivity to light, dry<br />
mouth, tardive dyskinesia—involuntary movements of mouth, tongue,<br />
extremities)<br />
3. Antidepressants<br />
a) Monoamine oxidase (MAO) inhibitors<br />
b) Tricyclics<br />
c) SSRIs; Fluoxetine (Prozac), Paxil (Paroxetine), and Zoloft (Sertraine)<br />
4. Antimanic drugs (for bipolar disorder)<br />
a) Lithium effective but has limitations—only preventative, toxic dosage must be<br />
monitored<br />
5. Psychopharmacological considerations<br />
a) Specific drugs for specific subtypes of disorder and individuals<br />
b) Reduce symptoms but do not cure, do not teach skills<br />
c) Controls people<br />
II. Psychotherapy<br />
A. Definition: systematic application of techniques derived from psychological principles by<br />
professionals for purpose of aiding psychologically troubled people<br />
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Chapter 17: Therapeutic Interventions 281<br />
B. Many variations but four common characteristics<br />
1. Opportunity for relearning<br />
2. Development of new, emotionally important experiences<br />
3. Provides a therapeutic relationship<br />
4. Clients have motivations and expectations, anxiety and hope<br />
C. Mental health services can be made culturally appropriate for ethnic minorities<br />
III. Insight-oriented approaches to individual psychotherapy<br />
A. Psychoanalysis: uncovering repressed material to achieve insight; inappropriate for children<br />
and for nonverbal and schizoid adults<br />
1. Free association and dream analysis: manifest and latent content<br />
2. Analysis of resistance<br />
3. Transference; avoid countertransference<br />
4. Interpretation<br />
5. Modern psychodynamic therapy: loosened therapeutic techniques<br />
6. Effectiveness of psychoanalysis<br />
a) Impossibility of operational definitions makes confirmation difficult<br />
b) Questions about symptom substitution in nonanalytic therapies<br />
c) Declining use in future is predicted<br />
B. Humanistic–existential therapies: focus on qualities of “humanness”<br />
1. Person-centered therapy (Rogers): acceptance, empathy, unconditional positive regard;<br />
emphasis on relationship<br />
2. Existential analysis: philosophical encounter; case studies but little empirical support<br />
for effectiveness<br />
3. Gestalt therapy (Perls): totality of here-and-now, exaggeration of feelings, dream<br />
analysis<br />
IV. Action-oriented approaches to individual psychotherapy<br />
A. Classical conditioning techniques<br />
1. Systematic desensitization (Wolpe): anxiety reduction through relaxation paired with<br />
steps in anxiety hierarchy; highly effective<br />
2. Flooding and implosion: anxiety induced and then extinguished in real life (flooding)<br />
or imagination (implosion)<br />
a) Developers claim they are effective<br />
b) Some clients find procedures traumatic<br />
3. Aversive conditioning: undesirable behavior (such as smoking or alcohol use) paired<br />
with noxious stimulus<br />
a) Rapid smoking produces nausea and avoidance<br />
b) Covert sensitization (imagined disgusting scenes associated with unwanted<br />
behavior)<br />
B. Operant conditioning techniques<br />
1. Token economies: tokens for desirable behavior exchanged for reinforcers; used in<br />
institutional settings<br />
2. Punishment: suppresses self-destructive behavior<br />
a) Electric shock to suppress self-destructive behavior<br />
b) Ethical issues led to decline in use<br />
C. Observational learning techniques (modeling)<br />
D. Cognitive-behavioral therapy: change irrational thoughts, teach coping skills and problemsolving<br />
techniques<br />
1. Rational-emotive therapy (Ellis): confront irrational beliefs<br />
2. Beck’s cognitive-behavioral therapy: gradual assessment of validity of client’s<br />
assumptions<br />
3. Meichenbaum’s stress inoculation therapy
282 Chapter 17: Therapeutic Interventions<br />
4. Effectiveness: better than drugs for certain depressions<br />
E. Health psychology: goal of changing lifestyles to prevent illness or to enhance quality of life<br />
1. Biofeedback: information about autonomic functions and reward for changing<br />
functions in desired direction<br />
2. Relationship between Type A and heart disease<br />
3. General strategies<br />
a) Establish priorities<br />
b) Avoid stressful situations<br />
c) Take time out for yourself<br />
d) Exercise regularly<br />
e) Eat right<br />
f) Make friends<br />
g) Learn to relax<br />
V. Evaluating individual psychotherapy<br />
A. Controversies between action-oriented and insight-oriented therapists<br />
1. Recent survey suggests movement toward integration and cognitive, away from<br />
psychoanalysis and transactional analysis<br />
B. Eysenck’s criticisms of psychotherapy<br />
1. Therapy ineffective<br />
2. Methodological flaws invalidate claim<br />
3. Do outcome studies accurately reflect psychotherapy? Persons (1991): outcome studies<br />
were methodologically flawed<br />
C. Meta-analysis and effect size (large number of studies analyzed by looking at effect size?<br />
treatment-produced change)<br />
1. Meta-analysis is controversial? it has supporters and detractors<br />
2. 79 percent of those in treatment better off than those untreated; largest gains in first<br />
few months<br />
3. Empirically supported treatments (ESTs) specify psychological treatments shown to be<br />
efficacious in controlled research with specific populations and demonstrate that they<br />
benefit clients<br />
a) cognitive-behavioral treatment for anxiety and depression<br />
b) interpersonal therapy for depression and bulimia<br />
c) behavioral therapy for sexual dysfunctions<br />
d) other therapies may be effective, but have not been rigorously studied<br />
the “common factors” approach identifies four common dimensions of curative<br />
influence in therapy<br />
D. Important characteristics of therapists and therapies<br />
1. Demographic characteristics, e.g., age, gender, ethnicity<br />
2. Overall reputation<br />
3. Experience with clients who have similar problems<br />
4. Therapeutic orientation<br />
5. Interpersonal style<br />
6. Values and beliefs<br />
VI. Group, family, and couples therapy<br />
A. Group therapy<br />
1. Wide range of formats, theoretical perspectives, purposes<br />
2. Commonalities of group therapy<br />
a) Social situation<br />
b) Interpersonal response in real-life context<br />
c) Develop new communication and social skills<br />
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Chapter 17: Therapeutic Interventions 283<br />
d) Reduce isolation and fear<br />
e) Provide strong social support<br />
3. Little substantial research on effectiveness<br />
4. Disadvantages: lack of individual attention; group pressures<br />
B. Family therapy<br />
1. Assumptions<br />
a) Economical and logical to see family<br />
b) “Identified patient” only shows family’s symptoms<br />
c) Therapist should modify relationships<br />
2. Communications approach (Satir, Haley)<br />
a) Identify present patterns<br />
b) Work for changes in communication<br />
3. Systems approach (Minuchin)<br />
a) Emphasis on interlocking roles, including “sick role”<br />
b) Create flexible roles to foster positive relationships<br />
C. Couples therapy<br />
1. Normal for conflicts to develop<br />
2. Clarify and improve communications and role relationships<br />
3. Not designed to save the marriage<br />
VII. Systemic integration and eclecticism<br />
A. Therapeutic eclecticism: process of selecting concepts, methods, and strategies from a<br />
variety of current theories that work<br />
1. Lazarus' early "technical eclecticism" has been modified into multimodal behavior<br />
therapy, which is behavioral in basis but embraces cognitive and affective concepts<br />
also<br />
2. Openness and flexibility; but can encourage indiscriminate, haphazard, inconsistent use<br />
of therapeutic techniques and concepts<br />
B. Goal to find therapies that work best with specific clients who have specific problems under<br />
specific conditions<br />
VIII. Culturally diverse populations and psychotherapy<br />
A. Western psychology and mental health concepts characterized by assumption that they are<br />
universal, that human condition is governed by universal principles, and members of groups<br />
that don't fit those standards are deficient<br />
1. Surgeon General's Report on Mental Health: using European American standards to<br />
judge normality and abnormality is fraught with dangers, may result in denying<br />
appropriate treatment to minority groups, may oppress culturally different clients, it is<br />
important to recognize and respond to cultural concerns of other groups<br />
2. Few studies exist on empirically supported treatments with minority populations<br />
B. Guidelines are suggested for working with particular groups, but they should not be adhered<br />
to rigidly.<br />
1. African Americans: bring up issue of racial differences between the client and the<br />
white therapist; to try to understand client's worldview; see client's<br />
suspiciousness/reluctance to self-disclose as a survival mechanism; assess client's<br />
positive assets; problem-solving approaches are useful for external problems.<br />
2. Asian Americans and Pacific Islanders: be aware of potential social stigma of seeing a<br />
therapist; psychological conflicts may be expressed via somatic complaints and/or<br />
other socially acceptable issues; reluctance to self-disclose/ express feelings may be<br />
due to cultural factors, not psychopathology; explain purpose, expectations, and<br />
process of therapy, and use action-oriented, problem-solving approach.<br />
3. Latino or Hispanic Americans: engage client in a warm, respectful manner while<br />
maintaining a formal persona; linguistic misunderstandings are possible; discuss
284 Chapter 17: Therapeutic Interventions<br />
therapy goals; watch for misinterpretations, e.g., differences in body language;<br />
consider client's positive assets and resources, including the nuclear and extended<br />
family.<br />
4. Native Americans: patience is important; basic needs should be addressed first; client's<br />
communal environment is important; sensitivity to differences in communication<br />
styles, especially body language; consider consulting with indigenous healers.<br />
IX. Community psychology<br />
A. Managed health care: reforms needed to make care accessible and affordable<br />
1. Changes: shift to HMOs, short-term treatment, reliance on master’s (less expensive)<br />
level providers, increased accountability, and quality assurance<br />
2. Criticisms: reduce costs and reduce quality<br />
3. American Psychological Association endorses principle of properly trained<br />
psychologists prescribing medication<br />
4. Use of treatment manuals to make care more systematic<br />
5. Increased use of computer programs to provide psychotherapy to clients<br />
B. Prevention of psychopathology<br />
1. Primary prevention: reduce the number of new cases of disorders<br />
a) Head Start is one example<br />
b) Munoz and colleagues (1995) report communitywide effort to prevent depression<br />
c) Interventions to prevent juvenile delinquency<br />
2. Secondary prevention: shorten duration of mental disorders, but problems exist<br />
a) traditional diagnostic methods are often unreliable, provide little insight into<br />
which treatment procedures to use; more specialized diagnostic techniques are<br />
needed<br />
b) once detected, it may be difficult to decide what therapy is most effective for the<br />
specific disorder and patient<br />
c) prompt treatment often unavailable<br />
3. Tertiary prevention: facilitate readjustment to community life of people hospitalized<br />
for mental disorders<br />
LEARNING OBJECTIVES<br />
1. Discuss the various biological therapies, including electroconvulsive therapy (ECT) and<br />
psychosurgery, and their use and effectiveness in treating mental disorders. (pp. 559-561)<br />
2. Define psychopharmacology. Describe and evaluate the use of antianxiety, antipsychotic,<br />
antidepressant, and antimanic medications. (pp. 561-564)<br />
3. Define psychotherapy and describe its basic characteristics. Discuss why traditional psychotherapy<br />
may not be effective with individuals from non-Western cultures and ethnic minority<br />
groups. (pp. 564-566)<br />
4. Describe the goals and techniques of psychoanalysis and post-Freudian psychoanalytic therapy.<br />
Evaluate the effectiveness of psychoanalytic therapy. (pp. 566-568)<br />
5. Describe the therapies based on the humanistic/existential perspective, including person-centered<br />
therapy, existential analysis, and gestalt therapy. (pp. 568-569)<br />
6. Describe the therapeutic techniques based on classical conditioning, including systematic<br />
desensitization, flooding and implosion, and aversive conditioning. (pp. 569-571)<br />
7. Describe the therapeutic techniques based on operant conditioning, including token economies<br />
and punishment. (pp. 571-572)<br />
8. Describe observational learning techniques and cognitive-behavioral therapies. (pp. 572-574)<br />
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9. Discuss the goal of health psychology and describe the techniques used to promote lifestyle<br />
changes, including biofeedback. (pp. 574-575)<br />
10. Discuss research on the effectiveness of individual psychotherapy. (pp. 575-576)<br />
11. Describe the common components and types of group therapy; evaluate the effectiveness of group<br />
therapy. Describe the functions of couples and family therapy, and the different emphases of the<br />
communications and systems approaches. (pp. 578-581)<br />
12. Evaluate the factors involved in choosing a therapist. (p. 578; Critical Thinking)<br />
13. Discuss the movement toward systematic integration and eclecticism. (p. 582)<br />
14. Consider the issues raised with respect to culturally diverse populations and psychotherapy. (pp.<br />
582-587)<br />
15. Discuss the changes in mental health service delivery caused by managed health care. (pp. 587-<br />
589)<br />
16. Describe primary, secondary, and tertiary prevention and give examples of each. (pp. 589-592)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Family therapy usually captures the attention and interest of students. Several family therapy<br />
tactics are provocative and unique. One is the development of a family genogram. Draw on the<br />
board a three- or four-generational diagram of a hypothetical family in which one or two current<br />
family functions or traits (“alcohol-abusing black sheep” or “workaholic, distant parent”) can be<br />
traced from previous generations. The genogram also clarifies the “sides of the family” issue in<br />
most marriages and the tendency for traits or problems to skip generations because children use<br />
their parents as a negative reference.<br />
A second family therapy stratagem is paradoxical instructions. Many family theorists (for<br />
example, Jay Haley and Paul Watzlawick) suggest that two things occur when a symptom is<br />
described to a family: The family is challenged with an entirely original reappraisal of its<br />
experience, and it is influenced by the change agent. If the family accepts the therapist’s<br />
suggestion, the influence of this change agent is clear, and it can be used for future interventions.<br />
If the family resists the suggestion, the family shows itself its own power and moves toward<br />
health. Either way, the therapist wins! Students will react strongly to the manipulative aspects of<br />
this strategy. You should accept concerns that acceptance of the paradoxical instruction (“Go<br />
home and beat your children; it’s how you show your love”) can be dangerous. However, an<br />
analogue study shows that although students find paradoxical interventions less acceptable than<br />
nonparadoxical ones, they do not negatively influence the perceptions of the therapist’s expertness<br />
or trustworthiness (Betts & Remer, 1993).<br />
Source: Betts, G. R., & Remer, R. (1993). The impact of paradoxical interventions on perceptions<br />
of the therapist and ratings of treatment acceptability. Professional Psychology: Research and<br />
Practice, 24, 164–170.<br />
2. A series of articles in Psychological Bulletin illustrates the difficulties in performing therapyeffectiveness<br />
research. It also shows students how researchers from different viewpoints can<br />
interpret the same information differently. Bowers and Clum (1988) performed a meta-analysis on<br />
69 studies comparing behavior therapy with placebo and nonspecific treatment conditions to<br />
assess the value of behavior therapy for a wide range of conditions. The meta-analysis yielded an<br />
effect size (ES) relative to placebo conditions of .55, a strong indication that behavior therapy is<br />
far better than placebo. Several years later Brody, (1990) argued that the meta-analysis gave a<br />
misleading picture. Brody noted that a wide range of behavior therapies (systematic<br />
desensitization, meditation, social-skill training, and so forth) and patient problems (test anxiety,
286 Chapter 17: Therapeutic Interventions<br />
schizophrenia, anorexia, and so forth) were lumped together. Brody took the ten studies that<br />
involved “neurotic” conditions such as agoraphobia and anorexia and did a simple box-score to<br />
see if behavior therapy was more effective than placebo conditions. Brody concluded that there<br />
was no evidence for the superiority of behavior therapy. Further, Brody argued that few, if any, of<br />
the studies had long-term follow-ups. Therefore, the outcome studies and the meta-analysis on<br />
which they were based did not yield clinically significant information. Clum and Bowers (1990)<br />
agreed that longer follow-ups were needed but calculated the median ES (eliminating the chance<br />
of the mean being influenced by extreme scores) for the same ten studies. They report an ES of<br />
.63, even stronger than the average for the entire analysis of 69 studies. The same data prove both<br />
that behavior therapy is superior and is not superior to placebo treatment conditions; the result<br />
depends on the method of analysis.<br />
Sources: Bowers, T. G., & Clum, G. A. (1988). Relative contribution of specific and nonspecific<br />
treatment effects: Meta-analysis of placebo-controlled behavior therapy research. Psychological<br />
Bulletin, 103, 315–323.<br />
Brody, N. (1990). <strong>Behavior</strong> therapy versus placebo: Comment on Bowers & Clum’s metaanalysis.<br />
Psychological Bulletin, 107, 106–109.<br />
Clum, G. A., & Bowers, T. G. (1990). <strong>Behavior</strong> therapy better than placebo treatments: Fact or<br />
artifact? Psychological Bulletin, 107, 110–113.<br />
Internet Site: www.apa.org/journals/bul.htm. The home page for the Psychological Bulletin.<br />
3. The ethics of methodologically sound psychotherapy-effectiveness research is a good topic for<br />
discussion. Ask students to suggest an appropriate control group for a study of treated individuals.<br />
If they respond, “people who do not receive treatment,” point out the possibility that people who<br />
ask for help (and get it) may be different in some outcome-relevant way from people who do not<br />
ask for help. Further, how can we be sure that untreated people do not get some other form of help<br />
(for example, read a self-help book) that might be much like therapy? These questions highlight<br />
the problem of random assignment, a key component of true experiments. A second kind of<br />
control group, the waiting-list control, includes random assignment but has its own problems. Ask<br />
students how they feel about the ethics of arbitrarily placing people in distress on a waiting list.<br />
Do the merits of the study outweigh the possible harmful effects? A third option is a<br />
pseudotherapy control group—the psychological equivalent of a placebo pill. But one wonders<br />
whether any treatment can be considered “inert.” Conclude by proposing that anyone placed on a<br />
waiting list or in a pseudotreatment control group should be given free access to the treatment if it<br />
proves to be effective. However, the economics of many (most?) treatment facilities makes this<br />
proposal difficult to implement.<br />
Internet Site: http://www.apa.org/ethics/code.html. The American Psychological Association site<br />
for ethical principles of psychologists.<br />
4. The common components of psychotherapy mentioned in the text are reasonable and accurate.<br />
Jerome Frank’s view of psychotherapy—and, in fact, of all forms of healing and persuading—can<br />
be added to the discussion. Frank, in his classic book, Persuasion and Healing, argues that the<br />
social aspects of the therapeutic relationship overwhelm any technical or theoretical<br />
considerations. According to him, the three active ingredients in the change process are (1) a<br />
socially sanctioned healer whose powers and status are respected by the sufferer, (2) a sufferer<br />
who seeks relief from symptoms, and (3) a fairly structured set of contacts (with their own rituals)<br />
that convinces the sufferer to change his or her attitudes and behavior. Key to this last process is<br />
the sufferer’s need to have mysteries explained by the healer and to feel that there is hope for<br />
improvement by relying on the expert. Ask students whether the same analysis can be applied to<br />
faith-healing evangelists or voodoo doctors.<br />
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Chapter 17: Therapeutic Interventions 287<br />
Imagine out loud this “therapy” with your students: A charismatic person writes a book and<br />
appears on television talk shows arguing that depression and fatigue are the result of certain<br />
allergens and toxic chemicals seeping into people’s bloodstreams through their clothes. The<br />
offending chemicals, this person asserts, come from polyesters and other synthetic fabrics and<br />
from modern laundry detergents. The cure is for people to throw away all their garments except<br />
for 100 percent natural cottons and wools and to wash only with “pure” soap. Given the mystery<br />
of depression and fatigue, the desperation of some, the status afforded television appearances, and<br />
the effort involved in the treatment, it is fairly likely that such a “therapy” could catch on (and be<br />
successful) with some sufferers.<br />
5. The most common form of community psychology activity is mental health consultation, a form<br />
of secondary prevention in which mental health professionals provide information to non–mental<br />
health professionals about a disorder, its causes, symptoms, and ways to make referrals. The<br />
professionals most often involved have frequent contact with troubled individuals but are not<br />
specifically trained to interact with them. For example, school teachers, police officers, and<br />
emergency room nurses often come in contact with distressed individuals and need to know how<br />
to best interact with them and make referrals to professionals when necessary. Ask students to<br />
think of other professions that have this kind of frequent contact with distressed individuals. Some<br />
examples are funeral directors, clergymen, general practice physicians, bartenders, hairdressers,<br />
and divorce attorneys. The consultant-consultee relationship is a unique one. It is a contracted<br />
arrangement in which the mental health professional listens to the consultee’s difficulties and<br />
provides advice. It is not a form of therapy. The consultee is seen as just as much a professional as<br />
the consultant: the consultant never tells the consultee how to do his/her job. Neither does the<br />
consultant have direct contact with the consultee’s clients. The relationship involves only indirect<br />
coaching; the consultant has no specific supervisory role.<br />
Gerald Caplan (1970) laid out a scheme that indicates the range of mental health consultations that<br />
are possible. Three of Caplan’s consultation types deserve description. The most common is casecentered,<br />
consultee consultation. In these consultations the mental health professional (MHP)<br />
works on a case-by-case basis with the consultee to assist in job-related problem solving. For<br />
example, the MHP might meet weekly with kindergarten teachers. One week, a teacher might<br />
mention the problems she has had with a boy who is suspected of having attention deficit<br />
hyperactivity disorder. Perhaps the boy is distracting other children. The consultant might provide<br />
tips on how to structure the environment to reduce the boy’s impact or how to set up a reward<br />
system so he stays on task longer. Another week, the focus might be on a student who is excluded<br />
from play activities because she is intensely shy. Consultees usually feel most comfortable asking<br />
for help when the focus is on cases, not on their own difficulties.<br />
However, Caplan notes that sometimes consultees reveal, indirectly and over time, that they have<br />
emotional blind spots that interfere with their ability to relate to clients. For instance, if one of the<br />
kindergarten teachers repeatedly described herself as losing her temper with children and storming<br />
out of the room, the focus of consultation might have to change to what Caplan calls “consulteecentered<br />
consultation.” Here, the consultant helps consultees develop skills to overcome their<br />
emotional blind spots. Care must be taken not to imply that the consultee has a psychological<br />
problem because this form of consultation can come dangerously close to therapy.<br />
A third type, called administrative consultation, focuses on the administration of a program. For<br />
instance, if a teacher wanted to establish a parent-teacher coordination program so that homework<br />
was more frequently checked and turned in, the consultant could act as a sounding board for ideas<br />
on how to approach parents, teachers, and administrators to get support for the program. Like<br />
case-centered consultations, the consultant would provide information (in this case about<br />
organizational behavior and persuasion) that would augment the consultee’s professional<br />
knowledge.
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These consultations can become politically complicated, especially if the program’s goals or<br />
methods are at odds with others in the organization or in the wider community.<br />
Source: Caplan, G. (1970). The theory and practice of mental health consultation. London:<br />
Tavistock.<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. If your training has prepared you to do so, model the style of various therapy strategies by asking<br />
a student volunteer to either think up a fictitious problem or discuss an actual, but not very<br />
significant, personal concern (for instance, trouble getting to sleep at night). Ask the volunteer to<br />
leave the classroom while you inform the rest of the class that during the first four to five minutes<br />
of the interview you will play the role of a Rogerian therapist and then, without warning, you will<br />
change roles and play an operant-conditioning-oriented therapist. The object will be to see<br />
whether the student volunteer notices that any change occurred and whether one or the other<br />
pattern of therapist behavior was preferred.<br />
When the student volunteer returns, spend the first four to five minutes mirroring statements of<br />
the student’s feelings and thoughts (for example, “Sounds like getting to sleep frustrates you”).<br />
Then the questions should abruptly take a decidedly behavioral turn (for example, “What exactly<br />
are the circumstances that precede sleepless nights?”). After ten minutes of interviewing, ask the<br />
volunteer whether he or she noticed any shift in the therapist’s behavior. Can he or she identify<br />
the therapeutic orientations? Was it easier to respond to one than to the other?<br />
This exercise should keep student interest and illustrate the differences in therapeutic strategies as<br />
well as their impact on the client.<br />
2. This activity helps students see how the theoretical orientation of a psychologist guides the<br />
development of a treatment plan. The experience also gives you a chance to correct any<br />
misperceptions the students may have about the techniques used in the various treatment<br />
approaches.<br />
The first step in this activity is for you to find some casebooks (the DSM-IV-TR casebook is<br />
excellent) or other sources from which you can take a case study illustrating a mental disorder. In<br />
order for the activity to be relevant to a range of therapeutic orientations, choose an adult,<br />
nonpsychotic condition such as an anxiety disorder, mood disorder, or form of substance abuse.<br />
Duplicate the case study for the class.<br />
Divide the class into four groups. Each group will be responsible for one therapeutic approach:<br />
drug treatment, psychoanalytic psychotherapy, behavior therapy (you can stipulate classical<br />
conditioning, operant conditioning, or modeling or allow them to use their own judgment), and<br />
cognitive behavioral (rational emotive or Beck’s cognitive) therapies. Have each group develop a<br />
treatment plan using the specific techniques of the therapeutic approach they were assigned. Also<br />
have the groups examine the potential barriers to successful treatment and their estimation that the<br />
client would be successfully treated.<br />
Ask each group to report to the whole class the results of their discussions and list their ideas on<br />
the board. Clarify and correct as necessary. At the end of the activity, encourage students to think<br />
about integrative treatments that might use the best of each approach. Underscore the fact that<br />
most therapists approach problems with this kind of eclecticism. You might also suggest that other<br />
treatment approaches not discussed—group therapy, family therapy, humanistic-existential—<br />
might have been just as valuable.<br />
Internet site: http://www.appi.org/dsm.html to order the DSM-IV-TR casebook from the APA<br />
(American Psychiatric Publishing, Inc.); it can also be ordered from http://www.amazon.com.<br />
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Chapter 17: Therapeutic Interventions 289<br />
3. One way to increase student involvement in the class and the material is to have them role-play<br />
different therapies. Ask students to volunteer to be therapists. You will need at least four<br />
therapists, one each for psychoanalysis, behavior therapy, humanistic-existential therapy, and<br />
cognitive therapy. You will also need four volunteers to play clients. It is a good idea to supply<br />
the clients with guidelines on what their problems are. On the Handout for Demonstration 3 is an<br />
example of these guidelines. Having some uniformity in the problems the clients present will<br />
foster discussion of how different therapies compare and contrast.<br />
To add to the entertainment value of this activity, assign the “therapists” to their therapeutic<br />
approach in private and tell them not to disclose what form of treatment they will be using. This<br />
way, the rest of the class can be involved in trying to guess the kind of therapy being<br />
demonstrated. Tell the therapists they should allot five minutes or so to conduct therapy. Pair up<br />
the clients and therapists randomly and have them perform one after the other before the class.<br />
After all the therapy sessions end, ask those in the audience to guess which therapist was<br />
demonstrating which form of treatment. Discuss whether the principles of each approach were<br />
adhered to and whether techniques were left out because of time constraints. Interview the clients<br />
and find out how the exercise felt for them. Participants and audience can discuss what they think<br />
would be most helpful to the client, including integrative combinations of the approaches. Finally,<br />
students will probably want to voice opinions about the therapy they would personally be most<br />
comfortable with. Point out that comfort and effectiveness may not come in the same therapeutic<br />
approach. Also, indicate that outcome research suggests that nontheoretical factors (the<br />
interpersonal quality of the therapist, the therapist’s professional experience, or the client-therapist<br />
match) may have more to do with positive outcomes than the techniques used in treatment.<br />
4. Many psychoactive drugs are used to treat people with emotional and behavioral disorders.<br />
Develop a list on the board that indicates each general category of drug, when it is prescribed, the<br />
generic and brand names for the more commonly used ones, and the side effects or<br />
contraindications for each. An abbreviated example is given in the Handout for Demonstration 4.<br />
Stress that each drug has many side effects, some of which are serious but exceedingly rare. One<br />
way to illustrate this point is to bring the Physician’s Desk Reference to class and look up the<br />
contraindications and side effects segments on several commonly used drugs, such as Mellaril or<br />
Librium. Students are often shocked at the number and variety of possible side effects.<br />
The irresponsible prescription of psychoactive drugs is a serious concern. Note on the board that<br />
each drug is therapeutic in a range of dosages (dependent on weight, age, health status, and<br />
condition of the patient). Above this range the drug becomes toxic; below this range the drug is<br />
ineffective. A commonly suggested way of treating mental disorders biologically is to increase the<br />
drug dosage to the patient until the toxic (side effects) level is reached and then back off the<br />
dosage. The danger to the patient is that the side effects may be serious or the doctor may not be<br />
consulted for a reduction in dosage. In the case of lithium carbonate, the therapeutic range is very<br />
narrow. Only a small change in dose or diet can effect a toxic overdose. Further, some drugs are<br />
prescribed to treat the side effects of other drugs, and they themselves have side effects. Cogentin<br />
and Artane are trade names for anti-Parkinsonian drugs given when schizophrenics are on<br />
phenothiazines. But because these drugs tend to cause a drying out of tissues in patients, other<br />
drugs are given to offset this effect. Warn students that some psychiatrists go overboard when<br />
using drugs to treat behavioral and emotional problems.<br />
Internet Site: http://www.mentalhealth.com/fr30.html. An extensive list of drugs used in the<br />
treatment of psychological disorders, including dosage, warning, effects, and side effects.<br />
5. Ask students to recall portrayals of psychotherapy from television and movies. Although there are<br />
relatively few television portrayals, the movies Ordinary People, Prince of Tides, and others show<br />
a dramatized version of psychoanalytic therapy. Point out that therapy is usually much less
290 Chapter 17: Therapeutic Interventions<br />
immediately helpful than is shown in the media; as in most other things, therapy is usually a<br />
process of two steps forward and one step back. Alternatively, therapy is shown to be clichéd and<br />
ineffective as in What About Bob?, Nuts, and the old Bob "Newhart Show" of the 1970s.<br />
Only a very small sample of the psychotherapies is shown in the media. Challenge students to<br />
recall any portrayals of behavior or cognitive therapy. The only example I can recall is the<br />
damning one in the movie A Clockwork Orange, which showed behavior therapists in the future<br />
depriving the protagonist of his only enjoyment (listening to Beethoven) for the good of the<br />
state—not a very accurate or positive reflection of behavior therapy.<br />
6. This demonstration heightens students’ awareness of the role of nonverbal messages in counseling<br />
and psychotherapy. What therapists say with their bodies can be as important as what they say<br />
with words, particularly in initial sessions. The experienced therapist knows that the client will<br />
reveal more when the therapist conveys, verbally and nonverbally, an attitude of openness,<br />
attention, and concern.<br />
Gerard Egan (1982), a noted writer on the subject of training clinicians, suggests that physical<br />
attending—the nonverbal signals that tell clients they are being listened to—has five components,<br />
which can be remembered with the acronym SOLER. S stands for squarely facing the other<br />
person so you convey that you are available to that person. O stands for adopting an open posture,<br />
with arms unfolded and legs uncrossed. L stands for leaning slightly forward at times to<br />
underscore the idea that you are listening and empathizing with the other person. E stands for eye<br />
contact that avoids staring but tells the other person you are interested. And R stands for<br />
remaining relatively relaxed so as to model an attitude of trust. You should cover the five<br />
components, model them, and show the opposite of good posture or gesture for each so that<br />
students can learn how not to do it.<br />
When you think students understand what SOLER stands for, have class members pair up. Tell<br />
them they will be interviewing each other on a specific topic for about six minutes. One topic<br />
might be what they think of the different therapies that are discussed in your text. The topic is<br />
really irrelevant; it just needs to be something on which all participants can voice an opinion. Each<br />
pair must decide who will interview first. Now instruct the interviewers that during the first<br />
several minutes they should adopt good nonverbal attending postures but, at your signal, violate<br />
every SOLER principle they can. They should slouch, avert eye contact, fiddle with pens, and so<br />
on while continuing the interview. Those who are being interviewed should keep track of how<br />
they felt and what they thought during the two parts of the interview.<br />
Tell the students to begin interviewing. At about three minutes, say loudly, “Switch to bad<br />
nonverbal postures!” At about six minutes, stop the interviewing and ask for comments from both<br />
the interviewers and interviewees. Was it harder for interviewers to remember what was said<br />
when they were physically distant? How did the interviewees feel during the two parts of the<br />
interview? If you have enough time, have the pairs switch roles and do the interviews again.<br />
When the exercise is over, suggest that, as homework, students note the quality of nonverbal<br />
communications in their daily conversations during the next several days. Have them write down<br />
their observations and ask for them in the next class period. This exercise makes students aware of<br />
the generally poor quality of listening that characterizes day-to-day interactions and points up the<br />
special quality of therapeutic ones.<br />
Source: Adapted from Exercises in Helping Skills, Second Edition by Gerard Egan. Copyright ©<br />
1982, by Wadsworth, Inc. Adapted by permission of Brooks/Cole Publishing Company, Pacific<br />
Grove, CA 93950.<br />
7. Community psychology emphasizes the potential for community resources to be used for the<br />
prevention of psychological and other problems. To that extent, it is a field that must be optimistic<br />
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Chapter 17: Therapeutic Interventions 291<br />
about the ability of people to work collaboratively and consistently for the common good. It is<br />
interesting to poll students on their optimism for social change. The 1980s were characterized by a<br />
general pessimism that government or any other community agency could reduce suffering and<br />
prevent problems. The 1990s may be showing a small swing in the pendulum toward social<br />
activism. The author has polled students in the way described in the Handout for Demonstration 7<br />
for some 15 years and has seen a small increase in optimism lately. Some conditions, however, are<br />
seen as unalterable: mental retardation and addictions among them.<br />
Survey your students using the Handout for Demonstration 7. Give feedback to the class about the<br />
issues that were seen as likely to be eradicated and the ones that are seen as unchangeable. Ask<br />
students why they feel as they do. Probe the kinds of research and interventions that would be<br />
necessary to prevent social problems. Clarify for them the difference between primary and<br />
secondary prevention approaches.<br />
8. Ask the students to conduct their own Internet research into the common psychotropic<br />
medications listed in the text. The students should gather information concerning the situations in<br />
which these medications are most commonly prescribed, recommended dosage, side effects,<br />
possible drug interactions, and any other information of interest. Use the Internet site below as a<br />
reference or baseline for this demonstration.<br />
Internet Site: http://www.mentalhealth.com/fr30.html. An extensive list of drugs used in the<br />
treatment of psychological disorders, including dosage, warning, effects, and side effects.<br />
9. Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask each group to develop this list based on the following topic with the most salient<br />
examples first. Ask the students to discuss which type(s) of therapy they liked the best for the<br />
lecture and textbook. Which type of therapy would be the most useful for most people? What are<br />
the barriers for people who don't seek some form of therapeutic treatment when it is needed? Can<br />
anything be done to change this?
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HANDOUT FOR DEMONSTRATION 3:<br />
A CASE FOR ROLE PLAYING THERAPY<br />
You and another person in the class will role-play a short therapy session. You are to play the role of<br />
the client. The following paragraph presents background information about the character you will play.<br />
Feel free to add details to this basic description. Please memorize the information so that when you are<br />
interviewed you will not need to look at this handout.<br />
You are a 20-year-old college student with symptoms of both anxiety and depressive disorders. For the<br />
past six weeks you have had trouble sleeping—you wake up at 3 or 4 A.M. and cannot get back to<br />
sleep. You have had recurring nightmares in which you are threatened by a large man who snickers at<br />
your fear of him. During the day, you are fatigued and apathetic; you push yourself through the day.<br />
You have never before experienced such a feeling. Formerly you enjoyed conversations with friends<br />
and family; now it is a chore to be around them. Avoiding people you know is hard to do, but you try.<br />
You find it hard to study because you have trouble concentrating. You often worry about both major<br />
and minor things. For instance, you are concerned about your financial situation: Your part-time job<br />
was eliminated and you have many bills to pay. More distressing, you are preoccupied with how<br />
unfriendly your friends seem to be and whether you have offended them in small ways. You also feel<br />
that college isn’t what you really want to be doing, but you do not know what is. You have always been<br />
something of a perfectionist, so recent inadequacies in academic, social, and job-related situations have<br />
you doubting your worth.<br />
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Chapter 17: Therapeutic Interventions 293<br />
HANDOUT FOR DEMONSTRATION 4:<br />
A SAMPLE OF DRUGS USED TO TREAT MENTAL DISORDERS,<br />
USUAL DOSAGE, AND THEIR SIDE EFFECTS*<br />
Antianxiety drugs<br />
Benzodiazepines<br />
diazepam<br />
Triazolobenzodiazepine<br />
Valium 2–40 mg/day drowsiness, dizziness, confusion<br />
alprazolam Xanax 0.75–4 mg/day drowsiness, dizziness, confusion<br />
Antidepressants<br />
Tricyclics<br />
imipramine Tofranil 75 mg/day initially changes in blood pressure and<br />
heart rate, anxiety, dry mouth<br />
Serotonin-specific reuptake inhibitors<br />
fluoxetine Prozac 20–80 mg/day anxiety, drowsiness, insomnia<br />
Antipsychotic drugs<br />
Phenothiazines<br />
chlorpromazine<br />
Butyrophenones<br />
Thorazine 30–1,000 mg/day drowsiness, jaundice, tremors,<br />
light sensitivity, dry mouth<br />
haloperidol Haldol 1–6 mg/day drowsiness, jaundice, tremors,<br />
light sensitivity, dry mouth<br />
Antimanic drugs<br />
lithium Eskalith must be individualized tremor, thirst, nausea<br />
*Underlined term = category of drug, italic term = drug class. Under each class is the generic and trade<br />
name.
294 Chapter 17: Therapeutic Interventions<br />
HANDOUT FOR DEMONSTRATION 7:<br />
SURVEY ON SOCIAL PROBLEMS<br />
Many of our society’s problems are listed below. For each, indicate the degree to which you think the<br />
problem could be eliminated within your lifetime if adequate money and other resources were put to<br />
work to prevent it.<br />
Within your lifetime, given adequate resources, how likely is it that this problem will be eliminated?<br />
Problem Very Likely Likely Unlikely Very Unlikely<br />
1. Illiteracy 4 3 2 1<br />
2. Homelessness 4 3 2 1<br />
3. Sexually transmitted diseases 4 3 2 1<br />
4. Mental retardation 4 3 2 1<br />
5. Domestic violence 4 3 2 1<br />
6. Schizophrenia 4 3 2 1<br />
7. Child abuse 4 3 2 1<br />
8. Suicide 4 3 2 1<br />
9. Cigarette smoking 4 3 2 1<br />
10. Unwanted pregnancies 4 3 2 1<br />
11. Gang violence 4 3 2 1<br />
12. Depression 4 3 2 1<br />
13. Heroin addiction 4 3 2 1<br />
14. Coronary heart disease 4 3 2 1<br />
15. Cancer 4 3 2 1<br />
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Chapter 17: Therapeutic Interventions 295<br />
SELECTED READINGS<br />
Andreason, N. C. (1986). The broken brain: The biological revolution in psychiatry. New York: Harper<br />
& Row.<br />
Bergin, A. E., & Garfield, S. L. (Eds.) (1994). Handbook of psychotherapy and behavior change (3rd<br />
ed.). New York: Wiley.<br />
Freedheim, D. K. (Ed.) (1992). History of psychotherapy: A century of change. Washington, DC:<br />
American Psychological Association.<br />
Schreter, R. K., Sharfstein, S. S., & Schreter, C. A. (Eds.) (1994). Allies and adversaries: The impact of<br />
managed care on mental health services. Washington, DC: American Psychiatric Press.<br />
Sue, D. W., & Sue, D. (1990). Counseling the culturally different: Theory and practice. New York:<br />
Wiley.<br />
Sattler, D., Shabatay, V., & Kramer, G. (1998). <strong>Abnormal</strong> psychology in context: Voices and<br />
perspectives. Boston, MA: Houghton Mifflin Company. Chapter 13, Individual and Group Therapy.<br />
VIDEO RESOURCES<br />
Asylum (video, color, 51 min). An outstanding documentary about St. Elizabeth’s Hospital in<br />
Washington, D.C., traces the history of psychiatric treatment. It gives credit to underpaid and<br />
overworked psychiatric staff. An excellent debate on the pros and cons of the asylum concept, and<br />
long-term care is a highlight. Director Cinema Limited, P.O. Box 69899, Los Angeles, CA 90069.<br />
Awareness (16 mm, color, 27 min). Dr. Frederick (Fritz) Perls shows how the gestalt method can teach<br />
individuals to increase their potential and to understand the idea of suffering. Films, Inc., 1144<br />
Wilmette Avenue, Wilmette, IL 60091.<br />
<strong>Behavior</strong> Therapy: An Introduction (16 mm, color, 29 min). Demonstrates the three forms of behavior<br />
therapy—classical conditioning, operant conditioning, and observational learning—and includes an<br />
interview with Joseph Wolpe. Pennsylvania State University Film Center, University Park, PA 16802.<br />
Demonstration of Gestalt Therapy (16 mm, color, 38 min). This film shows factors that speed up the<br />
therapeutic process and demonstrates gestalt therapy by working with a man’s recent fantasy.<br />
Emphasizes the importance of self-realization in therapy. Human Development Institute, 20 Executive<br />
Park West, Atlanta, GA 30329.<br />
Electroconvulsive Therapy (ECT): The Treatment, the Questions, the Answers (video, color, 16 min).<br />
This short video gives a clear, calm, and objective description of ECT without sidestepping the<br />
problems. The film uses real patients and interviews them about the experience. It discusses the benefits<br />
of unilateral ECT. University of Michigan Medical Center R-4440 Kresge 1, Box 56, Ann Arbor, MI<br />
48109-0010.<br />
Group Psychotherapy—The Dynamics of Change (16 mm, color, 32 min). This film presents six<br />
patients and a psychiatrist in a portion of a group psychotherapy session. It shows one patient who<br />
achieves a significant breakthrough toward self-understanding. Association Films, Inc., 512 Burlington<br />
Avenue, La Grange, IL 60525.<br />
Madness and Medicine: Parts I and II (16 mm, color, 21 and 28 min). Part I examines a mental<br />
institution and patients’ feelings about institutional life. Doctors and patients discuss medications used<br />
in therapy. Part II deals with issues in ECT and psychosurgery. Patients, family members, and doctors<br />
are interviewed, and reentry into community life is discussed. CRM Educational Films, 1011 Camino<br />
Del Mar, Del Mar, CA 92014.
296 Chapter 17: Therapeutic Interventions<br />
"An Ounce of Prevention" (13) from The World of <strong>Abnormal</strong> Psychology series (video, color, 60 min).<br />
This segment examines community-based projects (mostly primary prevention) at different points in the<br />
lifespan of the person: one for infants, one for adolescents, and one for middle-aged people. Each<br />
provides skills to participants but also examines environmental factors that produce disorders. To order,<br />
call The Annenberg/CBP Collection at 1-800-532-7637.<br />
Psychotherapy (16 mm, color, 26 min). This film depicts three phases in the therapist-client interaction<br />
(building trust, self-awareness, and working through) that are found in most psychotherapies. CRM<br />
Educational Films, 1011 Camino Del Mar, Del Mar, CA 92014.<br />
"Psychotherapy" (22) from the Discovering Psychology series (video, color, 28 min). Shows the<br />
relationships among theory, research, and practice and how cultural and social forces influence the<br />
treatment of psychological disorders. To order, call The Annenberg/CPB Collection at 1-800-532-7637.<br />
"Psychotherapies" (12) from The World of <strong>Abnormal</strong> Psychology series (video, color, 60 min). This<br />
segment demonstrates the three major forms of psychotherapy—psychodynamic, experiential, and<br />
cognitive-behavioral—and explains how they can be useful in individual and group work. To order, call<br />
The Annenberg/CBP Collection at 1-800-532-7637.<br />
Rational Emotive Therapy (16 mm, color, 30 min). This film shows Dr. Albert Ellis in practice. He<br />
explains his paradigm in which irrational beliefs determine the effect of events on feelings, and he<br />
presents alternatives to irrational self-talk. Research Press, Box 317740, Champaign, IL 61820.<br />
Social Network Therapy (video, color, 11 min). This very short video describes a unique approach to<br />
treatment: the coaching and convening of schizophrenics and their family and friends for the purpose of<br />
reducing social isolation and mobilizing continuing care. Actors enact situations; founder of the<br />
therapy, Ross Speck, narrates. Because of its brevity, the video glosses over the complexities of<br />
network therapy. Mental Health Library, 331 Dundas Street, East Toronto, Ontario Canada M5A 2A2.<br />
Token Economy (16 mm, color, 20 min). This film illustrates the use of tokens in an inpatient treatment<br />
program, and B. F. Skinner explains the approach. CRM Educational Films, 1011 Camino Del Mar, Del<br />
Mar, CA 92014.<br />
ON THE INTERNET<br />
http://www.appi.org is a brief descriptions of articles in recent issues of the American Journal of<br />
Psychiatry, Psychiatric News, and Journal of Psychotherapy: Practice and Research.<br />
http://www.rebt.org is the web site for the Albert Ellis Institute, which contains information on rational<br />
emotive behavior therapy<br />
http://www.mentalhealth.com/fr30.html which provides an extensive list of drugs used in the treatment<br />
of psychological disorders, including dosage, warnings, effects, and side effects<br />
http://helping.apa.org/brochure/index.html offers helpful information about when you might need a<br />
therapist and how to choose one<br />
Copyright © Houghton Mifflin Company. All rights reserved.
CHAPTER 18<br />
Legal and Ethical Issues in <strong>Abnormal</strong><br />
Psychology<br />
CHAPTER OUTLINE<br />
I. Mental health concerns can become legal and ethical issues<br />
A. Several example of the interaction of psychology and the legal system<br />
B. Tarasoff case concerns limits of confidentiality<br />
C. Ethics of therapist-client relationships<br />
II. Criminal commitment: the incarceration of an individual for having committed a crime<br />
A. Criminal law assumes free will and personal responsibility for actions<br />
B. Insanity defense: legal term (not psychological) arguing that defendant who admits to<br />
committing a crime is not guilty because of being mentally disturbed at the time<br />
1. Martin Ome cleverly deduced that Kenneth Bianchi was faking multiple personality<br />
2. Legal precedents<br />
a) M’Naghten Rule (England, 1843): at time of act, defendant did not know right<br />
from wrong or know what he or she was doing (purely cognitive)<br />
b) Irresistible impulse test: lacked will power to control behavior<br />
c) Durham standard (United States, 1954): products test (actions were the product of<br />
mental disease or defect)<br />
d) American Law Institute (ALI) Code (United States, 1962): “as a result of mental<br />
disease or defect he lacks substantial capacity either to appreciate the criminality<br />
of his conduct or to conform his conduct to the requirements of the law” (does<br />
not include antisocial personality as mental disease or defect)<br />
e) Diminished capacity: in some jurisdictions, often in sentencing phase; Dan White<br />
“Twinkies defense”<br />
3. Guilty, but mentally ill: adopted after John Hinckley verdict; Insanity Reform Act<br />
(1984) bases insanity solely on ability to understand what one did<br />
4. Thomas S. Szasz against insanity defense and involuntary commitment<br />
C. Competency to stand trial: defendant knows nature of proceedings and can assist in own<br />
defense (not mental state at time of crime)<br />
1. Much more common than insanity issue<br />
2. Jackson v. Indiana (1972)<br />
a) Prevents indefinite incarceration for incompetence without trial<br />
b) Protects due process<br />
III. Civil commitment: involuntary confinement of a person judged to be a danger to himself, herself,<br />
or others, even though the person has not committed a crime<br />
A. Negative effects: lifelong social stigma, lowered self-esteem, lost civil liberties<br />
B. Criteria for commitment<br />
1. Clear and imminent danger to self or others<br />
2. Unable to care for self and without communal support (most common reason)<br />
3. Unable to make responsible decisions<br />
4. In unmanageable state of panic<br />
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298 Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology<br />
C. Assessing dangerousness (the person's potential for doing harm to self or others): difficult to<br />
predict<br />
1. Clinicians usually overpredict dangerousness<br />
2. Mistakes due to rarity of the event (fewer than 10 percent of psychotic patients are<br />
assaultive), dangerousness situation-specific, best predictor is past conduct or history<br />
of violence<br />
D. Procedures in civil commitment<br />
1. Voluntary commitment preferred<br />
2. Involuntary (temporary action or longer detention after court hearing)<br />
a) Concerned person petitions the court<br />
b) Court hears testimony of two independent professionals as well as others<br />
c) Length of treatment usually finite (generally six to twelve months)<br />
3. Protection against involuntary commitment<br />
a) Critics argue that criminals have more rights than mentally ill (liberty denied in<br />
anticipation of actions)<br />
b) Opposite view: committed incapable of decision, will be grateful later<br />
4. Rights of mental patients<br />
a) Level of proof (Addington v. Texas, 1979): “clear and convincing evidence” (75<br />
percent sure)<br />
b) Least restrictive environment<br />
5. Right to treatment (constitutional right)<br />
a) Wyatt v. Stickney (1972): stipulates treatment, environmental standards if<br />
committed<br />
b) O’Connor v. Donaldson (1975): cannot confine nondangerous person capable of<br />
independent or supervised living<br />
c) Youngberg v. Romeo (1982): allows mental health professionals to define<br />
“treatment”<br />
6. Right to refuse treatment<br />
a) Rennie v. Klein (1978): people have constitutional right to refuse drug medication<br />
b) Rogers v. Okin (1979): supports Rennie<br />
c) Application to psychotherapy unclear<br />
IV. Deinstitutionalization: shifting responsibility for care of mental patients from large central<br />
institutions to agencies within local communities<br />
A. Produced a 75 percent decrease in average daily number of committed patients<br />
B. Reasons for deinstitutionalization<br />
1. Hospital may hinder recovery<br />
2. Patient rights; belief that mainstreaming in community can be accomplished by<br />
outpatient service or halfway house<br />
3. Insufficient state funds to treat<br />
C. Impact of deinstitutionalization<br />
1. Dumping; homeless mentally ill<br />
2. Lack of family and friends support system<br />
3. Criminalization<br />
4. Often low-quality care in nursing homes, group residences<br />
5. Alternative community programs have more positive outcomes<br />
V. The therapist-client relationship<br />
A. Confidentiality and privileged communication<br />
1. Confidentiality an ethical standard to protect clients from disclosure without their<br />
consent<br />
a) Disclose only as required by law<br />
b) Important in therapeutic relationship<br />
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Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology 299<br />
2. Privileged communication a narrower legal concept<br />
a) Client holds privilege of privileged communication<br />
b) Exemptions from privileged communication: civil or criminal commitment; client<br />
sues therapist; client under 16 and victim of crime; criminal action involved;<br />
client dangerous<br />
3. Exceptions from privileged communications<br />
a) Civil and criminal commitment<br />
b) Defense in a civil action<br />
c) Client is younger than sixteen or is a dependent elderly person who the therapist<br />
believes has been the victim of a crime<br />
d) Client is a danger to self or others<br />
B. The duty-to-warn principle (Tarasoff v. Board of Regents, 1976)<br />
1. Therapist must warn intended victim and others who might be with the victim<br />
2. Jaffee v. Redmond<br />
3. Criticism of the duty-to-warn principle<br />
a) The Family Law and Privacy Act<br />
C. Sexual relationships with clients<br />
1. Always unethical, according to every mental health organization<br />
2. Nationwide survey: 5.5 percent of male, 0.6 percent of female therapists admit to<br />
having had intercourse with clients<br />
3. Fosters dependency, objectivity is lost, client open to exploitation<br />
a) 90 percent of clients who had sexual involvement with therapist were adversely<br />
affected<br />
b) Committee on Women in Psychology of APA says sexual relationship between<br />
therapists and client is never the fault of the client<br />
4. Processes for revoking license of therapist for misconduct exist<br />
VI. Cultural Competence and the Mental Health Profession<br />
A. Cultural bound concepts of mental health and mental disorders (specific to middle-class,<br />
white, highly individualistic, ethnocentric population) result in misdiagnosis and<br />
inappropriate treatments that often victimize ethnic-minority clients<br />
B. Similar problems extend to other marginalized groups (women, homosexuals, the disabled)<br />
C. APA Code of Conduct<br />
1. Working with culturally different clients is unethical unless the mental health<br />
professional has adequate training and expertise in multicultural psychology<br />
2. A historic move by the American Psychological Association (2003), the council of<br />
representatives passed “Guidelines on multicultural education, training, research,<br />
practice and organizational change for psychologists”.<br />
LEARNING OBJECTIVES<br />
1. Describe the range of legal and ethical issues relevant to abnormal psychology. (pp. 595-600;<br />
Table 18.1)<br />
2. Define criminal commitment processes and discuss criminal law’s position on free will. (p. 600)<br />
3. Discuss the rationale for the insanity defense and the legal precedents that have shaped the current<br />
standing of the insanity defense, including the M’Naghten Rule, the irresistible impulse test, the<br />
Durham standard, the American Law Institute (ALI) Model Penal Code, and diminished capacity.<br />
(pp. 600-603)<br />
4. Discuss the arguments for and against the plea “guilty, but mentally ill,” including Thomas<br />
Szasz’s arguments against the insanity defense and involuntary commitment. (pp. 603-604)
300 Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology<br />
5. Describe the criteria for finding a defendant competent to stand trial and the procedures involved<br />
in determining it, including due process. (pp. 604-605)<br />
6. Describe the concept of civil commitment and the criteria by which individuals are committed.<br />
Explain why the assessment of dangerousness is difficult. (pp. 605-607)<br />
7. Explain the rationale for civil commitment, the procedures involved, and the protections that exist<br />
against its abuse. Outline the criticisms of civil commitment. (pp. 607-609)<br />
8. Discuss the key legal rulings concerning the rights of mental patients, including the level of proof<br />
necessary for commitment (Addington v. Texas), the least restrictive environment principle, and<br />
the right to treatment (Wyatt v. Stickney , O’Connor v. Donaldson, and Youngberg v. Romeo). (pp.<br />
609-611)<br />
9. Discuss the legal rulings concerning the right to refuse treatment (Rennie v. Klein and Rogers v.<br />
Okin) and the arguments for and against this right. Define the term least intrusive treatment. (pp.<br />
611-612)<br />
10. Discuss the reasons for and the impact of the deinstitutionalization of mental patients. Evaluate<br />
the present living conditions of many ex–mental hospital patients and the prospects for<br />
mainstreaming and alternative community programs. (pp. 612-614)<br />
11. Distinguish between the concepts of confidential and privileged communications. Discuss when<br />
therapists may disclose confidential information and where there are exemptions to privileged<br />
communications. (p. 614-615)<br />
12. Describe the duty-to-warn principle, the legal rulings related to it (Tarasoff v. Board of Regents of<br />
the University of California), and the criticisms of the duty-to-warn principle. (pp. 615-617)<br />
13. Identify the position of professional organizations on the issue of sexual intimacies between<br />
therapist and client. Discuss the research on the impact of therapists’ sexual involvement with<br />
clients. (pp. 617-619)<br />
14. Discuss how mental health professionals need to accommodate the changes in the ethnic profile of<br />
Americans. Describe the ethical guidelines for working with culturally different clients and the<br />
information in DSM-IV-TR that deals with multicultural influences. (pp. 619-621)<br />
CLASSROOM TOPICS FOR LECTURE AND DISCUSSION<br />
1. Pope and Tabachnick (1993) report the results of a national survey of 285 clinical and counseling<br />
psychologists, equally divided among men and women and those over and under the age of 45.<br />
From the 67-item survey, here are some thought-provoking results. In the table below is the<br />
percentage of psychologists who responded “rarely” or more often to each item. This survey is the<br />
source of the textbook authors’ comment that having sexual fantasies about clients is not<br />
uncommon, but losing control of behavior is extremely uncommon.<br />
Item Percentage responding “Rarely,”<br />
“Sometimes,” “Often,” or “Most<br />
Always”<br />
A client hugs you 89.1<br />
Feeling sexually attracted to a client 87.3<br />
A client flirts with you 87.0<br />
You hug a client 81.1<br />
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Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology 301<br />
A client tells you that he/she is sexually attracted to you 73.3<br />
You hold a client’s hand 60.4<br />
Feeling sexually aroused while in the presence of a client 57.9<br />
A client seems to become sexually aroused in your<br />
presence<br />
48.4<br />
A client kisses you 24.2<br />
You flirt with a client 19.6<br />
Client files a complaint against you (for example,<br />
malpractice, ethics)<br />
11.6<br />
You kiss a client 5.6<br />
Talking with a current client about sharing a sexual<br />
2.1<br />
relationship after termination of therapy<br />
Psychologists’ theoretical orientation had an effect on ratings. Psychodynamic therapists were<br />
more likely to experience clients flirting, clients becoming sexually aroused, and the therapist<br />
suggesting the client tell about sexual fantasies. Psychodynamically oriented therapists were less<br />
likely than others to hug, be hugged, or hold a client’s hand.<br />
Gender also had strong effects. Male therapists were more likely than female therapists to have<br />
had a client file a complaint (17 percent versus 6 percent). Female clients were more likely than<br />
male clients to have been hugged and seen as physically attractive by their therapists.<br />
Source: Pope, K. S., & Tabachnick, B. G. (1993). Therapists’ anger, hate, fear, and sexual<br />
feelings: National survey of therapist responses, client characteristics, critical events, formal<br />
complaints, and training. Professional Psychology: Research and Practice, 24, 142–152.<br />
Copyright © 1993 by the American Psychological Association. Reprinted with permission<br />
2. A flowchart diagram either drawn on the board or distributed as a handout can help students<br />
understand the general procedures in civil commitment and criminal cases, including competency<br />
hearings and the insanity defense. Because there are considerable differences between states, it is<br />
not possible to present such a flowchart here. (Consult with an attorney familiar with civil and<br />
criminal commitment who can describe correctly the specific procedures in your state.)<br />
A general map of the civil commitment terrain indicates that once someone (police, family, or<br />
social service agency) petitions the court for commitment, there are psychological evaluations, a<br />
hearing with counsel, and either release or confinement for a specific period or an indefinite<br />
period during which there is periodic review. Let students know that some variance often occurs<br />
between the process as described on paper and as it occurs in real life. For instance, although<br />
people who face civil commitment have the right to counsel, some studies show that attorneys<br />
meet and discuss the case with their clients for only a few minutes before the commitment<br />
hearing.<br />
In criminal cases the prosecution or defense (and often both) can question defendants’<br />
competency—their ability to understand the proceedings and assist rationally in their defense.<br />
Following psychological examinations, the court will either find the defendant competent, which<br />
leads to a trial, or find the dependent not competent, which leads to the same kind of confinement<br />
as in civil commitment. However, charges can be dropped and the person freed at this point. If,<br />
after a period of involuntary treatment, experts feel the person will not regain sufficient mental<br />
stability to be competent, either the defendant is released or a petition for civil commitment
302 Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology<br />
ensues. If the person is found competent to stand trial, the person may choose to plead not guilty<br />
by reason of insanity (NGBRI). If the verdict is NGBRI, the person is confined in a mental<br />
hospital until mental health experts report to the court that the person is no longer dangerous.<br />
There is no definite sentence or provision of parole or time off for good behavior. If the verdict is<br />
guilty, a sentencing hearing ensues at which time more psychological evidence is presented to<br />
determine the length of sentence in a penal facility.<br />
Emphasize to students the number of points in these procedures where mental health experts are<br />
asked to make evaluations, judgments, and predictions. At virtually every step in the process,<br />
expert testimony is requested. However, because the legal system is an adversarial one, the<br />
testimony is often conflicting and sometimes diametrically opposed. Coupled with the reliability<br />
problems in assessment mentioned in Chapter 3 and the time constraints due to the vast number of<br />
cases that must be processed, students should begin to see the opportunities for error that exist in<br />
the process. Still, the situation is far better than it was 50 percent ago when a person could be<br />
committed to a psychiatric facility for an indefinite period without any form of due process.<br />
Despite their comic value, you might mention the grim side of such movies as Arsenic and Old<br />
Lace and Harvey in this context.<br />
Internet site: http://www.nami.org the site of the National Alliance for the Mentally Ill, to check<br />
out issues concerning civil commitment<br />
3. Federal Judge Frank Johnson made a landmark decision in Wyatt v. Stickney. This class action suit<br />
was brought against the Commissioner of Mental Health in Alabama (Stickney) on behalf of<br />
Ricky Wyatt and other mentally retarded patients at a state hospital and school. Not only did<br />
Johnson declare that the state had failed to provide treatment, he described what adequate<br />
treatment entailed. You can contrast the dehumanizing conditions that existed in this facility with<br />
the requirements that Johnson stipulated.<br />
Before Wyatt, the state hospital housed patients in barnlike structures that had no privacy. There<br />
were no partitions between bathroom stalls, patients wore tattered clothing, and the wards were<br />
dark and filthy. The kitchens were unsanitary and the food was inedible—the state spent less than<br />
50 cents a day on food per patient. The patient-to-psychologist ratio was 1,000 to 1!<br />
Johnson required at least two psychiatrists, one doctoral-level psychologist, and two master’slevel<br />
social workers per 250 patients. No more than six patients were to be housed in a room, and<br />
screens or curtains had to be provided to afford privacy. No more than eight patients were to share<br />
one toilet facility, and separate stalls had to be provided to ensure privacy. Below is a more<br />
complete, but still partial, listing of patients’ rights Johnson specified:<br />
a. Right to privacy and to be treated with dignity<br />
b. Right to visitation and telephone privileges unless special restrictions apply<br />
c. Right to treatment under the least restrictive conditions that meet the purposes commitment<br />
was intended to serve<br />
d. Right to regular exercise and opportunities to spend time outdoors<br />
e. Right to suitable opportunities to interact with the opposite gender<br />
f. Right to refuse potentially hazardous treatments such as lobotomy, ECT, and aversive<br />
behavioral treatments<br />
g. Right to nutritionally balanced diets<br />
h. Right to wear their own clothing and keep personal possessions unless doing so proved to be<br />
dangerous or inappropriate to the treatment program<br />
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Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology 303<br />
i. Right not to be subject to experimental research unless their rights to informed consent are<br />
protected<br />
j. Protection from being kept in restraints or in isolation unless in emergency conditions where<br />
their safety or that of others is threatened<br />
k. Protection from being required to do work that is performed for the sake of maintaining the<br />
facility<br />
This ruling became the model for reforms nationwide and, to a great extent, is responsible for the<br />
infinitely better treatment that committed patients now receive. It is not too much to say that Judge<br />
Johnson was the Philippe Pinel of our age.<br />
Source: Wyatt v. Stickney, 334 F. Supp. 1341 (1972).<br />
CLASSROOM DEMONSTRATIONS & HANDOUTS<br />
1. The following demonstration can spark discussion about the value of the insanity defense. After<br />
each well-publicized insanity case hits the TV news, there is a strong emotional response from the<br />
public. One goal of this demonstration is to sensitize students to their own reactions to the insanity<br />
defense.<br />
In small groups (five to six people), have students read the Handout for Demonstration 1 and<br />
consider, individually, their responses to the situations. Then have them discuss their reactions<br />
with one another and explain their responses. Groups should then try to arrive at a consensus for<br />
each of the situations and report them to the rest of the class; these responses should also be listed<br />
on the board. Discuss whether levels of responsibility exist and whether the severity of a crime<br />
has any place in these deliberations; discuss the amount of emphasis that should be placed on<br />
expert testimony (particularly given the inevitable disagreements between prosecution and<br />
defense experts).<br />
As a final jolt, ask students whether their tolerance for the behavior of mental patients would<br />
change if, in each of the situations described in the handout, the victim were their mother!<br />
2. Divide the class into small groups, and instruct the groups that they have been asked by their local<br />
government to brainstorm ways of dealing with the problems of the discharged chronic mental<br />
patient. Each group must outline the following:<br />
a. What should mental hospitals do to increase the likelihood of successful patient adjustment<br />
in the community?<br />
b. What kinds of community supports are needed to increase the likelihood that former patients<br />
will develop stable living arrangements (either with family, independently, or with<br />
supervision)?<br />
c. What needs to be done to increase the community’s acceptance of discharged mental<br />
patients?<br />
d. What can be done to overcome the barriers discussed in question 3?<br />
This exercise will probably take an entire class period, but it can get students to appreciate the<br />
dilemmas that communities and professionals face in dealing with deinstitutionalization. It should<br />
also bring to the foreground the fact that money is a central issue in any of these debates.<br />
3. The success of therapy may be determined by ethnic and other cultural similarities or at least a<br />
willingness on the part of the therapist to modify interventions to accommodate cultural styles.<br />
This issue promises to become more widespread as the United States becomes more culturally<br />
diverse. Ask for student volunteers to role-play an assessment interview in which a therapist is all
304 Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology<br />
wrong for the client, being insensitive about gender issues as well as racial and social concerns.<br />
Ask the class to identify the problem areas and recommend specific changes that might make the<br />
interaction more successful. Then ask either the original volunteers or others to reenact the<br />
interview with greater cultural sensitivity. Finish the activity by asking if such sensitivity is a<br />
moral responsibility or simply a “nice thing to do.” Note that the textbook authors consider<br />
cultural sensitivity a moral and ethical obligation.<br />
4. The Ellie Nesler case was a very famous case in the national media and is appropriate for a group<br />
discussion activity. To review, Ellie Nesler, 41, shot and killed Daniel Driver in a Jamestown,<br />
California, courtroom on April 2, 1993. She smuggled the weapon into the courtroom and shot<br />
Driver five times. Driver had been on trial for molesting Nesler’s 6-year-old son.<br />
Divide the class into groups of eight to twelve members. Distribute the two-page handout for this<br />
activity. Each person should read the facts of the case and then decide Nesler’s guilty or insanity<br />
using the four tests for insanity. You may need to remind students of the legal language used for<br />
each test. You can put this information on the board, ask them to look it up in the text, provide a<br />
handout, or tell them verbally. Be sure they understand the differences. Like jurors, after they vote<br />
individually, they should discuss their reasoning and the group should attempt to arrive at a<br />
consensus. You may even want to have them assign a jury foreperson who will report the group’s<br />
“deliberations and verdict” to the class.<br />
Record on the board similarities and differences in judgments by each group. Ask for explanations<br />
of differences. Clarify any misconceptions students have about the four standards. Tell students<br />
that the jury in the case found Nesler guilty of voluntary manslaughter (she killed in the heat of<br />
passion, not after deliberation as in first-degree murder). She was found legally responsible for her<br />
actions, but the jury conceded that some mental disorders existed and that they hoped Nesler<br />
would receive psychological therapy. Point out the subjective judgments that are made in these<br />
cases. Note also that the M’Naghten standard is used exclusively at the federal level, whereas the<br />
states have various standards and, in a few, there is no insanity defense at all.<br />
Internet site: http://www.wisecounty.com/themuse/Column24.htm to read a press release on the<br />
Ellie Nesler case<br />
5. An ethical question that students should consider is summed up in the acronym NIMBY, which<br />
stands for “Not In My Back Yard.” At the end of a course in abnormal psychology, students are<br />
often more aware of the problems of people with mental disorders. They appreciate the need for<br />
more humane and community-based treatment and prevention services. However, are they ready<br />
to have direct contact with such people?<br />
Ask students to imagine that a halfway house for individuals with problems is to be located on<br />
their street at home. You can vary the clientele of the halfway house, from clearly innocent<br />
victims (abused children) to more “dangerous” individuals (alcoholic women or adults with<br />
mental retardation) to very “dangerous” individuals (ex-prison inmates). Ask students how the<br />
neighborhood would react, how their parents would react, and how they would feel. In what<br />
neighborhoods would such halfway houses be acceptable? For what kind of clients? Discuss with<br />
students the problem of citing community services in unsafe areas. Suggest that, having taken this<br />
course, they can help dispel myths about the dangerousness and incurability of people with mental<br />
disorders.<br />
6. Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask each group to develop a list of examples on the following topic, with the most<br />
salient examples first. Discuss the role of managed care in mental health services as a<br />
controversial issue. Ask the students how they would feel if their insurance provider chose to limit<br />
the number of visits they are allowed to see a therapist. Ask the students to discuss what other<br />
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Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology 305<br />
barriers to mental health treatment exist. What would the members of the discussion group do to<br />
make mental health services available for all who need them?<br />
7. The following demonstration can spark discussion about the value of the insanity defense. After<br />
each well-publicized insanity case hits the TV news, there is a strong emotional response from the<br />
public. One goal of this demonstration is to sensitize students to their own reactions to the<br />
insanity defense.<br />
Have the students form small groups of 4-7 individuals depending on your class size and space<br />
limitations. Ask each group to develop a list of examples on the following topic with the most<br />
salient examples first. Each group could then have a spokesperson deliver a short talk about the<br />
best examples. You could provide a blank overhead transparency to each group at the beginning<br />
of this demonstration.<br />
Discuss whether levels of responsibility exist for the defendant and whether the severity of a<br />
crime has any place in courtroom deliberations. Then discuss the amount of emphasis that should<br />
be placed on expert testimony (particularly given the inevitable disagreements between<br />
prosecution and defense experts). Use the most recent national or regional court case as an<br />
example to start the discussion.
306 Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology<br />
HANDOUT FOR DEMONSTRATION 1: THE INSANITY DEFENSE<br />
For each of the situations described, decide how you would feel about the defendant’s being found not<br />
guilty by reason of insanity (NGBRI). Be as honest as you can be.<br />
1. A woman sitting in a fast food restaurant is shot in the back and paralyzed for life. The person<br />
who fired the shot is John, a mentally retarded young man who says he found the loaded gun and<br />
was playing with it in the restaurant. “I just wanted to see what would happen if I pulled the<br />
trigger,” he says. Psychological assessments indicate that he is moderately retarded and did not<br />
know that what he was doing was against the law.<br />
Is John responsible for his actions (NGBRI fails)?<br />
Definitely Probably Not Not Sure Probably Definitely<br />
Not Guilty Guilty<br />
Guilty Guilty<br />
1 2 3 4 5<br />
2. A woman sitting in a fast food restaurant is shot in the back and paralyzed for life. The person<br />
who fired the shot is Bill, a chronic schizophrenic young man who says he had seen the woman<br />
looking at him the way the devil does. “I must protect myself from demons—and she was one,” he<br />
says. Psychological assessments indicate that, at the time of the crime, Bill’s delusions prevented<br />
him from acting in any other way.<br />
Is Bill responsible for his actions (NGBRI fails)?<br />
Definitely Probably Not Not Sure Probably Definitely<br />
Not Guilty Guilty<br />
Guilty Guilty<br />
1 2 3 4 5<br />
3. A woman sitting in a fast food restaurant is shot in the back and paralyzed for life. The person<br />
who fired the shot is Pete, a chemically dependent young man who says he was drunk and high<br />
when he saw a woman who looked like his ex-girlfriend. “I was so out of my mind on drugs that<br />
she looked like my old lady,” he says. Psychological assessments indicate that, at the time of the<br />
crime, Pete was suffering from a chemically induced organic brain syndrome called delirium.<br />
Is Pete responsible for his actions (NGBRI fails)?<br />
Definitely Probably Not Not Sure Probably Definitely<br />
Not Guilty Guilty<br />
Guilty Guilty<br />
1 2 3 4 5<br />
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Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology 307<br />
HANDOUT FOR DEMONSTRATION 4:<br />
DECIDING WHETHER ELLIE NESLER WAS NOT GUILTY<br />
BY REASON OF INSANITY<br />
Ellie Nesler, 41, shot and killed Daniel Driver in a Jamestown, California, courtroom on April 2, 1993.<br />
She smuggled the weapon into the courtroom and shot Driver five times. Driver had been on trial for<br />
molesting Nesler’s 6-year-old son.<br />
The defense argued that Nesler was insane at the time of the crime. Here are the defense’s arguments:<br />
1. Nesler had lived in violent family environments. Her alcoholic father often battered her mother,<br />
she was attacked when she tried to shield her mother and two younger sisters from her father, and<br />
she was molested at the age of 3 and was sexually abused by at least three other men. As a child<br />
she had thoughts of suicide. She, therefore, had a history of trauma that made her psychologically<br />
vulnerable.<br />
2. Nesler discovered that her 6-year-old son had been molested by Daniel Driver, a man Nesler<br />
trusted but did not know was a convicted child molester. She was racked with guilt knowing she<br />
had entrusted her son to this man. During the three percent when Driver was sought by law<br />
enforcement for the molestation, the son (Danny) lived in constant fear that Driver would find and<br />
harm him.<br />
3. Nesler saw “secret signs” from the routine comments of friends and relatives that ordered her to<br />
kill Driver. These caused her to smuggle a pistol into the courtroom and kill Driver.<br />
4. Several mental health professionals evaluated Nesler and, although their diagnoses varied, one<br />
included brief reactive psychosis and another posttraumatic stress disorder.<br />
The prosecution argued that Nesler did not act like an insane person and should be found guilty of the<br />
crime. Here are the prosecution’s arguments:<br />
1. Nesler’s behaviors leading up to the crime were planned and deliberate. She admitted that she<br />
wanted to see if Driver would be remorseful before shooting him. She wanted to see if he would<br />
“cop a plea” (accept a level of guilt for his actions rather than plead not guilty).<br />
2. She checked to see if a deputy whom she had befriended would get in trouble if Driver was killed.<br />
3. She made sure no children were present in the courtroom so they would not witness the shooting.<br />
4. Several mental health professionals with credentials equal to the defense’s evaluated Nesler and<br />
argued that she had the ability to distinguish right from wrong.<br />
Consider all the information presented here and decide individually, Was Ellie Nesler insane at the time<br />
she shot Daniel Driver? Next, individually, check for each test of insanity on the next page whether<br />
Nesler was guilty or not guilty by reason of insanity. Be prepared to defend your judgments.<br />
Now reveal your verdicts to others in your group. See if, like real juries, you can come to a consensus<br />
on Nesler’s guilt or insanity. Would it differ or remain the same for each of the four insanity tests? Be<br />
prepared to report your group’s decision and its rationale to the rest of the class.<br />
Verdict<br />
M’Naghten<br />
Rule<br />
Irresistible<br />
Impulse<br />
Durham<br />
Rule<br />
ALI<br />
Guidelines<br />
Guilty ___________ ___________ ___________ ___________<br />
Not Guilty ___________ ___________ ___________ ___________
308 Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology<br />
Rationale for M’Naghten Rule:<br />
Rationale for Irresistible Impulse:<br />
Rationale for Durham Rule:<br />
Rationale for ALI Guidelines:<br />
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Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology 309<br />
SELECTED READINGS<br />
Appelbaum, P. A. (1994). Almost a revolution: Mental health law and the limits of change. New York:<br />
Oxford University Press.<br />
Corey, G., Corey, M. S., & Callanan, P. (1993). Issues and ethics in the helping professions (4th ed.).<br />
Pacific Grove, CA: Brooks/Cole.<br />
McNeil, D. E., & Binder, R. L. (1986). Violence, civil commitment, and hospitalization. Journal of<br />
Nervous and Mental Disease, 174, 107–111.<br />
Nietzel, M. T., & Dillehay, R. C. (1986). Psychological consultation in the courtroom. New York:<br />
Pergamon.<br />
Wrightsman, L. S. (1987). Psychology and the legal system (2nd ed.). Pacific Grove, CA: Brooks/ Cole.<br />
VIDEO RESOURCES<br />
Bitter Welcome (16 mm, 35 min). This film shows the effects of labeling on a newly discharged mental<br />
patient and his efforts to overcome community stigmatization. Psychological Cinema Register,<br />
Pennsylvania State University, University Park, PA 16802.<br />
Bold New Approach (16 mm, 59 min). This film from the mid-1960s depicts the dream of<br />
deinstitutionalization: community facilities available to all mental patients. Offers an interesting<br />
counterpoint to current concerns about unsupported chronically mentally ill patients. Psychological<br />
Cinema Register, Pennsylvania State University, University Park, PA 16802.<br />
Interrupted Lives (video, color, 60 min). This video describes the problems of people with chronic<br />
mental illness who have neither hospital nor community resources available. It argues for community<br />
integration. Boston University Center for Rehabilitation, Research, and Training in Mental Health,<br />
1019 Commonwealth Avenue, Boston, MA 02215.<br />
Operation Reentry (16 mm, 30 min). Demonstrates the successful rehabilitation of mental patients in<br />
the Palo Alto, California, VA hospital. Shows former patients as advisors to those preparing for<br />
independent living. Indiana University Audio-Visual Center, Bloomington, IN 47405.<br />
Storefronts (16 mm, 28 min). Documentary film that shows the community mental health services<br />
offered in Harlem as an extension of Lincoln Hospital. Contemporary Films, McGraw-Hill Book<br />
Company, 1221 Avenue of the Americas, New York, NY 10020.<br />
Back from Madness: The Struggle for Sanity (VHS, color, 53 mm.). Follows four psychiatric patients<br />
from the time they are admitted to Massachusetts General Hospital and for several years afterward.<br />
Films for the Humanities and Sciences. 1-800-257-5126.<br />
Committed in Error: The Mental Health System Gone Mad (VHS, color, 64 mm.). The story of a man<br />
incarcerated and forgotten in a mental health institution for sixty-six years. Films for the Humanities<br />
and Sciences. 1-800-257-5126.<br />
The Psychopathic Mind (VHS, color, 27 mm.). Describes the characteristics of a psychopath and how<br />
they are classified. Films for the Humanities and Sciences. 1-800-257-5126.<br />
ON THE INTERNET<br />
http://www.fbi.gov/ includes the FBI's "Ten Most Wanted" list of fugitives, as well as employment<br />
opportunities and general information on the FBI.
310 Chapter 18: Legal and Ethical Issues in <strong>Abnormal</strong> Psychology<br />
http://www.priory.com/forpsy.htm is useful for the study of forensic psychiatry with a number of links<br />
to articles on topics associated with the field.<br />
http://www.geocities.com/Athens/7429/psychlaw.html is a large resource page with many links, court<br />
cases, and journal references.<br />
http://www.aapl.org/ethics.htm is the Web site for the American Academy of Psychiatry and the Law,<br />
which is dedicated to the highest standards of practice in forensic psychiatry.<br />
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