Chapter 3 Models of Abnormality Karen Clay Rhines, Ph.D.

Chapter 3 Models of Abnormality Karen Clay Rhines, Ph.D.
Seton Hall University Chapter 3 Models of Abnormality 1

Comer, Abnormal Psychology, 6e
Models of Abnormality Paradigms: the perspectives used to explain phenomena (abnormal behavior for this class) Biological model Psychodynamic model Behavioral model Cognitive model Humanistic-Existential model Sociocultural model Comer, Abnormal Psychology, 6e 2

The Biological Model Takes a medical perspective Main focus is that psychological abnormality is an illness brought about by malfunctioning parts of the organism Typically focused on the brain Comer, Abnormal Psychology, 6e 3

How Do Biological Theorists Explain Abnormal Behavior?
Brain chemistry Researchers have identified dozens of NTs Examples: serotonin, dopamine, and GABA Studies indicate that abnormal activity in certain NTs can lead to specific mental disorders Examples: depression (serotonin and norepinephrine) and anxiety (GABA) Comer, Abnormal Psychology, 6e 5

Brain chemistry Additionally, researchers have learned that mental disorders are sometimes related to abnormal chemical activity in the endocrine system Hormone release, triggered by a variety of factors, propels body organs into action. Abnormal secretions have been linked to psychological disorders Example: cortisol release is related to anxiety and mood disorders Comer, Abnormal Psychology, 6e 6

Sources of biological abnormalities – Genetics Humans have 23 pairs of chromosomes, each with numerous genes that control the characteristics and traits a person inherits Studies suggest that inheritance plays a part in mood disorders, schizophrenia, mental retardation, Alzheimer’s disease, and other mental disorders Aren’t able (yet) to identify specific genes Don’t know the extent to which genetic factors contribute to disorders Seems no SINGLE gene is responsible for a particular behavior or disorder Comer, Abnormal Psychology, 6e 7

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Sources of biological abnormalities – Viral infections Infection provides another possible source of abnormal brain structure or biochemical dysfunction Example: schizophrenia and prenatal viral exposure Interest in viral explanations of psychological disorders has been growing in the past decade Example: anxiety and mood disorders Comer, Abnormal Psychology, 6e 9

Biological Treatments
Biological practitioners attempt to pinpoint the physical source of dysfunction to determine the course of treatment Three types of biological treatment: Drug therapy Electroconvulsive therapy (ECT) Psychosurgery Comer, Abnormal Psychology, 6e 10

Electroconvulsive therapy (ECT): Currently experiencing a revival Used for depression when drugs and other therapies have failed In 60% of cases, ECT can lift symptoms within a few weeks Comer, Abnormal Psychology, 6e 11

Psychosurgery (or neurosurgery): Historical roots in trephination 1930s = first lobotomy Much more precise than in the past Considered experimental and used only in extreme cases Comer, Abnormal Psychology, 6e 12

Assessing the Biological Model
Strengths: Enjoys considerable respect in the field Fruitful Creates new therapies Suggests new avenues of research Weaknesses: Can limit rather than enhance our understanding Too simplistic Evidence is incomplete or inconclusive Treatments produce significant undesirable (negative) effects Comer, Abnormal Psychology, 6e 13

Sometimes a cigar is just a cigar!
Comer, Abnormal Psychology, 6e 14

The Psychodynamic Model
Oldest and most famous psychological model Based on belief that a person’s behavior (whether normal or abnormal) is determined largely by underlying dynamic psychological forces of which she or he is not aware Abnormal symptoms are the result of conflict among these forces Father of psychodynamic theory and psychoanalytic therapy: Sigmund Freud (1856 – 1939) Comer, Abnormal Psychology, 6e 15

How Did Freud Explain Normal and Abnormal Functioning?
Freud says abnormal behavior is caused by three UNCONSCIOUS forces: Id – guided by the Pleasure Principle Instinctual needs, drives, & impulses Sexual; fueled by libido (sexual energy) Ego – guided by the Reality Principle Seeks gratification but guides us to know when we can & can’t express our wishes Ego defense mechanisms protect us from anxiety Comer, Abnormal Psychology, 6e 16

Caused by three UNCONSCIOUS forces: Superego – guided by the Morality Principle Conscience; unconsciously adopted from our parents These three parts of the personality are often in conflict A healthy personality is one in which compromise exists among the three forces If the id, ego, and superego are in excessive conflict, the person’s behavior may show signs of dysfunction Comer, Abnormal Psychology, 6e 17

Developmental stages Freud proposed that at each stage of development, new events and pressures require adjustment in the id, ego, and superego If successful → personal growth If unsuccessful → fixation at an early developmental stage, leading to psychological abnormality Because parents are the key figures in early life, they are often seen as the cause of improper development Comer, Abnormal Psychology, 6e 18

Developmental stages Oral (0 to 18 months of age) Anal (18 months to 3 years of age) Phallic (3 to 5 years of age) Latency (5 to 12 years of age) Genital (12 years of age to adulthood) Comer, Abnormal Psychology, 6e 19

How Do Other Psychodynamic Explanations Differ from Freud’s?
Although current models deviate from Freud’s in important ways, each retains the belief that human functioning is shaped by dynamic (interacting) forces: Ego theorists Emphasize the role of the ego; consider it independent Self theorists Emphasize the unified personality over any one component Object-relations theorists Emphasize the human need for interpersonal relationships Comer, Abnormal Psychology, 6e 20

Psychodynamic Therapies
Range from Freudian psychoanalysis to more modern therapies All seek to uncover past trauma and inner conflicts Understanding early life experience critically important Therapist acts as “subtle guide” Comer, Abnormal Psychology, 6e 21

Utilize various techniques: Free association Therapist interpretation Resistance Transference Dream interpretation Catharsis Working through Comer, Abnormal Psychology, 6e 23

Assessing the Psychodynamic Model
Strengths: First to recognize importance of psychological theories & treatment Saw internal conflict as important source of psychological health and abnormality First to apply theory and techniques systematically to treatment – monumental impact on the field Weaknesses: Unsupported ideas; difficult to research Non-observable Inaccessible to human subject (unconscious) Comer, Abnormal Psychology, 6e 24

The Behavioral Model Like the psychodynamic perspective, behaviorism is deterministic, and is based on the idea that our actions are determined largely by our life experiences Emphasizes observable behavior and environmental factors Focuses on how behavior is acquired (learned) and maintained over time Comer, Abnormal Psychology, 6e 25

The Behavioral Model Historical beginnings in laboratories where conditioning studies were conducted Three forms of conditioning (learning): Operant conditioning Modeling Classical conditioning May produce normal or abnormal behavior Comer, Abnormal Psychology, 6e 26

How Do Behaviorists Explain Abnormal Functioning?
Operant conditioning Organism “operates” on environment and produces an effect Humans and animals learn to behave in certain ways as a result of receiving rewards whenever they do so Comer, Abnormal Psychology, 6e 27

Modeling Individuals learn behavioral responses by observing and repeating behavior No direct reinforcement Comer, Abnormal Psychology, 6e 28

Classical conditioning Learning by temporal association When two events repeatedly occur close together in time, they become fused in a person’s mind; before long, the person responds in the same way to both events Father of classical conditioning: Ivan Pavlov (1849 – 1936) Classic study using dogs & meat powder Comer, Abnormal Psychology, 6e 29

Classical Conditioning
US Meat UR Salivate US Meat Tone UR Salivate + CS Tone CR Salivate Comer, Abnormal Psychology, 6e 30

Classical conditioning If, after conditioning, the CS is repeatedly presented alone, it will eventually stop eliciting the CR This process is called extinction Explains many familiar behaviors (both normal and abnormal) Comer, Abnormal Psychology, 6e 31

Behavioral Therapies Aim is to identify the behaviors that are causing problems and replace them with more appropriate ones May use classical conditioning, operant conditioning, or modeling Therapist is “teacher” rather than healer Early life experiences important only in providing clues to current learning Comer, Abnormal Psychology, 6e 32

Behavioral Therapies Classical conditioning treatments may be used to change abnormal reactions to particular stimuli Example: systematic desensitization for phobia Step-by-step procedure Learn relaxation skills Develop a fear hierarchy Confront feared situations (covertly or in vivo) Comer, Abnormal Psychology, 6e 33

Assessing the Behavioral Model
Strengths: Powerful force in the field Rooted in empiricism Phenomena can be observed and measured Significant research support for behavioral therapies Weaknesses: Too simplistic Unrealistic Downplays role of cognition New focus on self- efficacy, social cognition, and cognitive- behavioral theories Comer, Abnormal Psychology, 6e 34

The Cognitive Model Seeks to account for behavior by studying the ways in which the person attends to, interprets, and uses available information Argues that clinicians must ask questions about assumptions, attitudes, and thoughts of a client Concerned with internal processes Present-focused Comer, Abnormal Psychology, 6e 36

How Do Cognitive Theorists Explain Abnormal Functioning?
Maladaptive thinking is the cause of maladaptive behavior Several kinds of faulty thinking: Faulty assumptions and attitudes Illogical thinking processes Example: overgeneralization Comer, Abnormal Psychology, 6e 37

Cognitive Therapies People must be taught a new way of thinking to prevent maladaptive behavior Main model: Beck’s Cognitive Therapy The goal of therapy is to help clients recognize and restructure their thinking Therapists guide clients to challenge dysfunctional thoughts, try out new interpretations, and apply new ways of thinking in their daily lives Widely used in treating depression Comer, Abnormal Psychology, 6e 38

Assessing the Cognitive Model
Strengths: Very broad appeal Clinically useful & effective Focuses on a uniquely human process Correlation between symptoms and maladaptive cognition Therapies effective in treating several disorders Adapt well to technology Research-based Weaknesses: Singular, narrow focus Overemphasis on the present Limited effectiveness Verification of cognition is difficult Precise role is hard to determine Comer, Abnormal Psychology, 6e 39

The Humanistic-Existential Model
Combination model The humanist view Emphasis on people as friendly, cooperative, and constructive; focus on drive to self-actualization The existentialist view Emphasis on self-determination, choice, and individual responsibility; focus on authenticity Comer, Abnormal Psychology, 6e 40

Rogers’ Humanistic Theory and Therapy
Basic human need for unconditional positive regard If received, leads to unconditional self-regard If not, leads to “conditions of worth” Incapable of self-actualization because of distortion – don’t know what they really need, etc. Rogers’ “client-centered” therapy Therapist provides unconditional positive regard Both accurate & genuine in reflection (reflective listening) Focus on the “experiencing person” Little research support Comer, Abnormal Psychology, 6e 41

Existential Theories and Therapy
Psychological dysfunction is caused by self- deception: people hide from life’s responsibilities and fail to recognize that it is up to them to give meaning to their lives Therapy is focused on patient acceptance of personal responsibility and recognition of freedom of action Goals more important than technique Great emphasis placed on client-therapist relationship Comer, Abnormal Psychology, 6e 42

Assessing the Humanistic-Existential Model
Strengths: Emphasizes the individual Taps into domains missing from other theories Non-deterministic Optimistic Emphasizes health Weaknesses: Focuses on abstract issues Difficult to research Not much influence Weakened by disapproval of scientific approach Changing somewhat Comer, Abnormal Psychology, 6e 43

The Sociocultural Model
Argues that abnormal behavior is best understood in light of the social and cultural forces that influence an individual Addresses norms and roles in society Influenced by sociology and anthropology Argues that we must examine a person’s social surroundings to understand their (abnormal) behavior Comer, Abnormal Psychology, 6e 44

How Do Sociocultural Theorists Explain Abnormal Functioning?
Focus on: Societal labels & roles Diagnostic labels (example: Rosenhan study) Sick role Social networks and support Comer, Abnormal Psychology, 6e 45

Focus on: Family structure and communication Family systems theory = abnormal functioning within family leads to abnormal behavior (insane behavior becomes sane in an insane environment) Examples: enmeshed, disengaged structures Comer, Abnormal Psychology, 6e 46

Focus on: Culture Set of values, attitudes, beliefs, history, and behaviors shared by a group of people and communicated from one generation to the next “Multicultural” psychology is a growing field of study Comer, Abnormal Psychology, 6e 47

Focus on: Religion and spirituality For most of the twentieth century, clinical scientists viewed religion as a negative factor in mental health but this alienation now seems to be ending: Researchers have begun to systematically study the influence of religion and spirituality on mental health Many therapists now address spiritual issues when treating religious clients Comer, Abnormal Psychology, 6e 48

Sociocultural Treatments
May include traditional individual therapy Broadened therapy to include: Culturally sensitive therapy Group therapy Family therapy Couple therapy Community treatment Includes prevention work Comer, Abnormal Psychology, 6e 49

Assessing the Sociocultural Model
Strengths: Added greatly to the clinical understanding of abnormality Increased awareness of labeling Clinically successful when other treatments have failed Weaknesses: Research is difficult to interpret Correlation  causation Model unable to predict abnormality in specific individuals Comer, Abnormal Psychology, 6e 50

Integration of the Models
Each perspective is valuable to understanding abnormal behavior Different perspectives are more appropriate under differing conditions An integrative approach provides a general framework for thinking about abnormal behavior, and also allows for specification of the factors that are especially pertinent to particular disorders Comer, Abnormal Psychology, 6e 52

Many theorists, clinicians, and practitioners adhere to a biopsychosocial model Abnormality results from the interaction of genetic, biological, developmental, emotional, behavioral, cognitive, social, and societal influences Also popular: Diathesis-stress approach Diathesis = predisposition (bio, psycho, or social) Reciprocal effects explanation Comer, Abnormal Psychology, 6e 53

Integrative therapists are often called “eclectic” – taking the strengths from each model and using them in combination Comer, Abnormal Psychology, 6e 54

Chapter 4 Clinical Assessment, Diagnosis, and Treatment
Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 4 Clinical Assessment, Diagnosis, and Treatment Comer, Fundamentals of Abnormal Psychology, 3e 55

Clinical Assessment: How and Why Does the Client Behave Abnormally?
What is assessment? The collecting of relevant information in an effort to reach a conclusion Clinical assessment is used to determine how and why a person is behaving abnormally and how that person may be helped Focus is idiographic – on an individual person Also may be used to evaluate treatment progress Comer, Fundamentals of Abnormal Psychology, 3e 56

Clinical Assessment: How and Why Does the Client Behave Abnormally?
The specific tools used in an assessment depend on the clinician’s theoretical orientation Hundreds of clinical assessment tools have been developed and fall into three categories: Clinical interviews Tests Observations Comer, Fundamentals of Abnormal Psychology, 3e 57

Characteristics of Assessment Tools
To be useful, assessment tools must be standardized and have clear reliability and validity To standardize a technique is to set up common steps to be followed whenever it is administered One must standardize administration, scoring, and interpretation Comer, Fundamentals of Abnormal Psychology, 3e 58

Reliability refers to the consistency of a test A good test will yield the same results in the same situation Two main types: Test–retest reliability To test for this type of reliability, a subject is tested on two different occasions and the scores are correlated – the higher the correlation, the greater the test’s reliability Interrater reliability Independent judges agree on how to score and interpret a particular test Comer, Fundamentals of Abnormal Psychology, 3e 59

Validity refers to the accuracy of a test’s results A good test must accurately measure what it is supposed to be measuring Three specific types: Face validity – a test appears to measure what it is supposed to measure; does not necessarily indicate true validity Predictive validity – a test accurately predicts future characteristics or behavior Concurrent validity – a test’s results agree with independent measures assessing similar characteristics or behavior Comer, Fundamentals of Abnormal Psychology, 3e 60

Comer, Fundamentals of Abnormal Psychology, 3e
Clinical Interviews Conducting the interview Focus depends on theoretical orientation Can be either unstructured or structured In unstructured interviews, clinicians ask open- ended questions In structured interviews, clinicians ask prepared questions, often from a published interview schedule May include a mental status exam Comer, Fundamentals of Abnormal Psychology, 3e 61

Clinical Interviews Limitations: May lack validity or accuracy Interviewers may be biased or may make mistakes in judgment Interviews, particularly unstructured ones, may lack reliability Comer, Fundamentals of Abnormal Psychology, 3e 62

Clinical Tests Devices for gathering information about a few aspects of a person’s psychological functioning, from which broader information can be inferred More than 500 different tests are in use They fall into six categories… Comer, Fundamentals of Abnormal Psychology, 3e 63

Clinical Tests Projective tests Responses come from the unconscious mind Mainly used by psychodynamic practitioners Most popular: Rorschach Test Thematic Apperception Test Sentence Completion Test Drawings Comer, Fundamentals of Abnormal Psychology, 3e 64

Clinical Test: Rorschach Inkblot
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Clinical Test: Thematic Apperception Test

Clinical Test: Sentence-Completion Test
“I wish ___________________________” “My father ________________________” Comer, Fundamentals of Abnormal Psychology, 3e 67

Clinical Test: Drawings
Draw-a-Person (DAP) test: “Draw a person” “Draw another person of the opposite sex” Comer, Fundamentals of Abnormal Psychology, 3e 68

Clinical Tests Projective tests Strengths and weaknesses: Helpful for providing “supplementary” information Have rarely demonstrated much reliability or validity May be biased against minority ethnic groups Comer, Fundamentals of Abnormal Psychology, 3e 69

Clinical Tests Personality inventories Designed to measure broad personality characteristics Focus on behaviors, beliefs, and feelings Usually based on self-reported responses Most widely used: Minnesota Multiphasic Personality Inventory For Adults: MMPI (original) or MMPI-2 (1989 revision) For Adolescents: MMPI-A Comer, Fundamentals of Abnormal Psychology, 3e 70

Clinical Test: MMPI Minnesota Multiphasic Personality Inventory
Consists of 550 self-statements that can be answered “true,” “false,” or “cannot say” Statements describe physical concerns; mood; morale; attitudes toward religion, sex, and social activities; and psychological symptoms Assesses careless responding & lying Comer, Fundamentals of Abnormal Psychology, 3e 71

Clinical Test: MMPI Minnesota Multiphasic Personality Inventory
Comprised of ten clinical scales: Hypochondriasis (HS) Depression (D) Conversion hysteria (Hy) Psychopathic deviate (PD) Masculinity-femininity (Mf) Scores range from 0 – 120 Above 70 = deviant Graphed to create a “profile” Paranoia (P) Psychasthenia (Pt) Schizophrenia (Sc) Hypomania (Ma) Social introversion (Si) Comer, Fundamentals of Abnormal Psychology, 3e 72

Clinical Tests Personality inventories Strengths and weaknesses: Easier, cheaper, and faster to administer than projective tests Objectively scored and standardized Appear to have greater validity than projective tests Measured traits often cannot be directly examined – how can we really know the assessment is correct? Tests fail to allow for cultural differences in responses Comer, Fundamentals of Abnormal Psychology, 3e 74

Clinical Tests Response inventories Usually based on self-reported responses Focus on one specific area of functioning Affective inventories (example: Beck Depression Inventory) Social skills inventories Cognitive inventories Comer, Fundamentals of Abnormal Psychology, 3e 75

Clinical Tests Response inventories Strengths and weaknesses: Have strong face validity Rarely include questions to assess careless or inaccurate responding Not all have been subjected to careful standardization, reliability, and/or validity procedures (BDI and a few others are exceptions) Comer, Fundamentals of Abnormal Psychology, 3e 77

Clinical Tests Psychophysiological tests Measure physiological response as an indication of psychological problems Includes heart rate, blood pressure, body temperature, galvanic skin response, and muscle contraction Most popular is the polygraph (lie detector) Comer, Fundamentals of Abnormal Psychology, 3e 78

Clinical Tests Neurological and neuropsychological tests Neurological tests directly assess brain function by assessing brain structure and activity Examples: EEG, PET scans, CAT scans, MRI Neuropsychological tests indirectly assess brain function by assessing cognitive, perceptual, and motor functioning Most widely used is the Bender Visual-Motor Gestalt Test Comer, Fundamentals of Abnormal Psychology, 3e 79

Clinical Test: Bender Visual-Motor Gestalt Test

Clinical Tests Neurological and neuropsychological tests Strengths and weaknesses: Can be very accurate At best, though, these tests are general screening devices Best when used in a battery of tests, each targeting a specific skill area Comer, Fundamentals of Abnormal Psychology, 3e 81

Clinical Tests Intelligence tests Designed to measure intellectual ability Composed of a series of tests assessing both verbal and nonverbal skills Generate an intelligence quotient (IQ) Most popular: Wechsler Adult Intelligence Scale (WAIS) & Wechsler Intelligence Scale for Children (WISC) Comer, Fundamentals of Abnormal Psychology, 3e 82

Clinical Observations
Systematic observation of behavior Several kinds: Naturalistic: in the subject’s environment Analog Self-monitoring: the subject records his/her own behaviors, thoughts, emotions, etc. Comer, Fundamentals of Abnormal Psychology, 3e 83

DSM-IV-TR Published in 1994, revised in 2000 (TR) Lists approximately 400 disorders Listed in the inside back flap of your text Describes criteria for diagnoses, key clinical features, and related features which are often but not always present People can be diagnosed with multiple disorders… Comer, Fundamentals of Abnormal Psychology, 3e 84

Lifetime Prevalence of DSM-IV-TR Diagnoses

The DSM-IV-TR Multiaxial Uses 5 axes (branches of information) to develop a full clinical picture People usually receive a diagnosis on either Axis I or Axis II, but they may receive diagnoses on both Comer, Fundamentals of Abnormal Psychology, 3e 86

The DSM-IV-TR Axis I Most frequently diagnosed disorders, except personality disorders and mental retardation Comer, Fundamentals of Abnormal Psychology, 3e 87

Major Axis I Diagnostic Categories
Anxiety disorders Mood disorders Disorders first diagnosed in infancy and childhood Substance-related disorders Schizophrenia and other psychotic disorders Delirium, dementia, amnestic, and other cognitive disorders Mental disorders due to a general medical condition Somatoform disorders Factitious disorders Dissociative disorders Other conditions that are the focus of clinical attention Eating disorders Sexual and gender identity disorders Impulse-control disorders Adjustment disorders Sleep disorders Comer, Fundamentals of Abnormal Psychology, 3e 88

The DSM-IV-TR Axis II Personality disorders and mental retardation Long-standing problems Axis III Relevant general medical conditions Axis IV Psychosocial and environmental problems Comer, Fundamentals of Abnormal Psychology, 3e 89

The DSM-IV-TR Axis V Global assessment of psychological, social, and occupational functioning (GAF) Current functioning and highest functioning in past year 0–100 scale Comer, Fundamentals of Abnormal Psychology, 3e 90

Are Classifications Reliable and Valid?
In this case reliability = different diagnosticians agreeing on a diagnosis using the same classification system DSM-IV-TR has greater reliability than any previous editions Used field trials to increase reliability Reliability is still a concern Comer, Fundamentals of Abnormal Psychology, 3e 91

In this case validity = accuracy of information that the diagnostic categories provide Predictive validity is of the most use clinically DSM-IV-TR has greater validity than any previous editions Conducted extensive literature reviews and ran field studies Validity is still a concern Comer, Fundamentals of Abnormal Psychology, 3e 92

Beyond concerns about reliability and validity, a growing number of theorists believe that two fundamental problems weaken the DSM-IV-TR: Basic assumption that disorders are qualitatively different from normal behavior Reliance on discrete diagnostic categories With such concerns, DSM-V certainly will include some key changes, but the new edition is not imminent Comer, Fundamentals of Abnormal Psychology, 3e 93

Can Diagnosis and Labeling Cause Harm?
Misdiagnosis always a concern Major issue is reliance on clinical judgment Also present is the issue of labeling and stigma Diagnosis may be a self-fulfilling prophecy Because of these problems, some clinicians would like to cease the practice of diagnosis Comer, Fundamentals of Abnormal Psychology, 3e 94

Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 5 Anxiety Disorders Comer, Fundamentals of Abnormal Psychology, 3e 95

Anxiety What distinguishes fear from anxiety? Fear is a state of immediate alarm in response to a serious, known threat to one’s well-being Anxiety is a state of alarm in response to a vague sense of threat or danger Both have the same physiological features: increase in respiration, perspiration, muscle tension, etc. Comer, Fundamentals of Abnormal Psychology, 3e 96

Anxiety Is the fear/anxiety response useful/adaptive? Yes, when the “fight or flight” response is protective However, when it is triggered by “inappropriate” situations, or when it is too severe or long-lasting, this response can be disabling Can lead to the development of anxiety disorders Comer, Fundamentals of Abnormal Psychology, 3e 97

Anxiety Disorders Most common mental disorders in the U.S. In any given year, 18% of the adult population in the U.S. experiences one of the six DSM-IV-TR anxiety disorders Close to 29% develop one of the disorders at some point in their lives Only ~20% of these individuals seek treatment Most individuals with one anxiety disorder suffer from a second disorder, as well Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivity Comer, Fundamentals of Abnormal Psychology, 3e 98

Anxiety Disorders Six disorders: Generalized anxiety disorder (GAD) Phobias Panic disorder Obsessive-compulsive disorder (OCD) Acute stress disorder Posttraumatic stress disorder (PTSD) Comer, Fundamentals of Abnormal Psychology, 3e 99

Generalized Anxiety Disorder (GAD)
Characterized by excessive anxiety under most circumstances and worry about practically anything Vague, intense concerns and fearfulness Often called “free-floating” anxiety “Danger” not a factor Symptoms include restlessness, easy fatigue, irritability, muscle tension, and/or sleep disturbance Symptoms last at least six months Comer, Fundamentals of Abnormal Psychology, 3e 100

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Generalized Anxiety Disorder (GAD)
The disorder is common in Western society Affects ~3% of the population in any given year and ~6% at sometime during their lives Usually first appears in childhood or adolescence Women are diagnosed more often than men by 2:1 ratio Various theories have been offered to explain the development of the disorder… Comer, Fundamentals of Abnormal Psychology, 3e 102

GAD: The Sociocultural Perspective
According to this theory, GAD is most likely to develop in people faced with social conditions that truly are dangerous Research supports this theory (example: Three Mile Island in 1979) One of the most powerful forms of societal stress is poverty Why? Run-down communities, higher crime rates, fewer educational and job opportunities, and greater risk for health problems As would be predicted by the model, there are higher rates of GAD in lower SES groups Comer, Fundamentals of Abnormal Psychology, 3e 103

GAD: The Sociocultural Perspective
Since race is closely tied to income and job opportunities in the U.S., it is also tied to the prevalence of GAD In any given year, ~6% of African Americans and 3.1% of Caucasians suffer from GAD African American women have highest rates (6.6%) Comer, Fundamentals of Abnormal Psychology, 3e 104

GAD: The Psychodynamic Perspective
Freud believed that all children experience anxiety Realistic anxiety when faced with actual danger Neurotic anxiety when prevented from expressing id impulses Moral anxiety when punished for expressing id impulses One can use ego defense mechanisms to control these forms of anxiety, but when they don’t work or when anxiety is too high…GAD develops Comer, Fundamentals of Abnormal Psychology, 3e 105

Today’s psychodynamic theorists often disagree with specific aspects of Freud’s explanation Researchers have found some support for the psychodynamic perspective: People with GAD are particularly likely to use defense mechanisms (especially repression) Children who were severely punished for expressing id impulses have higher levels of anxiety later in life Are these results “proof” of the model’s validity? Comer, Fundamentals of Abnormal Psychology, 3e 106

Not necessarily; there are alternative explanations of the data: Discomfort with painful memories or “forgetting” in therapy is not necessarily defensive Also, some data actually contradict the model Many (if not most) GAD clients report normal childhood upbringings Comer, Fundamentals of Abnormal Psychology, 3e 107

Psychodynamic therapies Use same general techniques for treating all dysfunction Free association Therapist interpretation Specific treatments for GAD Freudians: focus less on fear and more on control of id Object-relations therapists: help patients identify and settle early relationship conflicts Comer, Fundamentals of Abnormal Psychology, 3e 108

GAD: The Humanistic Perspective
Theorists propose that GAD, like other psychological disorders, arises when people stop looking at themselves honestly and acceptingly This view is best illustrated by Carl Rogers’s explanation: Lack of “unconditional positive regard” in childhood leads to “conditions of worth” (harsh self-standards) These threatening self-judgments break through and cause anxiety, setting the stage for GAD to develop Comer, Fundamentals of Abnormal Psychology, 3e 109

GAD: The Humanistic Perspective
Therapy based on this model is “client-centered” and focuses on creating an accepting environment where clients can “experience” themselves Although case reports have been positive, controlled studies have only sometimes found client-centered therapy to be more effective than placebo or no therapy Only limited support has been found for Rogers’s explanation of causal factors Comer, Fundamentals of Abnormal Psychology, 3e 110

GAD: The Cognitive Perspective
Theorists believe that psychological problems are caused by maladaptive and dysfunctional thinking Since GAD is characterized by excessive worry (cognition), this model is a good start… Comer, Fundamentals of Abnormal Psychology, 3e 111

Theory: GAD is caused by maladaptive assumptions Albert Ellis identified basic irrational assumptions: It is necessary for humans to be loved by everyone It is catastrophic when things are not as one wants them to be If something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occur One should be competent in all domains to be a worthwhile person When these assumptions are applied to everyday life, GAD may develop Comer, Fundamentals of Abnormal Psychology, 3e 112

Aaron Beck is another cognitive theorist Those with GAD hold unrealistic silent assumptions that imply imminent danger: Any strange situation is dangerous A situation/person is unsafe until proven safe Research supports the presence of these types of assumptions in GAD, particularly about dangerousness Comer, Fundamentals of Abnormal Psychology, 3e 113

Second-Generation Cognitive Explanations In recent years, two promising explanations have emerged: Metacognitive theory Worry about worrying (metaworrying) Avoidance theory worrying serves a “positive” function by reducing unusually high levels of bodily arousal Both theories have received considerable research support Comer, Fundamentals of Abnormal Psychology, 3e 114

Two kinds of cognitive therapy: Changing maladaptive assumptions Based on the work of Ellis and Beck Helping clients understand the special role that worrying plays, and changing their views about it Comer, Fundamentals of Abnormal Psychology, 3e 115

Cognitive therapies Focusing on worrying Therapists begin with psychoeducation about worrying and GAD Assign self-monitoring of somatic arousal and cognitive responses As therapy progresses, clients become increasingly skilled at identifying their worrying and its counterproductivity Comer, Fundamentals of Abnormal Psychology, 3e 116

GAD: The Biological Perspective
Theory holds that GAD is caused by biological factors Supported by family pedigree studies Blood relatives more likely to have GAD (~15%) than general population (~6%) The closer the relative, the greater the likelihood Issue of shared environment Comer, Fundamentals of Abnormal Psychology, 3e 117

GABA inactivity 1950s – Benzodiazepines (Valium, Xanax) found to reduce anxiety Why? Neurons have specific receptors (lock and key) Benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA, a common NT in the brain) GABA is an inhibitory messenger; when received, it causes a neuron to stop firing Comer, Fundamentals of Abnormal Psychology, 3e 118

Biological treatments Antianxiety drugs Pre-1950s: barbiturates (sedative-hypnotics) Post-1950s: benzodiazepines Provide temporary, modest relief Rebound anxiety with withdrawal and cessation of use Physical dependence is possible Undesirable effects (drowsiness, etc.) Multiply effects of other drugs (especially alcohol) 1980s: buspirone (BuSpar) Different receptors, same effectiveness, fewer problems Comer, Fundamentals of Abnormal Psychology, 3e 119

Biological treatments Relaxation training Theory: physical relaxation leads to psychological relaxation Research indicates that relaxation training is more effective than placebo or no treatment Best when used in combination with cognitive therapy or biofeedback Comer, Fundamentals of Abnormal Psychology, 3e 120

Biological treatments Biofeedback Therapist uses electrical signals from the body to train people to control physiological processes Electromyograph (EMG) is the most widely used; provides feedback about muscle tension Found to be most effective when used as an adjunct to other methods for the treatment of certain medical problems (headache, back pain, etc.) Comer, Fundamentals of Abnormal Psychology, 3e 121

Phobias From the Greek word for “fear” Formal names are also often from the Greek (see Box 5-2) Persistent and unreasonable fears of particular objects, activities, or situations Phobic people often avoid the object or thoughts about it Comer, Fundamentals of Abnormal Psychology, 3e 122

Phobias We all have some fears at some points in our lives; this is a normal and common experience How do phobias differ from these “normal” experiences? More intense fear Greater desire to avoid the feared object or situation Distress that interferes with functioning Comer, Fundamentals of Abnormal Psychology, 3e 123

Specific Phobias Persistent fear of specific objects or situations When exposed to the object or situation, sufferers experience immediate fear Most common: phobias of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood Comer, Fundamentals of Abnormal Psychology, 3e 124

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Specific Phobias ~9% of the U.S. population have symptoms in any given year ~12% develop a specific phobia at some point in their lives Many suffer from more than one phobia at a time Women outnumber men 2:1 Prevalence differs across racial and ethnic minority groups Vast majority do NOT seek treatment Comer, Fundamentals of Abnormal Psychology, 3e 126

Social Phobias Severe, persistent, and unreasonable fears of social or performance situations in which embarrassment may occur May be narrow – talking, performing, eating, or writing in public May be broad – general fear of functioning inadequately in front of others In both cases, people rate themselves as performing less adequately than they actually did Comer, Fundamentals of Abnormal Psychology, 3e 127

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Social Phobias Can greatly interfere with functioning Often kept a secret Affect ~7% of U.S. population in any given year Women outnumber men 3:2 Often begin in childhood and may persist for many years Comer, Fundamentals of Abnormal Psychology, 3e 129

What Causes Phobias? Each model offers explanations, but evidence tends to support the behavioral explanations: Phobias develop through conditioning Once fears are acquired, they are continued because feared objects are avoided Behaviorists propose a classical conditioning model… Comer, Fundamentals of Abnormal Psychology, 3e 130

What Causes Phobias? Other behavioral explanations Phobias may develop through modeling Observation and imitation Phobias are maintained through avoidance Phobias may develop into GAD when a person acquires a large number of phobias Process of stimulus generalization: responses to one stimulus are also elicited by similar stimuli Comer, Fundamentals of Abnormal Psychology, 3e 131

What Causes Phobias? Behavioral explanations have received some empirical support: Classical conditioning study involving Little Albert Modeling studies Bandura, confederates, buzz, and shock Research conclusion is that phobias CAN be acquired in these ways, but there is no evidence that this is how the disorder is ordinarily acquired Comer, Fundamentals of Abnormal Psychology, 3e 132

What Causes Phobias? A behavioral-evolutionary explanation Some phobias are much more common than others… Comer, Fundamentals of Abnormal Psychology, 3e 133

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What Causes Phobias? A behavioral-evolutionary explanation Theorists argue that there is a species- specific biological predisposition to develop certain fears Called “preparedness”: humans are more “prepared” to develop phobias around certain objects or situations Model explains why some phobias (snakes, heights) are more common than others (grass, meat) Unknown if these predispositions are due to evolutionary or environmental factors Comer, Fundamentals of Abnormal Psychology, 3e 135

How Are Phobias Treated?
Surveys reveal that ~19% of those with specific phobia and 25% of those with social phobia currently are in treatment Each model offers treatment approaches Behavioral techniques (exposure treatments) are most widely used, especially for specific phobias Shown to be highly effective Fare better in head-to-head comparisons than other approaches Include desensitization, flooding, and modeling Comer, Fundamentals of Abnormal Psychology, 3e 136

Treatments for Specific Phobias
Systematic desensitization Technique developed by Joseph Wolpe Teach relaxation skills Create fear hierarchy Sufferers learn to relax while facing feared objects Since relaxation is incompatible with fear, the relaxation response is thought to substitute for the fear response Several types: In vivo desensitization (live) Covert desensitization (imaginal) Comer, Fundamentals of Abnormal Psychology, 3e 137

Treatments for Specific Phobias
Other behavioral treatments: Flooding Forced nongradual exposure Modeling Therapist confronts the feared object while the fearful person observes Clinical research supports each of these treatments The key to success is ACTUAL contact with the feared object or situation Comer, Fundamentals of Abnormal Psychology, 3e 138

Treatments for Social Phobias
Treatments only recently successful Two components must be addressed: Overwhelming social fear Address fears behaviorally with exposure Lack of social skills Social skills and assertiveness trainings have proved helpful Comer, Fundamentals of Abnormal Psychology, 3e 139

Panic Disorder Panic, an extreme anxiety reaction, can result when a real threat suddenly emerges The experience of “panic attacks,” however, is different Panic attacks are periodic, short bouts of panic that occur suddenly, reach a peak, and pass Sufferers often fear they will die, go crazy, or lose control Attacks happen in the absence of a real threat Comer, Fundamentals of Abnormal Psychology, 3e 140

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Panic Disorder Anyone can experience a panic attack, but some people have panic attacks repeatedly, unexpectedly, and without apparent reason Diagnosis: panic disorder Sufferers also experience dysfunctional changes in thinking and behavior as a result of the attacks Example: sufferer worries persistently about having an attack; plans behavior around possibility of future attack Comer, Fundamentals of Abnormal Psychology, 3e 142

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Panic Disorder Often (but not always) accompanied by agoraphobia From the Greek “fear of the marketplace” Afraid to leave home and travel to locations from which escape might be difficult or help unavailable Intensity may fluctuate There has only recently been a recognition of the link between agoraphobia and panic attacks (or panic-like symptoms) Comer, Fundamentals of Abnormal Psychology, 3e 144

Panic Disorder Two diagnoses: panic disorder with agoraphobia; panic disorder without agoraphobia ~3% of U.S. population affected in a given year ~5% of U.S. population affected at some point in their lives Likely to develop in late adolescence and early adulthood Women are twice as likely as men to be affected Approximately 35% of those with panic disorder are in treatment Comer, Fundamentals of Abnormal Psychology, 3e 145

Panic Disorder: The Biological Perspective
In the 1960s, it was recognized that people with panic disorder were not helped by benzodiazepines, but were helped by antidepressants Researchers worked backward from their understanding of antidepressant drugs Comer, Fundamentals of Abnormal Psychology, 3e 146

What biological factors contribute to panic disorder? NT at work is norepinephrine Irregular in people with panic attacks Research suggests that panic reactions are related to changes in norepinephrine activity in the locus ceruleus Although norepinephrine is clearly linked to panic disorder, what goes wrong isn’t exactly understood May be excessive activity, deficient activity, or some other defect Other NTs and brain circuits seem to be involved Comer, Fundamentals of Abnormal Psychology, 3e 147

It is also unclear why some people have such abnormalities in norepinephrine activity Inherited biological predisposition is one possible reason If so, prevalence should be (and is) greater among close relatives Among monozygotic (MZ, or identical) twins = 24% Among dizygotic (DZ, or fraternal) twins = 11% Issue is still open to debate Comer, Fundamentals of Abnormal Psychology, 3e 148

Panic Disorder: The Cognitive Perspective
Cognitive theorists and practitioners recognize that biological factors are only part of the cause of panic attacks In their view, full panic reactions are experienced only by people who misinterpret bodily events Cognitive treatment is aimed at correcting such misinterpretations Comer, Fundamentals of Abnormal Psychology, 3e 149

Misinterpreting bodily sensations Panic-prone people have a high degree of “anxiety sensitivity” They focus on bodily sensations much of the time, are unable to assess the sensations logically, and interpret them as potentially harmful Examples include: overbreathing or hyperventilation, excitement, fullness in the abdomen, acute anger, and heart “palpitations” Comer, Fundamentals of Abnormal Psychology, 3e 150

Cognitive therapy Attempts to correct people’s misinterpretations of their bodily sensations Step 1: Educate clients About panic in general About the causes of bodily sensations About their tendency to misinterpret the sensations Step 2: Teach clients to apply more accurate interpretations (especially when stressed) Step 3: Teach clients skills for coping with anxiety Examples: relaxation, breathing Comer, Fundamentals of Abnormal Psychology, 3e 151

Cognitive therapy May also use “biological challenge” procedures to induce panic sensations Induce physical sensations which cause feelings of panic: Jump up and down Run up a flight of steps Practice coping strategies and making more accurate interpretations Comer, Fundamentals of Abnormal Psychology, 3e 152

Obsessive-Compulsive Disorder
Made up of two components: Obsessions Persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness Compulsions Repeated and rigid behaviors or mental acts that people feel they must perform to prevent or reduce anxiety Comer, Fundamentals of Abnormal Psychology, 3e 153

Diagnosis may be called for when symptoms: Feel excessive or unreasonable Cause great distress Consume considerable time Interfere with daily functions Comer, Fundamentals of Abnormal Psychology, 3e 154

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Classified as an anxiety disorder because obsessions cause anxiety, while compulsions are aimed at preventing or reducing anxiety Anxiety rises if obsessions or compulsions are avoided ~2% of U.S. population has OCD in a given year; between 2% and 3% over a lifetime Ratio of women to men is 1:1 It is estimated that more than 40% of those with OCD seek treatment Comer, Fundamentals of Abnormal Psychology, 3e 156

What Are the Features of Obsessions and Compulsions?
Thoughts that feel intrusive and foreign Attempts to ignore or avoid them trigger anxiety Take various forms: Wishes Impulses Images Ideas Doubts Have common themes: Dirt/contamination Violence and aggression Orderliness Religion Sexuality Comer, Fundamentals of Abnormal Psychology, 3e 157

“Voluntary” behaviors or mental acts Feel mandatory/unstoppable Person may recognize that behaviors are irrational Believe, though, that catastrophe will occur if they don’t perform the compulsive acts Performing behaviors reduces anxiety ONLY FOR A SHORT TIME! Behaviors often develop into rituals Comer, Fundamentals of Abnormal Psychology, 3e 158

Common forms/themes: Cleaning Checking Order or balance Touching, verbal, and/or counting Comer, Fundamentals of Abnormal Psychology, 3e 159

Are obsessions and compulsions related? Most (not all) people with OCD experience both Compulsive acts often occur in response to obsessive thoughts Compulsions seem to represent a yielding to obsessions Compulsions also sometimes serve to help control obsessions Comer, Fundamentals of Abnormal Psychology, 3e 160

Are obsessions and compulsions related? Many with OCD are concerned that they will act on their obsessions Most of these concerns are unfounded Compulsions usually do not lead to violence or “immoral acts” Comer, Fundamentals of Abnormal Psychology, 3e 161

OCD was once among the least understood of the psychological disorders In recent years, however, researchers have begun to learn more about it The most influential explanations are from the psychodynamic, behavioral, cognitive, and biological models… Comer, Fundamentals of Abnormal Psychology, 3e 162

OCD: The Psychodynamic Perspective
Anxiety disorders develop when children come to fear their id impulses and use ego defense mechanisms to lessen their anxiety OCD differs from anxiety disorders in that the “battle” is not unconscious; it is played out in explicit thoughts and action Id impulses = obsessive thoughts Ego defenses = counter-thoughts or compulsive actions At its core, OCD is related to aggressive impulses and the competing need to control them Comer, Fundamentals of Abnormal Psychology, 3e 163

The battle between the id and the ego Three ego defenses mechanisms are common: Isolation: disown disturbing thoughts Undoing: perform acts to “cancel out” thoughts Reaction formation: take on lifestyle in contrast to unacceptable impulses Freud believed that OCD was related to the anal stage of development Period of intense conflict between id and ego Not all psychodynamic theorists agree Comer, Fundamentals of Abnormal Psychology, 3e 164

Psychodynamic therapies Goals are to uncover and overcome underlying conflicts and defenses Main techniques are free association and interpretation Research evidence is poor Some therapists now prefer to treat these patients with short-term psychodynamic therapies Comer, Fundamentals of Abnormal Psychology, 3e 165

OCD: The Behavioral Perspective
Behaviorists concentrate on explaining and treating compulsions rather than obsessions Although the behavioral explanation of OCD has received little support, behavioral treatments for compulsive behaviors have been very successful Comer, Fundamentals of Abnormal Psychology, 3e 166

Learning by chance People happen upon compulsions randomly: In a fearful situation, they happen to perform a particular act (washing hands) When the threat lifts, they associate the improvement with the random act After repeated associations, they believe the compulsion is changing the situation Bringing luck, warding away evil, etc. The act becomes a key method to avoiding or reducing anxiety Comer, Fundamentals of Abnormal Psychology, 3e 167

Key investigator: Stanley Rachman Compulsions do appear to be rewarded by an eventual decrease in anxiety Studies provide no evidence of the learning of compulsions Comer, Fundamentals of Abnormal Psychology, 3e 168

Behavioral therapy Exposure and response prevention (ERP) Clients are repeatedly exposed to anxiety-provoking stimuli and prevented from responding with compulsions Therapists often model the behavior while the client watches Homework is an important component Treatment is offered in individual and group settings Treatment provides significant, long-lasting improvements for most patients However, as many as 25% fail to improve at all and the approach is of limited help to those with obsessions but no compulsions Comer, Fundamentals of Abnormal Psychology, 3e 169

OCD: The Cognitive Perspective
Cognitive theory begins by pointing out that everyone has repetitive, unwanted, and intrusive thoughts People with OCD blame themselves for normal (although repetitive and intrusive) thoughts and expect that terrible things will happen as a result Comer, Fundamentals of Abnormal Psychology, 3e 170

Overreacting to unwanted thoughts To avoid such negative outcomes, they attempt to neutralize their thoughts with actions (or other thoughts) Neutralizing thoughts/actions may include: Seeking reassurance Thinking “good” thoughts Washing Checking Comer, Fundamentals of Abnormal Psychology, 3e 171

When a neutralizing action reduces anxiety, it is reinforced Client becomes more convinced that the thoughts are dangerous As fear of thoughts increases, the number of thoughts increases Comer, Fundamentals of Abnormal Psychology, 3e 172

If everyone has intrusive thoughts, why do only some people develop OCD? People with OCD tend: To be more depressed than others To have higher standards of morality and conduct To believe thoughts are equal to actions and are capable of bringing harm To believe that they can and should have perfect control over their thoughts and behaviors Comer, Fundamentals of Abnormal Psychology, 3e 173

Cognitive therapies Focus on the cognitive processes that help to produce and maintain obsessive thoughts and compulsive acts May include: Psychoeducation Habituation training Comer, Fundamentals of Abnormal Psychology, 3e 174

Cognitive-Behavioral Therapy (CBT) Research suggests that a combination of the cognitive and behavioral models often is more effective than either intervention alone These treatments typically include psychoeducation and exposure and response prevention exercises Comer, Fundamentals of Abnormal Psychology, 3e 175

OCD: The Biological Perspective
Family pedigree studies provided the first clues that OCD may be linked in part to biological factors Studies of twins found a 53% concordance rate in identical twins versus 23% in fraternal twins Currently, more direct genetic studies are being conducted to try to pinpoint the cause of the genetic predisposition Comer, Fundamentals of Abnormal Psychology, 3e 176

Two additional lines of research: Role of NT serotonin Evidence that serotonin-based antidepressants reduce OCD symptoms Brain abnormalities OCD linked to orbital region of frontal cortex and caudate nuclei Frontal cortex and caudate nuclei compose brain circuit that converts sensory information into thoughts and actions Either area may be too active, letting through troublesome thoughts and actions Comer, Fundamentals of Abnormal Psychology, 3e 177

Some research provides evidence that these two lines may be connected Serotonin plays a very active role in the operation of the orbital region and the caudate nuclei Low serotonin activity might interfere with the proper functioning of these brain parts Comer, Fundamentals of Abnormal Psychology, 3e 178

Biological therapies Serotonin-based antidepressants clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine Bring improvement to 50%–80% of those with OCD Relapse occurs if medication is stopped Research suggests that combination therapy (medication + cognitive behavioral therapy approaches) may be most effective Comer, Fundamentals of Abnormal Psychology, 3e 179

Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 6 Stress Disorders Comer, Fundamentals of Abnormal Psychology, 3e 180

Stress, Coping, and the Anxiety Response
The state of stress has two components: Stressor: event creating demands Stress response: reactions to the demands Influenced by how we appraise (a) the event, and (b) our capacity to react to the event effectively People who sense that they have the ability and resources to cope are more likely to take stressors in stride Comer, Fundamentals of Abnormal Psychology, 3e 181

When we appraise a stressor as threatening, the natural reaction is fear Fear is a “package” of physical, emotional, and cognitive responses Stress reactions, and the fear they produce, are often at play in psychological disorders People who experience a large number of stressful events are particularly vulnerable to the onset of GAD, social phobia, panic disorder, and OCD, as well as other psychological problems Comer, Fundamentals of Abnormal Psychology, 3e 182

Stress also plays a more central role in certain psychological disorders, including: Acute stress disorder Posttraumatic stress disorder Technically, DSM-IV-TR lists these patterns as anxiety disorders …as well as certain physical disorders called psychophysiological disorders These disorders are listed in the DSM-IV-TR under “psychological factors affecting medical condition” Comer, Fundamentals of Abnormal Psychology, 3e 183

Stress and Arousal: The Fight-or-Flight Response
The features of arousal and fear are set in motion by the hypothalamus Two important systems are activated: Autonomic nervous system (ANS) An extensive network of nerve fibers that connect the central nervous system (the brain and spinal cord) to the body’s other organs Contains two systems: sympathetic and parasympathetic Endocrine system A network of glands throughout the body that release hormones Comer, Fundamentals of Abnormal Psychology, 3e 184

When confronting a dangerous situation, the hypothalamus first activates the sympathetic nervous system, which stimulates key organs either directly or indirectly When the perceived danger passes, the parasympathetic nervous system helps return bodily systems to normal Comer, Fundamentals of Abnormal Psychology, 3e 185

The reactions displayed by these two pathways are referred to as the fight-or- flight response People differ in their particular patterns of autonomic and endocrine functioning and therefore also in their particular ways of experiencing arousal and fear… Comer, Fundamentals of Abnormal Psychology, 3e 186

People differ in: Their general level of anxiety Called “trait anxiety” Some people are usually somewhat tense; others are usually relaxed Differences appear soon after birth Their sense of threat Called “state anxiety” Situation-based (example: fear of flying) Comer, Fundamentals of Abnormal Psychology, 3e 187

The Psychological Stress Disorders
During and immediately after trauma, many people become highly anxious and depressed For some, feelings persist well after the trauma These people may be experiencing: Acute stress disorder Posttraumatic stress disorder (PTSD) The precipitating event usually involves actual or threatened serious injury to self or others Occurs following an event which would be traumatic to anyone (unlike other anxiety disorders) Comer, Fundamentals of Abnormal Psychology, 3e 188

The Psychological Stress Disorders
Acute stress disorder Symptoms begin within four weeks of event and last for less than one month Posttraumatic stress disorder (PTSD) Symptoms can begin at any time following the event but must last for longer than one month May develop from acute stress disorder Comer, Fundamentals of Abnormal Psychology, 3e 189

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What Triggers a Psychological Stress Disorder?
Can occur at any age and affect all aspects of life ~4% of U.S. population affected each year ~7% of U.S. population affected sometime during life Approximately 2/3 seek treatment at some point Ratio of women to men is 2:1 After trauma, 20% of women and 8% of men develop disorders Some events – including combat, disasters, abuse, and victimization – are more likely to cause disorders than others Comer, Fundamentals of Abnormal Psychology, 3e 191

Combat and stress disorders It has long been recognized that soldiers experience distress during combat Called “shell shock,” “combat fatigue” Post-Vietnam War clinicians discovered that soldiers also experienced psychological distress after combat ~30% of Vietnam combat veterans suffered acute or posttraumatic stress disorders An additional 22% had some stress symptoms 10% still experiencing problems Comer, Fundamentals of Abnormal Psychology, 3e 192

Disasters and stress disorders Acute or posttraumatic stress disorders may also follow natural and accidental disasters Civilian traumas have been implicated in stress disorders at least 10 times as often as combat trauma Types of disasters include traffic accidents, weather, earthquakes, and airplane crashes Comer, Fundamentals of Abnormal Psychology, 3e 193

Victimization and stress disorders People who have been abused, victimized, or terrorized often experience lingering stress symptoms Common victimization is sexual assault/rape ~1 in 7 women is raped at some time during her life Psychological impact is immediate and may be long-lasting One study found that 94% of rape survivors developed an acute stress disorder within 12 days after assault Comer, Fundamentals of Abnormal Psychology, 3e 194

Why Do People Develop a Psychological Stress Disorder?
Biological and genetic factors Traumatic events trigger physical changes in the brain and body that may lead to severe stress reactions, and, possibly, stress disorders Some research suggests abnormal NT and hormone activity (especially norepinephrine and cortisol) There may be a biological/genetic predisposition to such reactions Evidence suggests that other biological changes and damage may also occur as a stress disorder sets in Comer, Fundamentals of Abnormal Psychology, 3e 195

Personality factors Some studies suggest that people with certain personality profiles, attitudes, and coping styles are more likely to develop stress disorders Risk factors include: Preexisting high anxiety A history of psychological problems Negative worldview A set of positive attitudes (called resiliency or hardiness) is protective against developing stress disorders Comer, Fundamentals of Abnormal Psychology, 3e 196

Negative childhood experiences A wave of studies has found that certain childhood experiences increase risk for later stress disorders Risk factors include: An impoverished childhood Psychological disorders in the family The experience of assault, abuse, or catastrophe at an early age Being younger than 10 years old when parents separated or divorced Comer, Fundamentals of Abnormal Psychology, 3e 197

Social support People whose social support systems are weak are more likely to develop a stress disorder after a negative event Severity of the trauma The more severe the trauma and the more direct one’s exposure to it, the greater the likelihood of developing a stress disorder Especially risky: mutilation and severe injury; witnessing the injury or death of others Comer, Fundamentals of Abnormal Psychology, 3e 198

How Do Clinicians Treat the Psychological Stress Disorders?
Psychological debriefing A form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within days of the critical incident Four-stage approach: Normalize responses to the disaster Encourage expressions of anxiety, anger, and frustration Teach self-help skills Provide referrals Relief workers themselves may become overwhelmed Research on this type of intervention has called into question its effectiveness Comer, Fundamentals of Abnormal Psychology, 3e 199

Chapter 7 Somatoform and Dissociative Disorders
Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 7 Somatoform and Dissociative Disorders Comer, Fundamentals of Abnormal Psychology, 3e 200

Somatoform and Dissociative Disorders
In addition to disorders covered earlier, two other kinds of disorders are commonly associated with stress and anxiety: Somatoform disorders Dissociative disorders Comer, Fundamentals of Abnormal Psychology, 3e 201

Somatoform disorders are problems that appear to be physical or medical but are due to psychosocial factors Unlike psychophysiological disorders, in which psychosocial factors interact with physical factors to produce genuine physical ailments and damage, somatoform disorders are psychological distress expressed as physical symptoms Comer, Fundamentals of Abnormal Psychology, 3e 202

Dissociative disorders: major losses or changes in memory, consciousness, and identity, but do not have physical causes Unlike dementia and other neurological disorders, these patterns are, like somatoform disorders, due almost entirely to psychosocial factors Comer, Fundamentals of Abnormal Psychology, 3e 203

Somatoform and dissociative disorders have much in common: Both occur in response to traumatic or ongoing stress Both are viewed as forms of escape from stress A number of individuals suffer from both a somatoform and a dissociative disorder Comer, Fundamentals of Abnormal Psychology, 3e 204

Somatoform Disorders When a physical illness has no apparent medical cause, physicians may suspect a somatoform disorder People with a somatoform disorder do not consciously want or purposely produce their symptoms suffer actual changes in their physical functioning There are two main types of somatoform disorders: Hysterical somatoform disorders Preoccupation somatoform disorders Comer, Fundamentals of Abnormal Psychology, 3e 205

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What Are Hysterical Somatoform Disorders?
Conversion disorder psychosocial conflict or need is converted into dramatic physical symptoms Symptoms often seem neurological, such as paralysis, blindness, or loss of feeling Most conversion disorders begin between late childhood and young adulthood They are diagnosed in women twice as often as in men They usually appear suddenly and are thought to be rare Comer, Fundamentals of Abnormal Psychology, 3e 207

Somatization disorder People with somatization disorder have numerous long-lasting physical ailments that have little or no organic basis Also known as Briquet’s syndrome To receive a diagnosis, a patient must have multiple ailments that include several pain symptoms, gastrointestinal symptoms, a sexual symptom, and a neurological symptom Patients usually go from doctor to doctor seeking relief Comer, Fundamentals of Abnormal Psychology, 3e 208

Somatization disorder typically lasts much longer than a conversion disorder, typically for many years Symptoms may fluctuate over time but rarely disappear completely without psychotherapy Comer, Fundamentals of Abnormal Psychology, 3e 209

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Hysterical vs. factitious symptoms Hysterical somatoform disorders must also be distinguished from patterns in which individuals are faking medical symptoms malingering – intentionally faking illness to achieve external gain (e.g., financial compensation, military deferment) This is not a somataform disorder Patients may be manifesting a factitious disorder – intentionally producing or feigning symptoms simply from a wish to be a patient Comer, Fundamentals of Abnormal Psychology, 3e 211

Factitious Disorder People with a factitious disorder often go to extreme lengths to create the appearance of illness May give themselves medications to produce symptoms Patients often research their supposed ailments and become very knowledgeable about medicine May undergo painful testing or treatment, even surgery Comer, Fundamentals of Abnormal Psychology, 3e 212

Factitious Disorder Munchausen syndrome is the extreme and chronic form of factitious disorder In Munchausen syndrome by proxy, a related disorder, parents make up or produce physical illnesses in their children When children are removed from their parents, symptoms disappear Comer, Fundamentals of Abnormal Psychology, 3e 213

Factitious Disorder Dependable treatments have not yet been developed Psychotherapists and medical practitioners often become annoyed or angry at such patients Comer, Fundamentals of Abnormal Psychology, 3e 214

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What Are Preoccupation Somatoform Disorders?
Hypochondriasis People with hypochondriasis unrealistically interpret bodily symptoms as signs of serious illness Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or sweating Although some patients recognize that their concerns are excessive, many do not Comer, Fundamentals of Abnormal Psychology, 3e 216

Hypochondriasis Although this disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers Between 1% and 5% of all people experience the disorder For most patients, symptoms wax and wane over time Comer, Fundamentals of Abnormal Psychology, 3e 217

Body dysmorphic disorder (BDD) characterized by deep and extreme concern over an imagined or minor defect in one’s appearance Foci are most often wrinkles, spots, facial hair, or misshapen facial features (nose, jaw, or eyebrows) Most cases of the disorder begin in adolescence but are often not revealed until adulthood Up to 2% of people in the U.S. experience BDD, and it appears to be equally common among women and men Comer, Fundamentals of Abnormal Psychology, 3e 218

What Causes Somatoform Disorders?
The psychodynamic view Freud believed that hysterical disorders represented a conversion of underlying emotional conflicts into physical symptoms Because most of his patients were women, Freud looked at the psychosexual development of girls and focused on the phallic stage (ages 3 to 5)… Comer, Fundamentals of Abnormal Psychology, 3e 219

The psychodynamic view During this stage, girls experience a pattern of sexual desires for their fathers (the Electra complex) and recognize that they must compete with their mothers for his attention Because of the mother’s more powerful position, however, girls repress these sexual feelings Freud believed that if parents overreact to such feelings, the Electra complex would remain unresolved and the child might re-experience sexual anxiety throughout her life Freud concluded that some women hide their sexual feelings in adulthood by converting them into physical symptoms Comer, Fundamentals of Abnormal Psychology, 3e 220

The psychodynamic view Modern psychodynamic theorists have modified Freud’s explanation away from the Electra conflict They continue to believe that sufferers of these disorders carry unconscious conflicts from childhood Comer, Fundamentals of Abnormal Psychology, 3e 221

The psychodynamic view Modern theorists propose that two mechanisms are at work in the hysterical disorders: Primary gain: hysterical symptoms keep internal conflicts out of conscious awareness Secondary gain: hysterical symptoms further enable people to avoid unpleasant activities or to receive kindness or sympathy from others Comer, Fundamentals of Abnormal Psychology, 3e 222

The behavioral view Behavioral theorists propose that the physical symptoms of hysterical disorders bring rewards to sufferers May remove individual from an unpleasant situation May bring attention to the individual In response to such rewards, people learn to display symptoms more and more This focus on rewards is similar to the psychodynamic idea of secondary gain, but behaviorists view the gains as the primary cause of the development of the disorder Comer, Fundamentals of Abnormal Psychology, 3e 223

The cognitive view Cognitive theorists propose that hysterical disorders are a form of communication, providing a means for people to express difficult emotions Like psychodynamic theorists, cognitive theorists hold that emotions are being converted into physical symptoms This conversion is not to defend against anxiety but to communicate extreme feelings Comer, Fundamentals of Abnormal Psychology, 3e 224

How Are Somatoform Disorders Treated?
People with somatoform disorders usually seek psychotherapy as a last resort Individuals with preoccupation disorders typically receive the kinds of treatments applied to anxiety disorders: Antidepressant medication Exposure and response prevention (ERP) Comer, Fundamentals of Abnormal Psychology, 3e 225

Dissociative Disorders
When such changes in memory have no clear physical cause, they are called “dissociative” disorders In such disorders, one part of the person’s memory typically seems to be dissociated, or separated, from the rest Comer, Fundamentals of Abnormal Psychology, 3e 226

There are several kinds of dissociative disorders, including: Dissociative amnesia Dissociative fugue Dissociative identity disorder (multiple personality disorder) These disorders are often memorably portrayed in books, movies, and television programs DSM-IV-TR also lists depersonalization disorder as a dissociative disorder Comer, Fundamentals of Abnormal Psychology, 3e 227

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It is important to note that dissociative symptoms are often found in cases of acute and posttraumatic stress disorders When such symptoms occur as part of a stress disorder, they do not necessarily indicate a dissociative disorder (a pattern in which dissociative symptoms dominate) However, some research suggests that people with one of these disorders may be highly vulnerable to developing the other Comer, Fundamentals of Abnormal Psychology, 3e 229

Dissociative Amnesia People with dissociative amnesia are unable to recall important information, usually of an upsetting nature, about their lives The loss of memory is much more extensive than normal forgetting and is not caused by organic factors Very often an episode of amnesia is directly triggered by a specific upsetting event Comer, Fundamentals of Abnormal Psychology, 3e 230

Dissociative Amnesia All forms of the disorder are similar in that the amnesia interferes primarily with episodic memory (one’s autobiographical memory of personal material) Semantic memory – memory for abstract or encyclopedic information – usually remains intact It is not known how common dissociative amnesia is, but rates increase during times of serious threat to health and safety Comer, Fundamentals of Abnormal Psychology, 3e 231

Dissociative Fugue People with dissociative fugue not only forget their personal identities and details of their past, but also flee to an entirely different location For some, the fugue is brief: they may travel a short distance but do not take on a new identity For others, the fugue is more severe: they may travel thousands of miles, take on a new identity, build new relationships, and display new personality characteristics Comer, Fundamentals of Abnormal Psychology, 3e 232

Dissociative Fugue ~ 0.2% of the population experience dissociative fugue It usually follows a severely stressful event, although personal stress may also trigger it Fugues tend to end abruptly When people are found before their fugue has ended, therapists may find it necessary to continually remind them of their own identity and location Individuals tend to regain most or all of their memories and never have a recurrence Comer, Fundamentals of Abnormal Psychology, 3e 233

Dissociative Identity Disorder/ Multiple Personality Disorder
A person with dissociative identity disorder (DID; formerly multiple personality disorder) develops two or more distinct personalities – subpersonalities – each with a unique set of memories, behaviors, thoughts, and emotions Comer, Fundamentals of Abnormal Psychology, 3e 234

At any given time, one of the subpersonalities dominates the person’s functioning Usually one of these subpersonalities – called the primary, or host, personality – appears more often than the others The transition from one subpersonality to the next (“switching”) is usually sudden and may be dramatic Comer, Fundamentals of Abnormal Psychology, 3e 235

Most cases are first diagnosed in late adolescence or early adulthood Symptoms generally begin in childhood after episodes of abuse Typical onset is before the age of 5 Women receive the diagnosis three times as often as men Comer, Fundamentals of Abnormal Psychology, 3e 236

How do subpersonalities interact? The relationship between or among subpersonalities differs from case to case Generally there are three kinds of relationships: Mutually amnesic relationships – subpersonalities have no awareness of one another Mutually cognizant patterns – each subpersonality is well aware of the rest One-way amnesic relationships – most common pattern; some personalities are aware of others, but the awareness is not mutual Those who are aware (“co-conscious subpersonalities”) are “quiet observers” Comer, Fundamentals of Abnormal Psychology, 3e 237

How do subpersonalities interact? Investigators used to believe that most cases of the disorder involved two or three subpersonalities Studies now suggest that the average number is much higher – 15 for women, 8 for men There have been cases of more than 100! Comer, Fundamentals of Abnormal Psychology, 3e 238

How do subpersonalities differ? Subpersonalities often display dramatically different characteristics, including: Vital statistics Subpersonalities may differ in terms of age, sex, race, and family history Abilities and preferences Although encyclopedic knowledge is unaffected by dissociative amnesia or fugue, in DID it is often disturbed It is not uncommon for different subpersonalities to have different areas of expertise or abilities, including driving a car, speaking foreign languages, or playing an instrument Comer, Fundamentals of Abnormal Psychology, 3e 239

How do subpersonalities differ? Subpersonalities often display dramatically different characteristics, including: Physiological responses Researchers have discovered that subpersonalities may have physiological differences, such as differences in autonomic nervous system activity, blood pressure levels, and allergies Comer, Fundamentals of Abnormal Psychology, 3e 240

How common is DID? Traditionally, DID was believed to be rare Some researchers have argued that many or all cases of the disorder are iatrogenic; that is, unintentionally produced by practitioners These arguments are supported by the fact that many cases of DID surface only after a person is already in treatment Not true of all cases Comer, Fundamentals of Abnormal Psychology, 3e 241

How common is DID? The number of people diagnosed with the disorder has been increasing Although the disorder is still uncommon, thousands of cases have been documented in the U.S. and Canada alone Two factors may account for this increase: Clinicians are more willing to make such a diagnosis Diagnostic procedures have become more accurate Despite changes, many clinicians continue to question the legitimacy of the category and are reluctant to diagnose the disorder Comer, Fundamentals of Abnormal Psychology, 3e 242

How Do Theorists Explain Dissociative Disorders?
A variety of theories have been proposed to explain dissociative disorders Older explanations have not received much investigation Newer viewpoints, which combine cognitive, behavioral, and biological principles, have begun to interest clinical scientists Comer, Fundamentals of Abnormal Psychology, 3e 243

The psychodynamic view Psychodynamic theorists believe that dissociative disorders are caused by repression, the most basic ego defense mechanism People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness Comer, Fundamentals of Abnormal Psychology, 3e 244

The psychodynamic view In this view, dissociative amnesia and fugue are single episodes of massive repression DID is thought to result from a lifetime of excessive repression, motivated by very traumatic childhood events Comer, Fundamentals of Abnormal Psychology, 3e 245

The psychodynamic view Most of the support for this model is drawn from case histories, which report brutal childhood experiences, yet: Not all individuals with DID have had these experiences Child abuse is far more common than DID Why do only a small fraction of abused children develop this disorder? Comer, Fundamentals of Abnormal Psychology, 3e 246

The behavioral view Behaviorists believe that dissociation grows from normal memory processes and is a response learned through operant conditioning: forgetting of trauma decreases anxiety Like psychodynamic theorists, behaviorists see dissociation as escape behavior Like psychodynamic theorists, behaviorists rely largely on case histories to support their view of dissociative disorders While the case histories support this model, they are also consistent with other explanations… Comer, Fundamentals of Abnormal Psychology, 3e 247

How Are Dissociative Disorders Treated?
People with dissociative amnesia and fugue often recover on their own Only sometimes do memory problems linger and require treatment In contrast, people with DID usually require treatment to regain their lost memories and develop an integrated personality Treatment for dissociative amnesia and fugue tends to be more successful than treatment for DID Comer, Fundamentals of Abnormal Psychology, 3e 248

How do therapists help people with dissociative amnesia and fugue? The leading treatments for these disorders are psychodynamic therapy, hypnotic therapy, and drug therapy Psychodynamic therapists ask patients to free associate and search their unconscious In hypnotic therapy, patients are hypnotized and guided to recall forgotten events Sometimes intravenous injections of barbiturates are used to help patients regain lost memories Often called “truth serums,” the key to the drugs’ success is their ability to calm people and free their inhibitions Comer, Fundamentals of Abnormal Psychology, 3e 249

How do therapists help individuals with DID? Therapists usually try to help the client by: Integrating the subpersonalities The final goal of therapy is to merge the different subpersonalities into a single, integrated entity Integration is a continuous process; fusion is the final merging Many patients distrust this final treatment goal and many subpersonalities see integration as a form of death Once the subpersonalities are merged, further therapy is needed to maintain the complete personality and to teach social and coping skills to prevent future dissociations Comer, Fundamentals of Abnormal Psychology, 3e 250

Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 8 Mood Disorders Comer, Fundamentals of Abnormal Psychology, 3e 251

Mood Disorders Two key emotions on a continuum: Depression Low, sad state in which life seems dark and overwhelming Mania State of breathless euphoria and frenzied energy Depression Mania Comer, Fundamentals of Abnormal Psychology, 3e 252

Mood Disorders Most people with a mood disorder experience only depression This pattern is called unipolar depression Person has no history of mania Mood returns to normal when depression lifts Some people experience periods of depression that alternate with periods of mania This pattern is called bipolar disorder One might logically expect a third pattern – unipolar mania, in which people suffer from mania only – but this pattern is uncommon Comer, Fundamentals of Abnormal Psychology, 3e 253

Unipolar Depression The term “depression” is often used to describe general sadness or unhappiness This usage confuses a normal mood swing with a clinical syndrome Clinical depression can bring severe and long-lasting psychological pain that may intensify over time Comer, Fundamentals of Abnormal Psychology, 3e 254

How Common Is Unipolar Depression?
About 7% of the U.S. population experiences severe unipolar depression in any given year As many as 5% experience mild depression The prevalence is similar in Canada, England, France, and many other countries Approximately 17% of all adults experience unipolar depression at some time in their lives Rates have been steadily increasing since 1915 Comer, Fundamentals of Abnormal Psychology, 3e 255

How Common Is Unipolar Depression?
In almost all countries, women are twice as likely as men to experience severe unipolar depression Lifetime prevalence: 26% of women vs. 12% of men These rates hold true across socioeconomic classes and ethnic groups Approximately 50% recover within six weeks, some without treatment Most will experience another episode at some point Comer, Fundamentals of Abnormal Psychology, 3e 256

What Are the Symptoms of Depression?
Symptoms may differ dramatically from person to person Five main areas of functioning may be affected: Emotional symptoms Feeling “miserable,” “empty,” “humiliated” Experiencing little pleasure Motivational symptoms Lacking drive, initiative, spontaneity Between 6% and 15% of those with severe depression commit suicide Comer, Fundamentals of Abnormal Psychology, 3e 257

What Are the Symptoms of Unipolar Depression?
Five main areas of functioning may be affected: Behavioral symptoms Less active, less productive Cognitive symptoms Hold negative views of themselves Blame themselves for unfortunate events Pessimism Physical symptoms Headaches, dizzy spells, general pain Comer, Fundamentals of Abnormal Psychology, 3e 258

Diagnosing Unipolar Depression
Criteria 1: Major depressive episode Marked by five or more symptoms lasting two or more weeks In extreme cases, symptoms are psychotic, including Hallucinations Delusions Criteria 2: No history of mania Comer, Fundamentals of Abnormal Psychology, 3e 259

Diagnosing Unipolar Depression
Two diagnoses to consider: Major depressive disorder Criteria 1 and 2 are met Dysthymic disorder Symptoms are “mild but chronic” Depression is longer lasting but less disabling Consistent symptoms for at least two years When dysthymic disorder leads to major depressive disorder, the sequence is called “double depression” Comer, Fundamentals of Abnormal Psychology, 3e 260

What Causes Unipolar Depression?
Stress may be a trigger for depression People with depression experience a greater number of stressful life events during the month just prior to the onset of their symptoms Some clinicians distinguish reactive (exogenous) depression from endogenous depression, which seems to be a response to internal factors The utility of this distinction is questionable and today’s clinicians usually concentrate on recognizing the situational and the internal aspects of any given case Comer, Fundamentals of Abnormal Psychology, 3e 261

What Causes Unipolar Depression? The Biological View
Genetic factors Family pedigree, twin, adoption, and molecular gene studies suggest that some people inherit a biological predisposition Researchers have found that as many as 20% of relatives of those with depression are themselves depressed, compared with fewer than 10% of the general population Twin studies demonstrate a strong genetic component: Rates for identical (MZ) twins = 46% Rates for fraternal (DZ) twins = 20% Adoption and molecular gene studies also have implicated a genetic factor in cases of severe unipolar depression Comer, Fundamentals of Abnormal Psychology, 3e 262

Biochemical factors NTs: serotonin and norepinephrine In the 1950s, medications for high blood pressure were found to cause depression Some lowered serotonin, others lowered norepinephrine This led to the “discovery” of effective antidepressant medications which relieved depression by increasing either serotonin or norepinephrine Depression likely involves not just serotonin nor norepinephrine… a complex interaction is at work, and other NTs may be involved Comer, Fundamentals of Abnormal Psychology, 3e 263

Biochemical factors Endocrine system / hormone release People with depression have been found to have abnormal levels of cortisol Released by the adrenal glands during times of stress People with depression have been found to have abnormal melatonin secretion “Dracula hormone” Other researchers are investigating whether deficiencies of important proteins within neurons are tied to depression Comer, Fundamentals of Abnormal Psychology, 3e 264

What Causes Unipolar Depression? The Psychological Views
Three main models: Psychodynamic model Not strongly supported by research Behavioral model Modestly supported by research Cognitive model Has considerable research support Comer, Fundamentals of Abnormal Psychology, 3e 265

Psychodynamic view Link between depression and grief When a loved one dies, the mourner regresses to the oral stage For most people, grief is temporary If grief is severe and long-lasting, depression results Those with oral stage issues (unmet or excessively met needs) are at greater risk for developing depression Some people experience “symbolic” (not actual) loss Newer psychoanalysts focus on relationships with others (object relations theorists) Comer, Fundamentals of Abnormal Psychology, 3e 266

Psychodynamic view Strengths: Studies have offered general support for the psychodynamic idea that depression may be triggered by a major loss Research supports the theory that early losses set the stage for later depression Research also suggests that people whose childhood needs were improperly met are more likely to become depressed after suffering a loss Comer, Fundamentals of Abnormal Psychology, 3e 267

Psychodynamic view Limitations: Early losses don’t inevitably lead to depression May not be typically responsible for development of depression Many research findings are inconsistent Theory is largely untestable because of its reliance on unconscious processes Comer, Fundamentals of Abnormal Psychology, 3e 268

Behavioral view Depression results from changes in rewards and punishments people receive in their lives As life changes, we experience a change (loss) of rewards Research supports the relationship between the number of rewards received and the presence or absence of depression Social rewards are especially important Comer, Fundamentals of Abnormal Psychology, 3e 269

Behavioral view Strengths: Researchers have compiled significant data to support this theory Limitations: Research has relied heavily on the self-reports of depressed subjects Behavioral studies are largely correlational and do not establish that decreases in rewards are the cause of depression Comer, Fundamentals of Abnormal Psychology, 3e 270

Cognitive views Two main theories: Negative thinking Learned helplessness Comer, Fundamentals of Abnormal Psychology, 3e 271

Cognitive views Negative thinking According to Beck, four interrelated cognitive components combine to produce unipolar depression: Maladaptive attitudes Self-defeating attitudes are developed during childhood Beck suggests that upsetting situations later in life can trigger further rounds of negative thinking Comer, Fundamentals of Abnormal Psychology, 3e 272

Cognitive views This negative thinking often takes three forms, called the cognitive triad: Individuals repeatedly interpret (1) their experiences, (2) themselves, and (3) their futures in negative ways, leading to depression Comer, Fundamentals of Abnormal Psychology, 3e 273

Cognitive views Negative thinking Depressed people also make errors in their thinking, including: Arbitrary inferences Minimization of the positive and magnification of the negative Depressed people experience automatic thoughts A steady train of unpleasant thoughts that suggest inadequacy and hopelessness Comer, Fundamentals of Abnormal Psychology, 3e 274

Cognitive views Strengths: There is significant research support for Beck’s model: High correlation between the level of depression and the number of maladaptive attitudes Both the cognitive triad and errors in logic are seen in people with depression Automatic thinking has been linked to depression Limitations: Research fails to show that such cognitive patterns are the cause and core of unipolar depression Comer, Fundamentals of Abnormal Psychology, 3e 275

Cognitive views Learned helplessness Theory asserts that people become depressed when they think that: They no longer have control over the reinforcements in their lives They themselves are responsible for this helpless state Comer, Fundamentals of Abnormal Psychology, 3e 276

Cognitive views Learned helplessness Theory is based on Seligman’s work with laboratory dogs Dogs subjected to uncontrollable shock were later placed in a shuttle box Even when presented with an opportunity to escape, dogs that had experienced uncontrollable shocks made no attempt to do so Seligman theorized that the dogs had “learned” to be “helpless” and drew parallels to human depression Comer, Fundamentals of Abnormal Psychology, 3e 277

Cognitive views Learned helplessness There has been significant research support for this model Human subjects who undergo helplessness training score higher on depression scales and demonstrate passivity in laboratory trials Animal subjects lose interest in sex and social activities In rats, uncontrollable negative events result in lower serotonin and norepinephrine levels in the brain Comer, Fundamentals of Abnormal Psychology, 3e 279

What Causes Unipolar Depression? The Sociocultural View
Sociocultural theorists propose that unipolar depression is greatly influenced by the social structure in which people live This belief is supported by the finding that depression is often triggered by outside stressors Researchers have also found links between depression and culture, gender, race, and social support Comer, Fundamentals of Abnormal Psychology, 3e 280

How are culture and depression related? Depression is a worldwide phenomena, but the experience of symptoms differs from culture to culture For example, non-Westerners report more physical (rather than psychological) symptoms As cultures become more Western, symptoms shift Comer, Fundamentals of Abnormal Psychology, 3e 281

How do gender and race relate to depression? Rates of depression are much higher among women than men One sociocultural theory holds that the complexity of women’s roles in society leaves them particularly prone to depression (see Box 8-3) Few differences have been seen overall among Caucasians, African Americans, and Hispanic Americans, but striking differences exist in specific subcultures: In a study of one Native American village, lifetime risk was 37% among women, 19% among men, and 28% overall These findings are thought to be the result of economic and social pressures Comer, Fundamentals of Abnormal Psychology, 3e 282

How does social support relate to depression? Divorced individuals have higher rates of depression Comer, Fundamentals of Abnormal Psychology, 3e 283

Bipolar Disorders People with a bipolar disorder experience both the lows of depression and the highs of mania They describe their life as an emotional roller coaster Comer, Fundamentals of Abnormal Psychology, 3e 284

What Are the Symptoms of Mania?
Unlike those experiencing depression, people in a state of mania typically experience dramatic and inappropriate rises in mood Five main areas of functioning may be affected: Emotional symptoms Active, powerful emotions in search of outlet Motivational symptoms Need for constant excitement, involvement, companionship Comer, Fundamentals of Abnormal Psychology, 3e 285

What Are the Symptoms of Mania?
Five main areas of functioning may be affected: 3. Behavioral symptoms Very active – move quickly; talk loudly or rapidly Key word: flamboyance! 4. Cognitive symptoms Show poor judgment or planning Especially prone to poor (or no) planning 5. Physical symptoms High energy level – often in the presence of little or no rest Comer, Fundamentals of Abnormal Psychology, 3e 286

Diagnosing Bipolar Disorders
Criteria 1: Manic episode Three or more symptoms of mania lasting one week or more In extreme cases, symptoms are psychotic Criteria 2: History of mania If currently experiencing hypomania or depression Comer, Fundamentals of Abnormal Psychology, 3e 287

DSM-IV-TR distinguishes between two kinds of bipolar disorder: Bipolar I disorder Full manic and major depressive episodes Most sufferers experience an alternation of episodes Some experience mixed episodes Bipolar II disorder Hypomanic episodes and major depressive episodes Comer, Fundamentals of Abnormal Psychology, 3e 288

Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder If people experience four or more episodes within a one-year period, their disorder is further classified as rapid cycling If their episodes vary with the seasons, their disorder is further classified as seasonal Comer, Fundamentals of Abnormal Psychology, 3e 289

Regardless of particular pattern, individuals with bipolar disorder tend to experience depression more than mania over the years In most cases, depressive episodes occur three times as often as manic ones, and last longer Comer, Fundamentals of Abnormal Psychology, 3e 290

Between 1% and 2.6% of adults in the world suffer from a bipolar disorder at any given time The disorders are equally common in women and men Women may experience more depressive episodes and fewer manic episodes than men Rapid cycling is more common in women Comer, Fundamentals of Abnormal Psychology, 3e 291

The prevalence of the disorders is the same across socioeconomic classes and ethnic groups Onset usually occurs between 15 and 44 years of age In most cases, the manic and depressive episodes eventually subside, only to recur at a later time Generally, when episodes recur, the intervening periods of normality grow shorter and shorter Comer, Fundamentals of Abnormal Psychology, 3e 292

A final diagnostic option: If a person experiences numerous episodes of hypomania and mild depressive symptoms, a diagnosis of cyclothymic disorder is appropriate Mild symptoms for two or more years, interrupted by periods of normal mood Affects 0.4% of the population May blossom into bipolar I or II disorder Comer, Fundamentals of Abnormal Psychology, 3e 293

What Causes Bipolar Disorders?
Throughout the first half of the 20th century, the search for the cause of bipolar disorders made little progress More recently, biological research has produced some promising clues New insights have come from research into NT activity, ion activity, brain structure, and genetic factors Comer, Fundamentals of Abnormal Psychology, 3e 294

Neurotransmitters After finding a relationship between low norepinephrine and unipolar depression, early researchers expected to find a link between high norepinephrine levels and mania This theory is supported by some research studies; bipolar disorders may be related to overactivity of norepinephrine Comer, Fundamentals of Abnormal Psychology, 3e 295

Neurotransmitters Because serotonin activity often parallels norepinephrine activity in unipolar depression, theorists expected that mania would also be related to high serotonin activity Although no relationship with HIGH serotonin has been found, bipolar disorder may be linked to LOW serotonin activity, which seems contradictory… Comer, Fundamentals of Abnormal Psychology, 3e 296

Neurotransmitters This apparent contradiction is addressed by the “permissive theory” about mood disorders: Low serotonin may “open the door” to a mood disorder and permit norepinephrine activity to define the particular form the disorder will take: Low serotonin + Low norepinephrine = Depression Low serotonin + High norepinephrine = Mania Comer, Fundamentals of Abnormal Psychology, 3e 297

Brain structure Brain imaging and postmortem studies have identified a number of abnormal brain structures in people with bipolar disorder; in particular, the basal ganglia and cerebellum among others It is not clear what role such structural abnormalities play Comer, Fundamentals of Abnormal Psychology, 3e 298

Genetic factors Many experts believe that people inherit a biological predisposition to develop bipolar disorders Family pedigree studies support this theory; when one twin or sibling has bipolar disorder, the likelihood for the other twin or sibling increases: Identical (MZ) twins = 40% likelihood Fraternal (DZ) twins and siblings = 5% to 10% likelihood General population = 1% likelihood Recently, genetic linkage studies have examined the possibility of “faulty” genes Other researchers are using techniques from molecular biology to further examine genetic patterns Such wide-ranging findings suggest that a number of genetic abnormalities probably combine to help bring about bipolar disorders Comer, Fundamentals of Abnormal Psychology, 3e 299

Chapter 9 Treatments for Mood Disorders
Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 9 Treatments for Mood Disorders Comer, Fundamentals of Abnormal Psychology, 3e 300

Treatments for Mood Disorders
Mood disorders – as extraordinarily painful and disabling as they tend to be – respond more successfully to more kinds of treatments than do most other forms of psychological dysfunction This diversity of successful treatments has affected individuals with depression in both positive and negative ways Comer, Fundamentals of Abnormal Psychology, 3e 301

Treatments for Unipolar Depression: Psychological Approaches
Psychological approaches to treating unipolar depression come from the three main models: Psychodynamic – Widely used despite no strong research evidence of its effectiveness Behavioral – Primarily used for mild or moderate depression but practiced less than in past decades Cognitive – Has performed so well in research that it has a large and growing clinical following Comer, Fundamentals of Abnormal Psychology, 3e 302

Psychodynamic therapy Believing that unipolar depression results from unconscious grief over real or imagined losses, compounded by excessive dependence on other people, psychodynamic therapists seek to bring these issues into consciousness and work through them Psychodynamic therapists use the same basic procedures for all psychological disorders: Free association Therapist interpretation Comer, Fundamentals of Abnormal Psychology, 3e 303

Psychodynamic therapy Despite successful case reports, researchers have found that long-term psychodynamic therapy is only occasionally helpful in cases of unipolar depression Two features may be particularly limiting: Depressed clients may be too passive or weary to fully participate in clinical discussions Depressed clients may become discouraged and end treatment too early when treatment doesn’t provide fast relief Short-term approaches have performed better than traditional approaches Comer, Fundamentals of Abnormal Psychology, 3e 304

Behavioral therapy Lewinsohn, whose theory tied a person’s mood to his/her life rewards, developed a behavioral therapy for unipolar depression in the 1970s: Reintroduce clients to pleasurable activities and events, often using a weekly schedule Appropriately reinforce their nondepressive behaviors Use a contingency management approach Help them improve their social skills Comer, Fundamentals of Abnormal Psychology, 3e 305

Behavioral therapy The behavioral techniques seem to be of only limited help when just one of them is applied When treatment programs combine two or three of the techniques, as Lewinsohn had envisioned, depressive symptoms (especially mild symptoms) seem to be reduced Comer, Fundamentals of Abnormal Psychology, 3e 306

Cognitive therapy Beck views unipolar depression as resulting from a pattern of negative thinking that may be triggered by current upsetting situations Maladaptive attitudes lead people to the “cognitive triad” Negatively viewing oneself, the world, and the future These biased views combine with illogical thinking to produce automatic thoughts Comer, Fundamentals of Abnormal Psychology, 3e 307

Cognitive therapy Beck’s cognitive therapy – the leading cognitive treatment for unipolar depression – is designed to help clients recognize and change their negative cognitive processes This approach follows four phases and usually lasts fewer than 20 sessions Phases: Increasing activities and elevate mood Challenging automatic thoughts Identifying negative thinking and biases Changing primary attitudes Comer, Fundamentals of Abnormal Psychology, 3e 308

Cognitive therapy Over the past three decades, hundreds of studies have shown that cognitive therapy helps unipolar depression Around 50%–60% of clients show a near-total elimination of symptoms This treatment has also been used in a group therapy format Comer, Fundamentals of Abnormal Psychology, 3e 309

Treatments for Unipolar Depression: Sociocultural Approaches
Theorists trace the causes of unipolar depression to the broader social structure in which people live, and the roles they are required to play The most effective sociocultural approaches to treating unipolar depression are interpersonal psychotherapy and couple therapy The techniques used in these approaches borrow from other models Comer, Fundamentals of Abnormal Psychology, 3e 310

Treatments for Unipolar Depression: Sociocultural Approaches
Interpersonal therapy (IPT) This model holds that four interpersonal problems may lead to depression and must be addressed: Interpersonal loss Interpersonal role dispute Interpersonal role transition Interpersonal deficits Studies suggest that IPT is as effective as cognitive therapy for treating depression Comer, Fundamentals of Abnormal Psychology, 3e 311

Treatments for Unipolar Depression: Biological Approaches
Biological treatments can bring great relief to people with unipolar depression Usually biological treatment means, antidepressant drugs, but for severely depressed persons who do not respond to other forms of treatment, it sometimes includes electroconvulsive therapy Comer, Fundamentals of Abnormal Psychology, 3e 312

Electroconvulsive therapy (ECT) The use of ECT was -- and is -- controversial It is now used frequently but only in severe cases The procedure consists of targeted electrical stimulation to cause a brain seizure The usual course of treatment is 6 to 12 sessions spaced over two to four weeks Treatment may be bilateral or unilateral Comer, Fundamentals of Abnormal Psychology, 3e 313

Electroconvulsive therapy (ECT) The discovery of the effectiveness of ECT was accidental and based on a fallacious link between psychosis and epilepsy The procedure has been modified in recent years to reduce some of the negative effects For example, patients are given muscle relaxants and anesthetics before and during the procedure Patients generally report some memory loss Comer, Fundamentals of Abnormal Psychology, 3e 314

Electroconvulsive therapy (ECT) ECT is clearly effective in treating unipolar depression Studies find improvement in 60%–70% of patients The procedure seems particularly effective in cases of severe depression with delusions, but it has been difficult to determine why ECT works so well Although effective, the use of ECT has declined since the 1950s, because of the memory loss caused by the procedure and the emergence of effective antidepressant drugs Comer, Fundamentals of Abnormal Psychology, 3e 315

Antidepressant drugs In the 1950s, two kinds of drugs were found to be effective: Monoamine oxidase inhibitors (MAO inhibitors) Tricyclics These drugs have been joined in recent years by a third group, the second-generation antidepressants Comer, Fundamentals of Abnormal Psychology, 3e 316

Antidepressant drugs: MAO inhibitors Originally used to treat TB, doctors noticed that the medication seemed to make patients happier The drug works biochemically by slowing down the body’s production of MAO MAO breaks down norepinephrine MAO inhibitors stop this breakdown from occurring This leads to a rise in norepinephrine activity and a reduction in depressive symptoms About half of patients who take these drugs are helped by them Comer, Fundamentals of Abnormal Psychology, 3e 318

Antidepressant drugs: Tricyclics In searching for medications for schizophrenia, researchers discovered that imipramine lessened depressive symptoms Imipramine and related drugs are known as tricyclics because they share a three-ring molecular structure Comer, Fundamentals of Abnormal Psychology, 3e 319

Second-generation antidepressant drugs A third group of effective antidepressant drugs is structurally different from the MAO inhibitors and tricyclics Most of the drugs in this group are labeled selective serotonin reuptake inhibitors (SSRIs) These drugs act only on serotonin (no other NTs are affected) This class includes fluoxetine (Prozac) and sertraline (Zoloft) Selective norepinephrine reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are also now available Comer, Fundamentals of Abnormal Psychology, 3e 320

Second-generation antidepressant drugs The effectiveness and speed of action of these drugs is on par with the tricyclics yet they boast enormous sales Clinicians often prefer these drugs because it is harder to overdose on them than on other kinds of antidepressants There are no dietary restrictions like there are with MAO inhibitors There have fewer side effects than the tricyclics These drugs may cause some undesired effects of their own, including a reduction in sex drive Comer, Fundamentals of Abnormal Psychology, 3e 321

How Do the Treatments for Unipolar Depression Compare?
For most kinds of psychological disorders, no more than one or two treatments, if any, emerge as successful Unipolar depression seems to be the exception, responding to any of several approaches Comer, Fundamentals of Abnormal Psychology, 3e 322

Findings from a number of research studies suggest that: Cognitive, interpersonal, and biological therapies are all highly effective treatments for mild to severe unipolar depression Although cognitive and interpersonal therapies may lower the likelihood of relapse, they are hardly relapse-proof Comer, Fundamentals of Abnormal Psychology, 3e 323

Findings from a number of research studies suggest that: behavioral therapy have shown less effective than cognitive, interpersonal, or biological therapy Comer, Fundamentals of Abnormal Psychology, 3e 324

Findings from a number of research studies suggest that: Psychodynamic therapies are less effective than other therapies in depression A combination of psychotherapy and drug therapy is modestly more helpful to depressed people than either treatment alone Comer, Fundamentals of Abnormal Psychology, 3e 325

Findings from a number of research studies suggest that: Among biological treatments, antidepressant drugs and ECT appear to be equally effective for reducing depression, although ECT seems to act more quickly Comer, Fundamentals of Abnormal Psychology, 3e 326

Treatments for Bipolar Disorders
Until the latter part of the 20th century, people with bipolar disorders were destined to spend their lives on an emotional roller coaster Psychotherapists reported almost no success Antidepressant drugs were of limited help These drugs sometimes triggered manic episodes ECT only occasionally relieved either the depressive or the manic episodes of bipolar disorder Comer, Fundamentals of Abnormal Psychology, 3e 327

Treatments for Bipolar Disorders: Lithium Therapy
The use of lithium, a metallic element occurring as mineral salt, has dramatically changed this picture It is extraordinarily effective in treating bipolar disorders and mania Determining the correct dosage for a given patient is a delicate process Too low = no effect Too high = lithium intoxication (poisoning) Comer, Fundamentals of Abnormal Psychology, 3e 328

Treatments for Bipolar Disorder: Lithium Therapy
Lithium provides improvement for more than 60% of manic patients Most patients also experience fewer new episodes while on the drug Lithium also is a prophylactic drug, one that actually prevents symptoms from developing Lithium also helps those with bipolar disorder overcome their depressive episodes Comer, Fundamentals of Abnormal Psychology, 3e 329

Treatments for Bipolar Disorder: Lithium Therapy
Researchers do not fully understand how lithium operates They suspect that it changes synaptic activity in neurons, but in a different way from that of antidepressant drugs Although antidepressant drugs affect a neuron’s initial reception on NTs, lithium seems to affect a neuron’s second messengers Another theory is that lithium corrects bipolar functioning by directly changing sodium and potassium ion activity in neurons Comer, Fundamentals of Abnormal Psychology, 3e 330

Treatments for Bipolar Disorder: Adjunctive Psychotherapy
Psychotherapy alone is rarely helpful for persons with bipolar disorder Lithium therapy alone is also not always sufficient, either 30% or more of patients don’t respond, may not receive the correct dose, or may relapse while taking it As a result, clinicians often use psychotherapy as an adjunct to lithium (or other medication- based) therapy Comer, Fundamentals of Abnormal Psychology, 3e 331

Treatments for Bipolar Disorder: Adjunctive Psychotherapy
Therapy focuses on medication management, social skills, and relationship issues Few controlled studies have tested the effectiveness of such adjunctive therapy Growing research suggests that it helps reduce hospitalization, improves social functioning, and increases clients’ ability to obtain and hold a job Comer, Fundamentals of Abnormal Psychology, 3e 332

Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 10 Suicide Comer, Fundamentals of Abnormal Psychology, 3e 333

Suicide Suicide is a leading cause of death in the world There are about 700,000 people who die of it each year, with 31,000 suicides per year in the U.S. alone Many more unsuccessfully attempt suicide than actually succeed Such attempts are called “parasuicides” There are about 600,000 attempts per year in the U.S. Comer, Fundamentals of Abnormal Psychology, 3e 334

Suicide It is difficult to obtain accurate figures on suicide rates Many “accidents” may be intentional deaths Suicide is not classified as a mental disorder in the DSM-IV-TR While suicide is often linked to depression, about half of all suicides result from other mental disorders or involve no clear mental disorder at all Comer, Fundamentals of Abnormal Psychology, 3e 335

What Is Suicide? Shneidman defines suicide as an intentioned death – a self-inflicted death in which one makes an intentional, direct, and conscious effort to end one’s life He characterizes four kinds of suicide seekers… Comer, Fundamentals of Abnormal Psychology, 3e 336

What Is Suicide? Shneidman’s characterizations of suicide seekers: Death seekers – clearly intend to end their lives Death initiators – intend to end their lives because they believe that the process of death is already underway Comer, Fundamentals of Abnormal Psychology, 3e 337

What Is Suicide? Death ignorers – do not believe that their self- inflicted death will mean the end of their existence Death darers – have ambivalent feelings about death and show this in the act itself Comer, Fundamentals of Abnormal Psychology, 3e 338

How Is Suicide Studied? Suicide researchers face a major obstacle: their subjects are no longer alive Researchers use two different strategies to try to overcome this obstacle (with partial success): Retrospective analysis Studying people who survive their suicide attempts Comer, Fundamentals of Abnormal Psychology, 3e 339

Patterns and Statistics
The suicide rates of men and women also differ: Women have a higher attempt rate (3x men) Men have a higher completion rate (3x women) Why? Different methods have differing lethality Men tend to use more violent methods (shooting, stabbing, or hanging) than women (drug overdose) Guns are used in nearly two-thirds of male suicides in the U.S., compared to 40% of female suicides Comer, Fundamentals of Abnormal Psychology, 3e 340

Suicide is also related to marital status and level of social support Divorced people have a higher suicide rate than married or cohabiting individuals One study found that half of the subjects who had committed suicide were found to have no close friends Comer, Fundamentals of Abnormal Psychology, 3e 341

In the U.S., suicide also seems to vary according to race The suicide rate of white Americans (12 per 100,000) is almost twice as high as that of African Americans and members of other racial groups A major exception to this pattern is the very high suicide rate of Native Americans, which overall is 1.5 times the national average Comer, Fundamentals of Abnormal Psychology, 3e 342

What Triggers a Suicide?
Suicidal acts may be connected to recent events or current conditions in a person’s life Common triggers include stressful events, mood and thought changes, alcohol and other drug use, mental disorders, and modeling Comer, Fundamentals of Abnormal Psychology, 3e 343

Stressful Events and Suicide
Researchers have counted more stressful events in the lives of suicide attempters than in the lives of matched controls Both immediate and long-term stresses can be risk factors for suicide Immediate stresses can include the loss of a loved one, the loss of a job, or natural disaster Comer, Fundamentals of Abnormal Psychology, 3e 344

Stressful Events and Suicide
Long-term stressors can include: Serious illness Abusive environment Occupational stress Psychiatrists and psychologists, physicians, nurses, dentists, lawyers, farmers, and unskilled laborers have particularly high suicide rates Work outside the home may be linked to lower suicide rates among women, contrary to previously held beliefs Comer, Fundamentals of Abnormal Psychology, 3e 345

Mood and Thought Changes
Suicide attempts may also be preceded by shifts in patterns of thinking Individuals may become preoccupied, lose perspective, and see suicide as their only option They often develop a sense of hopelessness – a pessimistic belief that their present circumstances, problems, or mood will not change Some clinicians believe that a feeling of hopelessness is the single most likely indicator of suicidal intent Comer, Fundamentals of Abnormal Psychology, 3e 346

Mood and Thought Changes
People who attempt suicide may experience dichotomous thinking, viewing problems and solutions in rigid either/or terms The “four-letter word” in suicide is “only,” as in “suicide was the only thing I could do” Comer, Fundamentals of Abnormal Psychology, 3e 347

Alcohol and Other Drug Use
Studies indicate that as many as 70% of the people who attempt suicide drink alcohol just before the act Autopsies reveal that about 25% of these people are legally intoxicated Research shows the use of other kinds of drugs may have similar ties to suicide Comer, Fundamentals of Abnormal Psychology, 3e 348

Mental Disorders Attempting suicide does not necessarily indicate the presence of a psychological disorder Nevertheless, the majority of all suicide attempters do display such a disorder Those with mood disorders, substance use disorders, and/or schizophrenia are at greatest risk Comer, Fundamentals of Abnormal Psychology, 3e 349

Modeling: The Contagion of Suicide
It is not unusual for people, particularly teens, to commit suicide after observing or reading about someone who has done so One suicide appears to serve as a model for another Suicides by celebrities, other highly publicized suicides, and suicides by co-workers are particularly common triggers Comer, Fundamentals of Abnormal Psychology, 3e 351

Underlying Causes of Suicide: The Psychodynamic View
Theorists believe that suicide results from depression and from anger at others that is redirected toward oneself Additionally, Freud proposed that humans have a basic death instinct (“Thanatos”) that operates in opposition to the life instinct While most people learn to direct their death instinct toward others, suicidal people direct it at themselves Comer, Fundamentals of Abnormal Psychology, 3e 352

Underlying Causes of Suicide: The Sociocultural View
Durkheim argues that the probability of suicide is determined by how attached a person is to such social groups as the family, religious institutions, and community The more thoroughly a person belongs, the lower the risk of suicide Based on this premise, he developed several categories of suicide, including egoistic, altruistic, and anomic suicide… Comer, Fundamentals of Abnormal Psychology, 3e 353

Underlying Causes of Suicide: The Sociocultural View
Egoistic suicides are committed by people over whom society has little or no control Altruistic suicides are committed by people who are so well integrated into their society that they intentionally sacrifice their lives for its well-being Anomic suicides are those committed by people whose social environment fails to provide stable structures that support and give meaning to life A change in an individual’s immediate surroundings can also lead to this type of suicide Comer, Fundamentals of Abnormal Psychology, 3e 354

Underlying Causes of Suicide: The Biological View
Family pedigree and twin studies support the position that biological factors contribute to suicidal behavior For example, there are higher rates of suicide among the parents and close relatives of those who commit suicide than among nonsuicidal people As always with this type of research, however, nonbiological factors, such as shared environment, must also be considered Comer, Fundamentals of Abnormal Psychology, 3e 355

Underlying Causes of Suicide: The Biological View
Recent laboratory research has offered more direct support for a biological model of suicide Serotonin levels have been found to be low in people who commit suicide There is a known link between low serotonin and depression There is evidence, though, of low serotonin activity among suicidal subjects with no history of depression Serotonin activity may contribute to aggressive behavior Comer, Fundamentals of Abnormal Psychology, 3e 356

Is Suicide Linked to Age?
The likelihood of committing suicide increases with age, but people of all ages may try to kill themselves Although the general findings about suicide hold true across age groups, three groups (children, adolescents, and the elderly) have been the focus of much study because of the unique issues that face them Comer, Fundamentals of Abnormal Psychology, 3e 357

Children Suicide is infrequent among children Rates have been rising for the last decade About 500 children younger than 14 years of age commit suicide each year Boys outnumber girls by as much as 5:1 Comer, Fundamentals of Abnormal Psychology, 3e 358

Children Suicide attempts by the very young generally are preceded by such behavioral patterns as running away, temper tantrums, social withdrawal, dark fantasies, and marked personality changes Many child suicides appear to be based on a clear understanding of death and on a clear wish to die Comer, Fundamentals of Abnormal Psychology, 3e 359

Adolescents Suicidal actions become much more common after the age of 14 than at any earlier age About 2000 teens commit suicide in the U.S. each year As many as 500,000 may make attempts Young white Americans are more suicide- prone than African Americans at this age Suicide rates are growing closer Comer, Fundamentals of Abnormal Psychology, 3e 360

Adolescents About half of teen suicides have been linked to depression, low self-esteem, and feelings of hopelessness Anger, impulsiveness, poor problem-solving skills, and stress also play a role Some theorists believe that the period of adolescence itself produces a stressful climate in which suicidal actions are more likely Comer, Fundamentals of Abnormal Psychology, 3e 361

Adolescents Far more teens attempt suicide than succeed Ratio may be as high as 200:1 Several explanations, most pointing to societal factors, have been proposed for the high rate of attempts among teenagers Comer, Fundamentals of Abnormal Psychology, 3e 362

The Elderly In Western society the elderly are more likely to commit suicide than people in any other age group There are many contributory factors: Illness Loss of social support Loss of control over one’s life Loss of social status Comer, Fundamentals of Abnormal Psychology, 3e 363

The Elderly Elderly persons are typically more determined than younger persons in their decision to die, so their success rate is much higher Ratio of attempts to successes is 4:1 The suicide rate among the elderly is lower in some minority groups in the U.S.: Native Americans African Americans Comer, Fundamentals of Abnormal Psychology, 3e 364

Risk Assessment 1. How is the individual going to kill himself? 2. How fatal is this method? 3. Does he have the means to carry out this plan? Comer, Fundamentals of Abnormal Psychology, 3e 365

Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 11 Eating Disorders Comer, Fundamentals of Abnormal Psychology, 3e 366

Changing attitudes Comer, Fundamentals of Abnormal Psychology, 3e 367

Eating Disorders Although not historically true, current Western beauty standards equate thinness with health and beauty There has been a rise in eating disorders in the past three decades The core issue is a morbid fear of weight gain Two main diagnoses: Anorexia nervosa Bulimia nervosa Comer, Fundamentals of Abnormal Psychology, 3e 368

Anorexia Nervosa The main symptoms of anorexia nervosa are: A refusal to maintain more than 85% of normal body weight Intense fears of becoming overweight A distorted view of body weight and shape Amenorrhea Comer, Fundamentals of Abnormal Psychology, 3e 369

Anorexia Nervosa There are two main subtypes: Restricting type anorexia Lose weight by restricting “bad” foods, eventually restricting nearly all food Show almost no variability in diet Binge-eating/purging type anorexia Lose weight by vomiting after meals, abusing laxatives or diuretics, or engaging in excessive exercise Like those with bulimia nervosa, people with this subtype may engage in eating binges Comer, Fundamentals of Abnormal Psychology, 3e 370

Anorexia Nervosa About 90%–95% of cases occur in females The peak age of onset is between 14 and 18 years Between 0.5% and 2% of females in Western countries develop the disorder Many more display some symptoms Rates of anorexia nervosa are increasing in North America, Japan, and Europe Comer, Fundamentals of Abnormal Psychology, 3e 371

Anorexia Nervosa The “typical” case: A normal to slightly overweight female has been on a diet Escalation to anorexia nervosa may follow a stressful event Separation of parents Move or life transition Experience of personal failure Most patients recover However, about 2% to 6% become seriously ill and die as a result of medical complications or suicide Comer, Fundamentals of Abnormal Psychology, 3e 372

Anorexia Nervosa: The Clinical Picture
Despite their dietary restrictions, people with anorexia are extremely preoccupied with food This includes thinking and reading about food and planning for meals This relationship is not necessarily causal It may be the result of food deprivation, as evidenced by the famous 1940s “starvation study” with conscientious objectors Comer, Fundamentals of Abnormal Psychology, 3e 373

People with anorexia nervosa also think in distorted ways: Often have a low opinion of their body shape Tend to overestimate their actual proportions Hold maladaptive attitudes and misperceptions “I must be perfect in every way” “I will be a better person if I deprive myself” “I can avoid guilt by not eating” Comer, Fundamentals of Abnormal Psychology, 3e 374

People with anorexia may also display certain psychological problems: Depression (usually mild) Anxiety Low self-esteem Insomnia or other sleep disturbances Substance abuse Obsessive-compulsive patterns Perfectionism Comer, Fundamentals of Abnormal Psychology, 3e 375

Bulimia Nervosa Bulimia nervosa, also known as “binge- purge syndrome,” is characterized by binges Bouts of uncontrolled overeating during a limited period of time Eats objectively more than most people would/could eat in a similar period Comer, Fundamentals of Abnormal Psychology, 3e 376

Bulimia Nervosa The disorder is also characterized by compensatory behaviors: Purging-type bulimia nervosa Vomiting Misusing laxatives, diuretics, or enemas Nonpurging-type bulimia nervosa Fasting Exercising excessively Comer, Fundamentals of Abnormal Psychology, 3e 377

Bulimia Nervosa Like anorexia nervosa, about 90%–95% of bulimia nervosa cases occur in females The peak age of onset is between 15 and 21 years Symptoms may last for several years with periodic letup Comer, Fundamentals of Abnormal Psychology, 3e 378

Bulimia Nervosa Patients are generally of normal weight Often experience weight fluctuations Some may also qualify for a diagnosis of anorexia Binge-eating disorder: Symptoms include a pattern of binge eating with NO compensatory behaviors (such as vomiting) This condition is not yet listed in the DSM-IV- TR Comer, Fundamentals of Abnormal Psychology, 3e 379

Bulimia Nervosa: Binges
For people with bulimia nervosa, the number of binges per week can range from 2 to 40 Average: 10 per week Binges are often carried out in secret Binges involve eating massive amounts of food rapidly with little chewing Usually sweet foods with soft texture Binge-eaters commonly consume more than calories (often more than 3000 calories) per binge episode Comer, Fundamentals of Abnormal Psychology, 3e 380

Bulimia Nervosa: Binges
Binges are usually preceded by feelings of tension and/or powerlessness Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and “discovery” Comer, Fundamentals of Abnormal Psychology, 3e 381

Bulimia Nervosa The “typical” case: A normal to slightly overweight female has been on an intense diet Research suggests that even among normal subjects, bingeing often occurs after strict dieting For example, a study of binge-eating behavior in a low-calorie weight loss program found that 62% of patients reported binge-eating episodes during treatment Comer, Fundamentals of Abnormal Psychology, 3e 382

Bulimia Nervosa vs. Anorexia Nervosa
Similarities: Onset after a period of dieting Fear of becoming obese Drive to become thin Preoccupation with food, weight, appearance Elevated risk of self-harm or attempts at suicide Feelings of anxiety, depression, perfectionism Substance abuse Disturbed attitudes toward eating Comer, Fundamentals of Abnormal Psychology, 3e 383

Differences: People with bulimia are more worried about pleasing others, being attractive to others, and having intimate relationships People with bulimia tend to be more sexually experienced People with bulimia display fewer of the obsessive qualities that drive restricting-type anorexia People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping Comer, Fundamentals of Abnormal Psychology, 3e 384

Differences: People with bulimia tend to be controlled by emotion – may change friendships easily People with bulimia are more likely to display characteristics of a personality disorder Different medical complications: Only half of women with bulimia experience amenorrhea vs. almost all women with anorexia People with bulimia suffer damage caused by purging, especially from vomiting and laxatives Comer, Fundamentals of Abnormal Psychology, 3e 385

What Causes Eating Disorders?
Most theorists subscribe to a multidimensional risk perspective: Several key factors place individuals at risk More factors = greater risk Leading factors: Sociocultural conditions (societal and family pressures) Psychological problems (ego, cognitive, and mood disturbances) Biological factors Comer, Fundamentals of Abnormal Psychology, 3e 386

What Causes Eating Disorders? Societal Pressures
Many theorists believe that current Western standards of female attractiveness have contributed to the rise of eating disorders Standards have changed throughout history toward a thinner ideal Miss America contestants have declined in weight by 0.28 lbs/yr; winners have declined by 0.37 lbs/yr Playboy centerfolds have lower average weight, bust, and hip measurements than in the past Comer, Fundamentals of Abnormal Psychology, 3e 387

Certain groups are at greater risk from these pressures: Models, actors, dancers, and certain athletes Of college athletes surveyed, 9% met full criteria for an eating disorder while another 50% had symptoms 20% of surveyed gymnasts met full criteria for an eating disorder Comer, Fundamentals of Abnormal Psychology, 3e 388

Societal attitudes may explain economic and racial differences seen in prevalence rates In the past, Caucasian women of higher SES expressed more concern about thinness and dieting These women had higher rates of eating disorders than African American women or Caucasian women of lower SES Recently, dieting and preoccupation with food, along with rates of eating disorders, are increasing in all groups Comer, Fundamentals of Abnormal Psychology, 3e 389

What Causes Eating Disorders? Family Environment
As many as half of the families of those with eating disorders have a long history of emphasizing thinness, appearance, and dieting Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves Comer, Fundamentals of Abnormal Psychology, 3e 390

What Causes Eating Disorders? Family Environment
Minuchin cites “enmeshed family patterns” as causal factors of eating disorders These patterns include overinvolvement in, and overconcern about, family member’s lives Comer, Fundamentals of Abnormal Psychology, 3e 391

What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances Bruch argues that eating disorders are the result of disturbed mother–child interactions which lead to serious ego deficiencies in the child and to severe cognitive disturbances Comer, Fundamentals of Abnormal Psychology, 3e 392

What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances Bruch argues that parents may respond to their children either effectively or ineffectively Effective parents accurately attend to a child’s biological and emotional needs Ineffective parents fail to attend to child’s internal needs; they feed when the child is anxious, comfort when the child is tired, etc. Comer, Fundamentals of Abnormal Psychology, 3e 393

What Causes Eating Disorders? Mood Disorders
Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression Theorists believe mood disorders may “set the stage” for eating disorders Comer, Fundamentals of Abnormal Psychology, 3e 394

What Causes Eating Disorders? Mood Disorders
More people with an eating disorder qualify for a diagnosis of major depressive disorder than do people in the general population Close relatives of those with eating disorders seem to have higher rates of mood disorders People with eating disorders, especially those with bulimia nervosa, have low levels of serotonin Symptoms of eating disorders are helped by antidepressant medications Comer, Fundamentals of Abnormal Psychology, 3e 395

What Causes Eating Disorders? Biological Factors
Biological theorists suspect certain genes may leave some people particularly susceptible to eating disorders Consistent with this model: Relatives of people with eating disorders are 6 times more likely to develop the disorder themselves Identical (MZ) twins with bulimia: 23% Fraternal (DZ) twins with bulimia: 9% These findings may be related to low serotonin Comer, Fundamentals of Abnormal Psychology, 3e 396

Other theorists believe that eating disorders may be related to dysfunction of the hypothalamus Researchers have identified two separate areas that control eating: Lateral hypothalamus (LH) Ventromedial hypothalamus (VMH) Comer, Fundamentals of Abnormal Psychology, 3e 397

Set point: genetic inheritance and early eating practices determine our particular weight level If weight falls below set point:  hunger,  metabolism  binges If weight rises above set point:  hunger,  metabolism Comer, Fundamentals of Abnormal Psychology, 3e 398

Treatments for Eating Disorders
Eating disorder treatment goals: 1. Correct abnormal eating patterns 2. Address broader psychological and situational factors that have led to and are maintaining the eating problem This often requires the participation of family and friends Comer, Fundamentals of Abnormal Psychology, 3e 399

Treatments for Anorexia Nervosa
The initial aims of treatment for anorexia nervosa are to: Restore proper weight Recover from malnourishment Restore proper eating Comer, Fundamentals of Abnormal Psychology, 3e 400

Treatments for Anorexia Nervosa
In life-threatening cases, clinicians may need to force tube and intravenous feedings on the patient This may breed distrust in the patient and create a power struggle Most common technique now is the use of supportive nursing care and high-calorie diets Necessary weight gain is often achieved in 8 to 12 weeks Comer, Fundamentals of Abnormal Psychology, 3e 401

Treatments for Bulimia Nervosa
Several treatment strategies: Individual insight therapy The insight approach receiving the most attention is cognitive therapy, which helps clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape As many as 65% stop their binge-purge cycle Comer, Fundamentals of Abnormal Psychology, 3e 402

Treatments for Bulimia Nervosa
Several treatment strategies: Behavioral therapy Exposure and response prevention is used to break the binge-purge cycle Comer, Fundamentals of Abnormal Psychology, 3e 403

Chapter 12 Substance-Related Disorders
Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 12 Substance-Related Disorders Comer, Fundamentals of Abnormal Psychology, 3e 404

Substance-Related Disorders
Drug: Any substance other than food that affects our bodies or minds Current language uses the term “substance” rather than “drug” to include alcohol, tobacco, and caffeine Comer, Fundamentals of Abnormal Psychology, 3e 405

Substances may cause temporary changes in behavior, emotion, or thought Substance intoxication is actually a form of poisoning Comer, Fundamentals of Abnormal Psychology, 3e 406

Substance abuse: a pattern of behavior in which a person relies on a drug excessively and repeatedly, damaging their relationships, affecting work functioning, and/or putting themselves or others in danger Substance dependence: a more advanced pattern of use in which a person abuses a drug and centers his or her life around it Also called “addiction” May include tolerance (need increasing doses to get an effect) and withdrawal (unpleasant and dangerous symptoms when substance use is stopped) Comer, Fundamentals of Abnormal Psychology, 3e 407

About 10% of all adults in the U.S. display substance abuse or dependence Only 26% receive treatment Comer, Fundamentals of Abnormal Psychology, 3e 408

There are several categories of substances used and studied: Depressants Stimulants Hallucinogens Cannabis Polydrug use Comer, Fundamentals of Abnormal Psychology, 3e 409

Depressants Depressants slow the activity of the central nervous system (CNS) Reduce tension and inhibitions May affect judgment, motor activity, and concentration Three most widely used depressants: Alcohol Sedative-hypnotic drugs Opioids Comer, Fundamentals of Abnormal Psychology, 3e 410

Depressants: Alcohol Short-term: alcohol blocks messages between neurons Alcohol helps GABA (an inhibitory messenger) shut down neurons and “relax” the drinker Comer, Fundamentals of Abnormal Psychology, 3e 411

Depressants: Alcohol Levels of impairment are closely tied to the concentration of ethyl alcohol in the blood: BAC = 0.06: Relaxation and comfort BAC = 0.09: Intoxication BAC > 0.55: Death Most people lose consciousness before they can drink this much Comer, Fundamentals of Abnormal Psychology, 3e 412

Depressants: Alcohol The prevalence of alcoholism in a given year is about the same (7% to 10%) for white Americans, African Americans and Hispanic Americans The men in these groups show strikingly different age patterns Generally, Asians have lower rates of alcohol disorders than do people from other cultures As many as one-half of these individuals have a deficiency of alcohol dehydrogenase; thus they have a negative reaction to even modest alcohol use Comer, Fundamentals of Abnormal Psychology, 3e 413

Depressants: Alcohol Alcohol dependence Tolerance: a need to use greater amounts to feel its effect They may experience withdrawal, including nausea and vomiting, when they stop drinking A small percentage experience delirium tremens (“the DTs”) Can be fatal! Comer, Fundamentals of Abnormal Psychology, 3e 414

Depressants: Alcohol fetal alcohol syndrome (FAS): low birth weight, irregularities in head and face, intellectual deficits Comer, Fundamentals of Abnormal Psychology, 3e 415

Gender differences Men more likely to engage in binge drinking (more than 5 drinks) Women’s stomachs don’t break down alcohol as well Best predictor of binge drinking: Fraternity or sorority Comer, Fundamentals of Abnormal Psychology, 3e 416

Sedative-Hypnotic Drugs
Sedative-hypnotic (anxiolytic) drugs produce feelings of relaxation and drowsiness At low doses, they have a calming or sedative effect At high doses, they function as sleep inducers or hypnotics Sedative-hypnotic drugs include barbiturates and benzodiazepines Comer, Fundamentals of Abnormal Psychology, 3e 417

Sedative-Hypnotic Drugs: Barbiturates
Barbiturates are usually taken in pill form At low doses, reduce anxiety in a manner similar to alcohol by helping GABA operate Also similar to alcohol, barbiturates are metabolized by the liver Comer, Fundamentals of Abnormal Psychology, 3e 418

Sedative-Hypnotic Drugs: Benzodiazepines
Benzodiazepines are often prescribed to relieve anxiety Most popular sedative-hypnotics available Class includes Xanax and Valium Comer, Fundamentals of Abnormal Psychology, 3e 419

Opioids This class of drug includes both natural (opium, heroin, morphine, codeine) and synthetic (methadone) compounds and is known collectively as “narcotics” Each drug has a different strength, speed of action, and tolerance level Comer, Fundamentals of Abnormal Psychology, 3e 420

Opioids Opioids bind to the receptors in the brain that ordinarily receive endorphins (NTs that naturally help relieve pain and decrease emotional tension) When these sites receive opioids, they produce pleasurable and calming feelings just as endorphins do In addition to reducing tension, opioids can cause nausea, narrowing of the pupils, and constipation Comer, Fundamentals of Abnormal Psychology, 3e 421

Opioids Heroin abuse and dependence Heroin use exemplifies the problems posed by opioids After just a few weeks, users may become caught in a pattern of abuse (and often dependence) Users quickly build a tolerance for the drug and experience withdrawal when they stop taking it Early withdrawal symptoms include anxiety and restlessness; later symptoms include twitching, aches, fever, vomiting, and weight loss from dehydration Comer, Fundamentals of Abnormal Psychology, 3e 422

Opioids What are the dangers of heroin abuse? The most immediate danger is overdose The drug closes down the respiratory center in the brain, paralyzing breathing and causing death Death is particularly likely during sleep Ignorance of tolerance is also a problem About 2% of those dependent on heroin and other opioids die under the influence of the drug each year Users run the risk of getting impure drugs Opioids are often “cut” with noxious chemicals Dirty needles and other equipment can spread infection Comer, Fundamentals of Abnormal Psychology, 3e 423

Stimulants Stimulants are substances that increase the activity of the central nervous system (CNS) Cause increase in blood pressure, heart rate, and alertness Cause rapid behavior and thinking The four most common stimulants are: Cocaine Amphetamines Caffeine Nicotine Comer, Fundamentals of Abnormal Psychology, 3e 424

Stimulants: Cocaine Derived from the leaves of the coca plant, cocaine is the most powerful natural stimulant known 28 million people in the U.S. have tried cocaine 2 million people are currently using it Close to 3% of the population will become dependent on cocaine at some point in their lives Comer, Fundamentals of Abnormal Psychology, 3e 425

Stimulants: Cocaine Cocaine produces a euphoric rush of well- being It stimulates the central nervous system and decreases appetite It seems to work by increasing dopamine at key receptors in the brain by preventing the neurons that release it from reabsorbing it Also appears to increase norepinephrine and serotonin Comer, Fundamentals of Abnormal Psychology, 3e 426

Stimulants: Cocaine Cocaine abuse and dependence Cocaine use in the past was limited by the drug’s high cost Since 1984, cheaper versions of the drug have become available, including: A “freebase” form where the drug is heated and inhaled with a pipe “Crack,” a powerful form of freebase that has been boiled down for smoking in a pipe Comer, Fundamentals of Abnormal Psychology, 3e 427

Stimulants: Amphetamines
Amphetamines are stimulant drugs that are manufactured in the laboratory Methamphetamine, in particular, has had a surge in popularity in recent years Also in diet pills Comer, Fundamentals of Abnormal Psychology, 3e 428

Stimulants: Amphetamines
Also like cocaine, amphetamines stimulate the CNS by increasing dopamine, norepinephrine, and serotonin Tolerance builds quickly, so users are at great risk of becoming dependent When people dependent on the drug stop taking it, serious depression and extended sleep follow About 2% of Americans become dependent on amphetamines at some point in their lives Comer, Fundamentals of Abnormal Psychology, 3e 429

Stimulants: Caffeine Caffeine is the world’s most widely used stimulant Around 80% of the world’s population consume it daily Most consumption is in the form of coffee; the rest is in the form of tea, cola, chocolate, and over-the-counter medications More than 2 to 3 cups of brewed coffee can lead to caffeine intoxication Seizures and respiratory failure can occur at doses greater than 10 grams of caffeine (about 100 cups of coffee) Comer, Fundamentals of Abnormal Psychology, 3e 430

Hallucinogens Hallucinogens, also known as psychedelic drugs, produce powerful changes in sensory perceptions (sometimes called “trips”) Include natural hallucinogens Mescaline Psilocybin And synthetic hallucinogens Lysergic acid diethylamide (LSD) MDMA (Ecstasy) Comer, Fundamentals of Abnormal Psychology, 3e 431

Hallucinogens More than 14% of Americans have used hallucinogens at some point in their lives About 2% have used hallucinogens in the past year Tolerance and withdrawal are rare But the drugs do pose physical dangers Users may experience a “bad trip” – the experience of enormous unpleasant perceptual, emotional, and behavioral reactions Another danger is the risk of hallucinogen persisting perception disorder (“flashbacks”) Can occur a year or more after last drug use Comer, Fundamentals of Abnormal Psychology, 3e 432

Cannabis The drugs produced from varieties of the hemp plant are, as a group, called cannabis They include: Hashish, the solidified resin of the cannabis plant Marijuana, a mixture of buds, crushed leaves, and flowering tops The major active ingredient in cannabis is tetrahydrocannabinol (THC) The greater the THC content, the more powerful the drug Comer, Fundamentals of Abnormal Psychology, 3e 433

Cannabis Marijuana abuse and dependence Marijuana was once thought not to cause abuse or dependence Today many users are caught in a pattern of abuse Some users develop tolerance and withdrawal, experiencing flu-like symptoms and irritability when drug use is stopped About 2% of people in the U.S. displayed marijuana abuse or dependence in the past year About 5% will fall into these patterns at some point in their lives Comer, Fundamentals of Abnormal Psychology, 3e 434

Cannabis Is marijuana dangerous? As the potency of the drug has increased, so have the risks of using it May cause panic reactions similar to those caused by hallucinogens Because of its sensorimotor effects, marijuana has been implicated in accidents Marijuana use has been linked to poor concentration and impaired memory Comer, Fundamentals of Abnormal Psychology, 3e 435

What Causes Substance-Related Disorders?
Clinical theorists have developed sociocultural, psychological, and biological explanations for substance abuse and dependence No single explanation has gained broad support Best explanation: a COMBINATION of factors Comer, Fundamentals of Abnormal Psychology, 3e 436

Causes of Substance-Related Disorders: The Sociocultural View
A number of theorists propose that people are more likely to develop patterns of substance abuse or dependence when living in stressful socioeconomic conditions Example: higher rates of unemployment correlate with higher rates of alcohol use Example: people of lower SES have higher rates of substance use in general Comer, Fundamentals of Abnormal Psychology, 3e 437

Causes of Substance-Related Disorders: The Sociocultural View
Other theorists propose that substance abuse and dependence are more likely to appear in societies where substance use is valued or accepted Example: rates of alcohol use varies between cultures Comer, Fundamentals of Abnormal Psychology, 3e 438

Causes of Substance-Related Disorders: The Behavioral and Cognitive Views Behaviorists: operant conditioning may play a key role in the development and maintenance of substance abuse They argue that the temporary reduction of tension produced by a drug has a rewarding effect, thus increasing the likelihood that the user will seek this reaction again Similarly, the rewarding effects may also lead users to try higher doses or more powerful methods of ingestion Comer, Fundamentals of Abnormal Psychology, 3e 439

Causes of Substance-Related Disorders: The Behavioral and Cognitive Views Cognitive theorists further argue that such rewards eventually produce an expectancy that substances will be rewarding, and this expectation is sufficient to motivate individuals to increase drug use at times of tension Comer, Fundamentals of Abnormal Psychology, 3e 440

Causes of Substance-Related Disorders: The Biological View
In recent years, researchers have come to suspect that drug misuse may have biological causes Studies on genetic predisposition and specific biochemical processes have provided some support for this model Comer, Fundamentals of Abnormal Psychology, 3e 441

Genetic predisposition Research with “alcohol-preferring” rats has demonstrated that their offspring have similar alcohol preferences Similarly, research with human twins has suggested that people may inherit a predisposition to abuse substances Concordance rates in identical (MZ) twins: 54% Concordance rates in fraternal (DZ) twins: 28% Comer, Fundamentals of Abnormal Psychology, 3e 442

Genetic predisposition Stronger support for a genetic model may come from adoption studies Studies compared adoptees whose biological parents were dependent on alcohol with adoptees whose biological parents were not dependent By adulthood, those whose biological parents were dependent showed higher rates of alcohol use themselves Comer, Fundamentals of Abnormal Psychology, 3e 443

Psychodynamic therapists try to help those with substance-related disorders become aware of and correct underlying psychological problems Research has not found this model to be very effective Tends to be of greater help when combined with other approaches in a multidimensional treatment program Comer, Fundamentals of Abnormal Psychology, 3e 444

Behavioral Therapies A widely used behavioral treatment is aversion therapy, an approach based on classical conditioning principles Individuals are repeatedly presented with an unpleasant stimulus at the very moment they are taking a drug After repeated pairings, they are expected to react negatively to the substance itself and to lose their craving for it Comer, Fundamentals of Abnormal Psychology, 3e 445

Biological treatments may be used to help people withdraw from substances, abstain from them, or simply maintain their level of use without further increases These approaches are of limited success long-term when used alone but can be helpful when combined with other approaches Comer, Fundamentals of Abnormal Psychology, 3e 446

Antagonist drugs: Oppose the action of a neurotransmitter (Chantix for smoking) Comer, Fundamentals of Abnormal Psychology, 3e 447

Sociocultural Therapies
Three main sociocultural approaches to substance-related disorders: Self-help and residential treatment programs Culture- and gender-sensitive programs Community prevention programs Comer, Fundamentals of Abnormal Psychology, 3e 448

Sociocultural Therapies
Self-help and residential treatment programs Most common: AA Offers peer support along with moral and spiritual guidelines to help people overcome alcoholism. Focus on total abstinence. Comer, Fundamentals of Abnormal Psychology, 3e 449

Chapter 13 Sexual Disorders and Gender Identity Disorder
Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 13 Sexual Disorders and Gender Identity Disorder Comer, Fundamentals of Abnormal Psychology, 3e 450

Sexual Disorders and Gender Identity Disorder
Experts recognize two general categories of sexual disorders: Sexual dysfunctions – problems with sexual responses Paraphilias – sexual urges and fantasies in response to socially inappropriate objects or situations DSM-IV-TR also includes a diagnosis called gender identity disorder, a sex-related disorder in which people feel that they have been assigned to the wrong sex Comer, Fundamentals of Abnormal Psychology, 3e 451

Disorders of Desire Desire phase of the sexual response cycle Consists of an urge to have sex, sexual fantasies, and sexual attraction to others Two dysfunctions affect this phase: Hypoactive sexual desire disorder Sexual aversion disorder Comer, Fundamentals of Abnormal Psychology, 3e 454

Disorders of Desire Hypoactive sexual desire disorder Characterized by a lack of interest in sex and a low level of sexual activity Physical responses may be normal Prevalent in about 16% of men and 33% of women DSM-IV-TR refers to “deficient” sexual interest/activity but provides no definition of “deficient” In reality, this criterion is difficult to define Comer, Fundamentals of Abnormal Psychology, 3e 455

Disorders of Desire Sexual aversion disorder Characterized by a total aversion to (disgust of) sex Sexual advances may sicken, repulse, or frighten This disorder seems to be rare in men and more common in women Comer, Fundamentals of Abnormal Psychology, 3e 456

Disorders of Desire A person’s sex drive is determined by a combination of biological, psychological, and sociocultural factors, and any of these may reduce sexual desire Most cases of low sexual desire or sexual aversion are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly Comer, Fundamentals of Abnormal Psychology, 3e 457

Disorders of Desire Biological causes A number of hormones interact to produce sexual desire and behavior Abnormalities in their activity can lower sex drive These hormones include prolactin, testosterone, and estrogen for both men and women Sex drive can also be lowered by chronic illness, some medications, some psychotropic drugs, and a number of illegal drugs Comer, Fundamentals of Abnormal Psychology, 3e 458

Disorders of Desire Psychological causes anxiety or anger Fears, attitudes, and memories psychological disorders, including depression and obsessive-compulsive disorder Comer, Fundamentals of Abnormal Psychology, 3e 459

Disorders of Desire Sociocultural causes Examples: divorce, death, job stress, infertility, and/or relationship difficulties Cultural standards can impact the development of these disorders Comer, Fundamentals of Abnormal Psychology, 3e 460

Disorders of Excitement
Two dysfunctions affect this phase: Female sexual arousal disorder (formerly “frigidity”) Male erectile disorder (formerly “impotence”) Comer, Fundamentals of Abnormal Psychology, 3e 461

Female sexual arousal disorder repeated inability to maintain proper lubrication or genital swelling during sexual activity Many with this disorder also have desire or orgasmic disorders It is estimated that more than 10% of women experience this disorder Because this disorder is so often tied to an orgasmic disorder, researchers usually study the two together; causes of the two disorders will be examined together Comer, Fundamentals of Abnormal Psychology, 3e 462

Male erectile disorder (ED) repeated inability to attain or maintain an adequate erection during sexual activity An estimated 10% of men experience this disorder According to surveys, half of all adult men have erectile difficulty during intercourse at least some of the time Comer, Fundamentals of Abnormal Psychology, 3e 463

Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes Even minor physical impairment of the erection response may make a man vulnerable to the effects of psychosocial factors Comer, Fundamentals of Abnormal Psychology, 3e 464

Biological causes The same hormonal imbalances that can cause hypoactive sexual desire can also produce ED Most commonly, vascular problems are involved ED can also be caused by damage to the nervous system from various diseases, disorders, or injuries The use of certain medications and substances may interfere with erections Comer, Fundamentals of Abnormal Psychology, 3e 465

Biological causes Medical devices have been developed for diagnosing biological causes of ED One strategy involves measuring nocturnal penile tumescence (NPT) Men typically have erections during REM sleep; abnormal or absent nighttime erections usually indicate a physical basis for erectile failure Comer, Fundamentals of Abnormal Psychology, 3e 466

Psychological causes One well-supported cognitive explanation for ED emphasizes performance anxiety and the spectator role Once a man begins to have erectile difficulties, he becomes fearful and worried during sexual encounters; instead of being a participant, he becomes a spectator and judge This can create a vicious cycle of sexual dysfunction where the original cause of the erectile failure becomes less important than the fear of failure Comer, Fundamentals of Abnormal Psychology, 3e 467

Sociocultural causes Each of the sociocultural factors tied to hypoactive sexual desire has also been linked to ED Job and marital distress are particularly relevant Comer, Fundamentals of Abnormal Psychology, 3e 468

Disorders of Orgasm Orgasm phase of the sexual response cycle Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically For men: semen is ejaculated For women: the outer third of the vaginal walls contract There are three disorders of this phase: Premature ejaculation Male orgasmic disorder Female orgasmic disorder Comer, Fundamentals of Abnormal Psychology, 3e 469

Disorders of Orgasm Premature ejaculation persistent reaching of orgasm and ejaculation with little sexual stimulation About 30% of men experience premature ejaculation at some time Psychological, particularly behavioral, explanations of this disorder have received more research support than other theories The dysfunction seems to be typical of young, sexually inexperienced men It may also be related to anxiety, hurried masturbation experiences, or poor recognition of arousal Comer, Fundamentals of Abnormal Psychology, 3e 470

Disorders of Orgasm Male orgasmic disorder repeated inability to reach orgasm or by a very delayed orgasm after normal sexual excitement Occurs in 8% of the male population Biological causes include low testosterone, neurological disease, and head or spinal injury Medications, including certain antidepressants (especially SSRIs) and drugs that slow down the CNS, can also affect ejaculation Comer, Fundamentals of Abnormal Psychology, 3e 471

Disorders of Orgasm Male orgasmic disorder Cognitive factors such as performance anxiety and the spectator role may also contribute to this disorder Comer, Fundamentals of Abnormal Psychology, 3e 472

Disorders of Orgasm Female orgasmic disorder persistent delay in or absence of orgasm following normal sexual excitement Almost 25% of women appear to have this problem 10% or more have never reached orgasm An additional 10% reach orgasm only rarely Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly Female orgasmic disorder is more common in single women than in married or cohabiting women Comer, Fundamentals of Abnormal Psychology, 3e 473

Disorders of Orgasm Female orgasmic disorder Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning Early psychoanalytic theory used to consider lack of orgasm during intercourse to be pathological Typically linked to female sexual arousal disorder The two disorders tend to be studied and treated together Once again, biological, psychological, and sociocultural factors may combine to produce these disorders Comer, Fundamentals of Abnormal Psychology, 3e 474

Disorders of Orgasm Female orgasmic disorder Biological causes A variety of physiological conditions can affect a woman’s arousal and orgasm These conditions include diabetes and multiple sclerosis The same medications and illegal substances that affect erection in men can affect arousal and orgasm in women Postmenopausal changes may also be responsible Comer, Fundamentals of Abnormal Psychology, 3e 475

Disorders of Orgasm Female orgasmic disorder Psychological causes The psychological causes of hypoactive sexual desire and sexual aversion may also lead to female arousal and orgasmic disorders Memories of childhood trauma and relationship distress may also be related Comer, Fundamentals of Abnormal Psychology, 3e 476

Disorders of Orgasm Female orgasmic disorder Sociocultural causes For decades, the leading sociocultural theory of female sexual dysfunction was that it resulted from sexually restrictive cultural messages This theory has been challenged because: Sexually restrictive histories are equally common in women with and without disorders Cultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant Comer, Fundamentals of Abnormal Psychology, 3e 477

Disorders of Orgasm Female orgasmic disorder Sociocultural causes Researchers suggest that unusually stressful events, traumas, or relationships may produce the fears, memories, and attitudes that characterize these dysfunctions Research has also linked certain qualities in a woman’s intimate relationships (such as emotional intimacy) to orgasmic behavior Comer, Fundamentals of Abnormal Psychology, 3e 478

Disorders of Sexual Pain
Vaginismus involuntary contractions of the muscles of the outer third of the vagina Most clinicians agree with the cognitive-behavioral theory that vaginismus is a learned fear response Comer, Fundamentals of Abnormal Psychology, 3e 479

Disorders of Sexual Pain
Dyspareunia severe pain in the genitals during sexual activity Affects almost 15% of women and about 3% of men Dyspareunia in women usually has a physical cause, most commonly from injury sustained in childbirth Although relationship problems or psychological trauma from abuse may contribute to dyspareunia, psychosocial factors alone are rarely responsible Comer, Fundamentals of Abnormal Psychology, 3e 480

Treatments for Sexual Dysfunctions
The last 35 years have brought major changes in the treatment of sexual dysfunction Early 20th century: psychodynamic therapy Believed that sexual dysfunction was caused by a failure to negotiate the stages of psychosexual development Therapy focused on gaining insight and making broad personality changes; was generally unhelpful Comer, Fundamentals of Abnormal Psychology, 3e 481

1950s and 1960s: behavioral therapy Behavioral therapists attempted to reduce fear by applying relaxation training and systematic desensitization Had moderate success, but failed to work in cases where the key problems were cognitive or psychoeducational Comer, Fundamentals of Abnormal Psychology, 3e 482

1970: Human Sexual Inadequacy This book, written by William Masters and Virginia Johnson, revolutionized treatment of sexual dysfunctions This original “sex therapy” program has evolved into a complex, multidimensional approach Includes techniques from cognitive, behavioral, couples, and family systems therapies More recently, biological interventions have also been incorporated Comer, Fundamentals of Abnormal Psychology, 3e 483

What Techniques Are Applied to Particular Dysfunctions?
Hypoactive sexual desire and sexual aversion These disorders are among the most difficult to treat because of the many issues that feed into them Therapists typically apply a combination of techniques which may include: Affectual awareness, self-instruction training, behavioral techniques, insight-oriented exercises, and biological interventions such as hormone treatments Comer, Fundamentals of Abnormal Psychology, 3e 484

Erectile disorder Treatments for ED focus on reducing a man’s performance anxiety and/or increasing his stimulation May include sensate-focus exercises such as the “tease technique” Biological approaches, used when the ED has biological causes, have gained great momentum with the recent approval of sildenafil (Viagra) Most other biological approaches have been around for decades and include gels, suppositories, penile injections, a vacuum erection device (VED), and penile implant surgery Comer, Fundamentals of Abnormal Psychology, 3e 485

Male orgasmic disorder Like treatment for ED, therapies for this disorder include techniques to reduce performance anxiety and increase stimulation When the cause of the disorder is physical, treatment may include a drug to increase arousal of the nervous system Comer, Fundamentals of Abnormal Psychology, 3e 486

Premature ejaculation behavioral procedures such as the “stop-start” or “pause” technique Some clinicians favor the use of fluoxetine (Prozac) and other serotonin-enhancing antidepressant drugs Because these drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation While some studies have reported positive findings, long- term outcome studies have yet to be conducted Comer, Fundamentals of Abnormal Psychology, 3e 487

Female arousal and orgasmic disorders Specific treatment techniques for these disorders include self-exploration, enhancement of body awareness, and directed masturbation training Again, a lack of orgasm during intercourse is not necessarily a sexual dysfunction, provided the woman enjoys intercourse and is orgasmic through other means For this reason, some therapists believe that the wisest course of action is simply to educate women whose only concern is lack of orgasm through intercourse Comer, Fundamentals of Abnormal Psychology, 3e 488

Vaginismus Practice tightening and releasing the muscles of the vagina to gain more voluntary control Overcome fear of intercourse through gradual behavioral exposure treatment Over 75% of women treated for vaginismus using these methods eventually report pain-free intercourse Comer, Fundamentals of Abnormal Psychology, 3e 489

Paraphilias unusual fantasies and sexual urges or behaviors that are recurrent and sexually arousing Often involve: Humiliation of self or partner Children Nonconsenting people Nonhuman objects Comer, Fundamentals of Abnormal Psychology, 3e 490

Paraphilias According to the DSM-IV-TR, paraphilias should be diagnosed only when the urges, fantasies, or behaviors last at least 6 months For most paraphilias, the urges, fantasies, or behaviors must also cause great distress or impairment For certain paraphilias, however, performance of the behavior itself is indicative of a disorder Example: sexual contact with children Comer, Fundamentals of Abnormal Psychology, 3e 491

Fetishism recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object The disorder usually begins in adolescence Almost anything can be a fetish Women’s underwear, shoes, and boots are especially common Comer, Fundamentals of Abnormal Psychology, 3e 492

Fetishism Behaviorists: fetishes are learned through classical conditioning Fetishes are sometimes treated with aversion therapy, covert sensitization, or imaginal exposure An additional behavioral treatment is orgasmic reorientation, a process which teaches individuals to respond to more appropriate sources of sexual stimulation Comer, Fundamentals of Abnormal Psychology, 3e 493

Transvestic Fetishism
Also known as transvestism or cross- dressing fantasies, urges, or behaviors involving dressing in the clothes of the opposite sex in order to achieve sexual arousal Comer, Fundamentals of Abnormal Psychology, 3e 494

Transvestic Fetishism
The typical person with transvestism is a heterosexual male who began cross-dressing in childhood or adolescence Transvestism is often confused with gender identity disorder (transsexualism), but the two are separate patterns The development of the disorder seems to follow the behavioral principles of operant conditioning Comer, Fundamentals of Abnormal Psychology, 3e 495

Voyeurism repeated and intense sexual desires to observe people in secret as they undress or to spy on couples having intercourse; may involve acting upon these desires The person may masturbate during the act of observing or while remembering it later The risk of discovery often adds to the excitement Comer, Fundamentals of Abnormal Psychology, 3e 496

Frotteurism fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person Almost always male, the person fantasizes during the act that he is having a caring relationship with the victim Usually begins in the teenage years or earlier Acts generally decrease and disappear after age 25 Comer, Fundamentals of Abnormal Psychology, 3e 497

Pedophilia fantasies, urges, or behaviors involving sexual activity with a prepubescent child, usually 13 years of age or younger Some people are satisfied with child pornography Others are driven to watching, fondling, or engaging in intercourse with children Evidence suggests that two-thirds of victims are female Comer, Fundamentals of Abnormal Psychology, 3e 498

Pedophilia People with pedophilia develop the disorder in adolescence Some were sexually abused as children Many were neglected, excessively punished, or deprived of close relationships in childhood Most are immature, display faulty thinking, and have an additional psychological disorder Some theorists have proposed a related biochemical or brain structure abnormality Comer, Fundamentals of Abnormal Psychology, 3e 499

Pedophilia Most people with pedophilia are imprisoned or forced into treatment Treatments include aversion therapy, masturbatory satiation, and orgasmic reorientation Cognitive-behavioral treatment involves relapse-prevention training, modeled after programs used for substance dependence Comer, Fundamentals of Abnormal Psychology, 3e 500

A Word of Caution The definitions of paraphilias, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur Some clinicians argue that, except when people are hurt by them, paraphilic behaviors should not be considered disorders at all Comer, Fundamentals of Abnormal Psychology, 3e 501

Gender Identity Disorder
Gender identity disorder, or transsexualism, is one of the most fascinating disorders related to sexuality persistent feeling that one has been assigned to the wrong biological sex They would like to remove their primary and secondary sex characteristics and acquire the characteristics of the opposite sex Comer, Fundamentals of Abnormal Psychology, 3e 502

Men with gender identity disorder outnumber women 2 to 1 People with gender identity disorder often experience anxiety or depression and may have thoughts of suicide Comer, Fundamentals of Abnormal Psychology, 3e 503

People with gender identity disorder usually feel uncomfortable wearing the clothes of their own sex and may cross-dress This is distinctly different from a transsexual fetish; there is no sexual arousal related to this disorder The disorder sometimes emerges in childhood and disappears with adolescence In some cases it develops into adult gender identity disorder Comer, Fundamentals of Abnormal Psychology, 3e 504

Several theories have been proposed to explain this disorder, but research is limited and generally weak Some clinicians suspect biological – perhaps genetic - factors Abnormalities in the hypothalamus (particularly the bed nucleus of stria terminalis) are a potential link Some adults with this disorder change their sexual characteristics by way of hormones; others opt for sexual reassignment (sex change) surgery Comer, Fundamentals of Abnormal Psychology, 3e 505

Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 14 Schizophrenia Comer, Fundamentals of Abnormal Psychology, 3e 506

Psychosis Psychosis: a state defined by a loss of contact with reality Hallucinations: false sensory perceptions Delusions false beliefs Psychosis may be substance-induced or caused by brain injury, but most psychoses appear in the form of schizophrenia Comer, Fundamentals of Abnormal Psychology, 3e 507

Schizophrenia Schizophrenia affects approximately 1 in 100 people in the world About 2.5 million Americans currently have the disorder Comer, Fundamentals of Abnormal Psychology, 3e 508

Schizophrenia Schizophrenia appears in all socioeconomic groups, but is found more frequently in the lower levels Leading theorists argue that the stress of poverty causes the disorder Other theorists argue that the disorder causes victims from higher social levels to fall to lower social levels and remain at lower levels This is called the “downward drift” theory Comer, Fundamentals of Abnormal Psychology, 3e 509

Schizophrenia Equal numbers of men are women are diagnosed In men, symptoms begin earlier and are more severe Rates of diagnosis differ by marital status 3% of divorced or separated people 2% of single people 1% of married people It is unclear whether marital problems are a cause or a result Comer, Fundamentals of Abnormal Psychology, 3e 510

Schizophrenia Rates of the disorder differ by ethnicity and race About 2% of African Americans are diagnosed, compared with 1.4% of Caucasians According to the census, however, African Americans are also more likely to be poor and to experience marital separation When controlling for these factors, rates of schizophrenia become closer between the two racial groups Rates also differ between countries, as do the course and outcome of the disorder Comer, Fundamentals of Abnormal Psychology, 3e 511

What Are the Symptoms of Schizophrenia?
Symptoms can be grouped into three categories: Positive symptoms Negative symptoms Psychomotor symptoms Comer, Fundamentals of Abnormal Psychology, 3e 512

Positive symptoms These “pathological excesses” are bizarre additions to a person’s behavior Positive symptoms include: Delusions – faulty interpretations of reality Delusions may have a variety of bizarre content: being controlled by others; persecution; reference; grandeur; control Disordered thinking and speech May include loose associations; neologisms; perseverations; and clang Comer, Fundamentals of Abnormal Psychology, 3e 513

Examples of positive symptoms Loose associations: “The problem is insects. My brother used to collect insects. He’s now a man 5 foot 10 inches. You know, 10 is my favorite number; I also like to dance, draw, and watch TV.” Neologisms: “This desk is a cramstile”; “He’s an easterhorned head” Clang: How are you? “Well, hell, it’s well to tell” How’s the weather? “So hot, you know it runs on a cot” Comer, Fundamentals of Abnormal Psychology, 3e 514

Examples of positive symptoms Heightened perceptions People may feel that their senses are being flooded by sights and sounds, making it impossible to attend to anything important Hallucinations – faulty sensory perceptions Most common are auditory Generally involve a running commentary and/or accusations Spoken directly to or overheard by the hallucinator Hallucinations can involve any of the other senses: tactile, somatic, visual, gustatory, or olfactory Inappropriate affect: mood does not match situation Comer, Fundamentals of Abnormal Psychology, 3e 515

Negative symptoms These “pathological deficits” are characteristics that are lacking in an individual Negative symptoms include: Poverty of speech (alogia) Long lapses before responding to questions, or failure to answer Reduction of quantity of speech Slow speech Comer, Fundamentals of Abnormal Psychology, 3e 516

Examples of negative symptoms Blunted and flat affect Avoidance of eye contact Immobile, expressionless face Lack of emotion when discussing emotional material Apathetic and uninterested Monotonous voice, low and difficult to hear Comer, Fundamentals of Abnormal Psychology, 3e 517

Examples of negative symptoms Loss of volition (motivation or directedness) Feeling drained of energy and interest in normal goals Inability to start or follow through on a course of action Social withdrawal Withdrawal from social environment Seems to lead to a breakdown of social skills, including the ability to accurately recognize other people’s needs and emotions Comer, Fundamentals of Abnormal Psychology, 3e 518

Psychomotor symptoms Awkward movements, repeated grimaces, odd gestures The movements seem to have a magical quality These symptoms may take extreme forms, collectively called catatonia Includes stupor, rigidity, posturing, and excitement Comer, Fundamentals of Abnormal Psychology, 3e 519

What Is the Course of Schizophrenia?
Schizophrenia usually first appears between the late teens and mid-30s Many sufferers experience three phases: Prodromal – beginning of deterioration; mild symptoms Active – symptoms become increasingly apparent Residual – a return to prodromal levels One-quarter of patients fully recover; three-quarters continue to have residual problems Comer, Fundamentals of Abnormal Psychology, 3e 520

What Is the Course of Schizophrenia?
Each phase of the disorder may last for days or years A fuller recovery from the disorder is more likely in people: With high premorbid functioning Whose disorder was triggered by stress With rapid onset With later onset Comer, Fundamentals of Abnormal Psychology, 3e 521

Diagnosing Schizophrenia
DSM-IV-TR diagnosis only after signs of the disorder continue for six months or more deterioration in their work, social relations, and ability to care for themselves Comer, Fundamentals of Abnormal Psychology, 3e 522

Diagnosing Schizophrenia
The DSM-IV-TR distinguishes five subtypes: Disorganized – characterized by confusion, incoherence, and flat or inappropriate affect Catatonic – characterized by psychomotor disturbance of some sort Paranoid – characterized by an organized system of delusions and auditory hallucinations Undifferentiated – characterized by symptoms which fit no subtype; vague category Residual – characterized by symptoms which have lessened in strength and number; person may continue to display blunted or inappropriate emotions Comer, Fundamentals of Abnormal Psychology, 3e 523

How Do Theorists Explain Schizophrenia?
While there is no known cause, research has focused on: Biological factors (most promising) Psychological factors Sociocultural factors diathesis-stress model People with a biological predisposition will develop schizophrenia only if certain kinds of stressors or events are also present Comer, Fundamentals of Abnormal Psychology, 3e 524

Biological Views Genetic factors Following the principles of a diathesis-stress approach, genetic researchers believe that some people inherit a biological predisposition to schizophrenia This disposition (and disorder) are triggered by later exposure to stress This theory has been supported by studies of relatives, twins, and adoptees, and by genetic linkage studies Comer, Fundamentals of Abnormal Psychology, 3e 525

Biological Views Genetic factors Family pedigree studies have repeatedly shown that schizophrenia is more common among relatives of people with the disorder The more closely related they are to the person with schizophrenia, the greater their likelihood for developing the disorder General population: 1% Second-degree relatives: 3% First-degree relatives: 10% Factors other than genetics may explain these findings Comer, Fundamentals of Abnormal Psychology, 3e 526

Biological Views Genetic factors Twins have received particular research study Studies of identical twins have found that if one twin develops the disorder, there is a 48% chance that the other twin will do so as well If the twins are fraternal, the second twin has a 17% chance of developing the disorder Again, factors other than genetics may explain these findings Comer, Fundamentals of Abnormal Psychology, 3e 527

Biological Views Genetic factors Adoption studies have compared adults with schizophrenia who were adopted as infants with both their biological and adoptive relatives Because they were reared apart from their biological relatives, similar symptoms in those relatives would indicate genetic influences; similarities to their adoptive relatives would suggest environmental influences Researchers have repeatedly found that the biological relatives of adoptees with schizophrenia are more likely to display schizophrenic symptoms than are their adoptive relatives Comer, Fundamentals of Abnormal Psychology, 3e 528

Biological Views Genetic factors Genetic linkage and molecular biology studies indicate that possible gene defects on numerous chromosomes may predispose individuals to develop schizophrenia These varied findings may indicate: A case of “mistaken identity” -- that is, some of these gene sites do not contribute to the disorder; Various types of schizophrenia are linked to different genes; or Schizophrenia, like many disorders, is a polygenic disorder, caused by a combination of gene defects Comer, Fundamentals of Abnormal Psychology, 3e 529

Biological Views Genetic factors Genetic factors may lead to the development of schizophrenia through two kinds of (potentially inherited) biological abnormalities: Biochemical abnormalities Abnormal brain structure Comer, Fundamentals of Abnormal Psychology, 3e 530

Biological Views Biochemical abnormalities the dopamine hypothesis: Neurons using dopamine fire too often, producing symptoms of schizophrenia This theory is based on the effectiveness of antipsychotic medications (dopamine antagonists) Comer, Fundamentals of Abnormal Psychology, 3e 531

Biological Views Biochemical abnormalities Originally developed for treatment of allergies, antipsychotic drugs were found to cause a Parkinson’s disease-like tremor response in patients Scientists knew that Parkinson’s patients had abnormally low levels of dopamine which caused their shaking This relationship between symptoms suggested that symptoms of schizophrenia were related to excess dopamine Comer, Fundamentals of Abnormal Psychology, 3e 532

Biological Views Biochemical abnormalities Research since the 1960s has supported and clarified this hypothesis Example: patients with Parkinson’s develop schizophrenic symptoms if they take too much L- dopa, a medication that raises dopamine levels Example: people who take high doses of amphetamines, which increase dopamine activity in the brain, may develop amphetamine psychosis – a syndrome similar to schizophrenia Comer, Fundamentals of Abnormal Psychology, 3e 533

Biological Views Biochemical abnormalities Investigators have also located the dopamine receptors to which antipsychotic drugs bind The drugs are apparently dopamine antagonists which bind to the receptors, preventing further dopamine binding and neuron firing An appealing theory because certain dopamine receptors are known to play a role in guiding attention Comer, Fundamentals of Abnormal Psychology, 3e 534

Biological Views Biochemical abnormalities Dopamine may be overactive in people with schizophrenia because of a larger-than-usual number of dopamine receptors (particularly D- 2) Autopsy findings have found an unusually large number of dopamine receptors in people with schizophrenia Comer, Fundamentals of Abnormal Psychology, 3e 535

Biological Views Biochemical abnormalities Though enlightening, the dopamine hypothesis has limitations It has been challenged by the discovery of a new type of antipsychotic drug (“atypical” antipsychotics) that are more effective than traditional antipsychotics and also bind to serotonin receptors It has also been challenged by theorists who claim that excessive dopamine activity contributes primarily to the positive symptoms of schizophrenia These symptoms respond particularly well to conventional antipsychotic drugs Comer, Fundamentals of Abnormal Psychology, 3e 536

Biological Views Abnormal brain structure During the past decade, researchers have also linked schizophrenia (particularly cases dominated by negative symptoms) to abnormalities in brain structure For example, brain scans have found that many people with schizophrenia have enlarged ventricles This enlargement may be a sign of poor development in related brain regions People with schizophrenia have also been found to have smaller temporal and frontal lobes, and abnormal blood flow to certain brain areas Comer, Fundamentals of Abnormal Psychology, 3e 537

Biological Views Viral problems A growing number of researchers suggest that the brain abnormalities seen in schizophrenia result from exposure to viruses before birth Circumstantial evidence for this theory comes from the unusually large number of people with schizophrenia born in winter months More direct evidence comes from studies showing that mothers of children with schizophrenia were more often exposed to the influenza virus during pregnancy than mothers of children without schizophrenia Other studies have found a link between schizophrenia and a particular group of viruses found in animals Comer, Fundamentals of Abnormal Psychology, 3e 538

Biological Views While the biochemical, brain structure, and viral findings are beginning to shed much light on the mysteries of schizophrenia, they offer only a partial explanation Some people who have these biological problems never develop schizophrenia May be because biology sets the stage for the disorder, but psychological and sociocultural factors must be present for it to appear Comer, Fundamentals of Abnormal Psychology, 3e 539

Psychological Views As schizophrenia investigators began to identify genetic and biological factors of schizophrenia, clinicians largely abandoned psychological theories In the past decade, however, psychological factors are again being considered important Leading psychological explanations come from the psychodynamic, behavioral, and cognitive perspectives Comer, Fundamentals of Abnormal Psychology, 3e 540

Psychological Views The psychodynamic explanation Freud believed that schizophrenia developed from two processes: Regression to a pre-ego stage Efforts to re-establish ego control He proposed that when their world is extremely harsh, people who develop schizophrenia regress to the earliest points in their development (primary narcissism), in which they recognize and meet only their own needs This regression leads to self-centered symptoms such as neologisms, loose associations, and delusions of grandeur Comer, Fundamentals of Abnormal Psychology, 3e 541

Psychological Views The psychodynamic explanation Freud’s theory posits that attempts to reestablish ego control from such a state fail and lead to further schizophrenic symptoms Years later, another psychodynamic theorist elaborated on Freud’s idea of harsh parents The theory of schizophrenogenic mothers proposed that mothers of people with schizophrenia were cold, domineering, and uninterested in their children’s needs Both of these theories have received little research support and have been rejected by most psychodynamic theorists Comer, Fundamentals of Abnormal Psychology, 3e 542

Psychological Views The behavioral view Behaviorists cite operant conditioning and principles of reinforcement as the cause of schizophrenia They propose that some people are not reinforced for their attention to social cues and, as a result, they stop attending to those cues and focus instead on irrelevant cues (e.g., room lighting) Their responses become increasingly bizarre Support for this model has been circumstantial and the view is considered (at best) a partial explanation Comer, Fundamentals of Abnormal Psychology, 3e 543

Psychological Views The cognitive view Leading cognitive theorists agree that biological factors produce symptoms They theorize that further features of the disorder develop because of faulty interpretation and a misunderstanding of symptoms Example: a man experiences auditory hallucinations and approaches his friends for help; they deny the reality of his sensations; he concludes that they are trying to hide the truth from him; he begins to reject all feedback and starts feeling persecuted There is little direct research support for this view Comer, Fundamentals of Abnormal Psychology, 3e 544

Sociocultural Views Sociocultural theorists believe that people with mental disorders are victims of two main social forces: Social labeling Family dysfunction Although social and family forces are considered important in the development of schizophrenia, research has not yet clarified what their precise relationships might be Comer, Fundamentals of Abnormal Psychology, 3e 545

Sociocultural Views Social labeling Many sociocultural theorists believe that the features of schizophrenia are influenced by the diagnosis itself Society labels people who fail to conform to certain norms of behavior Once assigned, the label becomes a self-fulfilling prophecy The dangers of social labeling have been well demonstrated Example: Rosenhan “pseudo-patient” study Comer, Fundamentals of Abnormal Psychology, 3e 546

Sociocultural Views Family dysfunctioning One of the best-known family theories of schizophrenia is the double-bind hypothesis: Some parents repeatedly communicate pairs of mutually contradictory messages that place the child in so-called double-bind situations; the child cannot avoid displeasing the parents because nothing the child does is right In theory, the symptoms of schizophrenia represent the child’s attempt to deal with the double binds Comer, Fundamentals of Abnormal Psychology, 3e 547

Sociocultural Views Family dysfunctioning Double-bind messages typically consist of a “primary” verbal communication and an accompanying contradictory nonverbal “metacommunication” According to the double-bind theory, a child repeatedly exposed to these communications will adopt a special strategy for coping with them and may progress toward paranoid schizophrenia This theory is closely related to the psychodynamic notion of a schizophrenogenic mother It has been similarly unsupported by research, but is popular in clinical practice Comer, Fundamentals of Abnormal Psychology, 3e 548

Sociocultural Views Family dysfunctioning A number of studies suggest that schizophrenia is often linked to family stress: Parents of people with the disorder often: Display more conflict Have greater difficulty communicating Are more critical of and overinvolved with their children than other parents Family theorists have long recognized that some families are high in “expressed emotion” – family members frequently express criticism and hostility and intrude on each other’s privacy Individuals who are trying to recover from schizophrenia are almost four times more likely to relapse if they live with such a family Comer, Fundamentals of Abnormal Psychology, 3e 549

Sociocultural Views A sociocultural-existential view Most controversial explanation of schizophrenia Argues that the disorder is actually a constructive process in which people try to cure themselves of the confusion and unhappiness caused by their social environment Most theorists reject this notion; research has largely ignored it Comer, Fundamentals of Abnormal Psychology, 3e 550

Slides & Handouts by Karen Clay Rhines, Ph.D.
Seton Hall University Chapter 15 Treatments for Schizophrenia and Other Severe Mental Disorders Comer, Fundamentals of Abnormal Psychology, 3e 551

How Is Schizophrenia Treated?
Historically, people with schizophrenia were considered beyond help and without hope Though schizophrenia is still hard to treat, the discovery of antipsychotic drugs has enabled people with the disorder to think clearly and profit from psychotherapies Each of the models offers treatments for schizophrenia, and all have been influential at one time or another Comer, Fundamentals of Abnormal Psychology, 3e 552

Institutional Care in the Past
The move toward institutionalization began in 1793 with the practice of “moral treatment” Hospitals were created in isolated areas to protect patients from the stresses of daily life and to offer them a healthful psychological environment Comer, Fundamentals of Abnormal Psychology, 3e 553

Institutional Care in the Past
States throughout the U.S. were required by law to establish public mental institutions (state hospitals) for patients who could not afford private care Unfortunately, problems with overcrowding, understaffing, and poor patient outcomes led to loss of individual care and the creation of “back wards” – human warehouses filled with hopelessness Comer, Fundamentals of Abnormal Psychology, 3e 554

Institutional Care Takes a Turn for the Better
In the 1950s, clinicians developed two institutional approaches that brought some hope to chronic patients: Milieu therapy Based on humanistic principles Token economies Based on behavioral principles These approaches particularly helped improve the personal care and self-image of patients, problem areas that were worsened by institutionalization Comer, Fundamentals of Abnormal Psychology, 3e 555

Milieu therapy The guiding principle is that institutions can help patients make clinical progress by creating a social climate (“milieu”) that promotes productive activity, self-respect, and individual responsibility Milieu programs have been set up in institutions throughout the Western world with moderate success Research has shown that patients with schizophrenia in milieu programs often leave the hospital at higher rates than patients receiving custodial care Comer, Fundamentals of Abnormal Psychology, 3e 556

The token economy Based on operant conditioning principles, token economies are used in institutions to change the behavior of patients with schizophrenia Patients are rewarded when they behave in socially acceptable ways and are not rewarded when they behave unacceptably Immediate rewards are tokens that can later be exchanged for food, cigarettes, privileges, and other desirable objects Acceptable behaviors likely to be targeted include care for oneself and one’s possessions, going to a work program, and showing self-control Comer, Fundamentals of Abnormal Psychology, 3e 557

Milieu therapy and token economies have helped improve the gloomy outlook for patients with schizophrenia They are still used in many mental hospitals, usually along with medication This approach has also been applied to other clinical problems Comer, Fundamentals of Abnormal Psychology, 3e 558

Antipsychotic Drugs The discovery of antipsychotic medications dates back to the 1940s, when researchers developed antihistamine drugs for allergies It was discovered that one group of antihistamines, phenothiazines, could be used to calm patients about to undergo surgery Psychiatrists tested one of the drugs, chlorpromazine, on six patients with psychosis and observed a sharp reduction in their symptoms In 1954, chlorpromazine (under the trade name Thorazine) was approved for sale in the U.S. as an antipsychotic drug Comer, Fundamentals of Abnormal Psychology, 3e 559

Antipsychotic Drugs Since the discovery of the phenothiazines, other kinds of psychotic drugs have been developed Those developed throughout the 1960s, 1970s, and 1980s are now referred to as “conventional” antipsychotic drugs These drugs are also known as neuroleptic drugs because they often produce undesired movement effects similar to symptoms of neurological diseases Drugs developed in recent years are known as “atypical” or “second-generation” antipsychotics Comer, Fundamentals of Abnormal Psychology, 3e 560

How Effective Are Antipsychotic Drugs?
Antipsychotic drugs: Drugs that help correct grossly confused or distorted thinking -Correspondingly, people who display largely positive symptoms generally have better rates of recovery than those with primarily negative symptoms Since men with the disorder tend to have more negative symptoms than women, they require higher doses and respond less readily to the antipsychotic drugs Comer, Fundamentals of Abnormal Psychology, 3e 561

The Unwanted Effects of Conventional Antipsychotic Drugs
Neuroleptic Drugs: Conventional antipsychotic drugs, often produce undesired effects similar to the symptoms Tardive Dyskinesia: Shaking, bizarre grimaces, twisting of the body Comer, Fundamentals of Abnormal Psychology, 3e 562

The most common of these effects produce Parkinsonian symptoms, reactions that closely resemble the features of the neurological disorder Parkinson’s disease, including: Muscle tremor and rigidity Dystonia (bizarre movements of the face, neck, tongue, and back) Akathisia (great restlessness, agitation, and discomfort in the limbs) Comer, Fundamentals of Abnormal Psychology, 3e 563

The Parkinsonian and related symptoms seem to be the result of medication- induced reductions of dopamine activity in the substantia nigra, a part of the brain that coordinates movement and posture In most cases, the symptoms can be reversed if an anti-Parkinsonian drug is taken along with the antipsychotic Sometimes medication use must be halted altogether Comer, Fundamentals of Abnormal Psychology, 3e 564

In as many as 1% of patients, particularly elderly ones, conventional antipsychotic drugs produce neuroleptic malignant syndrome – a severe, potentially fatal reaction Symptoms include muscle rigidity, fever, altered consciousness, and improper functioning of the autonomic nervous system As soon as the syndrome is recognized, drug use is discontinued and each symptom is treated medically Individuals may also be given dopamine-enhancing drugs Comer, Fundamentals of Abnormal Psychology, 3e 565

New Antipsychotic Drugs
In recent years, new antipsychotic drugs have been developed Examples: Clozaril, Risperdal, Zyprexa, Seroquel, Geodon, and Abilify Comer, Fundamentals of Abnormal Psychology, 3e 566

New Antipsychotic Drugs
These new drugs are called “atypical” because their biological operation differs from that of conventional antipsychotics They appear more effective than conventional drugs, especially for negative symptoms They cause few extrapyramidal side effects They do, however, carry a risk of agranulocytosis, a potentially fatal drop in white blood cells Comer, Fundamentals of Abnormal Psychology, 3e 567

Psychotherapy Before the discovery of antipsychotic drugs, psychotherapy was not an option for people with schizophrenia Most were simply too far removed from reality to profit from psychotherapy Comer, Fundamentals of Abnormal Psychology, 3e 568

Psychotherapy Insight therapy A variety of insight therapies have been used to treat schizophrenia Studies suggest that the orientation of the therapist is less important than their experience with schizophrenia In addition, the most successful therapists are those who take an active role, set limits, express opinions, and challenge the patients’ statements Comer, Fundamentals of Abnormal Psychology, 3e 569

Psychotherapy Family therapy Around 25% of persons recovering from schizophrenia live with family members This creates significant family stress Those who live with relatives who display high levels of expressed emotion are at greater risk for relapse than those who live with more positive or supportive families Family therapy attempts to address such issues, create more realistic expectations, and provide psychoeducation about the disorder Families may also turn to family support groups and family psychoeducation programs Comer, Fundamentals of Abnormal Psychology, 3e 570

Social Therapy Many clinicians believe that the treatment of people with schizophrenia should include techniques that address social and personal difficulties in the clients’ lives These include: practical advice, problem solving, decision making, social skills training, medication management, employment counseling, financial assistance, and housing Research finds that this approach reduces rehospitalization Comer, Fundamentals of Abnormal Psychology, 3e 571

The Community Approach
The community approach is the broadest approach for the treatment of schizophrenia In 1963, Congress passed the Community Mental Health Act, which said that patients should be able to receive care within their own communities, rather than being transported to institutions far from home This led to massive deinstitutionalization of patients with schizophrenia Unfortunately, community care was (and is) inadequate for their care The result is a “revolving door” syndrome Comer, Fundamentals of Abnormal Psychology, 3e 572

What Are the Features of Effective Community Care?
Coordinated services Community mental health centers provide medications, psychotherapy, and inpatient emergency care Coordination of services is especially important for mentally ill chemical abusers (MICAs) Short-term hospitalization If treatment on an outpatient basis is unsuccessful, patients may be transferred to short-term hospital programs After being hospitalized for up to a few weeks, patients are released to aftercare programs for follow- up in the community Comer, Fundamentals of Abnormal Psychology, 3e 573

Supervised residences Halfway houses provide shelter and supervision for those patients who are unable to live alone or with their families but who do not require hospitalization Staff are usually paraprofessionals Houses are run with a milieu therapy philosophy These programs help those with schizophrenia adjust to community life and avoid rehospitalization Comer, Fundamentals of Abnormal Psychology, 3e 574

Occupational training Many people recovering from schizophrenia receive occupational training in a sheltered workshop – a supervised workplace for employees who are not ready for competitive or complicated jobs Comer, Fundamentals of Abnormal Psychology, 3e 575

How Has Community Treatment Failed?
There is no doubt that effective community programs can help people with schizophrenia recover However, fewer than half of all people who need them receive appropriate community mental health services In any given year, 40% to 60% of all people with schizophrenia receive no treatment at all Two factors are primarily responsible: Poor coordination of services Shortage of services Comer, Fundamentals of Abnormal Psychology, 3e 576

How Has Community Treatment Failed?
Shortage of services The number of community programs available to people with schizophrenia is woefully inadequate The centers that do exist generally fail to provide adequate services for people with severe disorders This shortage is due to: A lack of mental health professionals who wish to work with severely disturbed patients Objections to such programs by neighborhood residents Funding shortages (primary reason) Comer, Fundamentals of Abnormal Psychology, 3e 577

What Are the Consequences of Inadequate Community Treatment?
When community treatment fails, many people with schizophrenia receive no treatment at all Some return to their families and receive medication and perhaps emotional and financial support, but little else in the way of treatment Comer, Fundamentals of Abnormal Psychology, 3e 578

About 8% of patients enter an alternative care facility (such as a nursing home), where they receive custodial care and medication About 18% are placed in privately run residences (such as foster homes or boardinghouses) where supervision is provided by untrained individuals As many as 31% of patients are placed in single-room occupancy hotels, generally in rundown environments, where they survive on government disability payments Comer, Fundamentals of Abnormal Psychology, 3e 579

Finally, a great number of people with schizophrenia become homeless Approximately one-third of the homeless people in America have a severe mental disorder, commonly schizophrenia Comer, Fundamentals of Abnormal Psychology, 3e 580

Chapter 3 Models of Abnormality Karen Clay Rhines, Ph.D.

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Chapter 3 Models of Abnormality Karen Clay Rhines, Ph.D.

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