22 Assessment & Anxiety Disorders

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A. Factors in Mental Disorders B. Assessing Mental Disorders C. Diagnosing Mental Disorders D. Anxiety Disorders E. Somatoform Disorders Concept Review F. Cultural Diversity: An Asian Disorder G. Research Focus: School Shootings H. Application: Treating Phobias 508 510 512 513 517 520 521 522 523 524 Summary Test Critical Thinking Why Women Marry Killers behind Bars Links to Learning PowerStudy 4.5™ Complete Module 526 528 529 Photo Credit: © Pierre Perrin/Corbis Sygma MODULE 22 Assessment & Anxiety Disorders Introduction Photo Credits: left, © Jeff Tuttle/AFP/Getty Images; right, © Elizabeth Roll Mental Disorder He was a loving husband, devoted father, How did a respected church elder, and straitlaced county official. He also worked for a home security serial killer go company, where he would help individuals unnoticed? protect themselves from dangerous people. Until the day he was caught, he blended into the Wichita community as an average next-door neighbor. But over a period of 17 years, Dennis Rader planned and carried out the cruel murders of 10 people. He became known as the “BTK killer,” which stands for Bind, Torture, and Kill, describing the methods he used with his victims. In a very real sense, Rader led two different lives. In public, Rader seemed like a quiet, law-abiding guy who helped to protect the safety of others. However, in private, Rader would break into people’s homes, hide, and then sneak up on his victims. He would proceed to tie them up, callously strangle them, and eventually murder them. Although no two serial killers are alike, Rader fits the typical pattern. Serial killers usually look like ordinary people, often with families and good jobs. Many serial killers have experienced a traumatic childhood event and have serious personality defects, such as low self-esteem and a lifelong sense of loneliness. They are obsessed with control, manipulation, and dominance and often con their victims into agreeing to their requests. Most serial killers enjoy not the actual killing, but the ruthless torturing of their victims. This explains why serial killers feel special when their victims suffer and plead for help, and why Rader became sexually aroused as he strangled each of Dennis Rader, who his victims (Hickey, 2006; Mann, 2005). murdered 10 people, fits When Rader’s trial began, his defense the pattern of serial killers. attorneys had to decide whether they wanted to claim he was legally insane when he committed the murders. You are probably thinking that a person who coldheartedly plans and carries out 10 violent murders must certainly be insane, but let’s consider what it means to be insane. Insanity, according to its legal definition, means not knowing the difference between right and wrong. As inhumane as Rader’s behaviors may seem, his defense did not claim he was insane. Based on Rader’s testimony, it was clear he knew all along that his actions were wrong and conducted for his own selfish interests. In 2005, thirty-one years after the first BTK attacks, Rader was charged with 10 counts of first-degree murder for which he must serve 10 life sentences (Davey, 2005; O’Driscoll, 2005; Wilgoren, 2005). When mental health professionals examine Rader’s behaviors, they are trying to identify his particular mental disorder. A mental disorder is generally defined as a prolonged or recurring problem that seriously interferes with an individual’s ability to live a satisfying personal life and function adequately in society. Deciding whether a person has a mental disorder can be difficult because so many factors are involved in defining what is abnormal. As you’ll learn in this module, someone’s behavior may be described as abnormal but the person may or may not have a mental disorder. Phobia There is no doubt that Dennis Rader’s murder and mutilation of 10 individuals indicate extremely abnormal behavior and a severe mental disorder (Hickey, 2006). In other cases, mental disorders may involve a relatively common behavior or event that, through some learning, observation, or other process, has the power to elicit tremendous anxiety and becomes a phobia (Rowa et al., 2006). What’s so scary about flying? A phobia (FOE-bee-ah) is an anxiety disorder characterized by an intense, excessive, and irrational fear that is out of all proportion to the danger elicited by the object or situation. Kate Premo’s phobia of f lying began in her childhood, when she experienced a turbulent flight that left her scared and anxious. Later, as a young adult, her fear of f lying was worsened by memories of the 1988 terrorist bombing of Pan Am flight 103, which killed several of her fellow students from Syracuse University. After that incident, her phobia of flying kept her from visiting friends and family. She would try to f ly and even make reservaKate Premo is trying to overcome her phobia of flying. tions but always cancel them at the last minute. An estimated 9% of American adults have a similar irrational and intense fear of flying, which is called aviophobia; they refuse to get on a plane. Another 27% of American adults report being at least somewhat afraid to fly (USA Today/CNN/ Gallup, 2006). To treat her phobia, Kate Premo (photo above) took part in a weekend seminar that included actually flying in a plane. We’ll tell you about Kate’s phobia and treatment later in this module. These two examples of Dennis Rader and Kate Premo raise a number of questions about mental disorders: How do they develop? How are they diagnosed? How are they treated? We’ll answer these three questions as we discuss mental disorders. What’s Coming In this module, we’ll discuss three approaches to understanding mental disorders. We’ll explain how mental disorders are assessed and diagnosed and go into some specific examples of mental disorders, such as generalized anxiety, phobias, obsessive-compulsive behaviors, and somatoform disorders. Finally, we’ll discuss how common phobias, such as fear of flying, are treated. We’ll begin with the different factors that are involved in defining, explaining, and treating mental disorders, such as that of Dennis Rader. INTRODUCTION 509 A. Factors in Mental Disorders Causes of Abnormal Behavior girls and God-fearing adults (L. Shapiro, 1992). In the 1960s, one major cause of mental disorders was thought to be environmental factors, such as stressful events. In the 1990s came advances in studying genetic factors as well as new methods to study the structures and functions of living brains (p. 70). As a result, current researchers and clinicians believe that mental disorders, such as that of Dennis Rader, result from a number of factors, which include biological, cognitive-emotionalbehavioral, and environmental influences (Hersen & Thomas, 2006). Biological Factors Cognitive-Emotional-Behavioral & Environmental Factors Biological influences include genetic or inherited factors and various neurological factors that influence how the brain functions. Genetic factors. As an infant, Joan would cry, show great fear, and try to avoid new or novel objects or situations. Because Joan showed great fear as an infant, researchers concluded that her fearfulness was primarily due to genetic factors (Kagan, 2003a). Because biological factors themselves do not always explain why people develop mental disorders, psychologists point to various cognitive-emotional-behavioral factors that interact with and contribute to developing mental disorders. Genetic factors that contribute to the development of mental disorders are unlearned or inherited tendencies that influence how a person thinks, behaves, and feels. Genetic factors operate by affecting the developing brain and/ or the neurotransmitters that the brain uses for communication. Researchers estimate that genetic factors contribute from 30% to 60% to the development of mental disorders, such as depression, schizophrenia, and anxiety disorders (Rutter & Silberg, 2002). Neurological factors. Joan, who had started life as a fearful infant, had developed a serious mental disorder called a social phobia (p. 518) by the time she was 20. Researchers believed that one reason she developed a social phobia was that her brain’s emotional detector, called the amygdala (p. 362), was overactive and too often identified stimuli as threatening when they were only new or novel. In fact, when researchers measured the activity (fMRI) of Joan’s amygdala, they found that her amygdala overreacted when she looked at new or novel faces, something that did not happen Amygdalain the amygdalas of individuals who did emotions not have social phobias (C. E. Schwartz et al., 2003). In a related study, individuals Very fearful adults who had developed social phobias, like had more activity in Joan, showed far more amygdala activity the amygdala. when looking at angry, fearful, or disgusted faces than did individuals without social phobias (Luan et al., 2006). The studies illustrate neurological factors, such as having an overactive brain structure that contributes to the development of a mental disorder by causing a person to see the world in a biased or distorted way and to see threats when none really exist. Although these studies show that biological factors—genetic and neurological—can contribute to the development of mental disorders, not everyone with an overactive amygdala develops a mental disorder. This means that other factors are also involved in the development of mental disorders. 510 MODULE 22 ASSESSMENT & ANXIETY DISORDERS Cognitive-emotional-behavioral and environmental factors that contribute to the development of mental disorders include deficits in cognitive processes, such as having unusual thoughts and beliefs; deficits in processing emotional stimuli, such as underor overreacting to emotional situations; behavioral problems, such as lacking social skills; and environmental challenges, such Unusual thoughts, emotions, as dealing with stressful situations. behaviors, or events contribute For example, Dennis Rader was to developing mental disorders. a shy and polite child who preferred to spend time alone. As a boy, he recalls watching his grandparents strangle chickens at their farm, and by the time he reached high school, he was strangling cats and dogs. Rader’s hobby during childhood was looking at pictures of women in bondage. By his teens, he fantasized about tying up, controlling, and torturing women. He was becoming increasingly bothered by murderous impulses but did not know how to tell anyone about it (Ortiz, 2005; Singular, 2006). Rader’s many maladaptive thoughts, emotions, and behaviors interacted with his biological factors and resulted in his serious mental disorder. Environmental factors. In some cases, traumatic events, such as being in a war, having a serious car accident, watching some horrible event (a dog attacking and killing a child), or being brutally mugged, assaulted, or raped, can result in a long-lasting emotional disorder called posttraumatic stress disorder, or PTSD. As we discussed earlier (p. 491), a person with PTSD may relive the terrible event through memories and nightmares and have serious emotional problems that often require professional help (Resick et al., 2008). Experiencing PTSD is an example of how traumatic environmental factors can contribute to developing a serious mental disorder. Many factors. The answer to why Joan developed a social phobia, or Dennis Rader became a serial killer, or a family member, friend, or relative developed a mental disorder involves a number of factors—genetic, neurological, cognitive-emotional-behavioral, and environmental. As several or more of these factors interact, the result in some cases can be the development of one of the mental disorders that we’ll discuss in this and the next module. Photo Credit: right, © Colin Anderson/Brand X/Corbis Explanations for the causes of mental disorders have changed dramatically through the centuries. In the Middle Ages, mental disorders were thought to be the result of demons or devils who inhabited individuals and made them do strange and horrible things. In the 1600s, mental disorders were thought to involve witches, who were believed to speak to the devil. This was the case in Salem, Massachusetts, in 1692, where, in a short span of four months, 14 women and 5 men were hanged as witches on the testimony of young Definitions of Abnormal Behavior In some cases, such as Dennis Rader’s murder and mutilation of 10 individuals, we have no doubt that he demonstrated an extremely abnormal behavior pattern. In other cases, such as Kate Premo’s phobia of flying, we would probably say that most of her life appears to be normal except for a small piece—fear of flying in airplanes—that is abnormal. In still other cases, such as that of 54-year-old Richard Thompson (right photo), it is less clear what is abnormal behavior. The City of San Diego evicted Thompson and all his belongings from his home. His belongings included shirts, pants, dozens of shoes, several Bibles, a cooler, a tool chest, lawn chairs, a barbecue grill, tin plates, bird cages, two pet rats, and his self-fashioned bed. For the previous nine months, Thompson had lived happily and without any problems in a downtown storm drain (sewer). Because the city does not allow people to live in storm drains, however, Thompson was evicted from his underground stormdrain home and forbidden to return. Although Thompson later lived in several care centers and mental hospitals, he much preferred the privacy and comfort of the sewer (Grimaldi, 1986). There are three different ways to decide whether Richard Thompson’s behavior—living in the sewer—was abnormal. Photo Credits: top and bottom center, © San Diego Union Tribune/ZUMA Press; bottom left, © PhotoDisc, Inc.; bottom right, © Kelly Redinger/Design Pics/Corbis Is Mr. Thompson abnormal? Is it abnormal to live in a storm drain if you don’t bother anyone? Statistical Frequency Deviation from Social Norms Maladaptive Behavior Although Thompson caused no problems to others except to violate a city law against living in a storm drain, his preferred living style could be considered abnormal according to statistical frequency. Thompson’s behavior—preferring to live in a sewer—could also be considered abnormal based on social norms. The major problem with the first two definitions of abnormal behavior—statistical frequency and deviation from social norms—is that they don’t say whether a particular behavior is psychologically damaging or maladaptive. The statistical frequency approach says that a behavior may be considered abnormal if it occurs rarely or infrequently in relation to the behaviors of the general population. By this definition, Thompson’s living in a storm drain would be According to considered very abnorstatistical mal since, out of over frequency, living in a 300 million people in monastery is the United States, only abnormal. a very few prefer his kind of home. This illustrates that even though statistical frequency is a relatively precise measure, it is not a very useful measure of abnormality. By this criterion, getting a Ph.D., being president, living in a monastery, and selling a million records are abnormal, although some of these behaviors would be considered very desirable by most people. In fact, Guinness World Records (2009) lists thousands of people who have performed some statistically abnormal behaviors and are very proud of them. We would not consider any of these individuals to necessarily have mental disorders. As all these examples demonstrate, the statistical frequency definition of abnormality has very limited usefulness. The social norms approach says that a behavior is considered abnormal if it deviates greatly from accepted social standards, values, or norms. Thompson’s decision to live by himself in a storm drain greatly deviates from society’s norms about where people should live. However, a definition of abnormality based solely on deviations from social norms runs into problems when social norms change with time. For exa mple, 25 years ago, very few males wore earrings, while today many males consider earrings ver y f a s h ionable. Similarly, 40 years ago, a woman who preAccording to ferred to be very social norms, thin was considliving in a storm ered to be ill and drain is abnormal. in need of medical help. Today, our society pressures women to be thin like the fashion models in the media. Thus, defining abnormality on the basis of social norms can be risky, as social norms may, and do, change over time. The definition of abnormality most used by mental health professionals is the next one. The maladaptive behavior approach defines a behavior as psychologically damaging or abnormal if it interferes with the individual’s ability to function in his or her personal life or in society. For example, being terrified of flying, hearing voices that dictate dangerous acts, feeling compelled to wash one’s hands for hours on end, starving oneself to the point of death (anorexia nervosa), and Dennis Rader’s committing serial murders would all be considered maladaptive and, in that sense, abnormal. However, Thompson’s seemingly successful adaptation to living in a sewer may not be maladaptive for him and certainly has no adverse consequences to society. Most useful. Of the three definitions discussed here, menta l hea lt h professiona ls find that the most useful definition of abnormal behaviors is the one based on the maladaptive definition—that is, whether a behavior or behavior pattern interferes with a person’s According to the ability to function normaladaptive definition, behavior is abnormal mally in society (Sue et if it interferes with a al., 2010). person’s functioning. However, you’ll see that deciding whether behavior is truly maladaptive is not always so easy. A . FACTO RS IN ME N TA L DIS O RDE RS 511 B. Assessing Mental Disorders Definition of Assessment In some cases, it’s relatively easy to identify her car by the edge of the lake, strapped her two children into their what’s wrong with a person. For example, car seats, shut the windows and doors, got out of the car, walked to it’s clear that Dennis Rader was a serial the rear, and pushed the car into the lake. She covered her ears so killer and that Kate Premo has an intense she couldn’t hear the splash. The car disappeared under the water. and irrational fear of flying. But in other The two little boys, strapped into their seats, drowned. cases, it’s more difficult to identify exactly what the Susan’s confession stunned the nation as everyone asked, person’s motivation and mental problem are. Take “How could she have killed her own children?” “What’s the tragic case of Susan Smith. wrong with Susan?” To answer these questions, mental health Susan Smith appeared on the “Today” show, professionals evaluated Susan’s mental health with a procecrying for the return of her two little boys (right dure called the clinical assessment (J. M. Wood et al., 2002). photo), Michael, 3 years old, and Alex, 14 months A clinical assessment involves a systematic evaluation of an Susan first said her individual’s various psychological, biological, and social factors, as old, who, she said, had been kidnapped. She begged sons were kidnapped well as identifying past and present problems, stressors, and other the kidnapper to feed them, care for them, and but later confessed that please, please, return them. And then, nine days she had drowned them. cognitive or behavioral symptoms. later, after a rigorous investigation turned up doubts A clinical assessment is the first step in figuring out about the kidnapping story, the police questioned Susan again. Not which past or current problems may have contributed to Susan only did she change her story, but she made the teary confession killing her own children (Begley, 1998b). We’ll discuss how a that she had killed her two children. She said that she had parked clinical assessment is done. How do you find out what’s wrong? Three Methods of Assessment After Susan’s arrest, mental health professionals did clinical assessments to try to discover what terrible forces pushed her over the edge. Depending on their training, mental health professionals use one or more of three major techniques—neurological exams, clinical interviews, and psychological tests—to do clinical assessments. Neurological Tests Clinical Interviews Psychological Tests We can assume that Susan was given a number of neurological tests to check for possible brain damage or malfunction. These tests might include evaluating reflexes, brain structures (MRI scans), and brain functions (fMRI scans—p. 70). Neurological exams are part of a clinical assessment because a variety of abnormal psychological symptoms may be caused by tumors, diseases, or infections of the Did Susan have brain. neurological Neurological problems? tests are used to distinguish physical or organic causes (tumors) from psychological ones (strange beliefs) (Zillmer et al., 2008). Susan was reported to have no neurological problems. As part of her clinical assessment, several psychiatrists spent many hours interviewing Susan. This method is called a clinical interview (Hersen & Thomas, 2007). As part of her assessment, psychologists may have given Susan a number of personality tests (pp. 450, 474). During the clinical interview, Susan would have been asked about the history of her current problems, such as when they started and what What are other events accompanied them. The Susan’s past focus of the interview would have and current been on Susan’s current problem, psychological problems? killing her children, especially on the details of the symptoms that led up to the killing. The clinical interview is perhaps the primary technique used to assess abnormal behavior (Durand & Barlow, 2006). Based on 15 hours of interviews, Dr. Seymour Halleck testified that Susan was scarred by her father’s suicide and her stepfather sexually abusing her, which led to periods of depression, her current problem (Towle, 1995). As we also discussed in Modules 19 and 20, personality tests help clinicians evaluate a person’s traits, attitudes, emotions, and beliefs. Purpose. A major goal of doing a clinical assessment is to decide which mental health disorder best accounts for a client’s symptoms. For example, based on her symptoms, Susan was described as having a mood disorder, which you’ll see next is one of many possible mental health problems. 512 The clinical interview is one method of gathering information about a person’s past and current behaviors, beliefs, attitudes, emotions, and problems. Some clinical interviews are unstructured, which means they have no set questions; others are structured, which means they follow a standard format of asking a similar set of questions. MODULE 22 ASSESSMENT & ANXIETY DISORDERS Personality tests include two different kinds of tests: objective tests (self-report questionnaires), such as the MMPI, which consist of specific statements or questions to which the person responds with specific answers, and projective tests, such as the Rorschach inkblot test, which have no set answers but consist of ambiguous stimuli that a person interprets or makes up a story about. Photo Credits: top, © Time & Life Pictures/Getty Images; bottom center, © AP Images/Tim Kimzey How was Susan evaluated? C. Diagnosing Mental Disorders Real-Life Assessment What can a clinical assessment tell us? In criminal trials that involve questions of mental health, the defense and prosecution usually hire their own psychiatrists or psychologists because they are looking for different problems or symptoms. In Susan’s case, at least two psychiatrists did clinical assessments to answer a number of questions: What are her current symptoms? What past events and situations caused these symptoms? What role did her symptoms play in the killing of her children? Her Past Her Present During clinical interviews, the psychiatrist The psychiatrist found that Susan’s present problems included found that when Susan was 8 years old, her becoming depressed after being rejected by her current boyfriend. father shot himself. When she was 13, psyShe confessed to being so lonely in the months before the killings chologists wanted to admit her to a hospital that she had multiple sexual encounters: with her stepfather, who to treat her depression, but her mother and had molested her as a teenager; with her estranged husband, stepfather refused to cooperate. Later, when whom she was divorcing; with her current boyfriend, who later Susan was 15, her stepfather sexually molestwrote a good-bye letter; and with her boyfriend’s father. In addied her, but her mother refused to press chargtion, Susan was drinking heavily during this period. es. When she was in high school, she had Dr. Halleck testified that Susan suffered from severe depresSusan’s clinical periods of depression and attempted suicide. sion, drinking, and an adjustment disorder that caused her to have assessment revealed a disturbed person. She is However, she did well academically, was an a heightened emotional reaction to stress (D. Morgan, 1995). led away to serve a honor student and a member of the math being life In just 2½ hours, the jury decided that Susan Smith was guilty sentence. club, and was voted the “friendliest female” of murder. She was led from the courthouse (upper left photo) to in the class of 1989. She married David in 1991, but one serve a life sentence. year after the birth of their second son, their marriage fell As a result of her clinical assessment, Susan was diagnosed as having a apart and they filed for divorce (Bragg, 1995). mood disorder and was treated in prison with antidepressants. Dr. Seymour Halleck testified that Susan was scarred A clinical assessment is a method of identifying a client’s symptoms, by her father’s suicide, her stepfather’s sexual abuse, which are used to make a diagnosis. Making a diagnosis requires matchand her periods of depression, which contributed to her ing the symptoms to a particular disorder, which involves using the DSMcurrent difficulties (Towle, 1995). IV-TR. DSM-IV-TR Those who knew Susan tried to diagnose the problem that led to her tragic crime. “Maybe Susan was just plain crazy.” “Maybe she was too depressed to know what she was doing.” “Maybe she had bad genes.” “Maybe something bad happened to her as a child.” Using a more rigorous method, mental health professionals conduct clinical assessments to identify symptoms, which are then used to make a clinical diagnosis. How many mental disorders? Photo Credit: © AP Images/Ruth Fremson A clinical diagnosis is a process of matching an individual’s specific symptoms to those that define a particular mental disorder. Making a clinical diagnosis was very difficult prior to the 1950s because there was no uniform code or diagnostic system. However, since 1952, the American Psychiatric Association (APA) has been developing a uniform diagnostic system, whose most recent version is known as the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision, abbreviated as DSM-IV-TR (American Psychiatric Association, 2000). The Diagnostic and Statistical Manual of Mental Disorders-IVText Revision, or DSM-IV-TR, describes a uniform system for assessing specific symptoms and matching them to almost 300 different mental disorders. With each revision of the DSM, there have been improvements in diagnosing mental disorders. For example, the DSM-II (1968) gave only general descriptions of mental problems because it was based on Sigmund Freud’s general concepts of psychoses (severe mental disorders, such as schizophrenia) and neuroses (less severe forms of psychological conflict, such as anxiety). Using only general descriptions caused disagreements in diagnosing problems. The DSM-III (1980) dropped Freudian terminology and instead listed specific symptoms and criteria for mental disorders. However, these criteria were based primarily on clinical opinions, not research, so disagreements continued. A major improvement in the current DSM-IV-TR is that it establishes criteria and symptoms for mental disorders based more on research findings than on clinical opinions (L. A. Clark et al., 1995). When the next DSM comes out, likely in 2012, mental health experts predict that Number of Disorders it will use new findings from genetics and neuroscience to better identify the DSM-I 106 underlying causes of mental disorders (First, 2007; M. C. Miller, 2007). DSM-II 182 Interestingly, the first Diagnostic and 265 Statistical Manual of Mental Disorders DSM-III (1952) described about 100 mental dis297 orders, as compared to almost 300 in the DSM-IV-TR most recent DSM-IV-TR (right figure). We’ll use the cases of Dennis Rader (serial killer), Susan Smith (murderer), and Kate Premo (phobia of flying) to show how mental health professionals use the DSM-IV-TR to make a diagnosis. C. DI AGNO SIN G ME N TA L DIS O RDE RS 513 C. Diagnosing Mental Disorders In making a clinical diagnosis, a mental health professional first assesses the client’s specific symptoms and then matches these symptoms to those described in the DSM-IV-TR. The DSM-IV-TR has five major dimensions, called axes, which serve as guidelines for making decisions about symptoms. We’ll first describe Axis I and show how it can be used to diagnose the very different problems of Susan Smith and Kate Premo. (The numbered items below and on the opposite page are based on the Diagnostic and Statistical Manual of Mental DisordersIV-Text Revision [2000], American Psychiatric Association.) How do we make a diagnosis? Axis I: Nine Major Clinical Syndromes Axis I contains lists of symptoms and criteria about the onset, severity, and duration of these symptoms. In turn these lists of symptoms are used to make a clinical diagnosis of the following nine major clinical syndromes. 1. Disorders usually first diagnosed in infancy, childhood, or adolescence. This category includes disorders that arise before adolescence, such as attention-deficit disorders, autism, mental retardation, enuresis, and stuttering (discussed in Modules 1, 2, and 13). 2. Organic mental disorders. These disorders are temporary or permanent dysfunctions of brain tissue caused by diseases or chemicals, such as delirium, dementia (Alzheimer’s—p. 50), and amnesia (p. 265). 3. Substance-related disorders. This category refers to the maladaptive use of drugs and alcohol. Mere consumption and recreational use of such substances are not disorders. This category requires an abnormal pattern of use, as with alcohol abuse and cocaine dependence (pp. 188–189). 4. Schizophrenia and other psychotic disorders. The schizophrenias are characterized by psychotic symptoms (for example, grossly disorganized behavior, delusions, and hallucinations) and by over six months of behavioral deterioration. This category, which also includes delusional disorder and schizoaffective disorder, will be discussed in Module 23. 5. Mood disorders. The cardinal feature is emotional disturbance. Patients may or may not have psychotic symptoms. These disorders, including major depression, bipolar disorder, dysthymic disorder, and cyclothymic disorder, are discussed in Module 23. Susan Smith is an example of a person with a mood disorder. Susan Smith: Diagnosis—Mood Disorder From childhood on, Susan’s symptoms include being depressed, attempting suicide, seeking sexual alliances to escape loneliness, drinking heavily, and having feelings of low self-esteem and hopelessness, all of which match the DSM-IV-TR’s list of symptoms for a mood disorder. In Susan’s case, the specific mood disorder most closely matches major depressive disorder but without serious thought disorders and delusions. 514 MODULE 22 ASSESSMENT & ANXIETY DISORDERS In diagnosing major depression, the DSMIV-TR distinguishes between early (before age 21) and late onset depression—Susan would be early, and between mild and severe depression, as judged by how many episodes of depression she had and whether she showed a decreased capacity to function normally, such as the inability to work or care for children. Susan’s ability to hold Diagnosis: a job and care for her children suggests mild Mood disorder depression. This example shows how the guidelines of Axis I are used to arrive at one of nine major clinical syndromes—in this case, major depression. 6. Anxiety disorders. These disorders are characterized by physiological signs of anxiety (for example, palpitations) and subjective feelings of tension, apprehension, or fear. Anxiety may be acute and focused (phobias) or continual and diffuse (generalized anxiety disorder). An example of an anxiety disorder is that of Kate Premo. Kate Premo: Diagnosis—Specific Phobia Kate Premo’s symptoms include having an intense fear of flying, knowing that her fear is irrational and that she can’t control it, going out of her way to avoid flying, and making reservations that she later cancels. Kate’s symptoms most closely match the DSM-IV-TR’s list of symptoms for an anxiety disorder called a Diagnosis: specific phobia. The DSM-IV-TR’s symptoms Specific phobia for a specific phobia match those of Premo— (aviophobia) experiencing intense and irrational fear when exposed to a feared situation (flying) and having to avoid that situation at all costs, which interferes with part of her normal activities (going to meetings). 7. Somatoform disorders. These disorders are dominated by somatic symptoms that resemble physical illnesses. These symptoms cannot be accounted for by organic damage. There must also be strong evidence that these symptoms are produced by psychological factors or conflicts. This category, which includes somatization and conversion disorders and hypochondriasis, will be discussed in this module. 8. Dissociative disorders. These disorders all feature a sudden, temporary alteration or dysfunction of memory, consciousness, identity, and behavior, as in dissociative amnesia and multiple personality disorder (discussed in Module 23). 9. Sexual and gender-identity disorders. There are three types of disorders in this category: gender-identity disorders (discomfort with identity as male or female), paraphilias (preference for unusual acts to achieve sexual arousal), and sexual dysfunctions (impairments in sexual functioning) (discussed in Module 15). Photo Credits: top, © AP Images/Tim Kimzey; right, © Elizabeth Roll Figure/Text Credit: Syndrome titles from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright © 1994 American Psychiatric Association. Nine Major Problems: Axis I Other Problems and Disorders: Axes II, III, IV, V We have explained how Axis I is used to make clinical diagnoses of such mental disorders as major depression (mood disorder) and specific phobias (fear of flying). Now, we’ll briefly describe how the other four axes are used in diagnosing problems. Axis II: Personality Disorders Photo Credit: © Jeff Tuttle/AFP/Getty Images Figure/Text Credit: Syndrome titles from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright © 1994 American Psychiatric Association. This axis refers to disorders that involve patterns of personality traits that are long-standing, maladaptive, and inflexible and involve impaired functioning or subjective distress. Examples include borderline, schizoid, and antisocial personality disorders. Personality disorders will be discussed in Module 23. An example of a personality disorder is that of Rader. Dennis Rader: Diagnosis—Antisocial Personality Disorder Dennis Rader’s symptoms include torturing and killing 10 individuals, feeling no guilt or remorse, and exhibiting this behavior over a considerable period of time. Rader’s symptoms may indicate a combination of mental disorders, but here we’ll focus on only one from the DSMIV-TR, a personality disorder. According to the DSM-IV-TR, the essential features of an antisocial personality disorder are strange inner experiences that differ greatly from the expectations of one’s culture, that lead to significant impairment in personal, occupational, or social functioning, and that form a pattern of disregard Diagnosis: Antisocial for, and violation of, the rights of others. This list of symptoms personality disorder from the DSM-IV-TR matches those of Rader. Axis III: Personality Disorders This axis refers to physical disorders or conditions, such as diabetes, arthritis, and hemophilia, that have an influence on someone’s mental disorder. Axis IV: Psychosocial and Environmental Problems This axis refers to psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders in Axes I and II. A psychosocial or environmental problem may be a negative life event (experiencing a traumatic event), an environmental difficulty or deficiency, a familial or other interpersonal stress, an inadequacy of social support or personal resources, or another problem that describes the context in which a person’s difficulties have developed (PTSD was discussed on p. 491). Axis V: Global Assessment of Functioning Scale This axis is used to rate the overall psychological, social, and occupational functioning of the individual on a scale from 1 (severe danger of hurting self) to 100 (superior functioning in all activities). Using all five axes. Mental health professionals use all five axes to make a clinical diagnosis. For example, in the case of Dennis Rader, his unusual sexual symptoms may match those of a sexual disorder in Axis I. His other maladaptive symptoms match those of an antisocial personality disorder in Axis II. Rader apparently had no related medical conditions listed in Axis III. Rader was a loner with poor self-esteem and struggled with his schoolwork, which match some of the psychological, social, and environmental factors listed in Axis IV. Amazingly, Rader functioned well enough to hold a job and go unnoticed in his neighborhood, which would be used to rate his general functioning listed in Axis V. As you can see, each of the five axes in the DSM-IV-TR focuses on a different factor that contributes to making an overall clinical diagnosis of a person’s mental health. Usefulness of DSM-IV-TR The figure below shows the steps in making a clinical diagnosis. Mental health professionals begin by using three different methods to identify a client’s symptoms, a process called clinical assessment. Next, the client’s symptoms are matched to the five axes in the DSM-IVTR to arrive at a diagnosis of each client’s particular mental disorder. 1. Clinical interviews 2. Psychological tests 3. Neurological tests Clinical assessment: identify symptoms DSM-IV-TR: Use symptoms to diagnose mental disorder For mental health professionals, there are three advantages of using the DSMIV-TR’s uniform system to diagnose and classify mental disorders (Widiger & Clark, 2000). First, mental health professionals use the classification system to communicate with one another and discuss their clients’ problems. Second, researchers use the classification system to study and explain mental disorders. Third, therapists use the classification system to design their treatment program so as to best fit a particular client’s problem. Although using the DSM-IV-TR system to diagnose mental problems has advantages, it also has a number of potential problems. For example, mental health professionals do not always agree on whether a client fits a particular diagnosis. In addition, there may be social, political, and labeling problems, which we’ll discuss next. C. DI AGNO SIN G ME N TA L DIS O RDE RS 515 C. Diagnosing Mental Disorders Potential Problems with Using the DSM-IV-TR Is labeling a problem? It’s not uncommon to hear people use labels, such as “Jim’s really anxious,” “Mary Ann is compulsive,” or “Vicki is schizophrenic.” Although the goal of the DSM-IV-TR is to give mental disorders particular diagnostic labels, once a person is labeled, the label itself may generate a negative stereotype. In turn, the negative stereotype results in negative social and political effects, such as biasing how others perceive and respond to the labeled person (Greatley, 2004). Labeling Mental Disorders Social and Political Implications David Oaks, a sophomore at Harvard University, was having such fearful emotional experiences that he was examined by a psychiatrist. Although David believed that he was having a mystical experience, the psychiatrist interpreted and labeled David’s fearful experiences as indicating a kind of short-term schizophrenic disorder (Japenga, 1994). This mental health professional made a clinical diagnosis that resulted in giving a label to David’s problem. Diagnostic labels can change how a person is perceived and thus have political and social implications. For instance, in the 1970s, gays protested that homosexuality should not be included in the DSM-I and II as a mental disorder. When studies found that homosexuals were no more or less mentally healthy than heterosexuals, homosexuality as a mental disorder was eliminated from the DSM-III. In the 1980s, women protested the DSM label of selfdefeating personality disorder because the label applied primarily to women who were said to make destructive life choices, such as staying in abusive relationships (Japenga, 1994). This label was dropped from the DSM-IV because it suggested that women were choosing bad relationships, which wasn’t true (P. Caplan, 1994). Despite these advances, labeling continues to be a serious problem. For instance, 68% of Americans don’t want someone with a mental illness marrying into their family and 58% don’t want people with mental illness at their workplace (J. K. Martin et al., 2000). Also, even though mental illness does not increase the chance of someone being violent, many Americans still believe that people with mental illness tend to behave in violent ways (Elbogen & Johnson, 2009). Japan has a special problem with labels: Mental disorder labels have very negative connotations, which discourages Japanese from seeking professional help for mental disorders. One result is that, compared to the United States, Japan has a very high rate of suicide. That’s because one risk for suicide is depression, a label the Japanese avoid and thus they do not get timely treatment. In comparison, in the United States, the label of depression is widely accepted, so people are more likely to be treated, even by doctors in general practice (Menchetti et al., 2009). These examples illustrate the social and political implications of labeling individuals with mental disorders. Labeling refers to identifying and naming differences among individuals. The label, which places individuals into specific categories, may have either positive or negative associations. Some labels (anxious, depressed) have negative stereotypes. At first David felt relieved to know that his problem had a diagnosis or label. Later he realized that his new label was changing his life for the worse. People no longer responded to him as Davidthe-college-sophomore but as David-with-schizophrenicdisorder. As David’s case shows, the advantage of diagnostic labels is their ability to summarize and communicate a whole lot of information in a single word or phrase. But, the disadvantage is that if the label has negative associations—for example, mentally ill, retarded, schizo—the very label may elicit negative or undesirable responses. For this reason, mental health professionals advise that we not respond to people with mental disorders by their labels and instead respond to the person behind the label (Albee & Joffe, 2004). Frequency of Mental Disorders Although labels are a fact of life, researchers and clinicians try to What was surprising was that 59% of those with a mental disorder apply the DSM labels as fairly as possible. Researchers interviewed had neither asked for nor received any professional treatment. This a national sample of 9,282 noninstistudy also found that about 50% of all lifePercentage Who Will Have a tutionalized civilians aged 18 and time mental disorders begin by age 14 and Mental Disorder in Their Lifetime older and diagnosed their problems 75% begin by age 24. using the DSM’s diagnostic system. Any disorder Researchers concluded that about one in 51% As the graph at the right shows, two people will develop a mental disorder 32% based on those surveyed, 51% of Anxiety disorders sometime in their life, most individuals with people will develop at least one disa mental disorder do not seek treatment, and Mood disorders 28% order during their lifetime (Kessler there is a need to understand how to best et al., 2005). The most common mentreat mental disorders in youth. 15% Alcohol use disorders tal disorder was anxiety, followed by Next, we’ll examine the symptoms and 9% Drug use disorders mood disorders and substance abuse, treatment of specific disorders, beginning especially problems with alcohol. with anxiety. 516 MODULE 22 ASSESSMENT & ANXIETY DISORDERS D. Anxiety Disorders The most common mental disorder reported by adults in the United States is any kind of anxiety disorder (right graph) (Kessler et al., 2005). We have already discussed two serious anxiety problems, panic disorder (p. 481) and posttraumatic stress disorder (PTSD) (p. 491). Here we’ll review panic disorder and PTSD, as well as discuss other common forms of anxiety: generalized anxiety disorder, three kinds of phobias, and obsessive-compulsive disorder. How common is anxiety? Anxiety Disorders Any anxiety disorder 13% 11% 8% Generalized Anxiety Disorder During his initial therapy interview, Fred was sweating, fidgeting in his chair, and repeatedly asking for water to quench a never-ending thirst. From all indications, Fred was visibly distressed and extremely nervous. At first, Fred spoke only of his dizziness and problems with sleeping. However, it soon became clear that he had nearly always felt tense. He admitted to a long history of difficulties in interacting with others, difficulties that led to his being fired from two jobs. He constantly worried about all kinds of possible disasters that might happen to him (Davison & Neale, 1990). Fred’s symptoms showed that he was suffering from generalized anxiety disorder. Generalized anxiety disorder (GAD) is characterized by excessive or unrealistic worry about almost everything or feeling that something bad is about to happen. These anxious feelings occur on a majority of days for a period of at least six months (American Psychiatric Association, 2000). About 5% of adults are reported to have GAD, but almost twice as many adult women (6.6%) report GAD as do men (3.6%) (Halbreich, 2003). Symptoms 3% Treatment Generalized anxiety disorder is commonly treated with psychotherapy (see Module 24), with or without drugs. The drugs most frequently prescribed are tranquilizers such as alprazolam and diazepam, which belong to a group known as the benzodiazepines (ben-zoh-die-AS-ah-peens). One of the limitations of these drugs is that at high doses they are addicting and interfere with the ability to remember newly learned information (Arkowitz & Lilienfeld, 2007a; Rupprecht et al., 2009). Antidepressant drugs are also used to treat GAD and have fewer side effects and a lower risk of addiction (Holmes & Newman, 2006). Researchers found that about 40–50% of clients treated for generalized anxiety disorder with either psychotherapy (cognitive-behavioral) or drugs (tranquilizers) were free of symptoms six months to one year later (Arntz, 2003; Holmes & Newman, 2006). Social phobia Specific phobia Posttraumatic stress disorder 5% Generalized anxiety 5% Agoraphobia 4% Panic disorder Obsessive-compulsive disorder Panic Disorder One afternoon, Luisa (pictured below), a 23-year-old college student, was walking on campus and she suddenly felt her heart rate rapidly accelerate, her throat tighten up, and her arms and legs tremble. She became so nauseous she almost vomited. Luisa felt she had no control over what was happening. Then, weeks later, while at the movies, she had another episode during which she experienced dizziness, chest pain, shortness of breath, and weakness in her legs and feet. She feared she was having a heart attack and might die, but after a series of tests, her doctors found no medical problem. Luisa’s symptoms indicate that she had a panic disorder. Anxiety can be treated with drugs and psychotherapy. Generalized anxiety disorder includes both psychological and physical symptoms. Psychological symptoms include being irritable, having difficulty concentrating, and being unable to control one’s worry, which is out of proportion to the actual event. Constant worrying causes significant distress or impaired functioning in social, occupational, and other areas. Physical symptoms include restlessness, fatigue, sweating, flushing, pounding heart, insomnia, headaches, and muscle tension or aches (American Psychiatric Association, 2000). 29% Panic disorder is characterized by recurrent and unexpected panic attacks (described below). The person becomes so worried about having another panic attack that this intense worrying interferes with normal psychological functioning (American Psychiatric Association, 2000). Like Luisa, about 4% of adults in the United States suffer from panic disorder, and women are two to three times more likely to report it than are men (Halbreich, 2003). People who suffer from panic disorder have an increased risk of alcohol and other drug abuse, an increased incidence of suicide, decreased social functioning, and less marital happiness. About half suffer from depression (Smits et al., 2006). Symptoms Luisa’s symptoms on campus and at the movies indicate that she was having a panic attack, which may occur in several different anxiety disorders but is the essential feature of panic disorder. A panic attack is a period of intense fear or discomfort in which four or more of the following symptoms are present: pounding heart, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, feeling dizzy, and fear of losing control or dying (American Psychiatric Association, 2000). Treatment Panic disorders are usually treated with drugs—benzodiazepines, antidepressants (Prozac-like drugs, which are selective serotonin reuptake inhibitors, or SSRIs)—and/or psychotherapy. Research indicates psychotherapy is at least as effective as drug therapy and drug therapy alone increases the risk of clients relapsing after treatment ends (Smits et al., 2006). Researchers found that, one year after treatment with a combination of psychotherapy and drugs, about 30–50% of clients were symptom-free (Page, 2002). Another kind of anxiety disorder that is relatively common involves different kinds of phobias. D. ANXIE T Y DISORDERS 517 D. Anxiety Disorders Phobias A phobia (FOE-bee-ah) is an anxiety disorder characterized by an intense and irrational fear that is out of all proportion to the possible danger of the object or situation. Because of this intense fear, which is accompanied by increased physiological arousal, a person goes to great lengths to avoid the feared event. If the feared event cannot be avoided, the person feels intense anxiety. Reseachers report that because many individuals with phobias trace their onset to specific traumatic events, phobias are learned through conditioning or observing a person showing fear of something. Research also points to genetic and environmental causes of phobias. Thus, different pathways may lead to people developing phobias (Rowa et al., 2006). Common Phobias We discussed fear of blood and injections Social phobia 13% earlier (pp. 201, 493). Here we’ll discuss three common phobias—social phobias, specific Specific phobia 11% phobias, and agoraphobia (graph at left) 5% Agoraphobia (Durand & Barlow, 2006). Social Phobias Specific Phobias Agoraphobia Why didn’t Billy speak up in class? In junior high school, Billy never, never spoke up in class or answered any questions. The school counselor said that Billy would be sick to his stomach the whole day if he knew that he was going to be called on. Billy began to hide out in the restrooms to avoid going to class. Billy’s fear of speaking up in class is a n exa mple of a socia l phobia (Durand & Barlow, 2010). Why couldn’t Kate get on a plane? In the beginning of this module, we told you about Kate Premo (photo at left), whose traumatic childhood and adult experiences with f ly ing turned into a phobia of f lying, which is called a specific phobia. Why couldn’t Rose leave her house? Fear trapped Rose in her house for years. If she thought about going outside to do her shopping, pain raced through her arms and chest. She grew hot and perspired. Her heart beat rapidly and her legs felt like rubber. She said that thinking about leaving her house caused stark terror, sometimes lasting for days. This 39-year-old mother of two is one of millions of A mer ic a n s suffering from an intense fear of being in public places, which is called agoraphobia (Los Angeles Times, October 19, 1980). Social phobias are characterized by irrational, marked, and continuous fear of performing in social situations. The individuals fear that they will humiliate or embarrass themselves (American Psychiatric Association, 2000). Social Phobias 8% 5% 4% Speaking in public Speaking to strangers Eating in public Source: Eaton et al., 1991 As a fearful social situation approaches (graph above), anxiety builds up and may result in considerable bodily distress, such as nausea, sweating, and other signs of heightened physiological arousal. Although a person with a social phobia realizes that the fear is excessive or irrational, he or she may not know how to deal with it, other than by avoiding the situation. 518 Specific phobias, formerly called simple phobias, are characterized by marked and persistent fears that are unreasonable and triggered by anticipation of, or exposure to, a specific object or situation (flying, heights, spiders, seeing blood) (American Psychiatric Association, 2000). Specific Phobias Bugs, snakes, etc. Heights Water Closed places 23% 22% 13% 10% Source: Eaton et al., 1991 Among the more common specific phobias seen in clinical practice (graph above) are fear of animals (zoophobia), fear of heights (acrophobia), fear of confinement (claustrophobia), fear of injury or blood, and fear of flying (Durand & Barlow, 2006). The content and occurrence of specific phobias vary with culture. For example, fears of spirits or ghosts are present in many cultures but become specific phobias only if the fear turns excessive and irrational (American Psychiatric Association, 2000). MODULE 22 ASSESSMENT & ANXIETY DISORDERS Agoraphobia is characterized by anxiety about being in places or situations from which escape might be difficult or embarrassing (graph above) if a panic attack or paniclike symptoms (sudden dizziness or onset of diAgoraphobia arrhea) were to occur Public transport 13% (American Psychiatric Tunnels 8% Association, 2000). or bridges Agoraphobia arises Crowds 7% Source: Eaton et al., 1991 out of an underlying fear of either having a full-blown panic attack or having a sudden and unexpected onset of paniclike symptoms. After any of these phobias are established, they are extremely persistent and may continue for years if not treated (M. E. Coles & Horng, 2006). We’ll discuss drug and psychological treatments for phobias later in this module—in the Application section. Next, we’ll look at another form of anxiety that can be very difficult to deal with—obsessivecompulsive disorder. Photo Credit: center, © Elizabeth Roll Figure/Text Credit: (bottom) Bar graphs data on phobias from “Panic and Phobia” by W. W. Eaton, A. Dryman & M. M. Weissman, 1991. In L. N. Robins & D. A. Regier (Eds.), Psychiatric Disorders in America: The Epidemiological Catchment Area Study. Free Press. When common fears of seeing blood, spiders, or mice, having injections, meeting new people, speaking in public, f lying, or being in small places turn into very intense fears, they are called phobias (over 500 phobias are listed on www.phobialist.com). Can fear go wild? Obsessive-Compulsive Disorder Shirley was an outgoing, popular high-school student with average Why grades. Her one problem was that she was late for school almost every day. Before she could leave the house in the morning, she had to be sure was Shirley always late? she was clean, so she needed to take a shower that lasted a full 2 hours. After her shower, she spent a long time dressing because, for each thing she did, such as putting on her stockings, underclothes, skirt, and blouse, she had to repeat the act precisely 17 times. When asked about her washing and counting, she said she knew it was crazy but she just had to do it and couldn’t explain why (Rapoport, 1988). Shirley’s symptoms would be diagnosed as indicative of an anxiety problem called obsessive-compulsive disorder. An obsessive-compulsive disorder consists of obsessions, which are persistent, recurring irrational thoughts, impulses, or images that a person is unable to control and that interfere with normal functioning, and compulsions, which are irresistible impulses to perform over and over some senseless behavior or ritual (hand washing, checking things, counting, putting things in order) (American Psychiatric Association, 2000). Obsessive-compulsive disorder, or OCD, was once considered relatively rare, but now it is known to affect about 3% of adults in the United States (Riggs & Foa, 2006). We’ll discuss OCD’s symptoms and treatments. Repeating an act 17 times is a sign of OCD. Posttraumatic Stress Disorder Mark was driving home from work when a huge truck unexpectedly lost control and rammed his car from behind. Mark had no way to escape the traumatic accident. Though he needed hospital treatment, he was lucky to walk away alive. However, since the accident Mark has become so fearful of driving that he works from home now. He still experiences troublesome, recurring memories of the event and frequently has terrifying nightmares about being in a car accident. Mark’s symptoms would be diagnosed as indicative of an anxiety problem called posttraumatic stress disorder. Symptoms Shirley’s symptoms included both obsession—need to be very clean and careful about dressing—and compulsions—need to take 2-hour showers and to perform each act of dressing precisely 17 times. Some individuals have obsessions (irrational, recurring thoughts) without compulsions. Because compulsions are usually very time-consuming, they often take an hour or more to complete each day. Common compulsions involve cleaning, checking, and counting; the less common include buying, hoarding, and putting things in order. For example, individuals obsessed with being contaminated reduce their anxiety by washing their hands until their skin is raw, while those obsessed with leaving a door unlocked may be driven to check the lock every few minutes (American Psychiatric Association, 2000). These kinds of obsessive-compulsive behaviors interfere with normal functioning and make holding a job or engaging in social interactions difficult. OCD can be a chronic problem that requires treatment with drugs, psychotherapy, or some combination (Riggs & Foa, 2006). Treatment Photo Credit: right, © Chip Simons/Science Faction/Corbis Shirley’s compulsive behaviors are thought to be one way that she reduces or avoids anxiety. Currently, about half of patients with OCD report improvement after being treated with drugs or exposure therapy (Franklin et al., 2002). Exposure therapy involves gradually exposing the person to the actual anxiety-producing situations or objects that he or she is attempting to avoid and continuing the exposure treatments until the anxiety decreases. For example, a client like Shirley with OCD could be exposed over and over to her fearful objects (dirt or dirty things) until such exposures elicit little or no anxiety. Exposure therapy may involve 15 twohour sessions over the course of a month. However, Shirley refused to try exposure therapy and instead was given antidepressant drugs. Clients like Shirley, who cannot tolerate or are not motivated to undergo exposure therapy, may be given antidepressant drugs. After taking an antidepressant for about three weeks, Shirley’s urges to wash and count faded sufficiently that she could try exposure therapy Treatment for OCD is psycho(Rapoport, 1988). However, about one-third of clients with OCD are therapy and/or antinot helped by antidepressants (Riggs & Foa, 2006). depressant drugs. A new, last resort treatment for OCD is deep brain stimulation (p. 61) (DeNoon, 2009b; Talan, 2009). Next, we’ll describe how a threatening event can lead to posttraumatic stress disorder. Posttraumatic stress disorder, or PTSD, is a disabling condition that results from personally experiencing an event that involves actual or threatened death or serious injury or from witnessing or hearing of such an event happening to a family member or close friend. People suffering from PTSD experience a number of psychological symptoms, including recurring and disturbing memories, terrible nightmares, and intense fear and anxiety (APA, 2000). These horrible memories and feelings of fear keep stress levels high and result in a range of psychosomatic symptoms, including sleep problems, pounding heart, and stomach problems (Marshall et al., 2006; Schnurr et al., 2002). Treatment. Treatment may involve drugs, but some form of cognitivebehavioral therapy (p. 568) is more effective in the long term (Bolton et al., 2004). Cognitive-behavioral therapy provides emotional support so victims can begin the healing process, helps to slowly eliminate the horrible memories by bringing out the details of the experience, and gradually replaces the feeling of fear with a sense of courage (Harvey et al., 2003; Resick et al., 2008). Next, we’ll discuss how people can create real physical symptoms that interfere with normal functioning. D. ANXIE T Y DISORDERS 519 E. Somatoform Disorders Definition and Examples Imagine someone whose whole life centers around physical symptoms, some that are imagined and others that appear real, such as developing paralysis in one’s legs. This intense focus on imagined, painful, or uncomfortable physical symptoms is characteristic of individuals with somatoform disorders. Somatoform (so-MA-tuh-form) disorders are marked by a pattern of recurring, multiple, and significant bodily (somatic) symptoms that extend over several years. The bodily symptoms (pain, vomiting, paralysis, blindness) are not under voluntary control, have no known physical causes, and are believed to be caused by psychological factors (American Psychiatric Association, 2000). Although not easily diagnosed, somatoform disorders are among the most common health problems seen in general medical practice (Wise & Birket-Smith, 2002). The DSM-IV-TR lists seven kinds of somatoform disorders. We’ll discuss two of the more common forms—somatization and conversion disorders. Somatization Disorder One kind of somatoform disorder, which was historically called hysteria, is now called somatization disorder and is relatively rare (2.7% of the population). Somatization disorder begins before age 30, lasts several years, and is characterized by multiple symptoms—including pain, gastrointestinal, sexual, and neurological symptoms—that have no physical causes but are triggered by psychological problems or distress (American Psychiatric Association, 2000). This disorder is especially common among women (P. Fink et al., 2004). Those who have somatization disorder use health services frequently and have twice the annual medical care costs of people without somatization disorder (Barsky et al., 2005). Many people with somatization disorder are raised in emotionally cold and unsupportive family environments and are often victims of emotional or physical abuse (R. J. Brown et al., 2005). Somatization disorders may be a means of coping with a stressful situation or obtaining attention (Durand & Barlow, 2010). A psychologically distressed individual may have painful physical symptoms that have no physical causes. Mass Hysteria As more than 500 students from various schools began to give a choir and orchestra concert, they suddenly began to complain of headaches, dizziness, weakness, abdominal pain, and nausea. These symptoms spread rapidly until about half the students developed one or more of the symptoms. Students who became ill were most often those who saw someone near them become ill. Students from one school, particularly girls in the soprano section, experienced the highest rate of symptoms. Younger members reported more symptoms than older ones, and girls (51%) reported more symptoms than boys (41%). At first, someone thought that a gas line had broken, but no one in the audience developed any symptoms. There was no ruptured gas line. The students’ symptoms resulted from mass hysteria (Small et al., 1991). Mass hysteria is a condition experienced by a group of people who, through suggestion, observation, or other psychological processes, develop similar fears, delusions, abnormal behaviors, or physical symptoms. In this case, several of the most popular and visible girls complained of feeling dizzy and nauseous (they had been standing for hours). Soon, other students were complaining about having similar physical symptoms until over 200 students eventually developed these same symptoms. A similar case of mass hysteria was reported in a group of teenage girls in Vietnam, 50 of whom were hospitalized due to sudden fainting after watching one girl collapse and be carried away by medical personnel (IANS, 2006). Conversion Disorder Some people report serious physical problems, such as blindness, that have no physical causes and are examples of conversion disorder, a type of somatoform disorder. Usually the symptoms of a conversion disorder are associated with psychological factors, such as depression, concerns about health, or the occurrence of a stressful situation. Recent research examining the brains of people with medically unexplainable paralysis has shown that when patients try to move their paralyzed limbs, the emotional areas of the brain are activated inappropriately and may inhibit the functioning of the motor cortex, leaving the patients unable to move their paralyzed limbs (Kinetz, 2006). The development of such physical symptoms gets the person attention, removes the person from threatening or anxiety-producing situations, and thus reinforces the occurrence and maintenance of the symptoms involved in the conversion disorder (Durand & Barlow, 2010). Researchers found that in some cultures, bodily complaints (somatoform disorders) are used instead of emotional complaints to express psychological problems (Lewis-Fernandez et al., 2005). The same kind of painful or uncomfortable physical symptoms observed in somatoform disorders are observed in individuals suffering from mass hysteria. 520 MODULE 22 ASSESSMENT & ANXIETY DISORDERS Individuals who are emotionally aroused in a group may experience similar physical symptoms. In the Middle Ages, hysteria was attributed to possession by evil spirits or the devil. Today, mass hysteria is known to involve members of a group who experience and share emotional arousal or excitement, which spreads through the group and results in its members developing real physical symptoms with no known physical causes (Barlow & Durand, 2009). Mass hysteria is another example of somatoform disorders. After the Concept Review, we’ll discuss how symptoms of mental disorders can vary among cultures, as we examine a disorder that seems to be unique to Asian cultures, especially Japan. Photo Credit: left, © Marvin Mattelson A conversion disorder refers to changing anxiety or emotional distress into real physical, motor, sensory, or neurological symptoms (headaches, nausea, dizziness, loss of sensation, paralysis) for which no physical or organic cause can be identified (American Psychiatric Association, 2000). Concept Review 1. A prolonged or recurring problem that seriously interferes with the ability of an individual to live a satisfying personal life and function in society is called a . Photo Credits: (#2) © Colin Anderson/Brand X/Corbis; (#3) © San Diego Union Tribune/ZUMA Press; (#4) © AP Images/Tim Kimzey 2. Mental disorders arise from the interaction of a number of factors. Biological factors include inherited behavioral tendencies, which are called (a) factors. These factors contribute from 30% to 60% to the development of mental disorders. Biological factors also include the overreaction of brain structures to certain stimuli, which are called (b) factors. Other factors that contribute to the development of mental disorders, such as deficits or problems in thinking, processing emotional stimuli, and social skills, are called (c) factors. Being in or seeing a traumatic event, which is called an (d) factor, can contribute to developing a mental disorder such as PTSD. 3. There are three definitions of abnormality. A behavior that occurs infrequently in the general population is abnormal according to the (a) definition. A behavior that deviates greatly from accepted social norms is abnormal according to the (b) definition. Behavior that interferes with the individual’s ability to function as a person or in society is abnormal according to the (c) definition, which is used by most mental health professionals. 4. When performed by a mental health professional, a systematic evaluation of an individual’s various psychological, biological, and social factors that may be contributing to his or her problem is called a clinical (a) . A mental health professional who determines whether an individual’s specific problem meets or matches the standard symptoms that define a particular mental disorder is doing a clinical (b) . One of the primary techniques used to gather an enormous amount of information about a person’s past behavior, attitudes, and emotions and details of current problems is the clinical (c) . 5. The manual that describes the symptoms for almost 300 different mental disorders is called the (a) . The manual’s primary goal is to provide mental health professionals with a means of (b) mental disorNumber of Disorders ders and (c) that informaDSM-I 106 tion in a systematic and uniform way. The DSM-II 182 DSM-IV-TR has five major dimensions, called DSM-III 265 (d) , that serve as guidelines DSM-IV-TR 297 for making decisions about symptoms. 6. There are several kinds of anxiety disorders. An anxiety disorder that is characterized by excessive and/or unrealistic worry or feelings of general apprehension about events or activities, when those feelings occur on a majority of days for a period of at least six months, is called disorder. An anxiety dis(a) order marked by the presence of recurrent and unexpected panic attacks, plus continued worry about having another panic attack, when such worry interferes with psychological functioning, is called a (b) disorder. Suppose a person has a period of intense fear or discomfort during which four or more of the following symptoms are present: pounding heart, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, feeling dizzy, and fear of losing control or dying. That person is experiencing a (c) . 7. An anxiety disorder characterized by an intense and irrational fear and heightened physiological arousal that is out of all proportion to the danger elicited by the object or situation is called a (a) , of which there are several kinds. Unreasonable, marked, and persistent fears that are triggered by anticipation of, or exposure to, a specific object or situation are called a (b) . An anxiety that comes from being in places or situations from which escape might be difficult or embarrassing if a panic attack or paniclike symptoms were to occur is called (c) . Irrational, marked, and continuous fear of performing in social situations and feeling humiliated or embarrassed is called a (d) . 8. A disorder that consists of persistent, recurring irrational thoughts, impulses, or images that a person is unable to control and irresistible impulses to perform over and over some senseless behavior or ritual is called (a) disorder. A nondrug treatment for this disorder, which consists of gradually exposing the person to the real anxiety-producing situations or objects that he or she is attempting to avoid, is called (b) therapy. 9. When something happens to a group of people so that all share the same fears or delusions or develop similar physical symptoms, it is called (a) . There is a disorder that involves a pattern of recurring, multiple, and significant bodily complaints that have no known physical causes. This is called (b) disorder, and one of its more common forms is somatization disorder. Answers: 1. mental disorder; 2. (a) genetic, (b) neurological, (c) cognitive-emotional-behavioral, (d) environmental; 3. (a) statistical frequency, (b) social norms, (c) maladaptive behavior; 4. (a) assessment, (b) diagnosis, (c) interview; 5. (a) Diagnostic and Statistical Manual of Mental Disorders-IV-TR, (b) diagnosing, (c) communicating, (d) axes; 6. (a) generalized anxiety, (b) panic, (c) panic attack; 7. (a) phobia, (b) specific phobia, (c) agoraphobia, (d) social phobia; 8. (a) obsessive-compulsive, (b) exposure; 9. (a) mass hysteria, (b) somatoform CONCEPT REVIEW 521 F. Cultural Diversity: An Asian Disorder Anxiety is a worldwide concern and is the second most comCan a mon mental disorder in the United States and several Asian culture create nations, notably Japan. The symptoms of one kind of anxiety disorder, somatoform disorder, occur in very similar form in a disorder? many cultures around the world (Lewis-Fernandez et al., 2005). However, it’s also true that the unique cultural values of some countries, such as Japan, can result in the development of a unique anxiety order not found in Western cultures, such as the United States. If you had a social phobia in the United States, it would usually mean that you had a great fear or were greatly embarrassed about behaving or performing in social situations, such as making a public speech. But if you had a social phobia in several Asian cultures, especially Japan and somewhat in Korea, it might mean that you had a very different kind of fear or embarrassment, called taijin kyofusho, or TKS (Tarumi et al., 2004). In Japan, the fear of offending others (by staring) is considered a kind of social phobia. Taijin kyofusho (tai-jin kyo-foo-show), or TKS, is a kind of social phobia characterized by a terrible fear of offending others through awkward social or physical behavior, such as staring, blushing, giving off an offensive odor, having an unpleasant facial expression, or having trembling hands (Dinnel et al., 2002). Although many Westerners are also concerned or embarrassed about offending others through staring, having offensive body odors, or blushing, TKS is different in that it is an intense, irrational, morbid fear—in other words, a true phobia. In desperately trying to avoid TKS symptoms, Asians may try to avoid social interactions altogether. The Japanese word taijin-kyofu literally means “fear of interpersonal relations.” Occurrence. The graph below shows that TKS is the third most common psychiatric disorder treated in Japanese college students (Kirmayer, 1991). TKS is more common in males than in females, with a ratio of about 5:4. Most patients have a primary symptom, which has changed during the past 40 years. Initially, fear of blushing was the primary symptom, but it has been replaced by Percentage of Students fear of making eye contact or staring (Yamashita, 1993). In comparison, making eye contact is very Psychosomatic 24% disorders common in Western cultures; if you do not make Depressive eye contact in social interactions, you may be 20% reactions judged as shy or lacking in social skills. TKS 19% TKS begins around adolescence, when interpersonal interactions play a big role in one’s life. TKS is rarely seen after the late twenties because, by then, individuals have learned the proper social behaviors. TKS seems to develop from certain cultural influences that are unique to Japan. Cultural values. The Japanese culture places great emphasis on the appropriate way to conduct oneself in public, which means a person should avoid making direct eye contact, staring, blushing, having trembling hands, or giving off offensive odors. To emphasize the importance of avoiding these improper behaviors, mothers often use threats of abandonment, ridicule, and embarrassment as punishment. Through this process of socialization, the child is made aware of the importance of avoiding improper public behaviors, which result in a loss of face and reflect badly on the person’s family and social group. Thus, from early on, Japanese children are strongly encouraged to live up to certain cultural expectations about avoiding improper public behaviors, especially staring and blushing, which are considered to be rude and disgraceful. 522 MODULE 22 ASSESSMENT & ANXIETY DISORDERS Social Customs In Japan, individuals are expected to know the needs and thoughts of others by reading the emotional expressions of faces rather than asking direct questions, which is considered rude social behavior. In contrast, Westerners may ask direct questions to clarify some point and often use direct eye contact to show interest. Individuals in Japan who make too much eye contact or ask too direct questions are likely to be viewed as insensitive to others, unpleasantly bold, or aggressive. In fact, Japanese children are taught to fix their gaze at the level of the neck of people they are talking to. This Japanese social custom that emphasizes not making eye contact, blushing, or having trembling hands or offensive body odors during social interactions results in about 20% of Japanese teenagers and young adults developing the intense, irrational fear called TKS. This social phobia is so common in Japan that there are special clinics devoted only to treating TKS. The Japanese TKS clinics are comparable in popularity to the numerous weight-loss clinics found in the United States. Interestingly, TKS is a kind of social phobia that doesn’t occur in Western cultures (Dinnel et al., 2002; Tarumi et al., 2004). Cultural differences. Although people in many cultures report anxiety about behaving or performing in public, the particular fears that they report may depend on their own culture’s values. For example, TKS is unique to Asian cultures and unknown in Western cultures. Japanese who are especially at risk for developing TKS are those who score low on independence and high on interdependence, two traits found in traditional Japanese cultural values (Dinnel et al., 2002). Clinicians emphasize the importance of taking cultural values, influences, and differences into account when diagnosing behaviors across cultures (Fernando, 2002). In Japan, it is very important to know and show the proper public behaviors. Next, we’ll discuss a very serious problem in the U.S. culture: school shootings. Photo Credits: left, © David Young Wolff/PhotoEdit; right, © PhotoDisc, Inc. Taijin Kyofusho, or TKS G. Research Focus: School Shootings What Drove Teens to Kill Fellow Students and Teachers? Sometimes researchers are faced w it h a nswer i ng tragic questions, such as why teenagers took guns to schools and shot and killed at least 500 and wounded another 1,000. Everyone wonders what turns these teens into killers. In some cases, but not all, these adolescents might be diagnosed with conduct disorder. What is their problem? The diagnosis of conduct disorder seems to apply to Kipland Kinkel, age 15, who was charged with firing 50 rounds from a semiautomatic rifle into the school cafeteria, killing 2 students and injuring 22. Those who knew him said that Kinkel had a violent temper and a history of behavioral problems, which included killing his cat by putting a firecracker in its mouth, blowing up a dead cow, stoning cars from a highway overpass, and making bombs (Witkin et al., 1998). In trying to answer the question “Why did these adolescents shoot their fellow students and teachers?” mental health profesAdolescent school sionals have primarily used the case study approach. Photo Credit: © AP Images/Virginia State Police Conduct disorder refers to a repetitive and persistent pattern of behaving that has been going on for at shooters may have least a year and that violates the established social rules A case study is an in-depth analysis of the thoughts, feelings, conduct disorder. or the rights of others. Problems may include aggressive beliefs, experiences, behaviors, and problems of a single individual. behaviors such as threatening to harm people, abusing or killing animals, We’ll give brief case studies of two school shooters and then examdestroying property, being deceitful, or stealing. ine some factors that put a student at risk for becoming a shooter. Case Studies Risks Shared by Adolescent School Shooters The first school shooting that received national attention occurred in Moses Lake, Washington, on February 2, 1996. On that date, Barry Loukaitis, 14, fired on his algebra class, killing three and wounding one. He said that he wanted to get back at a popular boy who had teased him. Loukaitis shot that boy dead. Since then, school shootings have continued at an alarming rate. Across the world, there have been at least 50 adolescents, mostly boys, who took guns to their schools, fired hundreds of shots, killed at least 500 teachers and students, and wounded about 1,000 more (IANSA, 2007). One such shooter is 23-year-old college student SeungHui Cho (below photo), who in 2007 killed 32 people and wounded 25 others on the Virginia Tech campus, making it the deadliest school shooting in history. Cho was born in South Korea and immigrated to the United States when he was 8 years old. As a child, he was relentlessly teased and bullied for being shy and speaking with a strong accent. Consequently, he was isolated and developed anger toward his more “privileged” peers. He came to view himself as an avenger against those who humiliated him (White and affluent). He wanted to get even with the “rich brats” who had trust funds and drove Mercedes. In a disturbing message on the day of his shooting, he stated to the privileged, “You have never felt a single ounce of pain in your whole lives.” At the Seung-Hui Cho committed the end of his killing spree, Cho took deadliest school his own life (Gibbs, 2007; Schute, shooting in history. 2007; E. Thomas, 2007). However, very, very few students who are picked on and bullied commit violent acts, such as shooting teachers and students. We’ll examine some of the factors that put students as risk for committing violent acts. Although there are differences among school shooters, researchers have identified a number of risk factors that these boys shared (FBI, 2001; Langman, 2009; R. Lee, 2005; Pollack, 2007; Robertz, 2007; Verlinden et al., 2000). O Most of the boys (shooters) showed uncontrolled anger and depression, blaming others for problems and threatening violence. Most had poor coping skills, discipline problems at school or home, access to weapons, and a history of drug use. O Half of the boys had been given little parental supervision, had troubled family relationships, and perceived themselves as receiving little support from their families. Most of the boys had recently experienced the breakup of a relationship, a stressful event, or loss of status. O Most of the boys were generally isolated and rejected by their peers in school. Most had poor social skills and felt picked on, bullied, and persecuted and made friends who were also antisocial. The most commonly stated motives for shootings were to mete out justice to peers or adults who the teenage shooters believed had wronged them and to obtain status or importance among their peers. Most teenage shooters gave warning signs of their violent intentions that were not taken seriously. Neurological factors. Although coming from a broken home, being bullied, and dealing with various life stressors are risk factors for adolescents committing violent acts, another important risk factor is inside an adolescent’s brain. Everyone gets angry and has felt rage and the desire to get revenge, but most of us are able to control these violent impulses. This control involves the prefrontal cortex (p. 411), which has executive functions, such as planning, making decisions, and controlling strong emotional and violent impulses that arise from a very primitive prefrontal limbic part of the brain called the limbic system (p. 411) cortex system (right figure). The prefrontal cortex in the adolescent brain is still immature and may not reach complete maturity until the early twenties. For this reason, adolescents are especially at risk for committing all kinds of impulsive and violent behaviors and, in extreme cases, even school shootings (Luna, 2006). Gathering data about what motivates school shooters is an example of using the case study method. Next, we turn to explaining several ways of treating two relatively common anxiety disorders—social and specific phobias. G. RESEARCH FOCUS: SCHOOL SHOOTINGS 523 H. Application: Treating Phobias Specific Phobia: Flying Kate is undergoing exposure therapy for fear of flying. Cognitive-Behavioral Therapy Kate’s phobia of f lying involves fearful and irrational thoughts, which in turn cause increased physiological arousal. She can learn to reduce her irrational and fearful thoughts and reduce her arousal through cognitivebehavioral therapy (Singer & Dobson, 2006). Cognitive-behavioral therapy involves using a combination of two methods: changing negative, unhealthy, or distorted thoughts and beliefs by substituting positive, healthy, and realistic ones; and changing limiting or disruptive behaviors by learning and practicing new skills to improve functioning. Thoughts. Cognitive-behavioral therapy is useful in helping Kate control her fearful thoughts and eliminate dangerous beliefs about flying. For example, Kate had learned to fear various noises during flight, which she believed indicated trouble. To change these fearful thoughts, an airplane pilot explained the various noises, such as the thumps meant the landing gear was retracting after takeoff or being put down for landing. Thus, when Kate has a fearful thought, for example, “That noise must mean trouble,” she immediately stops herself and substitutes a realistic thought, “That’s just the landing gear.” Behaviors. Because Kate automatically gets nervous and fearful when just thinking about flying, she is instructed to do breathing, relaxation, and imagery exercises that will help her calm down. Deep and rhythmic breathing is an effective calming exercise because it distracts Kate from her fears and focuses her attention on a pleasant activity. Relaxing and tensing groups of muscles are also calming and help to decrease physiological arousal. Finally, imagery exercises are calming because focusing on pleasant images is a very powerful way of using her mind to control (relax) her body’s fightflight response. Cognitive-behavioral methods have proved effective in treating a variety of phobias (Singer & Dobson, 2006). Sometimes cognitive-behavioral therapy is combined with another kind of therapy, called exposure therapy. 524 MODULE 22 ASSESSMENT & ANXIETY DISORDERS f lying, crashing, heights, being in small enclosed spaces, or not having control of the situation (Van Gerwen et al., 1997). Most phobias do not disappear without some treatment, and on the few occasions that Premo was forced to fly, she dosed herself with so much alcohol and tranquilizers that she was groggy for days. Finally, she joined a weekend seminar that helps people overcome their fears of flying (M. Miller, 2003). Treatment for phobias can involve psychotherapy or drugs, or some combination of them. We’ll discuss psychotherapy and drug treatment, beginning with cognitive-behavioral and exposure therapy. Exposure Therapy For treating phobias, cognitive-behavioral therapy is often combined with exposure therapy. The most difficult part of Kate’s phobia treatment is exposure therapy, when she must actually confront her most feared situation. Exposure therapy consists of gradually exposing the person to the real anxietyproducing situations or objects that he or she is attempting to avoid and continuing exposure treatments until the anxiety decreases. The first part of Kate’s treatment involved cognitive-behavioral therapy, in which she learned how to control her irrational thoughts and acquire some basic relaxation techniques. The second part of her treatment involves exposure therapy, in which she is required to fly on a regularly scheduled airline, meaning that she will be exposed to her most feared situation. To help Kate deal with her fear of flying, Captain Michael Freebairn (photo below) sat next to Kate. Each time Kate tensed or looked fearful, the captain reassured Kate that all was normal and then reminded her to begin relaxation exercises (breathing and relaxing muscles), to use pleasant images, and to substitute positive, healthy thoughts for negative, fearful ones. When the plane landed, Kate was all smiles (left photo) after realizing that exposure therapy had significantly reduced her fear or phobia of flying. Programs that treat specific phobias, such as fear of flying, often use some combination of cognitive-behavioral and expoKate smiles after successfully sure therapy, which significantly reduces flying without feeling fear in the majority of clients (R. A. Friedintense fear. man, 2006; M. Miller, 2003). Clients not helped by cognitive-behavioral or exposure therapy may be given drug therapy (see next page) or they may try virtual reality therapy. Virtual reality therapy. Although clients never leave the ground, they sit in real airplane seats that vibrate to the sound of airplane engines. Clients wear head-mounted displays that surround them with 3-D experiences of “taking off ” and “flying.” Everything appears so real that clients who have a fear of flying begin to sweat and their hearts pound just as on real flights. Virtual reality therapy is a kind of exposure therapy, and it can be combined with relaxation exercises and thought substitution and be used to treat a variety of specific phobias, including fear of flying (Rothbaum et al., 2006). Photo Credits: top and bottom, © Elizabeth Roll At the beginning of this module, we told you about Kate Premo (right photo), who developed a phobia of flying. In some cases, people don’t remember what caused their phobias, but Premo remembers exactly when her phobia began. Her fear began as a child when she was on a very turbulent and stressful flight. Her fear was further intensified by her memories of the terrorist bombing of Pan Am flight 103, which killed several of her fellow students. After that incident, her fear of flying turned into a real phobia that kept her from flying to visit friends and family. An estimated 9% of American adults have a phobia of flying called aviophobia, which may include fear of Social Phobia: Public Speaking Just as specific phobias can be successWhen does a fully treated with psychotherapy, so fear become too can social phobias, such as public speaking. Almost everyone is somea phobia? what anxious about getting up and speaking in public. For a fear to become a full-blown phobia, however, the fear must be intense, irrational, and out of all proportion to the object or situation. For example, individuals with social phobias have such intense, excessive, and irrational fears of doing something humiliating or embarrassing that they will go to almost any lengths to avoid speaking in public. There are a number of very effective nondrug programs for treating social phobias (fear of speaking, performing, or acting in public). These programs combine cognitive-behavioral and exposure therapies and usually include the following four components (M. E. Coles & Horng, 2006). 1 Explain. Clinicians explain to the person that, since the fears involved in social phobias are usually learned, there are also methods to unlearn or extinguish such fears. The person is told how both thoughts and physiological arousal can exaggerate the phobic feelings and make the person go to any lengths to avoid the feared situation. 2 Learn and substitute. Clinicians found that some individuals needed to learn new social skills (initiating a conversation, writing a speech) so that they would function better in social situations. In addition, individuals were told to record their thoughts immediately after thinking about being in a feared situation. Then they were shown how to substitute positive and healthy thoughts for negative Treating social and fearful ones. phobias involves four components. 3 Expose. Clinicians first used imaginary exposure, during which a person imagines being in the situation that elicits the fears. For example, some individuals imagined presenting material to their co-workers, making a classroom presentation, or initiating a conversation with the opposite sex. After imaginary exposure, clinicians used real (in vivo) exposure, in which the person gives his or her speech in front of a group of people or initiates conversations with strangers. 4 Practice. Clinicians asked subjects to practice homework assignments. For instance, individuals were asked to imagine themselves in feared situations and then to eliminate negative thoughts by substituting positive ones. In addition, individuals were instructed to gradually expose themselves to making longer and longer public presentations or having conversations with the opposite sex. Researchers report that programs similar to the one above resulted in reduced social fears in about 56% of those who completed the program (Lincoln et al., 2003). Drug Treatment of Phobias Imagine being told to walk into a room and meet a group of strangers while you are stark naked. For most of us, this idea would cause such embarrassment, fear, and anxiety that we would absolutely refuse. This imagined situation is similar to the terrible negative emotions that individuals with social phobia feel when they must initiate a conversation, meet strangers, or give a public presentation. As we have discussed, social phobias can be treated with cognitive-behavioral and exposure therapy. However, some individuals with social Drug therapy for phobias involves phobia do not choose to or are too fearful to tranquilizers or complete a therapy program that includes expoantidepressants. sure to the feared situation. Instead, these individuals may choose drug therapy, which may involve tranquilizers (benzodiazepines) or the increasingly prescribed antidepressants (Blanco et al., 2003; M. E. Coles & Horng, 2006). The graphs below show the results of a double-blind study in which individuals with social phobia were given either a placebo or an antidepressant, in this case sertraline Average Score on Fear Scale: (Zoloft). After 20 weeks of treatDrug reduced fear more ment, individuals given antidepresthan placebo sants showed a significant clinical Placebo 16 reduction in scores on both anxiety and fear tests, which means they Drug 13 were able to function relatively well Average Score on Fear Scale: in social situations (Van AmerinDrug reduced avoidance more gen et al., 2001). Although 34% of than placebo those on antidepressants showed Placebo 16 a significant decrease in social Drug 13 anxiety, a remarkable 18% of those given placebos (sugar pills) showed a similar decrease. This means that the significant decrease in the social fears of almost one out of five individuals resulted from purely psychological factors, such as a client’s expectations and beliefs (“The pill is powerful medicine and will reduce my fear”). Although drug treatments are effective in reducing social phobias, there are two potential problems. First, about 50–75% of individuals relapse when drugs are discontinued, which means that their original intense social phobic symptoms return. Second, long-term maintenance on drugs can result in tolerance and increases in dosage, which, in turn, can result in serious side effects, such as loss of memory (S. M. Stahl, 2000, 2002). Compared to drug treatment of phobias, psychotherapy programs have the advantages of no problems with tolerance and no unwanted physical side effects. Which treatment to choose? Whether a client chooses psychotherapy or drug treatment for phobias depends to a large extent on each individual client’s preference. That’s because drug treatment (tranquilizers or antidepressants) and cognitive-behavioral or exposure therapy are about equally effective in the treatment of different phobias, including specific phobias, social phobias, and agoraphobia (Liebowitz et al., 1999). How effective are drugs? H. A PPLICAT ION: T R E AT IN G P HO BI A S 525 Summary Test A. Factors in Mental Disorders C. Diagnosing Mental Disorders 1. A prolonged or recurring problem that seriously interferes with an individual’s ability to live a satisfying personal life and function in society is a . This definition takes into account genetic, behavioral, cognitive, and environmental factors, all of which may contribute to a mental disorder. 6. When mental health professionals determine whether an individual’s specific problem meets or matches the standard symptoms that define a particular mental disorder, they are making a (a) . In trying to reach an agreement on the clinical diagnosis, mental health professionals use a set of guidelines, developed by the American Psychiatric Association, called the (b) , which is abbreviated as DSM-IV-TR. 3. If a behavior is considered abnormal because it occurs infrequently in the general population, we are using a definition based on (a) frequency. If a behavior is considered abnormal because it deviates greatly from what’s acceptable, we are using a definition based on (b) . If a behavior is considered abnormal because it interferes with an individual’s ability to function as a person or in society, we are using a definition based on (c) behavior. B. Assessing Mental Disorders 4. A systematic evaluation of an individual’s various psychological, biological, and social factors that may be contributing to his or her problem is called a (a) . The primary method used in clinical assessments is to get information about a person’s background, current behavior, attitudes, and emotions and also details of present problems through a (b) . A complete clinical assessment usually includes three major methods: (c) , , and . 5. Assessing mental disorders may be difficult because (a) vary in intensity and complexity. The assessment must take into account past and present problems and current stressors. The accurate assessment of symptoms is important because it has significant implications for the kind of (b) that the client will be given. 526 MODULE 22 ASSESSMENT & ANXIETY DISORDERS 7. The DSM-IV-TR is a set of guidelines that uses five different dimensions or (a) to diagnose mental disorders. The advantage of the DSM-IV-TR is that it helps mental health professionals communicate their findings, conduct research, and plan for treatment. One disadvantage of using the DSM-IV-TR to make a diagnosis is that it places people into specific categories that may have bad associations; this problem is called (b) . D. Anxiety Disorders 8. A mental disorder that is marked by excessive and/or unrealistic worry or feelings of general apprehension about events or activities, when those feelings occur on a majority of days for a period of at least six months, is called . This anxiety disorder is treated with some form of psychotherapy and/or drugs known as benzodiazepines. 9. One mental disorder is characterized by recurring and unexpected panic attacks and continued worry about having another panic attack; such worry interferes with psychological functioning. This problem is called a disorder. 10. Suppose you experience a period of intense fear or discomfort in which four or more of the following symptoms are present: pounding heart, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, feeling dizzy, and fear of losing control or dying. You are having a (a) . Panic disorders are treated with a combination of benzodiazepines or antidepressants and (b) . 11. Another anxiety disorder characterized by increased physiological arousal and an intense, excessive, and irrational fear that is out of all proportion to the danger elicited by the object or situation is called a . 12. The DSM-IV-TR divides phobias into three categories. Those that are triggered by common objects, situations, or animals (such as snakes or heights) are called (a) phobias. Photo Credits: (#1) © San Diego Union Tribune/ZUMA Press; (#4) © AP Images/Ruth Fremson 2. Mental disorders arise from the interaction of a number of factors. Biological factors include inherited behavioral tendencies, which are called (a) factors. These factors contribute from 30% to 60% to the development of mental disorders. Biological factors also include the overreaction of brain structures to certain stimuli, which are called (b) factors. Other factors that contribute to the development of mental disorders, such as deficits or problems in thinking, processing emotional stimuli, and social skills, are called (c) factors. Being in or seeing a traumatic event, which is called an (d) factor, can contribute to developing a mental disorder such as PTSD. Those that are brought on by having to perform in social situations and expecting to be humiliated and embarrassed are called (b) phobias. Those that are characterized by fear of being in public places from which it may be difficult or embarrassing to escape if panic symptoms occur are called (c) . Once established, phobias are extremely persistent and may require treatment. 13. Persistent, recurring irrational thoughts that a person is unable to control and that interfere with normal functioning are called (a) . Irresistible impulses to perform some ritual over and over, even though the ritual serves no rational purpose, are called (b) . A disorder that consists of both of these behaviors and that interferes with normal functioning is called (c) . The most effective nondrug treatment for obsessive-compulsive disorder is (d) therapy. E. Somatoform Disorders 14. The appearance of real physical symptoms and bodily complaints that are not under voluntary control, have no known physical causes, extend over several years, and are believed to be caused by psychological factors is characteristic of (a) disorders. The DSM-IV-TR lists seven kinds of somatoform disorders. The occurrence of multiple symptoms—including pain, gastrointestinal, sexual, and neurological symptoms—that have no physical causes but are triggered by psychological problems or distress is referred to as (b) disorder; a disorder characterized by unexplained and significant physical symptoms or deficits that affect voluntary motor or sensory functions and that suggest a real neurological or medical problem is called a (c) disorder. A recent survey reported that somatoform disorders occur worldwide, although their symptoms may differ across cultures. Photo Credit: (#14) © Marvin Mattelson F. Cultural Diversity: An Asian Disorder 15. A social phobia found in Percentage of Students Asia, especially Japan, that is characterized by morbid fear Psychosomatic 24% disorders of making eye-to-eye contact, Depressive blushing, giving off an offensive 20% reactions odor, having an unpleasant or TKS 19% tense facial expression, or having trembling hands is called . This phobia appears to result from Asian cultural and social influences that stress the importance of showing proper behavior in public. G. Research Focus: School Shootings 16. A method of investigation that involves an indepth analysis of the thoughts, feelings, beliefs, experiences, behaviors, or problems of a single individual is called a (a) . This method was used to decide if teenage school shooters had repetitive and persistent patterns of behavior that had been going on for at least a year and involved threats or physical harm to people or animals, destruction of property, being deceitful, or stealing. These symptoms define a mental disorder that is called (b) . H. Application: Treating Phobias 17. There are several different treatments for phobias. A nondrug treatment combines changing negative, unhealthy, or distorted thoughts and beliefs by substituting positive, healthy, and realistic ones and learning new skills to improve functioning; this treatment is called (a) therapy. Another therapy that gradually exposes the person to the real anxiety-producing situations or objects that he or she has been avoiding is called (b) therapy. Individuals who are unwilling or too fearful to be exposed to fearful situations or objects may choose drug therapy. 18. Social and specific phobias have been successfully treated with tranquilizers called (a) . Although these drugs are effective, they have two problems: When individuals stop taking these drugs, the original fearful symptoms may return, which is called (b) ; and, if individuals are maintained on drugs for some length of time, they may develop tolerance, which means they will have to take larger doses, which in turn may cause side effects such as loss of (c) . Researchers found that drug therapy was about equally effective as cognitive-behavioral or exposure therapy in reducing both social and specific phobias, including agoraphobia. Answers: 1. mental disorder; 2. (a) genetic, (b) neurological, (c) cognitiveemotional-behavioral, (d) environmental; 3. (a) statistical frequency, (b) social norms, (c) maladaptive behavior; 4. (a) clinical assessment, (b) clinical interview, (c) clinical interview, psychological tests, neurological tests; 5. (a) symptoms, (b) treatment; 6. (a) clinical diagnosis, (b) Diagnostic and Statistical Manual of Mental Disorders-IV-TR; 7. (a) axes, (b) labeling; 8. generalized anxiety; 9. panic; 10. (a) panic attack, (b) psychotherapy; 11. phobia; 12. (a) specific, (b) social, (c) agoraphobia; 13. (a) obsessions, (b) compulsions, (c) obsessive-compulsive disorder, (d) exposure; 14. (a) somatoform, (b) somatization, (c) conversion; 15. taijin kyofusho, or TKS; 16. (a) case study, (b) conduct disorder; 17. (a) cognitive-behavioral, (b) exposure; 18. (a) benzodiazepines, (b) relapse, (c) memory SUMMARY TEST 527 Critical Thinking Why Women Marry Killers behind Bars I 1 How would clinicians decide if women who fall in love with killers have a mental disorder? 2 Do women who almost instantly fall in love with prisoners they have never met have obsessivecompulsive disorder? 3 According to the three definitions of abnormal behavior, is Doreen Lioy abnormal? 4 According to Freud’s psychodynamic theory of personality, why is it difficult to explain why women fall in love with and marry killers? 528 MODULE 22 ASSESSMENT & ANXIETY DISORDERS 5 Which of the five axes in the DSMIV-TR best describes the problems these women share? 6 What are the advantages and disadvantages of labeling these women’s problems? ANS W ERS TO CRITI CAL TH I NKI NG QUEST I ONS Photo Credit: © GN/RCS Reuters QUESTIONS n 2004, Scott Peterson was convicted of murdering his wife and unborn child. Within an hour of being on Death Row, he received a marriage proposal from a woman he didn’t even know. As if this prop o s a l wa s n’t bi z a r r e enough, on Scott’s first day at San Quentin State Prison, the warden’s office received calls from over 30 women A woman fell in love with a convicted and jailed killer. desperate to make contact with the convicted killer, many of kept by inmate after the marriage them believing they were in love ceremony. The marriage ceremony with Peterson. will be conducted in the visiting About a decade earlier, Doreen area with the glass separating the Lioy, a 41-year-old woman, fell in couple being married” (“Inmate love with satanic serial killer Rich- marriages,” 2007). ard Ramirez, who was convicted of According to Sheila Isenberg, autorturing, sexually abusing, and thor of Women Who Marry Men murdering 13 people. Lioy described Who Kill, women who pursue intiher attraction to Ramirez beginning mate relationships with killers are immediately upon seeing his mug usually attractive, intelligent, and shot on TV: “I saw something in his very well accomplished. Isenberg eyes. Something that captivated me” also says most of these women have (Warrick, 1996, E-1). Lioy began come from loveless homes and have sending Ramirez letters and visiting been abused by men earlier in their him behind bars, and soon after lives. Gilda Carle, a relationship adthey married at the prison, even viser, explains that these women are though Ramirez would eventually attracted to the “bad boy syndrome” be executed. Lioy speaks about her and they feel special when the man complete devotion to her new hus- who has hurt and killed others treats band: “Because of my love for Rich- them with love, kindness, and reard, I have given up my family, spect. In fact, the most repugnant home, employment, and friends” murderers receive the most attention (Warrick, 1996, E-1). from women. There is such a demand for prisonWomen in love with convicted killer romance that matchmaking web- ers find the danger, excitement, and sites, such as prisonpenpals.com, drama of prison romance more offer thousands of ads from inmates arousing than the routine and prewho want to find love outside of their dictability of romance outside prison. cellblocks. Marriages in prisons are Having an intimate relationship with common enough for each prison to a man behind bars also makes the rehave its own set of regulations for in- lationship exceptionally safe. (Adaptmate marriages. Some of the rules ed from Fimrite & Taylor, 2005; “Infor one California prison include: mate marriages,” 2007; Warrick, “No property will be exchanged and 1996, 1997; Wiltenburg, 2003) Links to Learning Key Terms/Key People agoraphobia, 518 antidepressant drugs, 519 assessment, 512 aviophobia, 509 Axis I: Nine major clinical syndromes, 514 Axis II: Personality disorders, 515 Axis III: General medical conditions, 515 Axis IV: Psychosocial and environmental problems, 515 Axis V: Global assessment of functioning scale, 515 case study, 523 clinical assessment, 512 clinical diagnosis, 513 clinical interviews, 512 cognitive-behavioral therapy, 524 cognitive-emotionalbehavioral and environmental factors, 510 conduct disorder, 523 conversion disorder, 520 definitions of abnormal behavior, 511 deviation from social norms, 511 Diagnostic and Statistical Manual of Mental Disorders, 513 drug treatment of phobias, 525 exposure therapy, 519, 524 frequency of mental disorders, 516 generalized anxiety disorder, 517 genetic factors, 510 insanity, 509 labeling, 516 maladaptive behavior, 511 maladaptive behavior approach, 511 mass hysteria, 520 mental disorder, 509 neurological tests, 512 obsessive-compulsive disorder, or OCD, 519 panic attack, 517 panic disorder, 517 personality tests, 512 phobia, 509, 518 posttraumatic stress disorder, 519 psychological tests, 512 school shootings, 523 social and political implications of labeling, 516 social customs, 522 social norms approach, 511 social phobia, 518 social phobia: public speaking, 525 somatization disorder, 520 somatoform disorders, 520 specific phobia, 518 statistical frequency approach, 511 taijin kyofusho, or TKS, 522 virtual reality therapy, 524 Learning Activities PowerStudy for Introduction PowerStudy 4.5™ to Psychology 4.5 Try out PowerStudy’s SuperModule for Assessment & Anxiety Disorders! In addition to the quizzes, learning activities, interactive Summary Test, key terms, module outline and abstract, and extended list of correlated websites provided for all modules, the DVD’s SuperModule for Assessment & Anxiety Disorders features: t
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pages 526–527 and the critical thinking questions for the article on page 528. CengageNOW! www.cengage.com/login Want to maximize your online study time? Take this easyto-use study system’s diagnostic pre-test and it will create a personalized study plan for you. The plan will help you identify the topics you need to understand better and direct you to relevant companion online resources that are specific to this book, speeding up your review of the module. Introduction to Psychology Book Companion Website www.cengage.com/psychology/plotnik Visit this book’s companion website for more resources to help you study, including learning objectives, additional quizzes, flash cards, updated links to useful websites, and a pronunciation glossary. Study Guide and WebTutor Work through the corresponding module in your Study Guide for tips on how to study effectively and for help learning the material covered in the book. WebTutor (an online Study Tool accessed through your eResources account) provides an interactive version of the Study Guide. Suggested Answers to Critical Thinking 1. Clinicians would use a clinical assessment (neurological and psychological/personality tests and interviews) to identify symptoms and then match symptoms to the mental disorders listed in the DSM-IV-TR. 2. These women may have obsessions, which are persistent, irrational thoughts, but there is no indication that the obsessions cause marked anxiety or that the women engage in compulsions, which are irresistible, senseless behaviors or rituals. 3. A woman who falls in love with a convicted killer after seeing his mug shot and pursues him even though he will never be able to leave prison is certainly abnormal in terms of statistical frequency, in terms of deviation from social norms, and in terms of engaging in maladaptive behavior (giving up family, home, work, friends). 4. According to Freud’s psychodynamic theory of personality, women who fall in love with and marry killers are influenced by unconscious forces, wishes, and repressed desires, which are difficult to examine and understand because they are unconscious and not easily revealed or brought to the surface. 5. To identify potential problems of women who fall in love with killers, clinicians might use Axis II, which focuses on long-standing personality traits that are maladaptive or impair functioning. 6. One advantage of labeling these women’s problem is that it may help decide which therapy is best. One disadvantage is that giving women a label may bias how others perceive and respond to her. LINKS TO LEARNING 529 A. Mood Disorders B. Electroconvulsive Therapy C. Personality Disorders D. Schizophrenia Concept Review E. Dissociative Disorders F. Cultural Diversity: Interpreting Symptoms G. Research Focus: Exercise Versus Drugs H. Application: Dealing with Mild Depression 530 532 535 536 538 543 544 546 547 548 Summary Test Critical Thinking What Is a Psychopath? Links to Learning PowerStudy 4.5™ Complete Module 550 552 553 Photo Credit: © AP Images/Vincent Yu MODULE 23 Mood Disorders & Schizophrenia Introduction Photo Credits: both, © Robert Gauthier Mood Disorder Chuck Elliot (photo below) was checkWhy do ing out the exhibits at an electronics his thoughts convention in Las Vegas when suddenly his mind seemed to go wild and spin at speed up? twice its regular speed. His words could not keep up with his thoughts, and he was talking in what sounded like some strange code, almost like rapid fire “dot, dot, dot.” Then he stripped off all his clothes a nd r a n s t a rk n a k e d through the gambling casi no of t he Hi lton Hotel. The police were called, and Chuck was taken to a mental hospital. After his symptoms were reviewed, Chuck was diagnosed with what was then called manic Chuck Elliot’s mind spins and whirls out of control. He depression. was diagnosed with having At one time, Chuck had a bipolar I disorder. very successful career. After taking postgraduate courses, he obtained a doctor of education degree (Ed.D.). He started and ran his own video production business while also designing computer software. But since that first strange episode at the computer electronics convention, Chuck has been hospitalized about twice a year when his mind races and spins wildly out of control in what are called manic episodes. He usually takes medication, but because the drug slows him down more than he likes, he stops taking his medication every so often. Without medication, his energy may come back with such force that it blasts him into superactive days and sleepless nights, and he often ends up in a psychiatric hospital. His last regular job ended when he was in the middle of another manic attack. He was going on 100 hours without sleep when he went out to his car, grabbed a bunch of magazines, books, fruits, and vegetables, and piled them all on the desk in his office. When his boss came by and found a desk piled high with junk and Chuck sitting there with his mind spinning, the boss fired him on the spot (C. Brooks, 1994). Since that time, despite his very good academic, computer, and business qualifications, he has not been able to hold a steady job. More recently, Chuck married a woman he had been dating for only ten days. She understands Chuck very well because she too is manic-depressive and has similar mental health problems. She hopes that they can care for each other. She says, “Chuck is the most brilliant man I have ever met. I am so lucky” (C. Brooks, 1994, p. 4). In this module, we’ll explain Chuck’s illness, his treatment, and how he is dealing with his problem. Schizophrenia When Michael McCabe was 18 years old, Marsha, his mother, thought that he was just about over his rebellious phase. She was looking forward to relaxing and enjoying herself. But then Michael said that he was hearing voices. At first Marsha thought that Michael’s voices came from his smoking marijuana. But the voices persisted for two weeks, and Marsha checked Michael into a private drug treatment center. He left the center after 30 days and seemed no better off than he had been before. Several days later, Marsha found Michael in her parents’ home, a couple of miles down the road from her own house. Michael was sitting on the floor, his head back, holding his throat and making grunting sounds like an animal. Marsha got really scared and called the police, but before they arrived, Michael ran off. Michael spent time with his grandparents, who finally called Marsha and said that they couldn’t take his strange behavior anymore. Once again Marsha called the police. Just as Michael (photo below) tried to run away, the police caught him and took him to the community psychiatric hospital. Marsha received a call from a psychiatrist at the hospital, who explained that Michael had been diagnosed as having schizophrenia, a serious mental disorder that includes hea ring voices a nd hav ing disoriented thinking. A few days later, Michael escaped from the hospital. He was later returned by police, put into leather restraints, and given antipsychotic drugs that would also calm him down. Michael Michael McCabe, 18 years old, began remained in the hospital and hearing voices and was diagnosed with was treated with drugs for about having schizophrenia. a month, with little success. Just about the time Marsha was at her wits’ end about what to do next, Michael was put on a new antipsychotic drug, clozapine. After about a month on the new drug, Michael improved enough to be discharged back into Marsha’s care (C. Brooks, 1994, 1995a). In this module, we’ll explain what schizophrenia is, describe the drugs Michael was given, and report how his treatment is working. Why was he hearing voices? What’s Coming We’ll discuss several different mental disorders and their treatments. We’ll explain mood disorders and their treatments, including the treatment of last resort for depression, electroconvulsive shock therapy. We’ll also examine several personality disorders and different kinds of schizophrenia, along with old and new antipsychotic drugs. We’ll end with a group of strange and unusual disorders, one of which is multiple personality disorder. We’ll begin with Chuck Elliot’s problem, which is an example of one kind of mood disorder. INTRODUCTION 531 A. Mood Disorders Kinds of Mood Disorders Depression is not choosy; it happens to about 6 million Americans a year. Major depression is one example of a mood disorder. blues that most of us feel as having a paper cut on our finger. Then major depression is more like having to undergo openheart surgery. It’s some of the worst news that you can get. The DSM-IV-TR lists ten different mood disorders, but we’ll focus on the symptoms of three of the more common forms: major depressive disorder, bipolar I disorder, and dysthymic disorder. A mood disorder is a prolonged and disturbed emotional state that affects almost all of a person’s thoughts, feelings, and behaviors. Most of us have experienced a continuum of moods, with depression on one end and elation on the other. However, think of the depression or Major Depression Bipolar I Disorder Dysthymic Disorder Popular singer-songwriter Sheryl Crow (photo below) says that she has battled major depression most of her life. Unlike Sheryl Crow, who has a major depressive disorder, Chuck Elliot (right photo) fluctuates between two extreme moods of depression and mania; he has what is called bipolar I disorder. Another mood disorder that is less serious than major depression is called dysthymic (dis-THY-mick) disorder. Major depressive disorder is marked by at least two weeks of continually being in a bad mood, having no interest in anything, and getting no pleasure from activities. In addition, a person must have at least four of the following symptoms: problems with eating, sleeping, thinking, concentrating, or making decisions, lacking energy, thinking about suicide, and feeling worthless or guilty (American Psychiatric Association, 2000). Sheryl Crow says that she had been on a world tour with Michael Jackson, singing in front of 70,000 screaming fans. When the tour ended, she was back in her lonely apartment with the anxiety of having to get a record contract. All this stress triggered her first bout of depression, which resulted in her lying in bed, hardly able to move, going unshowered, stringy-haired, and ordering take-out for seven straight months (Hirshey, 2003). Like Crow, about 16% Major Depressive Disorder of U.S. adults reported at least Manic one lifetime episode of major depression, Normal with women outnumbering Depressed men by a ratio Time (years) of 2 to 1 (Thase, 2006). To help understand mood disorders, look at the graph above, which shows three general mood states. The top bar shows a manic episode or period of incredible energy and euphoria that we’ll discuss later. The middle bar shows a normal period when a person’s moods and emotions do not interfere with normal psychological functioning. However, like what happened to Crow, some event may cause a person to go from a normal period to a period of depression (bottom bar). Individuals may fluctuate between a normal period and a bout of severe depression. 532 Bipolar I disorder is marked by fluctuations between episodes of depression and mania. A manic episode goes on for at least a week, during which a person is unusually euphoric, cheerful, and high and has at least three of the following symptoms: has great self-esteem, has little need for sleep, speaks rapidly and frequently, has racing thoughts, is easily distracted, and pursues pleasurable activities (American Psychiatric Association, 2000). About 1.3% of the population suffer from bipolar I disorder, and 1.6% suffer from only manic episodes (Rush, 2003). Chuck Elliot has the typical pattern of bipolar I disorder. As shown in the graph below, Elliot may have periods of being normal, which may turn into extreme manic episodes followed by periods of extreme depression. MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Bipolar I Disorder Manic Normal Depressed Time (years) Dysthymic disorder is characterized by being chronically but not continuously depressed for a period of two years. While depressed, a person experiences at least two of the following symptoms: poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and feelings of hopelessness (American Psychiatric Association, 2000). Individuals with dysthymic disorder, which affects about 6% of the population, are often described as “down in the dumps.” Some of these individuals become accustomed to such feelings and describe themselves as “always being this way.” Besides these three mood disorders, we have also discussed another mood disorder, seasonal affective disorder, or SAD (p. 159). People with SAD become depressed as a result of a decrease in the number of sunny days, such as occurs in fall and winter months, and they recover with the arrival of summer. Next, we’ll examine some of the common causes of mood disorders. Photo Credits: left, © Evan Agostini/Getty Images; center, © Robert Gauthier How bad is it? Causes of Mood Disorders Sheryl Crow says that she has had a lifetime battle with mood disorders and, contrary to popular myths, when depressed she cannot make great music or work much at anything. Crow thought her depression was due to some What caused Crow’s depression? Biological Factors Psychosocial Factors Using recently developed techniques for studying the living brain and information from mapping the genetic code (Human Genome Project— p. 68), researchers have been actively studying biological factors involved in mood disorders. In addition to biological factors, an individual may be at risk for depression because of psychosocial factors. Biological factors underlying depression are genetic, neurological, chemical, and physiological components that may predispose or put someone at risk for developing a mood disorder. Photo Credits: top, © Evan Agostini/Getty Images; right, © Imagesource/Photolibrary chemical imbalance in her brain and that depression ran in families (partly inherited or genetic) because her father suffered from similar mood problems (Hirshey, 2003). Let’s see if she’s right. Genetic factors. Sheryl Crow was right about depression having a genetic component. Research studies comparing depression rates of identical twins with those of fraternal twins, who share only 50% of their genes, find that 40–60% of each individual’s susceptibility to depression is explained by genetics (Canli, 2008). Researchers believe there is no single gene but rather a combination of genes that produces a risk, or predisposition, for developing a mood disorder (B. Bower, 2009b; Levinson, 2009). One theory states that defects in specific genes affect our sensitivity to stress, which can result in depression (D. R. Weinberger, 2005). Genes play a role in developing a mood disorder because genes are involved in regulating the brain’s neurotransmitter or chemical system used for communication (Canli, 2008). Neurological factors. Sheryl Crow was also right about depression involving a chemical imbalance in her brain. A group of neurotransmitters, called the monoamines (serotonin, norepinephrine, and dopamine), are known to be involved in mood problems. Abnormal levels of certain neurotransmitters can interfere with the functioning of the brain’s communication networks and, in turn, put individuals at risk for developing mood disorders. More recently, researchers discovered that continued stress causes the brain and the body’s stress management machinery (p. 485) to go into overdrive, which in turn alters hormonal and neurotransmitter levels and can trigger depression (Thase, 2009). Brain scans. Researchers took computerized photos of the structure and function of living brains and compared brains of depressed patients with those of individuals with normal moods. Researchers reported that a brain area called the anterior cingulate cortex (figure below) was overactive in very depressed patients. When the anterior cingulate cortex is overactive, it allows negative emotions to overwhelm thinking and mood. These same researchers cured two-thirds of a group of very depressed patients who had not benefitted from years of psychotherapy, drugs, or electroconvulsive therapy (p. 535) by electrically stimulating the brain, which led to reduced activity in the anterior cingulate cortex (Mayberg, 2006; Mayberg et al., 2005). This and other research examining the brains of depressed patients suggest that faulty The anterior cingulate cortex is overactive in very depressed patients, brain structure or function contribwhich allows negative emotions to utes to the onset and/or maintenance overwhelm thoughts and mood. of mood disorders (Thase, 2009). Psychosocial factors, such as personality traits, cognitive styles, social supports, and the ability to deal with stressors, interact with predisposing biological factors to put one at risk for developing a mood disorder. Stressful life events. Sheryl Crow says that her period of depression was triggered by the overwhelming stress of seeing a fantastic world tour end with her living in a lonely apartment, having to wait on tables while struggling to get a record contact. Researchers found that stressful life events are strongly related to the onset of mood disorders such as depression (Kendler et al., 2004). Negative cognitive style. There is considerable research to support Aaron Beck’s (1991) idea that depression may result from one’s perceiving the world in a negative way, which in turn leads to feeling depressed. We’ll discuss Beck’s theory later in the Application, but just note here that having a negative cognitive style or negative way of thinking and perceiving can put one at risk for developing a mood disorder such as depression. Personality factors. IndiCertain viduals who are especially personality sensitive to and overreact to factors increase negative events (rejections, critirisk for mood cisms) with feelings of fear, anxidisorders. ety, guilt, sadness, and anger are at risk for developing a mood disorder (D. N. Klein et al., 2002). Researchers also found that individuals who make their self-worth primarily dependent on what others say or think have a kind of socially dependent personality, which puts them at risk for becoming seriously depressed when facing the end of a close personal relationship or friendship. Some individuals have a need for control, which puts them at risk for depression when they encounter uncontrollable stress (Mazure et al., 2000). Depressed mothers. Research shows that a depressed mother significantly increases her child’s susceptibility to depression, even if the child is adopted and shares no genes with the mother. Also, when depressed mothers receive successful treatment, their depressed children experience mood improvement without receiving therapy themselves (B. Bower, 2008c; Tully et al., 2008). The above psychosocial factors interact with underlying biological factors to increase one’s risk of developing a mood disorder (Thase, 2006). Next, we discuss the treatment for depression. A. MOOD DISORDERS 533 A. Mood Disorders Treatment of Mood Disorders Because the causes of depression include both biological and psychosocial factors, the treatment for depression, depending upon the diagnosis and severity, may include psychotherapy, antidepressant drugs, or both. We’ll discuss the effectiveness of drugs and psychotherapy. Major Depression and Dysthymic Disorder Bipolar I Disorder After months of depression, Sheryl Crow’s mother finally persuaded her (with threats of coming to haul her baby out of bed) to get professional treatment, which involved both psychotherapy and antidepressant drugs. Unlike Sheryl Crow’s problem, which is major depressive disorder, Chuck Elliot has bipolar I disorder, which means he cycles between episodes of depression and mania. For example, one of Elliot’s manic episodes lasted four days, during which he was in almost constant motion and did not sleep. Several times, when he lost control, he screamed at his wife and ripped the blinds from the windows. His wife called the police, who handcuffed Elliot (right photo) and drove him to a psychiatric hospital for drug treatment. Treatment. In the past, the drug of choice to treat bipolar I disorder was a mood stabilizer called lithium (LITH-ee-um). Although still used Bipolar I is treated with today as the drug of choice, lithium and other is often combined with other drugs, lithium drugs. including antipsychotics and antidepressants, which offer a more effective long-term treatment program (C. F. Newman, 2006). Lithium is thought to prevent manic episodes by preventing neurons from being overstimulated (Lenox & Hahn, 2000). When Elliot takes medication, he functions well enough that he has enrolled in law school and is working toward his degree. The problem arises when Elliot doesn’t take lithium. When patients with bipolar I disorder stop taking lithium (and combined drugs), about 50% experience a manic episode (P. E. Keck & McElroy, 2003). In terms of effectiveness, 50% of bipolar patients are greatly helped with a combined drug program (lithium plus other drugs), 30% are partially helped, and 20% get little or no help (F. K. Goodwin, 2003). Mania. Lithium has been found to be effective in treating individuals with mania—that is, the manic episodes without the depression (F. K. Goodwin, 2003). Because lithium prevents mania, patients may stop taking it to experience the euphoria they miss, as Elliot did several times. Relapse. For both major depression and bipolar I disorder, 10–30% of patients receive no help from current drugs and 30–70% initially improve but later relapse. Researchers are constantly searching for new ways to treat mood disorders and prevent relapse. For individuals with major depression who are not helped by drugs, there is something called the treatment of last resort. Antidepressant drugs act by increasing the levels of a specific group of neurotransmitters (monoamines—serotonin, norepinephrine, and dopamine) that are involved in the regulation of emotions and moods. Selective serotonin reuptake inhibitors—SSRIs. About 80% of prescribed antidepressant drugs, such as Prozac and Zoloft, belong to a group of drugs called SSRIs (selective Treatment often requires serotonin reuptake inhibitors) (Noonan & Cowley, 2002). The professional SSRIs work primarily by raising the level of the neurotransmithelp. ter serotonin. Common side effects include nausea, insomnia, sedation, and sexual problems (decreased libido, erectile dysfunction) (Gitlin, 2009; Khawam et al., 2006). Antidepressants have recently become the most commonly prescribed medication in the United States, used by 10% of the population (Olfson & Marcus, 2009). Effectiveness of antidepressants. When depressed patients use an antidepressant, which may take up to 8 weeks to work, symptoms for only onethird of the patients will go away (comparable to the recovery rate for a placebo) (Berenson, 2006). The challenge for physicians prescribing antidepressants is that for any given individual, some antidepressants work better than others, but no one antidepressant has been found to be more effective for everyone. Often, patients must try a second or third antidepressant until they find one that works well and has minimal side effects (Arkowitz & Lilienfeld, 2007b). Psychotherapy. Researchers compared patients who had received antidepressant drugs, psychotherapy, or a combination of drugs and psychotherapy to treat major depression. For patients with less severe depression, psychotherapy was as effective as antidepressant drugs. For patients with more severe depression, a combination of antidepressant drugs (SSRIs) and psychotherapy was more effective than either treatment alone (Hollon et al., 2002). Relapse. When patients who had recovered were followed for 18 months, the results were discouraging because, within that time, 70% of the patients had Antidepressants relapsed, which means they became depressed again psychotherapy and required additional treatment. Of those who main- and are about equally tained their recovery and were doing well, 30% had effective. been treated with psychotherapy, 20% with antidepressant drugs, and 20% with placebos. Thus, patients treated with psychotherapy were somewhat less likely to relapse than those treated with drugs or placebos (Shea et al., 1992). Psychotherapy may take longer to begin working, but its strength is in reducing the likelihood of relapse (Charney, 2009). Because 70% of patients treated for depression relapse within 18 months and 82% relapse during the first five years, clinicians concluded that major depression is a long-term or chronic disorder that may require further treatments during the patient’s lifetime (Moran, 2004; Vos et al., 2004). 534 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Photo Credits: left, © Evan Agostini/Getty Images; right, © Robert Gauthier What’s the treatment? B. Electroconvulsive Therapy Photo Credits: top, © Photo Researchers, Inc.; bottom, © Canadian Press/Phototake Because the use of shock as therapy has What’s it often been portrayed incorrectly in the like to get media, it helps to see the treatment from the eyes of an actual patient. ECT? “. . . As far as manic-depressive tales go, my stories are typical. My illness went undiagnosed for a decade, a period of euphoric highs and desperate lows highlighted by $25,000 shoppi ng sprees, impetuous trips to Tokyo, Paris, and M i la n, d r ug a nd alcohol binges. . . . After seeing eight psychiatrists, I fin a l l y re c e i ve d a Electrodes on this patient’s forehead will diagnosis of bipocarry electricity through the brain and lar disorder on my cause a major seizure. 32nd birthday. Over the next year and a half, I was treated unsuccessfully with more than 30 medications. My suburban New Jersey upbringing, my achievements as a film major at Wesleyan, and a thriving career in public relations couldn’t help me. . . . As a last resort, I’m admitted to the hospital for ECT, electroconvulsive therapy, more commonly known as electroshock. . . . The doctor presses a button. Electric current shoots through my brain for an instant, causing a grand-mal seizure for 20 seconds. . . . I wake up 30 minutes later and think I’m in a hotel room in Acapulco. My head feels as if I’ve just downed a frozen margarita too quickly. . . . After four treatments, there is marked improvement. No more egregious highs or lows. But there are huge gaps in my memory. I avoid friends and neighbors because I don’t know their names anymore. I can’t remember the books I’ve read or the movies I’ve seen. I have trouble recalling simple vocabulary. I forget phone numbers. . . . But I continue treatment because I’m getting better. . . . On the one-year anniversary of my first electroshock treatment, I’m clearheaded and even-keeled. I call my doctor to announce my ‘new and improved’ status. . . . Two and a half years later, I still miss ECT. But medication keeps my illness in check, and I’m more sane than I’ve ever been” (Behrman, 1999, p. 67). This patient received electroconvulsive therapy (ECT). Electroconvulsive therapy, or ECT, involves placing electrodes on the skull and administering a mild electric current that passes through the brain and causes a seizure. Usual treatment consists of a series of 10 to 12 ECT sessions, at the rate of about three per week. Usage. Because antidepressants fail to decrease depression in up to 40% of patients, many of these patients choose to undergo ECT, a last resort option to treat their severe depression. In the United States, ECT is currently used for 100,000 patients per year (Gitlin, 2009; Newsweek, 2006; Westly, 2008). Effectiveness of ECT Because antidepressants had not worked, the patient we just described agreed to ECT. The reason ECT is the last resort for treating depression is that ECT produces major brain seizures and may cause varying degrees of memory loss. However, even as a treatment of last resort, ECT is effective in reducing depressive symptoms in about 70–90% of patients (Husain et al., 2004). For example, the graph below shows the results for eight out of nine seriously depressed patients who had received no help from antidepressants. After a series of ECT treatments, they showed a dramatic reduction in depressive symptoms and remained symptom-free after one year (Paul et al., 1981). However, the average 14 relapse rate after ECT treatment ECT 12 treatment exceeds 50%, which means patients may need antidepressant therapy 10 following ECT treatment or addi8 tional ECT treatments for depresPost-ECT 6 sion (Nemeroff, 2007). Researchers Pre4 are not sure how ECT works but ECT suggest it changes brain chemistry 2 1 0 1 2 3 4 5 and restores a normal balance to Week neurotransmitters (Salzman, 2008). Modern ECT. Unlike patients who received ECT in the movie One Flew Over the Cuckoo’s Nest, there is no evidence that modern ECT procedures cause brain damage or turn people into “vegetables” (Ende et al., 2000). Modifications to modern ECT, including the proper placement of electrodes on the scalp and reduced levels of electric current, have lessened the risk for complications (Nemeroff, 2007; Sackeim et al., 2000). Memory loss. A side effect of ECT is memory loss, which ranges from a loss of memory for events experienced during the weeks of treatment to events both before and after treatment. Following ECT treatment, there is a gradual improvement in memory functions, and for most patients, memory returns to normal levels. However, some patients complain of long-term memory problems (Gitlin, 2009; Sackeim & Stern, 1997). Mental health experts cautiously endorse ECT as a treatment of last resort for severe depression (Glass, 2001; K. G. Rasmussen, 2003). Now we’ll briefly discuss another last resort treatment. New treatment. For patients with treatment-resistant depression, a new treatment option is transcranial magnetic stimulation (shown below). Why is ECT considered the last resort? Daily depression rating Definition and Usage Transcranial magnetic stimulation (TMS) is a noninvasive technique that activates neurons by sending pulses of magnetic energy into the brain. Research shows that depressed patients who did not benefit from various medications experienced significant improvement in symptoms after 40 minutes of TMS daily for four weeks (O’Reardon et al., 2007). Although side effects, such as headache, light-headedness, and scalp discomfort, may occur, advantages of TMS over ECT are that it is unlikely to cause seizures and does not require anesthesia (Baldauf, 2009; George, 2009). Next, we’ll discuss a disorder shared by many serial killers. B. ELECTROCONVULSIVE THERAPY 535 C. Personality Disorders We have all heard the expression “Don’t judge a book by its What are serial cover.” That advice proved absolutely true when we heard what their friends and neighbors said about the following killers like? individuals. His boss said David Berkowitz was “quiet and reserved and kept pretty much to himself. That’s the way he was here, nice—a quiet, shy fellow.” Berkowitz, known as “Son of Sam,” was convicted of killing six people. A neighbor of Westley Allan Dodd said that he “seemed so harmless, such an all-around, basic good citizen.” Dodd was executed for kidnapping, raping, and murdering three small boys. A neighbor said John Esposito “was such a quiet, caring person. He was a very nice person.” Esposito was charged with kidnapping a young girl and keeping her in an underground bunker for 16 days. A friend said Jeffrey Dahmer “didn’t have much to say, was quiet, like the average Joe.” Dahmer confessed to killing and dismembering 15 people (Time, July 12, 1993, p. 18). Notice how friends and neighbors judged all these cold-blooded killers to be “quiet” and “nice” and even “caring” individuals. However, while these individuals appeared very ordinary in public appearance and behavior, each was hiding a deep-seated, serious, and dangerous personality disorder (Hickey, 2006). Why do friends describe serial killers, such as Dahmer, as quiet, nice, and caring? A personality disorder consists of inflexible, long-standing, maladaptive traits that cause significantly impaired functioning or great distress in one’s personal and social life (American Psychiatric Association, 2000). Personality disorders are found in about 9% of the adult population in the United States, affecting men and women equally, although gender may influence which personality disorder a person develops (Kluger, 2003). Of the ten different personality disorders described in DSM-IV-TR, here are seven of the more common types. O Paranoid personality disorder is a pattern of distrust and suspiciousness and perceiving others as having evil motives (0.5–2.5% of population). O Schizotypal personality disorder is characterized by an acute discomfort in close relationships, distortions in thinking, and eccentric behavior (3–5% of population). O Histrionic personality disorder is characterized by excessive emotionality and attention seeking (2% of population). O Obsessive-compulsive personality disorder is an intense interest in being orderly, achieving perfection, and having control (4% of population). O Dependent personality disorder refers to a pattern of being submissive and clingy because of an excessive need to be taken care of (2% of population). O Borderline personality disorder is a pattern of instability in personal relationships, selfimage, and emotions, as well as impulsive behavior (2% of population). O Antisocial personality disorder refers to a pattern of disregarding or violating the rights of others without feeling guilt or remorse (3% of population, predominantly males) (American Psychiatric Association, 2000). Individuals with personality disorders often have the following characteristics: troubled childhoods, childhood problems that continue into adulthood, maladaptive or poor personal relationships, and abnormal behaviors that are at the extreme end of the behavioral continuum. Their difficulties arise from a combination of genetic, psychological, social, and environmental factors (Vargha-Khadem, 2000). We’ll focus on two particular personality disorders, the borderline personality and antisocial personality, because they are mentioned most often by the media. 536 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Borderline Personality Disorder People who have borderline personality disorder have i nten s e , u npre d ic t able emotional outbursts and lack impulse control, which causes them to express inappropriate anger and engage in very dangerous behaviors. About 75% of patients with borderline personality disorder hurt themselves through cutting, burning, or other forms of self-mutilation, and another 10% eventually commit suicide. Patients with borderline personality are so emotionally erratic that they are capable of expressing profound love and intense rage almost simultaneously. Such emotional volatility makes it difficult for them to maintain stable interpersonal relationships. They are terrified of losing the people most close to them, yet they ragefully attack these same people, only to later show sweetness and affection toward them (APA, 2000; Cloud, 75% of people with 2009). borderline personality We’ll discuss the disorder hurt themselves. causes and treatment of borderline personality disorder. Causes. Borderline personality disorder appears to have both environmental and genetic causes. Experiencing trauma during childhood, such as being abused or prohibited from expressing negative emotions, places individuals at risk for this condition. Brain scan studies have shown that the amygdala (emotional center of the brain) in these patients is overactive, while the brain areas responsible for controlling emotional responses are underactive. This helps explain why these patients lack emotional regulation. Though no specific genes have been identified, we know that the major symptoms of this condition, such as impulsivity and aggression, are highly heritable (J. E. Brody, 2009; Cloud, 2009; Meyer-Lindenberg, 2009). Treatment. The most effective treatment for this condition is dialectical behavior therapy, What does it mean to be borderline? a type of cognitive-behavioral therapy, which helps patients identify thoughts, beliefs, and assumptions that make their life challenging and teaches them different ways to think and react (Linehan, 1993). Typically, intense, long-term therapy is required, as well as medication. Photo Credits: left, © Alan Fredrickson/Reuters/Corbis; right, © Angela Hampton Picture Library/Alamy Definition and Types Antisocial Personality Disorder The “nice,” “quiet” killers we described would probably be diagnosed as having antisocial personality disorder or some combination of personality disorders. Between 50% and 80% of prisoners meet the criteria for a diagnosis of antisocial personality disorder (Ogloff, 2006). But, not all people diagnosed with antisocial personality disorder are alike, and the diagnostic symptoms vary along a continuum. At one end of the continuum are the chronic delinquents, bullies, and lawbreakers; at the other end are the serial killers. Delinquent. An example of someone on the delinquent end of the continuum is Tom, who always seemed to be in trouble. As a child, he would steal items (silverware) from home and sell or swap them for things he wanted. As a teenager, he skipped classes in school, set deserted buildings on fire, forged his father’s name on checks, stole cars, and was finally sent to a federal institution. After Tom served his time, he continued to break the law, and by the age of 21, he had been arrested and imprisoned 50 to 60 times (Spitzer et al., 1994). Serial killer. At the other end of the psychopathic continuum is serial killer Jeffrey Dahmer, who would pick up young gay men, bring them home, drug them, strangle them, have sex with their corpses, and then, in some cases, eat their flesh. As Dahmer said in an interview, “I could completely control a person—a person that I found physically attractive, and keep them with me as long as possible, even if it meant just keep a part of them” (Gleick et al., 1994, p. 129). We’ll discuss the causes and treatment of antisocial personality disorder. Photo Credit: top, © Alan Fredrickson/Reuters/Corbis What are people with antisocial personality disorder like? Jeffrey Dahmer was diagnosed as having an antisocial personality disorder. Treatment Antisocial personality disorder involves complex psychosocial and biological factors (Moffitt, 2005). Psychosocial factors. Researchers have found that aggressive and antisocial children whom parents find almost impossible to control are at risk for developing an antisocial personality (Morey, 1997). Also, research shows that children who experience physical or sexual abuse are at an increased risk of developing antisocial personality disorder (D. Black, 2006). However, since many abused children do not develop an antisocial personality, it is difficult to determine how much childhood abuse contributes to the development of antisocial personality disorder. Biological factors. Researchers suggest that the early appearance of serious behavioral problems, such as having temper tantrums, bullying other children, torturing animals, and habitually lying, indicates that underlying biological factors, both genetic and neurological, may predispose or place a child at risk for developing antisocial personality disorder (Pinker, 2008). Evidence for genetic factors comes from twin and adoption studies that show that genetic factors contribute 30–50% to the development of antisocial personality disorder (Thapar & McGuffin, 1993). Evidence for neurological factors comes from individuals with brain damage and from MRI studies on the brains of individuals with antisocial personality disorder. For example, researchers found that early brain damage to the prefrontal cortex (shown below) resulted in two children who did not learn normal social and moral behaviors and showed no empathy, remorse, or guilt as adults. In addition, MRI scans (p. 70) indicated Prefrontal cortex that individuals diagnosed with antisocial personality disorder had 11% fewer brain cells in their prefrontal cortex (A. Raine et al., 2000). Since the prefrontal cortex is known to be involved in important executive functions, such as making decisions and planning, researchers suggest that damage to or maldevelopment of the prefrontal cortex predisposes or increases the risk of an individual developing antisocial personality disorder. Researchers believe that biological factors can predispose individuals to act in certain ways but that the interaction between biological and psychosocial factors results in the development and onset of personality disorders (A. B. Morgan & Lilienfeld, 2000). Psychotherapy has not proved very effective in treating people with antisocial personality disorder because these individuals are guiltless, mistrusting, irresponsible, and practiced liars, who fail to see that many of their behaviors are antisocial and maladaptive. As a result, psychotherapists have a very difficult time changing their behavior (Bateman & Fonagy, 2000). Because of the Drug that Increases Serotonin relative ineffective45 ness of psychotherapy, clinicians have 35 tried various drugs 25 that raise levels of serotonin in the 15 brain. Researchers 5 believe that some abnormality in the Baseline 2 brain’s serotonin 4 8 Weeks system may underlie the impulsive and aggressive behaviors observed in personality disorders (D. Black, 2006). As shown in the graph above, patients who took a serotonin-increasing drug (sertraline) reported significant decreases in their aggressive behaviors across eight weeks of treatment. However, researchers caution that aggressive behaviors may return once patients stop taking these serotonin-increasing drugs (Coccaro & Kavoussi, 1997). Other research shows that the use of antipsychotic medication (p. 541) can decrease impulsivity, hostility, aggressiveness, and rage in patients with antisocial personality disorder (C. Walker et al., 2003). Even though there are some treatment successes, researchers caution that for 69% of the patients, antisocial personality disorder is an ongoing, relatively stable, long-term problem that needs continual treatment (G. Parker, 2000). Next, we’ll examine one of the most tragic mental disorders—schizophrenia. Aggression score Causes C. PERSONALIT Y DISORDERS 537 D. Schizophrenia At the beginning of this module, we described 18-year-old Michael What if McCabe (photo below), who said that his mind began to weaken you lose touch during the summer of 1992. “I totally hit this point in my life where I was so high on life, it was amazing. I had this sense of indepenwith reality? dence. I was 18 and turning into an adult. Next thing I knew I got this feeling that people were trying to take things from me. Not my soul, but physical things from me. I couldn’t sleep because they [his mother and sister] were planning to do something to me. I think there was a higher power inside the 7-Eleven that was helping me out the whole time, just bringing me back to a strong mental state” (C. Brooks, 1994, p. 9). Michael was diagnosed as having schizophrenia (skit-suh-FREE-nee-ah). Schizophrenia is a serious mental disorder that lasts for at least six months and includes at least two of the following symptoms: delusions, hallucinations, disorganized speech, disorganized behavior, and decreased emotional expression. These symptoms interfere with personal or social functioning (American Psychiatric Association, 2000). Michael has a number of these symptoms, including delusions (higher power inside the 7-Eleven), halluciMichael McCabe had many of the nations (hearing voices), and disorganized behavior. symptoms described on the right. Schizophrenia affects about 0.2–2% of the adult population, or about 4.5 million people (equal numbers of men and women) in the United States (American Psychiatric Association, 2000). Subcategories of Schizophrenia Michael’s case illustrates some of the symptoms that occur in schizophrenia. In fact, no two patients have exactly the same set of symptoms, which are described in the list on the right. The DSM-IV-TR describes five subcategories of schizophrenia, each of which is characterized by different symptoms. We’ll briefly describe three of the more common schizophrenia subcategories. Paranoid schizophrenia is characterized by auditory hallucinations or delusions, such as thoughts of being persecuted by others or thoughts of grandeur. Disorganized schizophrenia is marked by bizarre ideas, often about one’s body (bones melting), confused speech, childish behavior (giggling for no apparent reason, making faces at people), great emotional swings (fits of laughing or crying), and often extreme neglect of personal appearance and hygiene. Catatonic schizophrenia is characterized by periods of wild excitement or periods of rigid, prolonged immobility; sometimes the person assumes the same frozen posture for hours on end. Differentiating between types of schizophrenia can be difficult because some symptoms, such as disordered thought processes and delusions, are shared by all types. Chances of Recovery Chances of recovery are dependent upon a number of factors, which have been grouped under two major types of schizophrenia (Crow, 1985). Type I schizophrenia includes having positive symptoms, such as hallucinations and delusions, which are a distortion of normal functions. In addition, this group has no intellectual impairment, good reaction to medication, and thus a good chance of recovery. Type II schizophrenia includes having negative symptoms, such as dulled emotions and little inclination to speak, which are a loss of normal functions. In addition, this group has intellectual impairment, poor reaction to medication, and thus a poor chance of recovery. According to this classification system, the best predictor of recovery for a person with schizophrenia is his or her symptoms: Those with positive symptoms have a good chance of recovery, while those with negative symptoms have a poor chance (Dyck et al., 2000). Next, we’ll describe the major symptoms of schizophrenia. 538 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Symptoms Schizophrenia is a serious mental disorder that lasts for at least six months and includes at least two of the following symptoms: 1 Disorders of thought. These are characterized by incoherent thought patterns, formation of new words (called neologisms), inability to stick to one topic, and irrational beliefs or delusions. For example, Michael believed that his mother and sister were plotting against him. 2 Disorders of attention. These include difficulties in concentration and in focusing on a single chain of events. For instance, one patient said that he could not concentrate on television because he couldn’t watch and listen at the same time. 3 Disorders of perception. These include strange bodily sensations and hallucinations. Hallucinations are sensory experiences without any stimulation from the environment. About 70% of schizophrenics report hearing voices that sound real and talk either to them (steal brain cells) or about them (mostly negative things, like “You have a cancer”) (Thraenhardt, 2006). Research using brain imaging shows that when schizophrenics hallucinate people, their visual cortex becomes active, and when they hallucinate voices, their auditory cortex is activated (Begley, 2008c). 4 Motor disorders. These include making strange facial expressions, being extremely active, or (the opposite) remaining immobile for long periods of time. 5 Emotional (affective) disorders. These may include having little or no emotional responsiveness or having emotional responses that are inappropriate to the situation—for example, laughing when told of the death of a close friend. The cause of these schizophrenia symptoms involves biological, neurological, and environmental factors. Photo Credit: © Robert Gauthier Definition and Types Biological Causes When Michael was in the hospital, his mother, Marsha (photo below), began going to a support group to get help and find out about schizophrenia. At one meeting, Marsha said, “I haven’t been doing very well with this, to be perfectly honest. How in the hell were we dealt this hand?” (C. Brooks, 1994, p. 8). The psychiatrist who led Marsha’s group answered that about 1 in 100 people get schizophrenia but the odds increase to 1 in 10 if Marsha tries to help her son, it’s already in the family. If a Michael, who has schizophrenia. person inherits a predisposition for schizophrenia, any number of things—such as drugs, a death in the family, growing-up problems—can trigger its onset (C. Brooks, 1994). The psychiatrist was pointing out three major factors—biological, neurological, and environmental— that interact in the development of schizophrenia. We’ll begin with biological factors, specifically genetic causes. Photo Credits: top, © Robert Gauthier; center, Courtesy of Edna Morlok What caused Michael’s problems? disorder. In comparison, if one brother or sister (sibling or fraternal twin) has schizophrenia, there is only about a 10–17% chance that the other will develop the disorder (Gottesman, 2001). Because genetic factors are involved in developing schizophrenia, researchers are searching for the location of specific genes involved in schizophrenia; such genes are called genetic markers (Levinson, 2003). A genetic marker refers to an identifiable gene or number of genes or a specific segment of a chromosome that is directly linked to some behavioral, physiological, or neurological trait or disease. Researchers have reported many genetic markers for schizophrenia, but none proved valid because none could be repeated or replicated by other laboratories. Researchers now believe that schizophrenia depends on a combination of genes and that no one gene by itself has a strong genetic influence (ISC, 2009; T. Walsh et al., 2008). Breakthroughs. There have been several reports of major breakthroughs in identifying genetic markers for schizophrenia. For instance, researchers found evidence of a slight excess of a protein in the prefrontal cortex of people with schizophrenia, resulting from a variation in a gene they believe may explain common symptoms of the disorder (Law & Weinberger, 2006). Also, researchers found that a disruption in a particular gene makes new neurons that are supposed to reach the hippocampus, an area of the brain important for memory and emotional processing, go elsewhere, causing a burst of abnormal brain activity, which may explain schizophrenia symptoms (H. Song, 2007). Other researchers found a gene linked to negative symptoms of schizophrenia (p. 541), which suggests that researchers should seek genes responsible for specific symptoms (Fanous et al., 2005). Taken together, recent genetic studies plus earlier studies on identical twins indicate that schizophrenia has a genetic factor. Genetic Predisposition In 1930, the birth of four identical baby girls (quadruplets) was a rare occurrence (1 in 16 million) and received great publicity. By the time the girls reached high school, all four were labeled “differInfections ent.’’ They sometimes broke Another biological factor that may contribute to the develAll four of these identical quadruplets light bulbs, tore buttons off opment of schizophrenia is infections. For instance, pregdeveloped schizophrenia. their clothes, complained of nant women who get the f lu have been found to be more bones slipping out of place, and had periods of great confusion. likely to give birth to children who will develop schizophrenia. Also, By young adulthood, all four girls, who are called the Genain some childhood infections, such as the mumps virus, have been associquadruplets and share nearly 100% of their genes, were diag- ated with an increased risk of later developing schizophrenia sympnosed with schizophrenia (Mirsky & Quinn, 1988). The finding toms. Researchers believe that some infections directly affect the brain, that all four Genain quadruplets (above photo) developed whereas others trigger immune reactions that interfere with normal schizophrenia indicates that increased genetic similarity is brain development (Dalman et al., 2008; Wenner, 2008a). associated with increased risk for developing schizophrenia and However, biological factors alone cannot completely explain why suggests that a person inherits a predisposition for developing individuals develop schizophrenia. As we’ll discuss, environmental the disorder. Support for a genetic predisposition also comes factors must interact with biological factors (Mueser et al., 2006). from twin studies. Genetic Markers Because researchers knew that schizophrenia might have a genetic factor, they compared rates of schizophrenia in identical twins, who share nearly 100% of their genes, with rates in fraternal twins and siblings (brothers and sisters), who share only 50% of their genes. The right graph shows the risk of developing schizophrenia for individuals who share different percentages of genes and thus have different degrees of genetic similarity. Notice that if one identical twin has schizophrenia, there is a 48–83% chance that the other twin will also develop the Risk of Developing Schizophrenia Identical twins (100% of genes in common) Offspring of two schizophrenic parents (50% of genes from each parent) Fraternal twins (50% of genes in common) Siblings 10% 48%–83% 45% 17% (50% of genes in common) 1%–2% General population (0% of genes in common) D. SCHIZOPHRENIA 539 D. Schizophrenia Is the brain different? New techniques for studying the structures and functions of the living brain (MRI and f MRI—p. 70) reveal major differences between brains of schizophrenics and brains of mentally healthy individuals. We’ll discuss two reliable differences—larger ventricles and decreased activity in the prefrontal cortex. Ventricle Size Most us of don’t realize that our brains have four fluid-filled Normal: cavities called ventricles (left figure). The fluid in these caviLateral ventricles ties helps to cushion the brain against blows and also serves as a reservoir of nutrients and hormones for the brain. One reliable finding is that in up to 80% of the brains of schizophrenics, the ventricles are larger than normal (NiznikieFluid-filled ventricles wicz et al., 2003). Using brain scans (MRIs), researchers in normal brains studied 15 pairs of identical twins; one was diagnosed with schizophrenia, while the other was mentally healthy (normal). The brains of twins with schizophrenia had larger Schizophrenia: ventricles than the brains of the mentally healthy twins (left Lateral ventricles figures) (Suddath et al., 1990). However, not all brains of people with schizophrenia have larger ventricles or an overall decrease in brain size. Also, the enlarged ventricles in some schizophrenics may remain the same over the course Increased size of of their illness, while the size of ventricles may change over fluid-filled ventricles in time for others (DeLisi et al., 2004). Researchers conclude brains of schizophrenics that some people with schizophrenia have abnormally large ventricles, which results in a reduction in brain size and in turn may contribute to the development of schizophrenia (I. C. Wright et al., 2000). Frontal Lobe: Prefrontal Cortex Another brain structure involved in many executive functions, such as reasoning, planning, remembering, paying attention, and making decisions, is the prefrontal cortex (figure below). Researchers report that in pairs of identical twins where one twin has schizophrenia and the other does not, the brain of the twin with schizophrenia was characterized by significantly less activation of the prefrontal cortex (F. E. Torrey et al., 1994). This decreased prefrontal lobe activity is consistent with the deficits in many executive functions observed in schizophrenics, such as disorganized thinking, irrational beliefs, and lack of concentration (Niznikiewicz et al., 2003). Other researchers report that in the brains of people with schizophrenia, the frontal and temporal lobes are smaller because there are fewer brain cells (neurons— p. 50) and fewer connections (axons—p. 50) among neurons (K. Davis, 2003; Pantelis et al., 2003). Fewer Prefrontal neurons with fewer connections cause deficits in cortex transmitting information, which in turn may underlie problems in executive functions, such as disorganized thinking and reasoning, which are major symptoms of patients diagnosed with schizophrenia (Holden, 2003). These studies point to neurological factors, such as abnormal brain structures and functions, that researchers believe underlie and contribute to the development of schizophrenia and make it so difficult to treat (Holden, 2003). Besides genetic and neurological factors, there are also environmental factors involved in developing schizophrenia. 540 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Environmental Causes If biological or neurological factors explained why people develop schizophrenia, then the risk for developing schizophrenia in identical twins would be almost 100% rather than 48– 83%. Because biological and neurological factors alone cannot explain the development of schizophrenia, researchers look at the influence of environmental factors, such as the incidence of stressful events and how individuals cope. For exa mple, when Michael McCabe (right photo) was 18, he began to develop Stressful events may symptoms of schizohave led to his onset phrenia. The onset of of schizophrenia. these symptoms occurred after the death of his father and during the potentially stressful period of adolescence. Stressful events, such as hostile parents, poor social relationships, the death of a parent or loved one, and career or personal problems, can contribute to the development and onset of schizophrenia. This relationship between stress and the onset of schizophrenia is called the diathesis stress theory (S. R. Jones & Fernyhough, 2007). Can stress act as a trigger? The diathesis (die-ATH-uh-sis) stress theory of schizophrenia says that some people have a genetic predisposition (a diathesis) that interacts with life stressors to result in the onset and development of schizophrenia. The diathesis stress theory assumes that biological or neurological factors have initially produced a predisposition for schizophrenia. If a person already has a predisposition for schizophrenia, then being faced with stressful environmental factors can increase the risk and vulnerability for developing schizophrenia as well as trigger the onset of schizophrenia symptoms (S. R. Jones & Fernyhough, 2007). Thus, the diathesis stress theory says that biological and neurological factors first create a predisposition, such as overreacting to stressful situations, that then makes a person vulnerable or at risk for developing schizophrenia. Now we’ll examine the drugs used to treat schizophrenia. Photo Credits: top left, Courtesy of Drs. E. Fuller Torrey & Daniel R. Weinberger, NIMH, Neuroscience Center, Washington D.C.; top right, © Robert Gauthier Neurological Causes Treatment After Michael (right photo) was taken to the psychiatric hospital, his symptoms were assessed and he was diagnosed with schizophrenia. Schizophrenia symptoms are commonly divided into positive and negative symptoms. How is Michael treated? ability to express thoughts, and decreased initiative to engage in goaldirected behaviors (American Psychiatric Association, 2000). Like most individuals diagnosed with schizophrenia, Michael had both positive symptoms, such as delusions that people were going to steal from him, and negative symptoms, such as loss of emotional expression. To reduce these symptoms, he was given haloperidol, which is an example of an antipsychotic or neuroleptic (meaning “taking hold of the nerves”) drug. Positive symptoms of schizophrenia reflect a disMichael was given a neuroNeuroleptic drugs, also called antipsychotic drugs, are used to tortion of normal functions: distorted thinking results in leptic drug to treat delusions; distorted perceptions result in hallucinations; his schizophrenia. treat serious mental disorders, such as schizophrenia, by changing the levels of neurotransmitters in the brain. and distorted language results in disorganized speech. There are two kinds of neuroleptic drugs: typical and Negative symptoms of schizophrenia reflect a decrease in or loss of atypical. normal functions: decreased range and intensity of emotions, decreased Typical Neuroleptics Typical neuroleptics: decrease dopamine Atypical Neuroleptics Typical neuroleptics were discovered in the 1950s and were the first effective medical treatment for schizophrenia. Photo Credits: both, © Robert Gauthier Typical neuroleptic drugs primarily reduce levels of the neurotransmitter dopamine. These drugs mainly reduce positive symptoms and have little effect on negative symptoms. Because typi- In Michael’s case and for about 20% of all schizophrenics, typical Atypical neuroleptic drugs (phenothiazines, such as haloperidol or Thoraneuroleptics: zine) have little or no effect on their symptoms. Many of these decrease dopamine patients are being helped by newer atypical neuroleptic drugs. & serotonin Atypical neuroleptic drugs (clozapine, risperidone) lower levels of dopamine and also lower levels of other neurotransmitters, especially serotonin. These drugs primarily reduce positive symptoms, may reduce negative symptoms, and prevent relapse (Downar & Kapur, 2008). The first atypical neuroleptic, clozapine, was approved for use in schizophrenia in 1990. Since then, atypical neuroleptics have proven effective in decreasing symptoms of cal neuroleptics reduce levels of dopamine, schizophrenia, especially in patients who were not helped by typical their action supports the dopamine theory neuroleptics (W. Carpenter, 2003). of schizophrenia (Downar & Kapur, 2008). Michael, for example, showed little improvement with typical The dopamine theory says that in schizophreneuroleptics (haloperidol). However, the atypical neuroleptic nia, the dopamine neurotransmitter system is clozapine reduced his positive symptoms to the point somehow overactive and gives rise to a wide that he was allowed to leave the psychiatric hospirange of symptoms. tal and return home. A year later, Michael was still The dopamine theory focuses on neurons taking clozapine and was making slow progress in in a group of brain structures called the overcoming his symptoms, such as paranoia. basal ganglia (figure below). Typical neuOn most days, Michael comes home from group roleptics block dopamine usage in the basal therapy and job-training classes, puts on a Bob Marganglia, which reduces commu- basal ganglia ley record, and sits and listens, afraid to do much Atypical neuroleptics helped Michael nication among these neurons else. As Michael explains, “I can’t go out and (shown with his mother and sister) and in turn reduces some of skate or do anything because I’m afraid I’m reduce his symptoms. the symptoms of schizogoing to have a paranoia attack” (C. Brooks, phrenia. However, because 1995b, p. D-3). His mother and sister provide Michael with financial and social 20% of people with schizosupport but wish Michael would take greater initiative to improve his own life. phrenia are not helped by Michael, as well as others with schizophrenia, face a daily struggle to overcome typical neuroleptics and their symptoms, which points to the need for continued social support and because recent findings psychotherapy (Bustillo et al., 2001). point to the involvement of Current treatment. For many years, compared to typical neuroleptics, atypiseveral nondopamine neucal neuroleptics were the preferred treatment because they were reported to be at rotransmitters (serotonin and least as effective in reducing positive symptoms, more effective in reducing negaglutamate), the dopamine thetive symptoms, and helpful for patients who showed no improvement with typical ory will need revision to include neuroleptics (S. Burton, 2006; J. M. Davis et al., 2003). More recently, a large, carefully other neurotransmitter systems. conducted study compared the cognitive effects of the two types of neuroleptics and Using typical neuroleptics to treat schizofound that, contrary to previous research outcomes, typical and atypical neuroleptics phrenia is being challenged by newer drugs, were about equally effective in boosting cognitive skills (R. S. E. Keefe et al., 2007). called atypical neuroleptics. Next, we’ll discuss the serious side effects of typical and atypical neuroleptics. D. SCHIZOPHRENIA 541 D. Schizophrenia Evaluation of Neuroleptic Drugs What are the side effects? The major advantage of neuroleptic drugs is that they effectively reduce positive symptoms so that many patients can regain some degree of normal functioning. However, neuroleptics also have two potentially serious disadvantages: They may produce undesirable side effects, and they may decrease but not prevent relapse or return of the original symptoms of schizophrenia. Typical Neuroleptics Typical: decrease dopamine Atypical: decrease dopamine & serotonin Atypical Neuroleptics Side effects. One group of typical neuroleptics, called the phenothiazines (pheen-no-THIGH-ahzeens), is widely prescribed to treat schizophrenia. Phenothiazines can produce unwanted motor movements, which is a side effect called tardive dyskinesia (Dolder, 2008). Side effects. One advantage of atypical neuroleptics is they cause tardive dyskinesia in only about 5% of patients, compared to 1–29% of patients given typical neuroleptics (Caroff et al., 2002). However, atypical neuroleptics can cause side effects, the most serious being increased levels of cholesterol and glucose or blood sugar, weight gain, and onset or worsening of diabetes (S. Burton, 2006; Dolder, 2008). Thus, typical and atypical neuroleptics may produce serious side effects. Tardive dyskinesia (TAR-div dis-cah-KNEE-zee-ah) Effectiveness and relapse. From the 1950s through the middle of the 1990s, involves the appearance of slow, involuntary, and unconthe drugs of choice for treating schizophrenia were typical neuroleptics. Begintrollable rhythmic movements and rapid twitching of the ning in the late 1990s and continuing to the present, there has been a general mouth and lips, as well as unusual movements of the limbs. switch to atypical neuroleptics. That’s because, compared to typical neurolepThis condition is associated with the tics, atypical neuroleptics have generally proved to Risks of Developing Tardive Dyskinesia continued use of typical neuroleptics. be as effective in reducing positive symptoms, more effective in reducing negative symptoms, less likely to As shown in the right graph, the 3 months 16% cause tardive dyskinesia, and more effective in preventrisk for developing tardive dyskine29% ing relapse, the recurrence of schizophrenia symptoms sia increases with use: After three 3–12 months months, 16% developed this side 1–10 years (S. Burton, 2006; J. M. Davis et al., 2003). However, some 30% effect; after ten years, 40% developed research found that the use of typical and atypical drugs 40% it (Sweet et al., 1995). About 30% of More than 10 years led to about equal improvement in patients with schizopatients with tardive dyskinesia will phrenia and similar rates of movement-related side experience a reduction in symptoms if they are taken effects, such as tardive dyskinesia (J. A. Lieberman, 2005). Due to these inconoff typical neuroleptics, but the remaining 70% may sistencies, clinicians must carefully consider which type of drug to prescribe to continue to have the problem when the drug therapy their patients. is stopped (Roy-Byrne & Fann, 1997). Conclusions. Two strange, recurring findings in the treatment of mental disEffectiveness. Researchers have completed orders are that the same drug may help one patient but not another, and for some several long-term follow-up studies on patients who patients drugs cause no improvement at all. One reason drugs don’t always work were treated for schizophrenia with typical neurois that mental disorders, like schizophrenia, may have different causes (genetic, leptics. They found that, 2 to 12 years after treatment, neurological, environmental) that may require a combination of different drugs about 20–30% of patients showed a good outcome, and/or psychotherapy. Another reason drugs don’t always work is that each perwhich means they needed no furson’s nervous system functions differently and has a different level of neurotransther treatment and had no relapse; mitters (Niznikiewicz et al., 2003). This explains why the same drug may about 40–60% continued to suffer cause various types and severities of side effects for different people. some behavior impairment and Researchers find that, for the majority of patients, schizophrenia relapse, although their symptoms is a chronic or life-long problem with a high risk for relapse. Thus, in reached a plateau in about 5 years addition to drug treatment, patients need psychotherapy and social and did not worsen after that; and support to improve their social interactions, work at an acceptable job, about 20% were not helped by these and maintain their quality of life (Lauriello, 2007; Mueser et al., 2006). drugs. New direction. Because some patients with schizophrenia either do Unwanted motor Relapse. The basic problem with movements (lip smacking) not benefit from typical or atypical neuroleptics or experience intolerare a side effect of typical taking patients off typical neuroable side effects, researchers have been working to create a new drug that neuroleptics but less so leptics is that they may relapse. For with atypical neuroleptics. targets a different neurotransmitter called glutamate. Glutamate may be example, after an average of about just as important as dopamine and serotonin in schizophrenia because one year, 60% of patients taken off a typical neuroit is associated with perception, memory, emotion, and concentration. Scientists leptic experienced a relapse, as compared to a relapse think drugs that target glutamate will provide patients with another treatment rate of 34% for those who were maintained on an option that promises to be effective and have limited side effects (Berenson, 2008; Downar & Kapur, 2008; Goff, 2008; S. F. Locke, 2008). atypical neuroleptic (Csernansky et al., 2002). After the Concept Review, we’ll discuss a disorder that has a very strange Next, we’ll learn about the side effects and effecsymptom—the person does not know who he or she is. tiveness of the newer atypical neuroleptics. 542 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Concept Review 1. A prolonged emotional state that affects almost all of a person’s thoughts and behaviors is called a disorder. 2. The most common form of mood disorder is marked by at least two weeks of daily being in a Normal bad mood, having no interest in anything, and getting no pleasure from activities and having at least Time (years) four of these additional symptoms: problems with weight or appetite, insomnia, fatigue, difficulty thinking, and feeling worthless and guilty. This problem is called disorder. 3. Another depressive disorder is characterized by being chronically depressed for many but not all days over a period of two years and having two of the following symptoms: poor appetite, insomnia, fatigue, low self-esteem, and feelings of hopelessness. This problem is called disorder. 4. Another mood disorder is characterized by a fluctuation between a depressive episode Normal and a manic episode that lasts about a week, during which a person is unusually euphoric, Time (years) cheerful, or high, speaks rapidly, feels great self-esteem, and needs little sleep. This problem is called disorder. 6. Factors such as dealing with stressors and stressful life events are believed to interact with predisposing biological factors and contribute to the development, onset, and maintenance of mood disorders. These are called factors. 7. One treatment for major depression involves placing electrodes on the skull and administering a mild electric current that passes through the brain and causes a seizure. Usual treatment consists of a series of 10 to 12 such sessions, at the rate of about three per week. This treatment is called . 14 Daily depression rating Photo Credits: (#9) © Alan Fredrickson/ Reuters/Corbis; (#10) © Robert Gauthier 5. Underlying genetic, neurological, chemical, or physiological components may predispose a person to developing a mood disorder. Together, these components are called factors. ECT treatment 12 10 8 Post-ECT 6 4 2 PreECT 1 0 1 2 3 Week 4 5 8. Certain psychoactive drugs act by increasing levels of a specific group of neurotransmitters (monoamines, such as serotonin) that are believed to be involved in the regulation of emotions and moods. These are called drugs. A mood stabilizer that is used to treat (a) bipolar I disorder is called (b) , and it’s often combined with antidepressants and antipsychotics. 9. A person who has inflexible, long-standing, maladaptive traits that cause significantly impaired functioning or great distress in his or her personal and social life is said to have a (a) disorder. Examples of this disorder include a pattern of distrust and suspiciousness and perceiving others as having evil motives, which is called a (b) personality disorder; a pattern of being submissive and clingy because of an excessive need to be taken care of, which is called a (c) personality disorder; and a pattern of disregarding or violating the rights of others without feeling guilt or remorse, which is called an (d) personality disorder. 10. A serious mental disturbance that lasts for at least six months and that includes at least two of the following persistent symptoms—delusions, hallucinations, disorganized speech, grossly disorganized behavior, and decreased emotional expression—is called (a) . There are subcategories of this disorder: the one characterized by auditory hallucinations or delusions, such as thoughts of being persecuted by others or thoughts of grandeur, is called (b) schizophrenia. 11. Drugs that are used to treat schizophrenia and act primarily to reduce levels of dopamine are called (a) drugs. Drugs that are used : : to treat schizophrenia and decrease decrease reduce levels of dopamine dopamine & dopamine serotonin and levels of serotonin are called (b) drugs, which are generally more effective than (c) drugs. The theory that, in schizophrenia, the dopamine neurotransmitter system is somehow overactive and gives rise to many of the symptoms observed in schizophrenics is called the (d) theory, which is supported by the actions of (e) drugs but not by the actions of (f) drugs. Answers: 1. mood; 2. major depressive; 3. dysthymic; 4. bipolar I; 5. biological; 6. psychosocial; 7. electroconvulsive therapy, or ECT; 8. (a) antidepressant, (b) lithium; 9. (a) personality, (b) paranoid, (c) dependent, (d) antisocial; 10. (a) schizophrenia, (b) paranoid; 11. (a) typical neuroleptic, (b) atypical neuroleptic, (c) typical neuroleptic, (d) dopamine, (e) typical neuroleptic, (f) atypical neuroleptic CONCEPT REVIEW 543 E. Dissociative Disorders Definition dissociative experience so extreme that your own self splits, breaks down, or disappears. A dissociative disorder is characterized by a person having a disruption, split, or breakdown in his or her normal integrated self, consciousness, memory, or sense of identity. This disorder is relatively rare and unusual (American Psychiatric Association, 2000). What if you had a split or breakdown in your self? We’ll discuss three of the five more common dissociative disorders listed in the DSM-IVTR. These are dissociative amnesia, dissociative fugue, and dissociative identity disorder (formerly called multiple personality disorder). Dissociative Amnesia Dissociative Fugue Mark is brought into the hospital emergency room by police. He looks exhausted and is badly sunburned. When questioned, he gives the wrong date, answering September 27th instead of October 1st. He has trouble answering specific questions about what happened to him. With much probing, he gradually remembers going sailing with friends on about September 25th and hitting bad weather. He cannot recall anything else; he doesn’t know what happened to his friends or the sailboat, how he got to shore, where he has been, or where he is now. Each time I can’t remember he is told that it is really October 1st and he anything about the is in a hospital, he looks very surprised past month. (Spitzer et al., 1994). Mark is suffering from dissociative amnesia. A 40-year-old man wanders the streets of Denver with $8 in his pocket. He asks people to help him figure out who he is and where he lives. He feels lost, alone, anxious, and desperate to learn his identity. He appears on news shows pleading for help: “If anybody recognizes me, knows who I am, please let somebody know” (Ingram, 2006). After his parents and fiancée Who am I? see him on television, they contact the police, What’s my name? informing them that the man’s name is Jeffrey Ingram and that he lives in Seattle. Upon reuniting with his fiancée and family, Jeffrey fails to recognize their faces. He also cannot recall anything about his past (Woodward, 2006). Jeffrey Ingram had experienced dissociative fugue. Dissociative amnesia is characterized by the inability to recall important personal information or events and is usually associated with stressful or traumatic events. The importance or extent of the information forgotten is too great to be explained by normal forgetfulness (American Psychiatric Association, 2000). In Mark’s case, you might think his forgetfulness was due to a blow to the head suffered on the sailboat in rough seas. However, doctors found no evidence of head injury or neural problems. To recall the events between September 25th and October 1st, Mark was given a drug (sodium amytal) that helps people relax and recall events that may be blocked by stressful experiences. While under the effect of the drug, Mark recalled a big storm that washed his companions overboard but spared him because he had tied himself to the boat. Thus, Mark did suffer from dissociative amnesia, which was triggered by the stressful event of seeing his friends washed overboard (Spitzer et al., 1994). In dissociative amnesia, the length of memory loss varies from days to weeks to years and is often associated with a series of stressful events (Eich et al., 1997). As we’ll see next, a person may even forget who he or she is. 544 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Dissociative fugue is a disturbance marked by suddenly and unexpectedly traveling away from one’s home or place of work and being unable to recall one’s past. The person may not remember his or her identity or may be confused about his or her new assumed identity (American Psychiatric Association, 2000). Before clinicians diagnosed Jeffrey as suffering from dissociative fugue, they ruled out drugs, medications, and head injuries. His fiancée explained that Jeffrey had been on his way to Canada to visit his friend’s wife, who was dying of cancer. She believes the stress of seeing his friend’s wife dying led him to an amnesia state. Jeffrey’s history is especially fascinating because he had experienced a similar dissociative fugue in 1995, when he disappeared during a trip to the grocery store and wasn’t found until 9 months later. And, Jeffrey recently went missing for a third time! This time, he was quickly identified because he had gotten a tattoo on his arm that gave his name and state ID number. Jeffrey is now considering his options to always have GPS technology with him so his family can quickly find him if he should go missing again (Alexander, 2007). As Jeffrey’s case illustrates, the onset of dissociative fugue is related to stressful life events. Usually, fugue states end quite suddenly, and the individual recalls most or all of his or her identity and past. In other cases, a person’s self splits into two or more “true” selves or identities, which is called dissociative identity disorder. Photo Credit: right, © AP Images/The Denver Post/Karl Gehring You have probably had the experience of being so absorbed in a fantasy, thought, or memory that, for a short period of time, you cut yourself off from the real world. However, if someone calls your name, you quickly return and explain, “I’m sorry, I wasn’t paying attention. I was off in my own world.” This is an example of a normal “break from reality,” or dissociative experience, which may occur when you are self-absorbed, hypnotized, or fantasizing (Berlin & Koch, 2009; Kihlstrom et al., 1994). Now imagine a What if you became someone else? Dissociative Identity Disorder Is it really true? Photo Credits: top, © Kabik/Retna Ltd./Corbis; bottom, © Ron Nickel/Photolibrary Definition The idea that one individual could possess two or more “different persons” who may or may not know one another and who may appear at different times to say and do different things describes one of the more remarkable and controversial mental disorders (Eich et al., 1997). Previously this disorder was called multiple personality disorder, but now it’s called dissociative identity disorder. We’ll discuss a real case of dissociative identity disorder and its possible causes. Occurrence and Causes Herschel Walker is recognized for being an NFL legThe worldwide occurrence of dissociative identity disorder was very end, Heisman Trophy winner, track star, Olympic rare before 1970, with only 36 cases reported. However, an “epicompetitor, and successful businessman. You demic” occurred in the 1970s and 1980s, with estimates ranging would think Herschel would feel as though he was from 300 to 2,000 cases (Spanos, 1994). Reasons for the upsurge on top of the world. On the contrary, Herschel felt include incorrect diagnosis, renewed professional interest, the that his life was out of his control. He had diffitrendiness of the disorder, and therapists’ (unknowing) encourculty managing his anger, he struggled to feel conagement of patients to play the roles. Whatever the reasons, the nected to people, and he experienced unexplained vast majority (70–80%) of mental health professionals are periods of memory loss. skeptical about the upsurge in occurrence of dissociative Herschel’s wife of 16 years (now divorced) identity disorder (Lilienfeld et al., 1999). The patients most also noticed several oddities about him. For often diagnosed with dissociative identity disorder (DID) Football legend Herschel Walker is diagnosed with instance, she described him as having many are females, who outnumber males by 8 to 1. In addition, dissociative identity different sides, such as the side with an interpatients with DID usually have a history of other mental disorder, formerly called est in the Marines, the side interested in bal- multiple personality disorder. disorders. let, the side interested in the FBI, and the side Explanations. There are two opposing explanations for interested in sports. She even noticed that he would occasionally DID. One is that DID results from the severe trauma of childhood speak in different voices and show uniquely different physical abuse, which causes a mental splitting or dissociation of identities mannerisms. as one way to defend against or After Herschel got the courage to seek professional help to cope with the terrible trauma. understand what had been happening to him, his therapist diagA second explanation is that nosed him as suffering from a very rare and complex disorder DID has become commonplace called dissociative identity disorder. because of cultural factors, such Dissociative identity disorder (formerly called multiple personality as DID becoming a legitimate disorder) is the presence of two or more distinct identities or personality way for people to express their states, each with its own pattern of perceiving, thinking about, and frustrations or to manipulate or relating to the world. Different personality states may take control of the gain personal rewards (Lilienindividual’s thoughts and behaviors at different times (American feld et al., 1999). These opposing Psychiatric Association, 2000). explanations reflect the current As a boy, Herschel was severely teased and bullied for being an controversy about why so many overweight child who had a severe stutter. His therapist explains patients have been diagnosed Dissociative identity disorder is said that Herschel developed his alter personalities to help him overwith DID. to have two very different causes. come the abuse by his peers as well as other major challenges he Researchers have found biofaced later in life. logical evidence to support the existence of dissociative identity Herschel identifies about a dozen alter personalities, includdisorder. For instance, they found that the brains of patients with ing “The Hero,” who came out in public appearances, and “The the condition generate multiple distinct patterns of seeing, thinking, Warrior,” who was in charge of playing football and coping with and behaving. Their physiological arousal patterns (e.g., heartbeat, the physical pain that came with it. Herschel’s therapist describes brain wave activity) are distinctively different depending on which meeting the alter personalities in therapy by saying, “They will alter is present (Reinders et al., 2006). come out and say, I am so-and-so. I’m here to tell you Herschel is Treatment. Patients diagnosed with DID may also have probnot doing too good. . . . When he finishes, it would just disappear lems with depression, anxiety, interpersonal relationships, and subback in him, and Herschel comes out” (Mungadze, 2008). stance abuse. As a result, treatment for DID involves helping patients As in Herschel’s case, the personalities are usually quite difwith these related problems as well as helping them integrate their ferent and complex, and the original personality is seldom aware various personalities into one unified self, which may take years. For of the others. After nearly ten years of psychotherapy, Herschel example, after two years of treatment, patients diagnosed with DID managed to obtain great insight about his condition and says who showed the greatest improvement were those who showed the he is doing much better now (H. Walker, 2008; Woodruff et greatest ability to integrate and resolve the differences of their sepaal., 2008). rate selves and see themselves as a person with a single self. CliniHow common is dissociative identity disorder, and what cians concluded that treatment for DID is a long-term process that causes it? usually involves some form of psychotherapy (Chu et al., 2005). E. DIS S OCI AT I V E DIS ORDE RS 545 F. Cultural Diversity: Interpreting Symptoms Spirit Possession Imagine being a clinician and where spirit possession is part of their culture and interviewing a 26-year-old female about 45% of married women over 15 years of age client who reports the following report spirit possession (Boddy, 1988). Although in sy mptoms: “Somet i mes a the United States symptoms of spirit possession would spirit takes complete control probably be interpreted as delusional and abnormal, in of my body and mind and makes me do things and say Northern Sudan spirit possession is interpreted as a things that I don’t always remember. The spirit is very normal behavior and an expression of the women’s powerful and I never know when it will take control. The culture. To deal with possible cultural differences, the spirit first appeared when I was 16 and has been with me DSM-IV-TR now includes an appendix that describes ever since.” how to diagnose symptoms within the context of a perAs a clinician, you would of course conduct a much son’s culture (American Psychiatric Association, 2000). more in-depth clinical interview and administer a Spirit possession is an example of how cultural About 45% of the women number of psychological tests. But on the basis of these factors determine whether symptoms are interpreted in Northern Sudan report symptoms alone, would you say that she has delusions as normal or abnormal. Researchers are also finding spirit possession, which and hallucinations and possibly schizophrenia or that that cultural factors and gender influence the occuris part of their culture. she has multiple identities and possibly dissociative rence of certain other kinds of mental disorders. identity disorder? In this case, both diagnoses would be incorrect. We’ll examine how culture and gender influence the occurrence of This female client comes from a small village in Northern Sudan, mental disorders. How does the world view mental disorders? Culture-Specific Mental Disorders Mental illness is present across all cultures; however, cultures often differ in what they consider to be normal and abnormal. There are some mental disorders that are unique to a culture and are best understood within the context of a particular culture. They are collectively referred to as culture-specific disorders. A culture-specific disorder is a pattern of mental illness or abnormal behavior that is unique to an ethnic or cultural population and does not match the Western classifications of mental disorders (APA, 2007). Cross-cultural research has identified numerous culturespecific disorders, a few of which are described below (Gaw, 2001). O Latah involves the inability to stop copying or imitating others’ behaviors, such as movements and speech. Individuals with this disorder are susceptible to doing things they wouldn’t typically do, such as using intense profanity. Latah is found in Malaysian and Indonesian cultures. O Bibloqtoq involves an intense urge to leave one’s home, tear off one’s clothes, and Some mental disorders are expose oneself to the freezing cold weather. unique to specific It is found in Greenland, Alaska, and the ethnic or cultural Canadian Arctic. populations. O Susto involves insomnia, depression, and anxiety and is often brought on by fear. It is found among the people of the Andean highlands and is believed to develop from contact with witches and the evil eye. O Koro involves the fear and sensation of one’s penis retracting into the body and the belief that one will die as a result. This syndrome is found in Malaysian cultures. These examples show the importance of cultural factors in mental disorders. Cultural factors influence not only the occurrence of disorders but also the rates of occurrence in males and females. 546 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Gender Differences in Mental Disorders Many mental disorders in the United States, such as bipolar I disorder and personality disorders, are reported about equally by women and men (Kluger, 2003; C. F. Newman, 2006). However, as shown in the graph below, disorders such as major depression and dysthymic disorders are reported significantly more frequently by women than by men in the United States as well as in many other countries around the world (Kessler, 2003; Thase, 2006). Major Depression and Dysthymic Disorder Women Men 67% 33% Some clinicians attribute the higher percentage of women reporting depression to cultural differences in gender roles. For example, the stereotypical gender role for men is to be independent and assertive and to take control, which tends to reduce levels of stress. In comparison, the stereotypical gender role for women is to be dependent, passive, and emotionally sensitive, which reinforces women’s feelings of being dependent, not having control, and Compared with men, twice as many women being helpless, and increases levels of stress report problems with and puts women at greater risk for developdepression. ing depression (Durand & Barlow, 2006). Some researchers suggest that biological (hormonal changes) and psychosocial (concerns over having and raising children) factors may also contribute to women’s higher rate of depression (NIMH, 2005). Next, we’ll look at a very simple yet effective treatment for depression. G. Research Focus: Exercise Versus Drugs Choices of Therapy for Depression at least four of the following symptoms: problems with eating, sleeping, thinking, concentrating, or making decisions, lacking energy, thinking about suicide, and feeling worthless or guilty (American Psychiatric Association, 2000). What would you think if you were in the middle of feeling very depressed and someone recommended running three times a week as a good treatment? It seems hard to believe that something as simple as exercising could be as effective as antidepressants. Remember that major depression is not how you feel from having a bad day or doing poorly on an exam. Major depression must meet the following definition. Can exercise help? Major depressive disorder is marked by at least two weeks of continually being in a bad mood, having no interest in anything, and getting no pleasure from activities. In addition, a person must have Can depressed people get help from walking? We have already discussed how psychotherapy, antidepressants, and a combination of the two have proven effective in treating major depression (Goode, 2003). Now researchers are asking if regular exercise can also be effective in treating major depression. This Research Focus shows how scientists used the experimental approach to answer a question that potentially has very practical or applied benefits. Photo Credits: top and left, © PhotoLink/PhotoDisc, Inc. Exercise Experiment: Seven Rules Method and Results You may remember that there are seven rules for doing an experiment (pp. 36–37). We’ll review these seven rules by showing how researchers followed them in their study (Babyak et al., 2000). Rule 1: Ask. Every experiment asks a specific question that is changed into a hypothesis or educated guess. In this study, the hypothesis is that exercise will be as effective a treatment for major depression as are antidepressants. Rule 2: Identify. Researchers identify the treatment, which is called the independent variable because researchers Antidepressants: independent are able to control or adminvariable ister it to the subjects. Here, the independent variable has three levels of treatments: the first level is 30 minutes of exercise (stationary bike or walking/jogging) three times Exercise: a week; the second level is taking independent antidepressants (Zoloft); and the variable third level is a combination of exercising and taking antidepressants. Next, researchers identify the behavior(s), called the dependent variable, which depends Scale to on the treatment, and measure its effectiveness. In measure this study, the dependent variable is a scale (Ham- depression: dependent ilton rating scale for depression) that measures variable increases or decreases in subjects’ depression. Rule 3: Choose. Researchers choose subjects, who in this study are 156 adult volunteers (50 years or older) who have been diagnosed with major depression (according to the above definition). Rule 4: Assign. The chosen patients are randomly assigned to groups, which means that each of the 156 patients has an equal chance of being assigned to one of the three treatment groups. Rule 5: Manipulate. Researchers administer or manipulate the three levels of the treatment by giving one level of treatment to each of the three groups of patients. Rule 6: Measure. After 4 months of treatments, researchers use the depression scale to measure how effective each one of the three levels of treatment was in decreasing the patients’ depression. Rule 7: Analyze. Researchers found that about 60% of patients in the exercise group had greatly improved, compared with 66% of subjects taking antidepressants and 69% of those who combined exercise and antidepressants. Although these percentages look different, statistical analysis indicated that the three treatments were equally effective. This means that exercise alone was as effective in reducing depression as were antidepressants or the combination, which supports the researchers’ original hypothesis. Relapse We discussed how, after treatRelapse Rate after Treatment ment for a mental disorder, a certain percentage of patients Antidepressants 38% relapse or again return to having symptoms. Of the 60–69% Combination 31% of patients in each of the three 8% Exercise treatment groups who showed significant improvement (few if any depressive symptoms), some patients had relapsed during the 6-month period following treatment. Researchers reported (above graph) that 38% of patients who had received antidepressants had relapsed and 31% of patients who had received both exercise and antidepressants had relapsed. However, only 8% of patients relapsed who were in the exercise-only treatment. Conclusions Researchers found that after 4 months of treatment for depression, patients in all three treatment groups showed improvement. However, when patients were retested 6 months later, those who had received exercise only showed less relapse. Researchers suggest that exercise helps patients develop a sense of personal mastery and positive selfregard, which helps patients get over being depressed and decreases the risk of future relapse (Babyak et al., 2000). Other research found that depressed patients who exercised 30 minutes, three to five times a week, reported a 50% reduction in symptoms of depression after 12 weeks (Dunn et al., 2005). Also, researchers found that exercise has an immediate positive effect on mood that lasts for as long as 12 hours (Sibold, 2009). As a treatment for depression, exercise is effective and inexpensive and has no unwanted side effects. Next, we’ll discuss several ways to overcome mild depression. G. RESEARCH FOCUS: EXERCISE VERSUS DRUGS 547 H. Application: Dealing with Mild Depression Mild Versus Major Depression There is a big difference between mild and major depression. How does Earlier, we discussed singer Sheryl Crow, who experienced major depressive disorder. Symptoms of major depressive disdepression order include being in a bad mood for at least two weeks, havdiffer? ing no interest in anything, and getting no pleasure from activities. Additionally, to be diagnosed with major depression, a person must have at least two of the following problems: difficulty in sleeping, eating, thinking, and making decisions or having no energy and feeling continually fatigued. Compared with the symptoms of major depressive disorder, the symptoms of mild depression are milder and generally have less impact on a person’s functioning. For example, take the case of Janice, who has what is often called the sophomore blues. “At first I was excited about going off to college and being on my own,” explains Janice. “But now I feel worn out from the constant pressure to study, get good grades, and scrape up enough bucks to pay my rent. I’ve lost interest in classes, I have trouble concentrating, I’m doing poorly on exams, and I’m thinking about changing my major—again. And to make everything even more depressing, my boyfriend just broke up with me. I sit around wondering what went wrong or what I did or why he broke it off. What did I do There is a big difference that was so bad? My friends are tired of my moping between the symptoms of around and complaining, and I know they are starting major and mild depression. to avoid me. Yeah, everyone says that I should just get over him and get on with my life. But exactly what do I do to get out of my funk?” Continuum. Some researchers have argued that the kind of depression reported by college students is related to general distress and does not represent any of the particular symptoms and feelings found in major depression (J. C. Coyne, 1994). However, other researchers find that depression is best thought of as a continuum. At one end of the continuum is mild depression, such as that experienced by many college students, which is basically similar in quality but just a milder form of major depression, which is at the other end of the continuum (Flett et al., 1997). College students. Although many college students experience mild depression, a considerable number also suffer from more severe forms of depression. For instance, a national survey found that 40% of college students have reported feeling “so depressed it’s difficult to function,” and another 10% reported they had “seriously considered suicide.” In fact, more than 5% of students reported they had actually attempted suicide, which is the second leading cause of death among college students, compared to its ranking as the ninth leading cause of death in the general population (ACHA, 2007; NAMH, 2008). These statistics are devastating but perhaps not surprising when you consider that college students are experiencing almost all the major stressors of adulthood, including coping with a new environment, dealing with academic pressures, trying to establish intimate personal relationships, experiencing financial difficulties, and trying to achieve some independence from parents and family (Pennebaker et al., 1990). Vulnerability. There are three major factors that increase an individual’s vulnerability or risk for developing mild depression. The first factor is being a young adult who is facing new, challenging, and threatening situations and feelings. The second factor is having a high number of negative life events. Since college students experience both of these factors, they are at high risk for developing mild depression, which may lead to major depression later in life. The third factor involves an individual’s pattern of thinking, which is the basis for Beck’s theory of depression. 548 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA Beck’s Theory of Depression Janice thinks that her depression is caused by outside forces, such as academic pressures, financial concerns, personal difficulties, and family pressures. There is no question that stressful events or negative situations can depress Janice’s mood. However, another factor that Janice may not be aware of and that may contribute to her depression is a particular pattern of thinking, which is described by Aaron Beck’s (1991) cognitive theory of depression. How much do thoughts matter? Beck’s cognitive theory of depression says that when we are feeling down, automatic negative thoughts that we rarely notice occur continually throughout the day. These negative thoughts distort how we perceive and interpret the world and thus influence our behaviors and feelings, which in turn contribute to our feeling depressed. Often these automatic negative thoughts are centered on personal inadequacies, such as thinking one is a failure, is not liked, or never gets anything done. Beck has identified a number of specific negative, maladaptive thoughts that he believes contribute to developing anxiety and depression. For example, thinking “I’m a failure” after doing poorly on one test is an example of overgeneralization—that is, making a blanket judgment about yourself based on a single incident. Thinking “People always criticize me” is an example of selective attention—that is, focusing on one detail so much that you do not notice other positive events, such as being complimented. Beck believes that maladaptive thought patterns cause a distorted view of oneself and one’s world, which in turn may lead to various emotional problems, such as Increased risk depression. Thus, for depression one of the things t h a t Ja n i c e mu s t work on to get out of her depressed state is to 1. Academic identify and change pressures her negative, mal2. Financial concerns adaptive thoughts. 3. Family pressures We’ll discuss how negative thoughts 4. Negative thought and two other facpatterns tors maintain depression, as well as ways to change them. Overcoming Mild Depression What can one do? Once we get “down in the dumps,” we are likely to stay there for some time unless we work at changing certain thoughts and behaviors, such as improving social skills, increasing social support, and eliminating negative thoughts. We’ll describe several ways to “get out of the dumps” and overcome mild depression. Improving Social Skills Eliminating Negative Thoughts Problem. In some cases, a person may feel mildly depressed because he or she has poor social skills, which lead to problems in having good social interactions. For example, researchers found that depressed teenagers and college students may be overly dependent, competitive, aggressive, or mistrustful, which in turn caused problems in developing and maintaining close social relationships (M. K. Reed, 1994). If part of being depressed involves poor social skills, a person can learn new ways of interacting with friends. Program. As with every behavioral Poor social skills can increase change program, the first step is to chances of feeling monitor our social interactions to notice depressed. what we are doing wrong, such as complaining too much and irritating our friends. Once we’re aware of our bad habits, such as being negative, not asking questions or showing interest, and not being sympathetic, we can begin to take positive steps. That means making a real effort to stop complaining and to show more interest in our friends’ activities and to be more sensitive to their feelings. By proceeding in gradual steps, we can learn to improve our social skills and get more rewards from social interactions, which in turn will make us feel better and help us get over our mild depression (Hokanson & Butler, 1992). Problem. Researchers find that individuals often become and remain mildly depressed because they do not give themselves credit for any success (however small), make every situation (however small) into a bad or unpleasant experience, and constantly blame themselves for every failure, which makes them more depressed and thus elicits more negative reactions from friends (Nurius & Berlin, 1994). Program. The first step in increasing our self-esteem is to become aware of Learning to take self-blame by monitoring our thoughts credit for our actions can help and noticing all the times we blame ourovercome selves for things, no matter how small. feelings of mild Once we become aware of self-blame, depression. we can substitute thoughts of our past or recent accomplishments, no matter how small. By substituting thoughts of accomplishment and focusing on recent successes, we will gradually improve our self-esteem. As our self-esteem improves, we will slowly get a more positive attitude, which increases the social support of our friends (Granvold, 1994). Problem. According to Beck’s theory of depression, a depressed person thinks negative, maladaptive thoughts, which in turn cause the person to pay attention to, perceive, and remember primarily negative and depressing situations, events, and conversations (A. T. Beck, 1991). Thus, besides improving social skills and increasing social support, depressed individuals also need to stop the automatic negative thought pattern After identifying that maintains depression. negative thoughts . . . Researchers found that depressed individuals have a tendency to select and remember unhappy, critical, . . . substitute or depressing thoughts, events, or positive thoughts remarks, remember fewer good things than bad things, and take a more pessimistic view of life (Corey, 2005). Although discussed later (pp. 574–575), here’s a brief description of a program for changing negative thought patterns. Program. The first step is to monitor the occurrence of negative, depressive thoughts. The second step is to eliminate depressive thoughts by substituting positive ones. This second step is difficult because it requires considerable effort to stop thinking negative thoughts (“I really am a failure”) and substitute positive ones (“I’ve got a lot going for me”). With practice, we can break the negative thought pattern by stopping negative thoughts and substituting positive ones. These kind of “talk” programs can help a person overcome mild depression and enjoy life more (Freeman et al., 2004). One reason “talk” programs can help as much as antidepressants is that “talk” programs and antidepressants produce strikingly similar changes in the brain. Power of Positive Thinking Everyone has heard about the power of positive thinking, and now researchers have found a concrete example. It began with the interesting and reliable finding that psychotherapy (“talk” therapy) can often reduce depressive symptoms as much as antidepressants can (Rupke et al., 2006). Wondering why psychotherapy was as powerful as drugs, researchers took brain scans (pp. 70–71) of patients diagnosed with depression before and after 12 weeks of treatment with either psychotherapy or antidepressants. The result was that both treatments, psychotherapy and antidepressants, decreased depression. But the surprising finding was that both psychotherapy and antidepressants produced similar changes in the brain, one of which was to decrease the abnormally high activity of the prefrontal cortex (right figure) (A. L. Brody et al., 2001). Several studies have now reported similar results: Talk therapy can and does alter brain functioning (Roffman et al., 2005). This means that the next time you are down in the Prefrontal dumps, try the power of positive thinking to cortex change your brain functioning. You may be pleasantly surprised by the happy results. H. A PPLICAT ION: DE A LIN G W I T H MIL D DEP R ES SION 549 Summary Test B. Electroconvulsive Therapy 1. A disturbed emotional state that affects almost all of a person’s thoughts and behaviors is called a disorder. 7. If antidepressant drugs fail to 14 ECT treat major depression, the treat12 treatment ment of last resort involves placing 10 electrodes on the skull and admin8 istering a mild electric current that Post-ECT 6 passes through the brain and causes 4 PreECT a seizure. This treatment is called 2 1 0 1 2 3 4 5 (a) therapy. A Week potentially serious side effect of this treatment is impairment or deficits in (b) , which usually affects events experienced during the weeks of treatment as well as events before and after treatment. However, following ECT treatment, there is a gradual improvement in memory functions. 3. A mood episode that is characterized by a distinct period, lasting at least a week, during which a person is unusually euphoric, cheerful, or high and has at least three of the following symptoms—has great self-esteem, needs little sleep, speaks rapidly and frequently, experiences racing thoughts, is easily distracted—is called a (a) episode. A disorder characterized by periods of fluctuation between episodes of depression and mania is called (b) disorder. 4. Underlying genetic, neurological, or physiological components may predispose a person to developing a mood disorder. These components are called (a) factors. Factors such as dealing with stressors and stressful life events are believed to interact with predisposing biological influences and contribute to the development, onset, and maintenance of mood disorders. These are called (b) factors. C. Personality Disorders 8. A disorder that involves inflexible, longstanding, maladaptive traits that cause significantly impaired functioning or great distress in one’s personal and social life is called a (a) disorder. Ten of these disorders are listed in the DSM-IV-TR, including: a pattern of being submissive and clingy because of an excessive need to be taken care of, which is called a (b) disorder, and a pattern of disregarding or violating the rights of others without feeling guilt or remorse, which is called an (c) disorder. There is evidence that personality disorders develop from an interaction of (d) and factors. 9. Evidence that genetic factors influence personality disorders comes from studies on , which show that genetic factors contribute 30–50% to the development of these personality disorders. 5. Some drugs increase levels of neurotransmitters (serotonin, norepinephrine, dopamine) called (a) . These drugs, which are involved in the regulation of emotions and moods, such as major depression, are called (b) and may take up to 8 weeks before they begin to work. The newer and more popular antidepressants (Prozac) are called (c) , or SSRIs, and are not more effective but have fewer unwanted (d) than older antidepressants. 10. Schizophrenia is a serious mental disNEUROLEPTICS turbance that lasts for at least six months Atypical: Typical: decrease and includes at least two of the following decrease dopamine & dopamine persistent symptoms: delusions, halluciserotonin nations, disorganized speech, grossly disorganized behavior, and decreased emotional expression. These symptoms interfere with personal or social . 6. A mood stabilizer used to treat bipolar I disorder is called (a) , and it’s often combined with antidepressants and antipsychotics. This drug is also used to treat euphoric periods without depression; this disorder is called (b) . 11. The DSM-IV-TR lists five subcategories of schizophrenia, which include the following three. A category characterized by bizarre ideas, confused speech, childish behavior, great emotional swings, and often extreme neglect of personal appearance and hygiene is called (a) schizophrenia. Another 550 MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA D. Schizophrenia Photo Credit: (#8) © Alan Fredrickson/Reuters/Corbis 2. One mood disorder is marked by being in a daily bad mood, having no interest in anything, getting no pleasure from activities, and having at least four of the following symptoms: problems with weight, appetite, sleep, fatigue, thinking, or making decisions and having suicidal thoughts. This is called (a) disorder, which is the most common form of mood disorder. Another mood disorder is characterized by being chronically depressed for many but not all days over a long period of time and having two of the following symptoms: problems with appetite and sleep, fatigue, low self-esteem, and feelings of hopelessness. This is called (b) disorder. Daily depression rating A. Mood Disorders form marked by periods of wild excitement or periods of rigid, prolonged immobility is called (b) schizophrenia. A third form characterized by thoughts of being persecuted or thoughts of grandeur is called (c) schizophrenia. 12. Researchers have searched for an identifiable gene or a specific segment of a chromosome that is directly linked to developing schizophrenia. This genetic link is called a . 13. Two kinds of neuroleptic drugs are used to treat schizophrenia symptoms by changing levels of neurotransmitters in the brain. Drugs that act primarily to reduce levels of the neurotransmitter dopamine are called (a) neuroleptics. An example is the phenothiazines. Drugs that lower levels of dopamine but, more important, also reduce levels of other neurotransmitters, especially serotonin, are called (b) neuroleptics. These drugs are generally more effective in reducing schizophrenia symptoms and better at preventing (c) . 14. One side effect of the continued use of phenothiazines is the appearance of slow, involuntary, and uncontrollable rhythmic movements and rapid twitching of the mouth and lips, as well as unusual movements of the limbs. This side effect is called . 15. One theory of schizophrenia says that it develops when the (a) neurotransmitter is overactive. Another related theory says that some people have a genetic predisposition, called a (b) , that interacts with life stressors to result in the onset and development of schizophrenia. Photo Credits: (#19) © PhotoLink/PhotoDisc, Inc.; (#16) © Ron Nickel/Photolibrary E. Dissociative Disorders 16. A dissociative disorder is characterized by a (a) in a person’s normally integrated functions of memory, identity, or perception of the environment. The DSM-IVTR lists five types of dissociative disorder, which include the following three. If a person is unable to recall important personal information or events, usually in connection with a stressful or traumatic event, and the information forgotten is too important or lengthy to be explained by normal forgetfulness, it is called (b) . If a person suddenly and unexpectedly travels away from home or place of work and is unable to recall the past and may assume a new identity, it is called (c) . If a person experiences the presence of two or more distinct identities or personality states, each with its own pattern of perceiving, thinking about, and relating to the world, it is called (d) disorder. 17. One theory says that dissociative identity disorder (DID) develops as a way to cope with the severe trauma of childhood (a) . A second explanation is that DID has become a culturally approved way for people to express their (b) or to control others or gain personal rewards. F. Cultural Diversity: Interpreting Symptoms 18. Spirit possession is one example of how cultural factors determine whether symptoms are interpreted as (a) or . An example of how cultural factors may increase the risk for development of mood disorders can be traced to the differences in assigned (b) roles: Males are expected to be independent and in control, and females are expected to be dependent and not have control. G. Research Focus: Exercise Versus Drugs 19. After three different treatments, including exercise only, researchers found that at least 60% of patients diagnosed with (a) showed significant improvement. Another finding was that when patients were retested 6 months later, those who had received exercise only showed significantly less (b) . Researchers suggest that (c) helps patients develop a sense of personal mastery and positive self-regard, which helps prevent relapse. H. Application: Dealing with Mild Depression 20. Beck’s cognitive theory of depression says that when we are depressed, we have automatically occurring (a) , which center around being personally inadequate. In turn, these negative thoughts (b) how we perceive and interpret the world and thus influence our behaviors and feelings. There are effective programs for developing better social skills and eliminating negative thoughts. Psychotherapy and antidepressant drugs both reduced depression and both produced similar changes in how the (c) functions. Answers: 1. mood; 2. (a) major depressive, (b) dysthymic; 3. (a) manic, (b) bipolar I; 4. (a) biological, (b) psychosocial; 5. (a) monoamines, (b) antidepressants, (c) selective serotonin reuptake inhibitors, (d) side effects; 6. (a) lithium, (b) mania; 7. (a) electroconvulsive, (b) memory; 8. (a) personality, (b) dependent, (c) antisocial, (d) biological, psychological; 9. twins; 10. functioning; 11. (a) disorganized, (b) catatonic, (c) paranoid; 12. genetic marker; 13. (a) typical, (b) atypical, (c) relapse; 14. tardive dyskinesia; 15. (a) dopamine, (b) diathesis; 16. (a) disruption, split, breakdown, (b) dissociative amnesia, (c) dissociative fugue, (d) dissociative identity; 17. (a) physical or sexual abuse, (b) frustrations, fears; 18. (a) normal, abnormal, (b) gender; 19. (a) major depression, (b) relapse, (c) exercise; 20. (a) negative thoughts, (b) bias or distort, (c) brain SUMMARY TEST 551 Critical Thinking What Is a Psychopath? J QUESTIONS 1 According to the three definitions of abnormal behavior (p. 511), are Dahmer and Rader abnormal? 2 What objective test can be used to best assess for these psychopathic personality traits? 3 Which trait theory can explain how an individual can display such drastically inconsistent behaviors? 4 What part of the limbic system explains how psychopaths can be so cold and fearless? 552 effrey Dahmer would pick up young gay men, bring them home, drug them, strangle them, have sex with their corpses, and then, in some cases, eat their flesh. Dennis Rader would break into people’s homes, tie them up, strangle them, and eventually murder them. His murder method earned him the name “BTK killer,” which stands for Bind, Torture, and Kill. Dahmer and Rader share much in common. They are superf icially charming, unemotional, impulsive, and self-centered. They are pathological liars who constantly manipulate others. Also, both men completely lack remorse, guilt, and empathy. Finally, they have low selfesteem, a strong desire to be in control, and a lifelong sense of loneliness. Dahmer, for example, felt so lonely that he admitted to killing people for company. Together, the above chara ct er ist ic s def i ne a psychopath. What may seem surprising is that psychopaths can love their parents, spouses, and children but have great diff iculty loving the rest of the world. Rader, for instance, was a loving husband and father. Yet, he seemed completely devoid of humanity as he plainly recounted the details of how he murdered his many victims. Some of the fascinating characteristics and behaviors of psychopaths may be explained by biological and neurological factors. For example, some psychopaths have abnormalities in their limbic system, which is responsible for motivational MODULE 23 MOOD DISORDERS & SCHIZOPHRENIA behaviors, such as eating and sex, as well as emotional behaviors, such as fear, anger, and aggression. Also, some psychopaths have a disruption in the communication between the hippocampus and the prefrontal cortex, which is believed to contribute to their lack of control, inability to regulate aggression, and insensitivity to cues that predict they will get caught and punished. Interestingly, psychopaths also have lower autonomic arousal and consequently experience less distress when exposed to threats. The life histories of psychopaths often include a chaotic upbringing, lack of parental attention, parental substance abuse, and child abuse. These life experiences may interact with biological or neurological factors linked to psychopathic behaviors. For instance, children may have genes for psychopathic behaviors that get activated only under stress; if they are raised in a nurturing environment, they may very well develop into well-behaved, moral adults. In other words, at least for some children, the consequences of having a stressful childhood can be deadly. (Adapted from B. Bower, 2006b, 2008e; Crenson, 2005; C. Goldberg, 2003; Hickey, 2006; Larsson et al., 2006; Lilienfeld & Arkowitz, 2007; Martens, 2002; A. Raine et al., 2004; Wilgoren, 2005; Yang et al., 2005b) 5 How would a psychopath do on a lie detector test? 6 What is it called when someone has inherited a gene for psychopathic behaviors but develops those behaviors only if he or she has a stressful childhood? ANS W ERS TO CRITI CAL TH I NKI NG QUEST I ONS Links to Learning Key Terms/Key People antidepressant drugs, 534 antisocial personality, 536 atypical neuroleptics, 541 Beck’s cognitive theory of depression, 548 biological factors and depression, 533 biological causes of schizophrenia, 539 bipolar I disorder, 532 bipolar I, treatment, 534 borderline personality disorder, 536 brain scans, 533 catatonic schizophrenia, 538 culture-specific disorders, 546 dependent personality, 536 depressed mothers, 533 dialectical behavior therapy, 536 diathesis stress theory, 540 disorganized schizophrenia, 538 dissociative amnesia, 544 dissociative disorder, 544 dissociative fugue, 544 dissociative identity disorder, 545 dopamine theory, 541 dysthymic disorder, 532 electroconvulsive therapy, ECT, 535 electroconvulsive therapy, effectiveness, 535 eliminating negative thoughts, 549 environmental causes of schizophrenia, 540 exercise versus drugs, 547 genetic factors, 533 genetic marker, 539 hallucinations, 538 histrionic personality, 536 improving social skills, 549 lithium, 534 major depressive disorder, 532, 547 major depression, treatment, 534 mania, 534 mood disorder, 532 negative cognitive style, 533 negative symptoms of schizophrenia, 541 neuroleptic drugs, 541 neurological causes of schizophrenia, 540 neurological factors, 533 obsessive-compulsive personality, 536 paranoid personality, 536 paranoid schizophrenia, 538 personality disorder, 536 personality factors, 533 positive symptoms of schizophrenia, 541 power of positive thinking, 549 psychosocial factors, 533 schizophrenia, 538 schizotypal personality, 536 selective serotonin reuptake inhibitors, 534 spirit possession, 546 stressful life events, 533 tardive dyskinesia, 542 transcranial magnetic stimulation, 535 Type I schizophrenia, 538 Type II schizophrenia, 538 typical neuroleptics, 541 Learning Activities PowerStudy for Introduction PowerStudy 4.5™ to Psychology 4.5 Try out PowerStudy’s SuperModule for Mood Disorders & Schizophrenia! In addition to the quizzes and learning activities, interactive Summary Test, key terms, module outline and abstract, and extended list of correlated websites provided for all modules, the DVD’s SuperModule for Mood Disorders & Schizophrenia offers features including: t
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pages 550–551 and the critical thinking questions for the article on page 552 CengageNOW! www.cengage.com/login Want to maximize your online study time? Take this easyto-use study system’s diagnostic pre-test and it will create a personalized study plan for you. The plan will help you identify the topics you need to understand better and direct you to relevant companion online resources that are specific to this book, speeding up your review of the module. Introduction to Psychology Book Companion Website www.cengage.com/psychology/plotnik Visit this book’s companion website for more resources to help you study, including learning objectives, additional quizzes, flash cards, updated links to useful websites, and a pronunciation glossary. Study Guide and WebTutor Work through the corresponding module in your Study Guide for tips on how to study effectively and for help learning the material covered in the book. WebTutor (an online Study Tool accessed through your eResources account) provides an interactive version of the Study Guide. Suggested Answers to Critical Thinking 1. Dahmer and Rader’s behaviors are abnormal in terms of statistical frequency, deviation from social norms, and being maladaptive. 2. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (p. 474) is an objective personality test that assesses a range of personality traits, including anger, truthfulness, self-esteem, friendliness, and seriously deviant behaviors. 3. The person-situation interaction (p. 464) explains how a person’s behavior results from an interaction between his or her traits and the effects of being in a particular situation. It explains how psychopaths, such as Dahmer and Rader, can be loving people with their families but cold-blooded, heartless serial killers in the community. 4. The amygdala (pp. 80, 362) is the structure located in the limbic system that is responsible for evaluating whether stimuli have positive (happy) or negative (fearful, threatening) emotional significance for our survival. Damage to the amygdala explains how psychopaths can completely lack empathy and not learn to fear and avoid dangerous situations, such as cues that predict they will get caught. 5. A lie detector test (pp. 370–371) measures involuntary physiological responses and is based on the theory that a person who lies will feel guilt or fear, which will result in an increase in the galvanic skin response and other physiological responses. Because psychopaths do not feel guilt or fear and do not sweat easily due to lower autonomic arousal, they should pass a lie detector test with flying colors. 6. Having biological or neurological factors for psychopathic behaviors produces a predisposition (p. 540) for psychopathic behaviors, which increases the risk or vulnerability of developing such behaviors. LINKS TO LEARNING 553