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Chapter 1 Notes What is abnormality Deviance Differ markedly from a society’s ideas about proper functioning, or norms Distress Behavior, ideas, or emotions usually have to cause distress before thy can be labeled abnormal Dysfunction Interferes with daily functioning Danger Behavior that becomes dangerous to oneself or others, research suggests that it is actually the exception rather than the rule Elusive Nature of Abnormality Society selects general criteria for defining abnormality and then uses those criteria to judge particular cases Thomas Szasz Concept of mental illness to be invalid, a myth Societies invent the concept of mental illness so they can better control or change people whose unusual patterns of functioning up-set or threaten the social order Eccentricity Unusual pattern with which others have no right to interfere What is treatment Three essential features A sufferer who seeks relief from the healer A trained, socially accepted healer, whose expertise is accepted by the sufferer and his or her social group A series of contacts between the healer and the sufferer, through which the healer…often tries to produce certain changes in the sufferer’s emotional state, attitudes, and behavior Clinicians who view abnormality as an illness consider therapy a procedure that helps cure the illness (patients) Clinicians who see abnormality as a problem in living and therapists as teachers of more useful behavior and thought (clients) How was abnormality viewed and Treated in the Past Any given year 30% adults, 19% children and adolescents in US display serious psychological disturbances Ancient views and Treatments Ancient societies regarded abnormal behavior as the work of evil spirits Trephination Circular section of skull cut away as form of treatment for abnormality Exorcism Coaxing evil spirits to leave person’s body as treatment for abnormality Greek and Roman Views and Treatments Hippocrates (460-377 B.C.) Abnormal behavior as a disease caused by internal physical problems Imbalance of humors Yellow bile, black bile, blood, and phlegm Europe in the Middle Ages: Demonology Returns Middle Ages (500-1350 A.D.) Cure was to rid person’s body of the devil that possessed it The Renaissance and the Rise of Asylums (1400-1700) Demonological views of abnormality decline Johann Weyer First physician to specialize in mental illness, mind was as susceptible to sickness as the body, considered founder of the modern study of psychopathology Asylums Institutions whose primary purpose was to care for people with mental illness, Decline in quality of patient care in mid sixteenth century Nineteenth Century: Reform and Moral Treatment Spread of moral treatment La Bicetre (Philippe Pinel) - Paris First site of asylum reform Patients were sick people whose illnesses should be treated with sympathy and kindness William Tuke - England Similar reform Benjamin Rush Spread of moral treatment in the US Father of American psychiatry Decline of Moral treatment Severe money and staffing shortages developed ( recovery rates declined Assumption behind moral treatment that all patients could be cured if treated with humanity and dignity ( insufficient for some Emergence of prejudice against people with mental disorders Long-term hospitalization became the rule once again Early Twentieth Century: the Somatogenic and Psychogenic Perspectives Somatogenic Perspective Abnormal psychological functioning has physical causes First thought by Hippocrates, reborn in the 19th century Two factors were responsible for rebirth Emil Kraepelin Argued physical factors, such as fatigue, are responsible for mental dysfunction New biological discoveries also triggered rebirth (syphilis – Richard von Krafft-Ebing) Psychogenic perspective The chief causes of abnormal functioning are psychological Friedrich Anton Mesmer – mesmerism (hypnosis) Hippolyte-Marie Bernheim and Ambroise-Auguste Liebault Josef Breuer Sigmund Freud – psychoanalysis and outpatient therapy Current Trends How are People with Severe Disturbances Cared For Psychotropic medications – drugs that mainly affect the brain and reduce many symptoms of mental dysfunctioning (1950’s) i.e. antipsychotic drugs, antidepressant drugs, antianxiety drugs Discovery of psychotropic medications lead to major deinstitutionalization Outpatient care has now become the primary mode of treatment Only 40% of persons with severe psychological disturbances currently receive treatment How are People with Less Severe Disturbances Treated Private psychotherapy One out of every five adults in the US receives treatment for who suffer from psychological disorders in the course of a year Programs devoted exclusively to one kind of psychological problem Growing Emphasis on Preventing Disorders and Promoting Mental Health Prevention Community programs try to correct the social conditions that give rise to psychological problems i.e. poverty Positive psychology Encouragement of positive feelings Growing Influence of Insurance Coverage Managed care program Insurance company determines such key issues as which therapists its clients may choose, cost of sessions, and number of sessions – 75% of all privately insured persons in US are currently enrolled in managed care programs What are Today’s Leading Theories and Professions Psychoanalytic perspective Emphasis on unconscious psychological problems as the cause of abnormal behavior Somatogenic or biological Behavioral Cognitive Humanistic-existential Sociocultural What do Clinical Researchers Do Three main methods of investigation Case study Detailed description of a person’s life and psychological problems Case studies can Source of new ideas about behavior Tentative support for a theory Challenge a theory’s assumptions Limitations Reported by biased observers Rely on subjective evidence Provide little basis for generalizations Correlational method Research procedure used to determine this “co-relationship” between variables Better position to generalize their correlations to people beyond DO NOT explain the relationship Forms of correlational studies Epidemiological studies – reveal incidence and prevalence rates in a particular population Longitudinal studies – researchers observe the same subjects on many occasions over a long period of time Experimental method Manipulate independent variable and see effects on dependent variable Alternate Experimental designs Quasi-experiments Cannot randomly assign subjects, make use of groups that already exist Match control subjects – match experimental subjects with control subjects who are similar in age, sex, race, socioeconomic status ect. Natural experiments Analogue Experiments Produce abnormal-like behavior in laboratory and then conduct experiments on the subjects Single-subject experimental design Single subject is observed both before and after the manipulation of an independent variable (ABAB design) Chapter 2 Notes The Biological Model How do Biological Theorists Explain Abnormal Behavior Illness is brought about by malfunctioning parts of the organism Brain Chemistry and Abnormal Behavior Abnormal activity by certain neurotransmitters can lead to specific mental disorders Low activity of GABA – anxiety disorders Excessive dopamine – schizophrenia Low serotonin and norepi – depression Sources of Biological abnormalities Genetics and Abnormal Behavior Each cell in body/brain has 23 pairs of chromosomes 30,000-40,000 genes per cell Evolution and Abnormal Behavior Gene responsible for abnormal behavior may be a mutation, an abnormal form of the appropriate gene that emerges by accident Many genes that contribute to abnormal functioning are actually the result of normal evolutionary principles Viral Infections and Abnormal Behavior Viral infections may be a possible source of abnormal brain structure or biochemical dysfunctioning Schizophrenia may be related to certain viruses during childhood Biological Treatments Drug therapy, electroconvulsive therapy, psychosurgery Psychotropic medications Antianxiety Minor tranquilizers or anxiolytics, help reduce tension Antidepressant Help improve mood Antibipolar Mood stabilizers, help steady the moods Antipsychotic Help reduce confusion, hallucinations, and delusions Electroconvulsive therapy (ECT) Electrical current of 65 to 140 volts is passed briefly through the brain Treatment for depression Psychosurgery or neurosurgery Lobotomy – cut connections between the brain’s frontal lobes The Psychodynamic Model A person’s behavior, normal or abnormal, is determined by underlying psychological forces of which he or she is not consciously aware Internal forces are dynamic – they interact with one another and give rise to behavior Psychological conflicts are tied to early relationships and to traumatic experiences that occur during childhood All behavior is determined by past experiences How did Freud Explain Normal and Abnormal Functioning Three central forces shape the personality – instinctual needs, rational thinking, and moral standards, all operate at the unconscious level ID – instinctual needs Follows pleasure principle, always seeks gratification All id instincts tend to be sexual – libido – sexual energy that fuels the id The Ego – rational thinking Grows from the id Unconsciously seeks gratification but does so in accordance with the reality principle – it can be unacceptable to express our id impulses outright Uses reason to guide us when we can and cannot express id impulses Ego defense mechanisms – control unacceptable id impulses Repression – prevents unacceptable impulses from ever reaching consciousness The superego Grows from the ego Adopt our parents’ values, judge ourselves by their standards If id, ego, and superego are in excessive conflict, persons’ behavior may show signs of dysfunction Development Stages If adjustments aren’t successful, person may become fixated Oral stage – first 18 months Anal stage – 18 months to 3yrs Phallic – 3 to 5yrs Latency – 5 to 12yrs Genital – 12 to adulthood How Do Other Psychodynamic Explanations Differ from Freud’s Ego theorists Emphasize the role of the ego and consider it a more independent and powerful force than Freud Self theorists Give greatest attention the to role of the self – believe the basic human motive is to strengthen the wholeness of the self Object Relations Theorists People are mainly motivated by a need to have relationships with others and that severe problems between children and their caregivers leads to ab. Development Psychodynamic Therapies Seek to uncover past traumas and resulting inner conflicts Therapist rely on free association, therapist interpretation, catharsis, and working through to discover underlying problems Free association Patient is responsible for starting and leading each discussion Patient says whats on the mind even if it seems unimportant Therapist expects that the patient’s associations will eventually uncover unconscious events Therapist Intrpretations Interpretations of three phenomena: resistance, transference, and dreams Resistance Unconscious refusal to participate fully in therapy Suddenly cannot free associate, or change subject to avoid a painful discussion Transference Act and feel towards the therapist as they did or do towards important person in their lives Dreams “royal road to the unconscious Repression and other defense mechanisms operate less completely during sleep Manifest content – consciously remembered dream Latent content – symbolic meaning Catharsis A reliving of past repressed feelings Working Through A singe episode of catharsis will not change a person, patient therapist must examine the same issue over and over Contemporary Trends in Pyschodynamic Therapy Short-term Psychodynamic Therapies Patients choose a single dynamic focus such as getting along with other people Relational psychoanalytic therapy Argues that therapists are key figures in the lives of patients – figures whose reactions and beliefs should be included in therapy Assessing the psychodynamic Model First to apply theory and techniques systematically to treatment First to demonstrate the potential of psychological, as opposed to biological, treatment Hard to research 19% of clinical psychologists identify themselves as psychodynamic therapists The Behavioral Model Our actions are determined largely by our experiences in life Concentrates entirely on behaviors, the responses an organism makes to its environment External – ie going to work Internal – i.e. having a feeling or thought Base their explanations and treatments on principles of learning The processes by which these behaviors change in response to the environment Conditioning – manipulation of stimuli and rewards, observed how manipulations affected their subjects responses How do Behaviorists Explain Abnormal Functioning Operant conditioning Learn to behave in a certain ways as a result of receiving rewards Modeling Individuals learn responses simply by observing other individuals and repeating their behaviors Classical Conditioning Learning occurs by temporal associations, two events repeatedly occur close together in time they become fused in a person’s mind Ivan Pavlov Behavioral Therapies Aims to identify troubled behaviors and then tries to replace them with more appropriate ones using the learning conditions above Systematic desensitization Often used for phobias Step-by-step procedure, clients learn to react calmly instead of with fear Fear hierarchy List of feared objects or situations starting with those that are less feared and ending with the ones that are most dreaded Assessing the Behavioral Model 13% of clinicians are mainly behavioral Can be tested in the laboratory There is still no evidence that most people with psychological disorders are victims of improper conditioning The Cognitive Model Albert Ellis (1962) and Aaron Beck (1967) – father of American Cognitive therapy How do Cognitive Theorists Explain Abnormal Functioning? Abnormal functioning can result from several kinds of cognitive problems Assumptions and attitudes may be disturbing and inaccurate Illogical thinking processes are another source of abnormal functioning Self-defeating conclusions Overgeneralization – drawing broad negative conclusions on the basis of a single insignificant event Cognitive Therapies People with psychological disorders can overcome their problems by developing new, more functional ways of thinking Cognitive therapy Therapists help clients recognize the negative thoughts, biased interpretations, and errors in logic that dominate their thinking and cause them to feel depressed (Beck) Guide clients to challenge their dysfunctional thoughts, and try out new interpretations Assessing the Cognitive Model Views thought as the primary cause of normal and abnormal behavior Is it enough to change the cognitive habits of a person with serious psychological dysfunction? Aren’t humans more than the sum total of their thoughts, emotions and behaviors? The Humanistic-Existential Model Humanists More optimistic of the two groups, believe that humans are born with natural tendency to be friendly, cooperative, and constructive Self-actualize – to fulfill this potential for goodness and growth Can do so only if they honestly recognize and accept their weakness as well as their strengths and establish satisfying personal values to live by Self-actualization leads to concern for the welfare of others Existentialists Humans must have an accurate awareness of themselves and live meaningful or “authentic” lives in order to be psychologically well adjusted People are naturally inclined to live positively Rogers’s Humanistic Theory and Therapy Client-centered therapy – Try to create a supportive climate in which clients feel able to look at themselves honestly and acceptingly Therapist displays three things: Unconditional positive regard (warm acceptance for the client) Accurate empathy (skillful listening and restatements) Genuineness (sincere communication) Those who receive unconditional positive regard early in life are likely to develop unconditional self-regard Conditions of worth – standards that tell them they are lovable and acceptable only when they conform to certain guidelines Seen in children who are repeatedly made to feel that they are not worthy of positive regard Rogers also helped pave the way for psychologists to practice psychotherapy, previously only done by psychiatrists Gestalt Theory and Therapy (Humanistic) Frederick Perls Gestalt therapy – guide their clients towards self-recognition and acceptance Achieve this goal by challenging and even frustrating their clients Skillful frustration – therapists refuse to meet their clients’ expectations Meant to help people see how often they try to manipulate others into meeting their needs 1% of clinicians Existential Theories and Therapy Believe that psychological dysfunctioning is caused by self-deception People hide from life’s responsibilities and fail to recognize that it is up to them to give meaning to their lives People look to others for explanations, guidance, and authority instead of realizing their own personal freedom Existential therapy People are encouraged to accept responsibility for their lives and for their problems The Sociocultural Model Abnormal behavior is best understood in light of the social and cultural forces that influence an individual How do Sociocultural Theorists Explain Abnormal Functioning We must examine a person’s social and cultural surroundings if we are to understand abnormal behavior Focus on societal labels and roles, social networks, family structure and communication, cultural influences, and religious factors Societal Labels and Roles When people stray from the norms of their society, the society calls them deviant and, in many cases “mentally ill” Labels have the tendency to stick David Rosenhan – asylum experiment Social Networks and Supports People who are isolated and lack social support or intimacy in their lives are more likely to become depressed Family structure and Communication Family systems theory Family is a system of interacting parts who interact with one another in consistent ways and follow rules unique to each family Families actually force individual members to behave in a way that otherwise seems abnormal Enmeshed structure Members are grossly over involved in each in each other’s activities, thoughts, and feelings (i.e. schads) Children have great difficulty becoming independent in life Disengagedment Very rigid boundaries between the members Children from these families may find it hard to function in a group or to give or request support Culture Multicultural or culturally diverse perspective Each culture has a particular set of values, beliefs, and the like all of which help account for individual behavior Behavior, normal or abnormal, is best understood in the context of the culture Religion and Spirituality Religion is a type of diversity that mental health professionals are obligated to respect Therapists now make a point of including spiritual issues in therapy Sociocultural Treatments Culture-sensitive Therapy Approaches that seek to address the special issues faced respectively by members of minority groups and women in our society Group Therapy Therapist meets with a group of clients who have similar problems Group collaboratively develops important insights, build social skills, strengthen feelings of self-worth, and share useful information or advice Self-help groups People with similar problems come together for help and support without the direct leadership of a professional clinician Offer more direct advice than is provided in group therapy and encourage more exchange of information or “tips” Family therapy Therapist meets with all family members, points out problem behaviors and interactions, and helps the whole family change The entire family is viewed as the unit under treatment 4% clinical psychologists, 13% social workers, 1% psychiatrists Family systems theory Structural family therapy Therapists try to change the family power structure, the roles each person plays, and the relationships between members Conjoint Family Therapy Help members change harmful patters of communication Couple or Marital Therapy Focuses on the structure and communication patterns occurring in the relationship Integrative Couple therapy – helps partners accept behaviors that they cannot change and embrace the whole relationship nevertheless 1/3 of successfully treated couples may relapse within two years Community Treatment Key principle is prevention Primary Consists of efforts to improve community attitudes and policies Secondary Consists of identifying and treating psychological disorders in the early stages before they become serious Tertiary Provide effective treatment as soon as it is needed so that moderate or severe disorders do not become long-term problems Assessing the Sociocultural Model Research is hard to interpret Research only establishes relationships, not causes Putting it all together Biopsychosocial Theories Abnormality results from the interaction of genetic, biological, developmental, emotional, behavioral, cognitive, social, cultural, and societal influences Diathesis-stress explanation People must first have a biological, psychological, or Sociocultural predisposition to develop a disorder and must then be subjected to episodes of sever stress Eclectic – integrative Chapter 3 Notes Clinical Assessment: How and Why Does the Client Behave Abnormally? Assessment – simply the collecting of relevant information in an effort to reach a conclusion Clinical assessment – determine how and why a person is behaving abnormally and how that person may be helped Characteristics of Assessment Tools Standardize – set up common steps to be followed whenever it is administered Also must standardize the way results of an assessment tools to understand what scores mean Reliability – consistency of assessment measures Test-retest reliability Inter-rater reliability Validity – assessment tool accurately measures what it is suppose to measure Face validity – aspects that make sense and seem reasonable Predictive validity – tool’s ability to predict future characteristics Concurrent validity – degree to which the measures gathered from one tool agree with measures gathered from other assessment techniques Clinical Interviews Face to face encounter Conducting the Interview Used to collect detailed information about the person’s problems and feelings, lifestyle and relationships, and other personal history Psychodynamic interviewers Try to learn about the person’s needs and memories of past events and relationships Behavioral interviewers Try to pinpoint information about the stimuli that trigger abnormal responses and their consequences Cognitive interviewers Try to discover assumptions and interpretations that influence the person Humanistic Clinicians Ask about the persons self-evaluation, self-concept, and values Biological clinicians Look for signs of biochemical or brain dysfunction Sociocultural interviewers Ask about family, social, and cultural environments Unstructured Interview Open-ended questions Allows interviewer to follow leads and explore relevant topics that could not be anticipated before the interview Appeal to psychodynamic and humanistic Structured interview Clinicians ask prepared questions, possibly use published interview schedule Many include mental status exam Set of questions and observations that systematically evaluate the client’s overall functioning Appeal to behavioral and cognitive clinicians What are the Limitations of Clinical Interviews? Sometimes lack validity, or accuracy Individuals may intentionally mislead to present themselves in positive light or avoid discussing embarrassing topics Interviewers may make mistakes in judgment Interviews, particularly unstructured ones, may also lack reliability Clinical Tests Tests – devices for gathering information about a few aspects of a person’s psychological functioning, from which broader information about the person can be inferred Projective Tests Require subjects to interpret vague stimuli, such as inkblots or ambiguous pictures, or follow open-ended instructions such as “draw a person” Used primarily by psychodynamic clinicians Rorschach Test Inkblots Testers pay attention to style of responses Thematic Apperception Test 30 black-and-white pictures of individuals in vague situations Sentence-completion test Complete a series of unfinished sentences Drawings Draw human figures and talk about them What are the Merits of Projective Tests? Gain “supplementary” insights Projective tests are sometimes biased against minority ethnic groups Personality Inventories Asks respondents a wide range of questions about their behavior, beliefs, and feelings MMPI 10 scales on the MMPI: Hypochondriasis, depression, hysteria, psychopathic deviate, masculinity-femininity, paranoia, psychasthenia, schizophrenia, hypomania, social introversion Appear to have greater validity than projective tests, but can hardly be considered highly valid Cultural limitations Response Inventiories Ask people to provide detailed information about themselves, tests focus on one specific area of functioning Affective inventories Measure the severity of such emotions such as anxiety, depression, and anger Beck Depression inventory, social skills inventories, cognitive inventories Psychophysiological tests Measure physiological responses as possible indicators of psychological problems Neurological and Neuropsychological tests Some problems in personality or behavior are caused primarily by damage to the brain or changes in brain activity Neurological tests – looks for brain abnormalities EEG (electroencephalogram) – records brain waves, electrical activity of neuronal firing Neuroimaging techniques CAT or CT scan – multiple x-rays PET scan – computer-produced motion picture of brain activity MRI – creates detailed picture of brain’s structure Neurophyschological tests – measure cognitive, perceptual, and motor performances on certain tasks and interpret abnormal performances as an indicator of underlying brain problems Bender Visual-motor Gestal test – memory/drawing test Intelligence tests Alfred Binet Play a key role in the diagnosis of mental retardation Clinical Observations Naturalistic and Analog Observations Take place in homes, schools, institutions such as hospitals Often made by participant observers, key persons in the client’s environment, and reported to the clinician Analog observations Video-tape recordings or one-way mirror Not always reliable Observer may suffer from Overload – inability to see or record all the important behaviors and events Observer drift – steady decline in accuracy as a result of fatigue or of gradual unintentional change in standards Observer bias – the observer’s judgments may be influenced by information and expectations he/she already has about the person Client reactivity – clients behavior may be affected by the very presence of the observer Lack of cross-situational validity – observations in one setting cannot always be applied to other settings Self-Monitoring People observe themselves and carefully record the frequency of certain behaviors, feelings, or thoughts as they occur over time Useful in assessing infrequent or frequent behavior Validity is a problem Diagnosis: Does the Client’s Syndrome Match a Known Disorder? Diagnosis – determination that a person’s psychological problems constitute a particular disorder Classification Syndrome – certain symptoms that regularly occur together and follow a particular course Classification System – List of categories, or disorders, with descriptions of the symptoms and guidelines for assigning individuals to the categories DSM-IV-TR Lists approx. 400 mental disorders 5 axes Axis 1 – list of clinical syndromes that typically cause significant impairments – ie anxiety and mood disorders Axis 2 – long-standing problems that are frequently over looked in the presence of the disorders on Axis 1 – ie mental retardation Axis 3 – information concerning relevant general medical conditions Axis 4 – special psycholosocial or environmental problems that the person is facing Axis 5 – global assessment of functioning Can Diagnosis and Labeling Cause Harm? Can be overly influenced by information gathered early in the assessment process Can be influenced by any number of personal biases Diagnostic labels can become self-fulfilling prophecies Society attaches a stigma to abnormality May be harder to get a job Once a label has been applied, it may stick for a long time Effectiveness of Treatment The average person who received treatment was better off than 75% of untreated Possibly more than 5% of patients actually seem to get worse because of therapy Chapter 4 anxiety – the vague sense of being in danger, prepare us for “fight-or-flight” anxiety disorders are the most common mental disorders in the US ~18% most common: generalized anxiety disorder, phobias, panic disorder, obsessive compulsive disorder, acute stress disorder, posttraumatic stress disorder Generalized Anxiety Disorder People experience excessive anxiety under most circumstances and worry about practically anything “free floating anxiety” Typically feel restless, keyed up, or on edger; tire easily, have difficulty concentrating, suffer from muscle tension, and have sleep problems 3% of US at any given time, holds true in other Western countries, 6% develop over lifetime ¼ are currently in treatment Sociocultural Perspective Most likely to develop in people who are faced with societal conditions that are truly dangerous, people in highly threatening environments are more likely to develop the general felling of tension, anxiety, fatigue, and sleep disturbances Poverty causes stress, as wages decrease, the rate of generalized anxiety disorder steadily increases Psychodynamic perspective Children use ego defense mechanisms to help control anxiety Realistic anxiety – danger kids actually feel Neurotic anxiety – experienced when kids are repeatedly prevented, by parents or by circumstances, from expressing their id impulses Moral anxiety – when they are punished or threatened for expressing their id Psychodynamic explanations: When childhood anxiety goes unresolved When a child is overrun by neurotic or moral anxiety, the stage is set for generalized anxiety disorder May come to believe that impulses are dangerous, and may experience overwhelming anxiety whenever he has such impulses Defense mechanisms may be too weak to cope with anxiety (overprotective parents) Most Freudians continue to believe that the disorder can be traced to inadequacies in the early relationship between children and their parents Psychodynamic therapies Free association, therapist’s interpretations, transference, resistance, and dreams Object relations therapists use them especially Psychodynamic treatments are modes to help persons with generalized anxiety disorder Humanistic Perspective Arise when people stop looking at themselves honestly and acceptingly Denials of true thoughts, emotions, and behavior make people extremely anxious and unable to fulfill their potential as human beings Children who fail to receive unconditional positive regard from others may become overly critical of themselves and develop harsh self-standards ( conditions of worth Threatening self-judgments keep breaking through and cause anxiety Client centered therapy – show unconditional positive regard, help clients feel secure enough to recognize their true needs, thoughts, and emotions. When clients are comfortable with themselves anxiety symptoms will disappear Approach only slightly superior to placebo therapy Cognitive Perspective Psychological problems are often caused by dysfunctional ways of thinking – excessive worry is a cognitive symptom Maladaptive Assumptions Albert Ellis Generalized anxiety disorder is caused by maladaptive assumptions Irrational beliefs cause people to act in inappropriate ways Aaron Beck People with generalized anxiety disorder constantly hold silent assumptions that imply that they are in imminent danger Those whose lives have been filled with unpredictable negative events are likely to develop generalized anxiety disorder Become fearful of the unknown and always wait for the boom to drop Subjects respond more fearfully to unpredictable negative events than predictable ones Second-Generation Cognitive Explanations Meta-cognitive Theory – people with generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying Positive side – worrying is a useful way of appraising and coping with threats in life Negative side (open the door to the disorder) – society teaches them that worrying is a bad thing, they come to believe that their worrying is harmful ( worry about the fact that they are worrying Avoidance Theory – people with generalized anxiety disorder have greater bodily arousal Worrying actually serves to reduce this arousal, perhaps by distracting the individuals from their unpleasant somatic feelings Worrying serves as a quick, though ultimately maladaptive, way of coping with unpleasant bodily states Cognitive Therapies – two approaches Changing Maladaptive assumptions – Ellis and Beck Rational emotive therapy – therapists point out the irrational assumptions held by clients, suggest more appropriate assumptions, and assign homework that gives the individual practice at changing old assumptions and applying new ones Focusing on Worrying Guide clients with generalized anxiety disorder to recognize and change their dysfunctional use of worrying Educate clients about he role of worrying in their disorder and have them observe their bodily arousal and cognitive responses across various situations Clients come to appreciate the triggers of their worrying, their misconceptions about worrying, and their misguided efforts to control their lives by worrying Mindfulness-based cognitive therapy Try to have clients accept their thoughts rather than trying to eliminate them, clients are expected to be less upset and affected by them Mindfulness mediation Teaches individuals to pay attention to the thoughts and feelings that flow through their minds during meditation and to accept such thoughts in a nonjudgmental way Biological Perspective Family pedigree studies – if biological tendencies toward generalized anxiety disorder are inherited, people who are biologically related should have similar probabilities of developing this disorder ~15% of relatives of people with the disorder display it themselves Biological explanations: GABA inactivity Benzodiazepines – provide relief from anxiety Receptors that receive benzodiazepines normally receive GABA (inhibitory neurotransmitter) Perhaps people with generalized anxiety disorder have too few GABA receptors, or their GABA receptors do not readily capture the neurotransmitter Biological Treatments Leading biological treatment is prescription of antianxiety drugs, relaxation training, and biofeedback Antianxiety drugs (sedative-hypnotic drugs) – less addictive than previous sedative-hypnotic medications such as barbiturates Symptoms return if medication treatment is stopped People can become physically dependent on them if taken for prolonged periods Side affects of the drug are drowsiness, lack of coordination, memory loss, depression, and aggressive behavior Drugs mix badly with certain other drugs or substances Relaxation Training State of deep muscle relaxation at will ( reduce state of anxiety More effective than no treatment or placebo treatment in cases of generalized anxiety disorder Best when combined with cognitive therapy or biofeedback Biofeedback Therapists use electrical signals from the body to train people to control physiological processes such as heart rate or muscle tension (EMG) Phobias phobia – persistent and unreasonable fear of a particular object, activity, or situation more intense and persistent and the desire to avoid the object or situation, is greater than normal fears Specific phobias – marked and persistent fear of a specific object or situation ~9% of people in the US have symptoms of specific phobias Women out number men 2:1 Social phobias – people worry about interacting with others or talking or performing in front of others Social phobias may be narrow (fear of talking in public or writing in front of others) or broad ( general fear of functioning poorly in front of others) Often misinterpreted as snobbery, lack of interest, or hostility ~7% of US 3:2 women to men, 12% in course of life time What causes Phobias? Evidence tends to support the behavioral explanations People with phobias first learn to fear certain objects, situations, or events through conditioning, fears then get locked in How are fears learned Classical conditioning – two events occur closely together in time and become closely associated in a person’s mind Modeling – through observation and imitation A person may observe that others are afraid of certain objects or events and develop fears of the same things Behaviorists believe that after acquiring a fear response, people try to avoid what they fear Stimulus Generalization - specific learned fears will blossom into a generalized anxiety disorder when a person acquires a large number of them How Have Behavioral Explanations Faired in Research Subjects can be taught to fear objects – little Albert A Behavioral-Evolutionary Explanation Preparedness - human beings have a predisposition to develop certain fears Two groups, one shocked to pictures of houses and faces, one to snakes and insects, fear prolonged longer for group that got shocked to snakes and insects than houses and faces when shocking ceased How are Phobias Treated ~19% of individuals with a specific phobia and 25% of those with social phobia receive treatment Behavioral treatment most common Treatments for Specific Phobias Exposure treatments - desensitization, flooding, and modeling Systematic Desensitization – learn to relax while gradually facing the objects or situations they fear, fear hierarchy In vivo - actual confrontation Covert desensitization – confrontation imagined Flooding – exposed to object of fear repeatedly and made to see that the object is/are quite harmless Modeling – therapist who confronts the feared object or situation while the fearful person observes Key to all these therapies appears to be actual contact with the feared object or situation In vivo desensitization is more effective than covert desensitization, in vivo flooding more effective than covert flooding, and participant modeling more helpful than strictly observational modeling Treatments for Social phobias Two features: 1. overwhelming social fears, and 2. may lack skills at starting conversations, communicating their needs, or meeting the needs of others How can Social Fears be Reduced Unlike specific phobias, which do not typically respond to psychotropic drugs, social fears are often reduced through medication Antidepressant (serotonin) medications more helpful than benzodiazepines (antianxiety) Several types of psychotherapy have proved to be at least as effective as medication at reducing social fears; people helped by such psychological treatments appear less likely to relapse than those treated with drugs alone Exposure therapy – guide, encourage, and persuade clients with social fears to expose themselves to the dreaded social situations and to remain until their fears subside, group therapy helpful Cognitive therapies are also commonly used in combination with behavioral techniques RET (ellis) and other cognitive approaches do indeed help reduce social fears How can social skills be improved Social skills training – therapists combine several behavioral techniques in order to help people improve their social skills Usually model appropriate social behaviors for clients and encourage the individuals to try them out, role-play Therapist provide frank feedback and reinforce for effective performances Social skills training groups and assertiveness training groups Reinforcement from other people with similar social difficulties is often more powerful than reinforcement from a therapist alone Members try out and rehearse new social behavior with other group members Panic Disorder panic attacks – periodic short bouts of panic that occur suddenly, reach peak within 10 min, and gradually pass palpitations of the heart, tingling in the hands or feet, shortness of breath, sweating, hot and cold flashes, trembling, chest pains, choking sensations, faintness, dizziness, and feeling of unreality panic disorder – experience panic attacks repeatedly and unexpectedly without apparent reason People who are diagnosed with panic disorder experience dysfunctional changes in their thinking or behavior as a result of the attacks for a period of a month or more often accompanied by agoraphobia – afraid to leave the house and travel to public places or other locations where escape might be difficult or help unavailable should panic symptoms develop panic disorder without agoraphobia panic disorder with agoraphobia around 35% of people with panic disorder receive treatment Biological Perspective – panic disorder was helped more by certain antidepressant (serotonin related) drugs than by benzodiazepine (antianxiety) drugs What biological Factors Contribute to Panic Disorder Norepi activity is irregular in people who suffer from panic attacks Locus Ceruleus – panic reactions may be related to changes in norepi activity in this area of the brain Brain circuit that produces panic reactions includes amygdale, ventromedial nucleus of the hypothalamus, central gray matter, and locus ceruleus Brain circuit responsible for generalized panic disorder is different Predisposition may be inherited Drug Therapies Drugs restore proper activity of norepi or other neurotransmitters that operate in the panic brain circuit Antidepressant drugs bring at least some improvement to 80% of patients Approximately half recover markedly or fully, and the improvements can last indefinitely, as long as the drugs are continued Antidepressants and powerful benzodiazepines are helpful in most cases of panic disorder with agoraphobia Cognitive Perspective – full panic reactions are experienced only by people who further misinterpret the physiological events that are occurring within their bodies Cognitive Explanations: Misinterpreting Bodily Sensations Panic prone people may be very sensitive to certain bodily sensations; when they unexpectedly experience such sensations, they misinterpret them as signs of a medical catastrophe It is possible that panic prone individuals generally experience more frequent or more intense bodily sensations than other people do Anxiety sensitivity – they focus on their bodily sensations much of the time, are unable to assess them logically, and interpret them as potentially harmful Cognitive therapy Cognitive therapists try to correct peoples misinterpretations of their bodily sensations, may use biological challenge procedures (ie hyperventilate and then practice learned skills to cope) 85% who received treatment were free of panic for a year At least as helpful as antidepressants, combination may not be as effective as cognitive alone Obsessive-Compulsive Disorder Obsessions - persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness Compulsions – repeated and rigid behaviors or mental acts that people feel they must perform in order to prevent or reduce anxiety Minor obsessions and compulsions can play a helpful role in life, can help calm us during times of stress obsessive-compulsive disorder – obsessions or compulsions feel excessive or unreasonable, cause great distress, take up much time, or interfere with daily functions victims’ obsessions cause intense anxiety, while their compulsions are aimed at preventing or reducing anxiety. Anxiety rises if they try to resist their obsessions or compulsions equally common between men and women across ethnic groups symptoms and their severity may fluctuate over time 40% of people with OCD seek treatment What are the Features of Obsessions and Compulsions Obsessive thoughts feel both intrusive and foreign to the people who experience them Obsessions take the form of obsessive wishes, impulses, images, ideas, or doubts Most common theme appears to be dirt or contamination, others are violence, aggression, orderliness, religion, and sexuality Compulsive behaviors are technically under voluntary control The people who feel they must do them have little sense of choice in the matter Feel that something terrible will happen if they don’t perform the compulsions, feel less anxious after carrying out act Compulsive acts are often a response to obsessive thoughts, help control obsessions The Psychodynamic Perspective Anxiety disorder develops when children come to fear their own id impulses and use ego defense mechanisms to less the resulting anxiety OCD differs from other anxiety disorders because in OCD the battle between anxiety-provoking id impulses and anxiety-reducing defense mechanisms is not buried in the unconscious but is played out in the overt thoughts and actions Id impulses are the obsessive thoughts, and ego defenses appear as counter-thoughts or compulsive actions 3 common defense mechanisms: Isolation – simply disown their unwanted thoughts and experience them as foreign intrusions Undoing – perform acts that are meant to cancel out their undesirable impulses (ie washing hands) Reaction formation – take on a lifestyle that directly opposes their unacceptable impulses Freud traced OCD to the anal stage Children repeatedly feel the need to express their aggressive id impulses while at the same time knowing that they should try to restrain and control the impulses. If conflict continues between id and ego, it turns into OCD Need to overcome their underlying conflicts and defenses Traditional psychodynamic approach is not much help, most psychodynamic use short-term (dynamic focus) action-oriented techniques The Behavioral Perspective Concentrated on explaining and treating compulsions rather than obsessions Compulsions appear to be rewarded by reduction in anxiety Exposure and response prevention (exposure and ritual prevention) Clients are repeatedly exposed to objects or situations that produce anxiety, obsessive fears, and compulsive behaviors, but they are told to resist performing the behaviors they feel so bound to perform 55-85% improve, as many as one quarter fail to improve at all Cognitive Perspective Everyone has repetitive, unwanted, and intrusive thoughts, most people dismiss or ignore them with ease Those who develop OCD blame themselves for such thoughts and expect that somehow terrible things will happen Try to neutralize the thoughts – thinking or behaving in ways meant to put matters right or to make amends Neutralization brings temporary reduction in discomfort therefore likely to be repeated OCD population tends: To be more depressed than other people Have exceptionally high standards of conduct and morality Believe that their intrusive negative thoughts are equivalent to actions and capable of causing harm Generally to believe that they should have perfect control over all their thoughts and behaviors Therapists provide psychoeducation, teach clients about their misinterpretations of unwanted thoughts, excessive sense of responsibility and neutralizing acts Habituation training – direct clients to intentionally call for the their obsessive thoughts again and again – helps reduce symptoms Behavioral (exposure and response prevention) and cognitive approach more effective than one treatment alone Biological Perspective Abnormally low activity of the neurotransmitter serotonin Two antidepressants drugs reduce obsessive and compulsive symptoms (increase serotonin activity) GABA, Glutamate, and dopamine also may be involved Antidepressant drugs help 50-80% Relapse if medication is stopped Combination of behavioral, cognitive, and drug therapies best Abnormal functioning in key regions of the brain Orbitofrontal cortex and caudate nuclei Too active leading to a constant eruption of troublesome thoughts and actions Chapter 5 stressor – the event that creates the demands, and a stress response, the person’s reactions to the demands include: everyday hassles, turning-point events, long-term problems, traumatic events people who sense that they have the ability and the resources to cope are more likely to take stressors in stride and to respond well Stress and Arousal: The Fight-or-Flight response Hypothalamus controls: Autonomic nervous system – connect CNS to all the other organs of the body Involuntary activities Endocrine system – network of glands located throughout the body Two pathways Sympathetic nervous system Works directly ie speed HR Works indirectly by stimulating the adrenal glands ( epi and norepi, important neurotransmitters, also act as hormones and travel through the bloodstream and produce arousal Hypothalamic-pituitary-adrenal (HPA) pathway Pituitary gland ( secreted ACTH ( adrenal cortex ( secretes corticosteroids (cortisol) ( produce fear and arousal Trait anxiety – a person’s general level of arousal and anxiety State (situation) anxiety – people differ in their sense of which situations are threatening The Psychological Stress Disorders: Acute and Posttraumatic Stress Disorders PTSD (symptoms linger for greater than 1 month) and acute stress disorder (1 or less month) Symptoms almost identical, include: Reexperiencing the traumatic event Avoidance Reduced responsiveness Increased arousal, anxiety, and guilt What Triggers a Psychological Stress Disorder 3.5% rate of incidence in US, 7% prevalence rate Women are twice as likely to suffer compared to men Combat and Stress Disorders Up to 29% of Viet. Vets suffered from acute or PTSD, 10% still suffereing Disasters and Stress Disorders – natural and accidental disasters Victimization and Stress Disorders 1/3 of all victims of physical or sexual assault develop posttraumatic stress disorder Sexual Assault – rape not good (1 in 7 women) 94% of victims qualify for a clinical diagnosis of acute stress disorder 12 days after Terrorism Why do people develop a psychological stress disorder Biological and Genetic Factors Abnormal activity of the hormone cortisone and neurotransmitter/hormone norepi Continuining arousal may eventually damage hippocampus (intrusive memories and constant arousal) and amygdale (helps control anxiety, panic, and other emotional responses and also works with the hippocampus to produce the emotional aspects of memory) People whose biochemical rxn to stress are particularly strong are more likely than others to develop acute and posttraumatic stress disorders Personality People with certain personalities, attitudes, and coping styles are particularly likely to develop stress disorders People who generally view life’s negative events as beyond their control tend to develop more severe stress symptoms Childhood Experiences Social Support People whose social and family support systems are weak are more likely to develop a stress disorder Severity of Trauma More severe = more likely to develop a stress disorder How do Clinicians treat the Psychological Stress Disorders PTSd symptoms lasted an average of 3 years with treatment and 5.5 years without it Treatment for Combat Veterans Drug therapy – antianxiety drugs help Behavioral techniques – exposure treatment is the single most helpful intervention for persons with stress disorders Eye movement desensitization and reprocessing (EMDR) – clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of the objects and situations they ordinarily try to avoid Some say it is the exposure feature of EMDR, rather than the eye movement, that accounts for its successes with the disorder Cognitive therapies – bring out deep-seated beliefs and feelings, accept what they have done and experienced, become less judgmental of themselves and learn to trust other people once again Family therapy format – help and support of their family members, individuals may come to examine their impact on others, learn to communicate better, and improve their problem-solving skills Rap groups – meet with others like themselves to share experiences and feelings, develop insights, and give mutual support (ie veteran outreach centers ) Psychological Debriefing: the Sociocultural Model in Action Psychological debriefing or critical incident stress debriefing Crisis intervention that has victims of trauma talk extensively about their feelings and reactions within days of the critical incident Expected to prevent or reduce stress reactions, they are often applied to victims who have not yet displayed any symptoms at all, as well as those who have Individuals are encouraged to describe the details of the recent trauma, clinicians then clarify to the victims that their reactions are perfectly normal responses to a terrible event, offer stress management tips Does Psychological debriefing work? Debriefed and the control patients had similar rates of PTSD Early disaster counseling may unintentionally “suggest” problems to victims, thus helping produce stress disorders in the first place Cultural expertise – are the counselors knowledgeable/sensitive to the population that they are serving Current clinical climate continues to favor disaster counseling The Physical Stress Disorders: Psychophysiological Disorders illnesses that seem to result from an interaction of biological psychological, and Sociocultural factors, bring about actual physical damage, different from “apparent” physical illnesses (factitous disorders or somatoform disorders) Traditional psychophysiological Disorders Ulcers – holes in the wall of the stomach or duodenum Caused by interaction of stress factors, and physiological factors such as bacteria Asthma – cause body’s airways (trachea and bronchi) to narrow perdiocally 70% of cases appear to be caused by an interaction of stress factors, and physiological factors such as allergies Insomnia – difficulty falling asleep or maintaining sleep, 35% prevalence Combination of psychosocial factors and physiological factors such as an overactive arousal system Chronic headaches Muscle contraction or tension, headaches Pain at the back or front of the head or back of the neck, caused by tight muscles surrounding the skull which narrow blood vessels and limit flow Migraine headaches Aches located on one side of the head 1) blood vessels in the brain narrow ( reduced blood flow Same blood vessels later expand so that blood flows through them rapidly stimulating many neuron endings and causing pain Hypertension – chronic state of high blood pressure Only 10% caused by physiological factors alone, rest are a combination CHD Leading cause of death in men over 35 and women over 40 Most cases of CHD are related to an interaction Sociocultural Factors – stressful demands placed on people by their culture or social group Psychological Factors Certain needs, attitudes, emotions, or coping styles may cause people to overreact repeatedly to stressors, and so increase their chances of developing psychophysiological disorders Personality – type A characteristics such as hostility, time urgency are very likely to be related to heart disease Biological Factors ANS – defects in this system are believed to contribute to the development of psychophysiological disorders People may be prone to develop certain disorders The interaction of psychosocial and physical factors is now considered the rule of bodily functioning New psychophysiological Disorders Are physical illnesses related to stress Social adjustment Rating scale – assigns numerical values to the stresses that people experience at some time in their lives People with high LCU scores are more likely to become ill, greater the amount of life stress, the greater the likelihood of illness Scale does not take into consideration the particular reactions of life stress of specific populations Psychoneuroimmunology – seeks to answer how stressful events result in a viral or bacterial infection Biochemical activity Stress leads to increased activity of the sympathetic nervous system, norepi may eventually slow the functioning of the immune system At low levels of stress norepi improves immune functioning, at higher levels it actually slows down immune functioning due to inhibitory signal sent to lymphocytes Corticosteroids have the same effect Cytokines lead to chronic inflammation throughout the body, contributing at times to heart disease, stroke and other illnesses Behavioral changes – not good to sleep badly, eat poorly, exercise less, smoke or drink excessively Personality styles – people who respond to life stress with optimism, constructive coping, and resilience experience better immune systems Spiritual people tend to be healthier Social support – people who have few social supports and feel lonely seem to display poorer immune functioning in the face of stress Psychological Treatments for Physical Disorders (Behavioral medicine) Relaxation Training – used widely with combination of medicine Biofeedback – enables people to gradually gain control over involuntary body activities Meditation – turning one’s concentration inward, achieving a slightly changes state of consciousness, and temporarily ignoring all stressors Hypnosis – sleeplike, suggestible state during which people can be directed to act in unusual ways Cognitive Interventions – people are taught new attitudes or cognitive responses toward their ailments as part of treatment, replace negative self-statements and replace them with coping self-statements instead Insight therapy and Support Groups – discussion of past and present upsets may indeed help improve a person’s health Combination Approaches – psychological interventions are often of greatest help when they are combined with other psychological interventions Chapter 6 anxiety is the key feature of disorders such as generalized anxiety disorder, phobias, panic disorder, and OCD Stress can produce lingering rxns seen in acute stress disorder, PTSD, and psychophysiological disorders Stress and anxiety is also linked to somatoform and dissociative disorders Somatoform Disorders somatoform disorder – when a physical ailment has no apparent medical cause, actually due to psychosocial factors psychological disorders masquerading as physical problems Hysterical Somatoform Disorders - actual change in physical functioning Conversion disorder Psychosocial conflict or need is converted into dramatic physical symptoms that affect voluntary motor or sensory functioning Paralysis, blindness, deafness Suddenly appear at times of stress, and last a matter of weeks People who develop this disorder are generally suggestible, highly susceptible to hypnotic procedures, quite rare 2:1 (F:M) Somatization Disorder (Briquet’s syndrome) Long-lasting physical ailments that have little or no organic basis Person must have range of ailments, including several pain symptoms, GI symptoms (nausea and diarrhea) sexual symptoms (ED), neurological symptom, feel anxious and depressed More common in women than men, lasts much longer tan a conversion disorder, symptoms may fluctuate over time but rarely disappear, 2/3 receive treatment Pain Disorder Associated with Psychological Factors Psychosocial factors play a central role in the onset, severity, or continuation of pain Develops after an accident or during an illness that has caused genuine pain which then takes on a life of its own Hysterical vs. Medical Symptoms Physicians rely on oddities in patient’s medical picture to help distinguish the two Ie people with conversion disorder paralysis do not experience muscle atrophy while real paralysis individuals do Conversion blindness people don’t have as many accidents as people with real blindness Hysterical vs. Factitious Symptoms Hysterical somatoform disorders are different from patterns in which individuals are purposefully producing or faking medical symptoms Factitious disorder – people go to extremes to create the appearance of illness Munchausen syndrome Munchausen syndrome by proxy (Factitious disorder by proxy Parents make up or produce physical illnesses in their children, leading in some cases to repeated painful diagnostic tests, medication, and surgery What are Preoccupations Somatoform Disorders People misinterpret and overreact to bodily symptoms or features no matter what friends, relatives, and physicians may say Hypochondriasis Unrealistically interpret bodily symptoms as signs of a serious illness 1-5% prevalence Symptoms rise and fall over the years Body Dysmorphic Disorder (dysmorphophobia) People become deeply concerned about some imagined or minor defect in their appearance 2% of ppl in US, 4% of college students, equal in males and females What causes Somatoform Disorders Psychodynamic View Hysterical disorder represents a conversion of underlying emotional conflicts into physical symptoms Women hide their sexual feelings by unconsciously converting them into physical symptoms (Freud) Sufferers of these disorders have unconscious conflicts carried forth from childhood which arousal anxiety and that the individual convert this anxiety into “more tolerable” physical symptoms Two mechanisms at work Primary gain – when hysterical symptoms keep their internal conflicts out of awareness Secondary gain – when hysterical symptoms further enable them to avoid unpleasant activities or to receive sympathy from others Behavioral View Physical symptoms or hysterical disorder bring rewards to sufferers. IN response to such rewards, sufferers learn to display the symptoms more and more prominently Many sufferers develop their hysterical symptoms after thy or their close relatives or friends have had similar medical problems Cognitive View Hysterical disorders are forms of communication, providing a means for people to express emotions that would otherwise be difficult to convey Not to defend against anxiety but to communicate extreme feelings – “physical language” People who find it particularly hard to recognize or express their emotions are candidates for hysterical disorder Possible Role for Biology Placebos and the placebo effect “pretend” treatments do bring help to many people Belief or expectation can trigger certain chemicals throughout the body into action How Are Somatoform Disorders Treated? People with somatoform disorders usually seek psychotherapy only as a last resort Individuals with preoccupation somatoform disorders typically receive the kinds of treatment that are applied to anxiety disorders, particularly to OCD Patients with body dysmorphic disorder improve considerably when treated with the same antidepressant drugs that are helpful in cases of OCD Exposure and response prevention (behavioral) may also be effective for body dysmorphic disorder Hysterical somatoform disorders - conversion, somatization, and pain disorders – treatments foucs on the cause of the disorder (the trauma or anxiety behind the physical symptoms) – same techniques used in the case of PTSD Conversion disorder and pain disorder respond better than somatization disorder to therapy that treats the symptoms Using confrontational strategy is less helpful than a reinforcement approach Dissociative Disorders person’s memory typically seems to be dissociated, or separated, from the rest dissociative symptoms are often fround in cases of acute or posttraumatic stress disorder it is often the case that persons meet the diagnostic criteria for both a stress disorder an a dissociative disorder Dissociative Amnesia Inability to recall important information, usually of an upsetting nature, about their lives Much more extensive than normal forgetting and is not caused by physical factors Very often an episode of amnesia is directly triggered by a specific upsetting event Localized amnesia – most common type of dissociative amnesia, person loses all memory of events that took place within a period of time, almost always beginning with some very disturbing occurrence Amnesic episode – forgotten period Selective amnesia – second most common from of dissociative amnesia, remember some but not all events that occurred during a period of time Generalized amnesia – can’t remember events that occurred earlier in life Continuous amnesia – forgetting continues into the present (more common in organic amnesia) All of these forms of dissociative amnesia are similar in that the amnesia interferes mostely with a person’s memory of personal material. Memory for abstract or encyclopedic information usually remains Dissociative Fugue Person not only forget their personal identities and details of their past lives but also flee to an entirely different location Affect personal memories from the past rather than encyclopedic or abstract knowledge Majority of people who experience dissociative fugue regain most or all of their memories and never have a recurrence Dissociative Identity Disorder (Multiple personality Disorder) Person develops two or more distinct personalities (subpersonalities or alternate personalities) Primary or host personality – sub personality that takes center stage and dominates the person’s functioning Switching – transition from on esubpersonality to another 3:1 (F:M) How Do Subpersonalities Interact Mutually amnesic relationships – subpersonalities have no awareness fo one another Mutually cognizant patterns – each subpersonality is well aware of the rest One-way amnesic relationships – most common relationship pattern, some subpersonalities are aware of others, but the awareness is not mutual Co-conscious subpersonalities – those that are aware are “quiet observers” who watch the actions and thoughts of the other subpersonalities but do not interact with them Average number of subpersonalities: 15 for women, 8 for men How do Subpersonalities Differ? Vital statistics – may differ in features as basic as age, sex, race, and family history Abilities and Preferences – not uncommon for the different subpersonalities to have different abilities: one may be able to drive, speak a foreign language, or play a musical instrument Physiological Responses – differences in autonomic nervous system activity Brain-activity pattern of each subpersonality was unique, showing the kinds of variations usually found in totally different people How Common is Dissociative Identity Disorder Iatrogenic – unintentionally produces by practitioners Some belive that therapists create this disorder by subtly suggesting the existence of other personalities during therapy or by explicitly asking a patient to produce different personalities while under hypnosis Number of diagnosed is increasing Growing number of today’s clinicians believe that the disorder does exist Diagnostic procedures tend to be more accurate today than in past years More differentiation from Schizophrenia now How Do theorists Explain Dissociative Disorders? Psychodynamic View Dissociative disorders are caused by repression Dissociative amnesia and fugue are single episodes of massive repression Dissociative identity disorder is thought to result from a lifetime of excessive repression Flight from it by pretending to be another person who is safely looking on from afar Behavioral view Response learned through operant conditioning People who experience a horrifying event may later find temporary relief when their minds drift to other subjects ( momentary forgetting, leading to a drop in anxiety, increases the likelihood for of future forgetting See dissociation as escape behavior State-Dependent Learning If people learn something when they are in a particular situation or state of mind, they are likely to remember it best when they are again in that same condiditon Different arousal levels may produce entirely different groups of memories, thoughts, and abilities – that is, different subpersonalities Self-Hypnosis People hypnotize themselves to forget unpleasant events Escape threatening world by self-hypnosis, mentally separating themselves from their bodies and fulfilling their wish to become some other person How are Dissociative Disorders Treated? Treatments for dissociative amnesia and fugue tend to be more successful than those for dissociative identity disorder How Do Therapists Help People with Dissociative Amnesia and Fugue? Psychodynamic therapists guide patiens with these disorders to search their unconscious in hope of bringing forgotten experiences back to conscoiousness Hypnotherapy Sometimes intravenous injections of barbiturates help (calm people and free their inhibitions) How do Therapists Help Individuals With Dissociative Identity Disorder? People with dissociative identity disorder do not typically recover without treatment, unlike victims of amnesia and fugue Therapists try to help clients: Recognize the disorder – bond with primiary personality and with each of the sub-personalities Group therapy may aid Recovering Memories – bring out experiences that some subpersonalities keep denying and others recall Integrating the subpersonalities Fusion – merge the different subpersonalities into a single, integrated identity Once subpersonalities are integrated, further therapy is typically needed to maintain the complete personality and to teach social and coping skills that may help prevent later dissociations Chapter 7 Mood Disorders Depression and mania are the key emotions in mood disorders Depression – a low, sad state in which life seems dark and its challenges overwhelming Mania – opposite of depression, a state of breathless euphoria, or at least frenzied energy, in which people may have an exaggerated belief that the world is theirs for the taking Unipolar depression – what most people with a mood disorder suffer; only depression Bipolar disorder – periods of mania that alternate with periods of depression Unipolar Depression Clinical depression brings severe and long-lasting psychological pain that may intensify as time goes by How common is Unipolar depression 7% of adults in US suffer in any given year 17% of adults may experience an episode of severe unipolar depression at some point in their lives At least 2:1 F:M ratio 26% of women may suffer compared to 12% of men in their life time Similar for all ses, ethnic groups, and for boys and girls About half of people with unipolar depression recover within six weeks and 90% recover within a year, some without treatment Most will have another episode in their life What Are the Symptoms of Depression Emotional Symptoms Feeling “miserable, empty, and humiliated” Anxiety, anger or agitation Motivational Symptoms Lose the desire to pursue their usual activities Lack of drive, initiative, and spontaneity Suicide represents the ultimate escape from life’s challenges Between 6-15% of ppl who suffer from severe depression will commit suicide Behavioral symptoms Less active and less productive More time alone, may stay in bed for long periods Move and even speak more slowly Cognitive Symptoms Extremely negative views of themselves Consider themselves inadequate, undesirable, inferior, or perhaps evil Blame themselves Feel confused, unable to remember things, easily distracted, and unable to solve even the smallest problems These difficulties may reflect motivational problems rather than cognitive ones Physical Symptoms Headaches, indigestion, constipation, dizzy spells, and general pain Disturbances in appetite and sleep Eat less, sleep less, and feel more fatigued Diagnosing Unipolar Depression Major depressive episode is a period marked by at least 5 symptoms of depression and lasting for two weeks or more Major depressive disorder – people who experience major depressive episode without having any history of mania>2yrs Dysthymic disorder – individuals who display longer-lasting but less disabling pattern of unipolar depression When dysthymic disorder leads to major depressive disorder, the sequence is called double depression Stress and Unipolar Depression Episodes of unipolar depression often seem to be triggered by stressful events Depressed people experience a greater number of stressful life events Stressful life events also precede other psychological disorders, but depressed people report more such events than anybody else Reactive (exogenous) depression – which follows clear-cut stressful events Endogenous depression – seems to be a response to internal factors The Biological Model of Unipolar Depression Genetic factors – three types of research Family pedigree study – select people with unipolar depression, examine their relatives, and see whether depression also afflicts other members of the family Twin studies – when an identical twin had unipolar depression, there was a 46% chance that the other twin would have the same disorder Molecular biology – abnormality of 5-HTT gene, a gene responsible for the brain’s transportation of serotonin Biochemical Factors Low activity of neurotransmitters (norepi and serotonin) is linked to unipolar depression Medications that lower norepi and/or serotonin often caused depression Antidepressant drugs – relieve depression by increasing either norepi or serotonin activity Interaction between serotonin and norepi activity, or between these neurotransmitters and yet other neurotransmitters in the brain, rather than the operation of one of the neurotransmitters alone, may account for unipolar depression Endocrine system may play a role in unipolar depression Hormones Abnormal levels of cortisol Melatonin (Dracula hormone) – only released in the dark – seasonal affective disorder May also be more closely tied to what happens within neurons than to the chemicals that carry messages from neuron to neuron Limitations – research has relied on studies that create depression-like symptoms in laboratory animals What are the Biological Treatments for Unipolar Depression Electroconvulsive Therapy (ECT) Current of 65 -140 volts is sent through the brain for half a second or less Current causes a brain seizure that lasts from 35 secs to a few minutes After 6-12 treatments, spaced over 2-4 wks most patients feel less depressed Bilateral ECT – one electrode is applied to each side of the forehead and a current is passed through both sides of the brain Unilateral ECT – the electrodes are placed so that the current passes through only one side of the brain By giving patients strong muscle relaxants convulsions are minimized Anesthetics to put patients to sleep during the procedure are also used 60-70% of ECT patients improve Particularly effective in severe cases of depression that include delusions Antidepressant drugs Monoamine oxidase (MAO) inhibitors and Tricyclics MAO Inhibit break down of norepi Dangerous rise in bp if patients eat foods containing the chemical tyramine Tricyclics 60-65% are significantly helped by the drug Patients that discontinue the drug run a high chance of relapse w/in a year If continue drugs for five months or more after being free of depressive symptoms (continuation therapy) their chances of relapse decrease Reduce depression by acting on neurotransmitter reuptake mechanisms, block the process Second-generation antidepressants Selective serotonin reuptake inhibitors (SSRI) Selective norepi reuptake inhibitors (increase norepi activity only) and serotonin-norepi reuptake inhibitors (increase both serotonin and norepi activity) Harder to overdose on Do not pose the dietary problems of the MAO inhibitors or produce some of the unpleasant effects of the tricyclics (dry mouth, constipation ect) Some side effects such as decreased sex drive Psychological Models of unipolar depression Psychodynamic model Mourners are unable to accept a loss, regress to the oral stage Direct all their feelings for the loved one, including sadness and anger, toward themselves Two kinds of people are particularly likely to become clinically depressed in the face of loss Those whose parents failed to meet their needs during the oral stage Those whose parents gratified those needs excessively For people who suffer from depression without the loss of a loved one Symbolic or imagined loss – persons equate other kinds of events with the loss of a loved one Object relations theorists People’s relationships leave them feeling unsafe and insecure People whose parents pushed them towards either excessive dependence or excessive reliance are more likely to become depressed when they later lose important relationships Parents’ child-rearing style Affectionless control – consisting of a mixture of low care and high protection What are the psychodynamic treatments for unipolar depression? Use of free association, suggest interpretations, dreams, resistance and transference Only occasionally helpful, limited by Depressed clients may be too passive and feel to weary to fully join in the subtle therapy discussions May become discouraged and end treatment too early when long-term approach is unable to provide quick relief Most helpful in cases that clearly involve a history of childhood loss or trauma, a long standing sense of emptiness, feelings of perfectionism, and extreme self-criticism Short-term psychodynamic therapies have performed better than the traditional approaches The Behavioral Model Depression results from significant changes in the number of rewards and punishments people receive in their lives, treat by helping to build more favorable patters of reinforcement The Behavioral Explanation Positive rewards in life dwindle for some persons, leading them to perform fewer and fewer constructive behaviors What are the Behavioral Treatments for Unipolar Depression Therapists use a variety of strategies to help increase the positive behaviors of their clients Activities that the client considers pleasurable – set a weekly schedule for engaging in them Person’s various behaviors are rewarded correctly Ignore a client’s depressive behaviors while praising or otherwise rewarding constructive statements and behavior Teach clients effective social skills Helpful in mild depression if all tactics are applied Cognitive Model People with unipolar depression repeatedly view events in negative ways and the such perceptions eventually lead to their disorder Learned helplessness – people become depressed when they think: That they no longer have control over the reinforcements in their lives That they themselves are responsible for this helpless state When people are exposed to uncontrollable negative events, they later score higher than other subjects on a depressive mood survey Uncontrollable negative events result in lower norepi and serotonin activity in rats Limitations Research relies on animal subjects Attribution-helplessness theory When people view events as beyond their control Internal, global and stable is bad Attributions are likely to cause depression only when they further produce a sense of hopelessness in an individual Limitations Can animals make attributions Negative Thinking (Aaron Beck) – maladaptive attitudes, a cognitive triad, errors in thinking, and automatic thoughts Cognitive triad Individuals interpret 1) their experiences, 2) themselves, 3) their futures in negative ways Errors in thinking Draw arbitrary inferences – negative conclusions based on little evidence Automatic thoughts A steady train of unpleasant thoughts that keep suggesting to them that they are inadequate and that their situation is hopeless Depressed subjects seem to recall unpleasant experiences more readily than positive ones, rate their performances lower than non-depressed subjects, and select pessimistic statements in storytelling tasks Ruminative responses – repeatedly dwell on their mood without acting to change it – experience dejection longer and are more likely to develop clinical depression Limitations Fails to show that thoughts are the cause of depression not a product Cognitive Treatment for Unipolar Depression – similar to RET 1) increase activities and elevating mood 2) challenging automatic thoughts 3) Identifying negative thinking and biases 4) changing primary attitudes 50-60% show elimination or their symptom The Sociocultural Model of Unipolar Depression How are Culture and Depression Related Non-western Countries – tend to be troubled by physical symptoms (fatuge, weakness, sleep disturbances, wt loss) Westernized countries – psychological character How do Gender and Race Relate to Depression Much higher among women than men Native Americans (28% prevalence) much higher risk than rest of US population Could be due to degree of poverty, family size, and number of health problems Much more common among US born Hispanic and AA than among Hispanic and AA immigrants How does Social Support Relate to Depression Availability of social support seems to influence likelihood of depression 3x rate of depression for those who are separated or divorced than of married or widowed, 2x of those who have never been married Depressed people who lack social support remain depressed longer than those who have a supportive spouse or warm friendship What are the Sociocultural Treatments for Unipolar Depression Interpersonal psychotherapy (IPT) – any 4 interpersonal problem areas may lead to depression Interpersonal loss Interpersonal role dispute Interpersonal role transition Interpersonal deficits Similar rate of recovery as to cognitive therapy (50-60% complete recovery) Couple Therapy Half of all depressed clients may be in a dysfunctional relationship Behavioral martial therapy – helps spouses change harmful marital behavior Bipolar Disorder What are the Symptoms of Mania Dramatic and inappropriate rise in mood Affects all areas of functioning (emotional, motivational, behavioral, cognitive, and physical Powerful emotions in search of an outlet Euphoric joy and well-being is out of proportion to the actual happenings Some instead become irritable and angry Motivational - people with mania seem to want constant excitement, involvement, and companionship Behavior – very active, move quickly, talk rapidly and loudly, jokes, efforts to be clever Cognitive – poor judgment and planning, rarely listen when others try to slow them down Physical – remarkably energetic, little sleep, act wide awake Diagnosing Bipolar Disorder Full manic episode – at least one week they display an abnormally high or irritable mood, along with 3 other symptoms of mania Hypomania – less severe (causing little impairment) Bipolar I disorder Have full manic and major depressive episodes, experience an alternation of mania and depression (most), some have mixed (mania to depression and back in same day) Bipolar II disorder – hypomanic Mildly manic episodes alternate with major depressive episodes, depressive episodes occur more often than manic ones 1-2.6% of adults suffer at any given time Equal between men and women In untreated cases, the manic and depressive episodes eventually subside, recur at later time Cyclothymic disorder – hypomanic symptoms and mild depression .4% of population Can develop into bipolar I or II What causes Bipolar Disorders Neurotransmitters Overactivity of norepi possible Low serotonin activity Could be that low serotonin opens the door to mood disorder and permits the activity of norepi to define particular form the disorder will take Low serotonin with low norepi may lead to depression, low serotonin and high norepi may lead to mania Ion Activity Improper ion transport (Na, K) may cause neurons to fire too easily (mania) or resist firing (depression) Membrane defects in the neurons of persons with bipolar disorder have been observed Brain Structure Basal ganglia and cerebellum tend to be smaller in those with bipolar disorder Genetic Factors 40% (72 in lecture) concordance rate in identical twins Genetic abnormalities probably play a role What are the Treatments for Bipolar Disorder Psychotherapies almost no success Lithium therapy Needs to be closely regulated Too little will have no effect, too much is toxic Helps more than 60% Don’t know how it works, different from other antidepressant drugs Appears to affect a neuron’s second messengers phosphoinsoitides Some respond better to other mood-stablizing drugs (antiseizure drugs) Others combinations of lithium and atypical antipsychotic drugs Adjunctive psychotherapy Emphasize the importance of continuing medication, help solve problems caused by the disorder Chapter 8 – Suicide What is Suicide Suicide Intentioned death, a self inflicted death in which one makes an intentional, direct, and conscious effort to end one’s life Parasuicides Unsuccessful attempts to kill themselves Death seekers Clearly intend to end their lives at the time they attempt suicide Death initiators Clearly intend to end their lives, but they act out of a belief that the process of death is already under way and that they are simply quickening the process Death ignorers Do not believe that their self-inflicted death will mean the end of their existence Death darers Experience mixed feelings, or ambivalence in their intent to die even at the moment of their attempt, and they show this ambivalence in their act itself (ie Russian roulette) may be interested in gaining attention (ie making someone feel guilty) Subintentional death When individuals play indirect, covert, or partial, or unconscious roles in their own deaths (ie seriously ill people who consistently mismanage their medicines), intent is unclear How is Suicide Studied Retrospective analysis Psychological autopsy in which clinicians and researchers piece together data from the suicide victim’s past (suicide notes) Limited sources Only half of victims have been to psychotherapy, less than a third leave notes Studying people who survived suicide attempts 8-20 nonfatal suicide attempts for every fatal suicide Patterns and Statistics Rates vary from country to country Countries that are largely catholic, Jewish, or Muslim tend to have low suicide rates Very religious people seem less likely to commit suicide 3:1 F:M attempt ratio 3x more men success (19/100,000 men compared to 4/100,000 women) Men use more violent methods Suicide is related to social support and marital status Divorced persons have a higher suicide rate than married or cohabitating individuals Vary according to race 2x more common in white Americans compared to most ethnic groups (12/100,000) except Native Americans (.5 over national average) What Triggers a Suicide? Stressful events, mood and thought changes, alcohol and other drug use, mental disorders, and modeling Stressful Events and Situations Immediate stress – ie loss of loved one, divorce, rejection, natural disasters Long term stress Serious illness – people experiencing great pain or severe disability may try suicide believing that death is unavoidable and imminent (37% of victims had been in poor physical health) Abusive environment Feeling of little or no hope of escape, feel that they can endure no more suffering Occupational Stress Jobs can create feeling of tension or dissatisfaction that may precipitate attempts Highest among psychiatrists and psychologists, physicians, nurses, dentists, lawyers, farmers, and unskilled laborers Mood and Thought Changes Increases in feelings of anxiety, tension, frustration, anger, or shame Feel of psychological pain that seems intolerable Shifts in pattern of thinking, preoccupied with their problems, lose perspective Hopelessness – pessimistic belief that their present circumstances will not change Dichotomus thinking – viewing problems and solutions in rigid either/or terms Alcohol and Other Drug Use 70% of ppl who attempt sucide drink alcohol just before the act, one fourth of these ppl are legally intoxicated Mental Disorders Half of all victims had been experiencing severe depression, 20% chronic alcoholism, 10% schizophrenia 15% of people with each of these disorders try to kill themselves Ppl who are both depressed and dependent on alcohol seem particularly prone to suicidal impulses Borderline personality disorder Among those who are severely depressed, the risk of suicide may actually increase as their mood improves and they have more energy to act on their suicidal wishes Schizophrenia Feelings of demoralization due to illness (ie unemployment) Suicide is the leading cause of premature death in this population Modeling: the Contagion of Sucide One suicidal act apparently serves as a model for another Celebrities Suicides by well-known persons are followed by unusual increases in the number of suicides across the nation Other Highly Publicized Cases Unusual aspects often receive special coverage by the news and media ( lead to similar suicides Co-workers and Colleagues Word-of-mouth publicity and attends suicides in a school, workplace, or small community may trigger suicide attempts What are the Underlying causes of Suicide? Psychodynamic View Suicide results from depression and anger at others that is redirected toward oneself (murder in the 180th degree) Extreme expression of self-hatred Death instinct (Thanatos) opposes life instinct Most people learn to redirect their death instinct by aiming it towards others, suicidal people, caught in a web of self-anger, direct it squarely upon themselves Sociocultural View Probability of suicide is determined by how attached a person is to social groups The more a person is attached the less likely suicide is Several groups of suicide Egoistic – people over whom society has little or no control Not concerned with the norms or rules of society, nor are they part of the social fabric Isolated, alienated, and nonreligious Altruistic suicides – people who are so well integrated into the social structure that they intentionally sacrifice their lives for its well-being Societies that encourage people to sacrifice themselves for others or to preserve their own honor (far eastern) Anomic suicides – people whose social environment fails to provide stable structures, ie family religion, to support and give meaning to life Persons who have been let down by a disorganized, inadequate, often decaying society (ie economic depression, Katrina) Biological View Low serotonin activity may be a “predictor of suicidal acts” Ppl with low serotonin 10x more likely to attempt and succeed than ppl with normal serotonin More suicides with ppl that have no depression, but low serotonin Low serotonin activity may contribute to aggressive behavior Is Suicide Linked to Age? Children 500 under 14 per year (.9/100,000) Commonly preceded by behavioral patters like running away from home, accident-proneness, aggressive acting out, temper tantrums, self-criticism, social withdrawal, and loneliness, extreme sensitivity to criticism, low tolerance of frustration, dark fantasies and daydreams ect Most appear to have a clear understanding of death and clear wish to die Adolescents Period of rapid growth, marked by conflicts, depressed feelings, tensions, and difficulties at home and school Suicidal actions become much more common after the age 14 than at any earlier age (11/100,000, 500,000 more may attempt) Tied to clinical depression, low self-esteem, and feelings of hopelessness, many seem to struggle with anger and impulsiveness, often under great stress Serious alcohol or drug problems 93% of adolescent suicide attempters had known someone who had attempted suicide Many may simply want to make others understand how desperate they are, get help, or teach others a lesson Half of attempters make future attempts, 14% eventually die by suicide Elderly 19/100,000 persons over 65 Commit 19% of all suicides in US, only account for 12% of the population Become ill, lose close friends and relatives, lose control over their lives, lose status in society Elderly are more determined than younger persons, give fewer warnings ¼ succeed Rate among Native Americans is lower (1/3 national rate) Treatment and Suicide What treatments are used after Suicide Attempts? Care for physical damage that may have been caused then begin psycho/drug therapy Only half receive later psychological treatment, 1/3 of adolescents report getting no help after attempt Goals of therapy are to keep people alive, help them achieve a nonsuicidal state of mind, and guide them to develop better ways of handling stress Various therapies: drug, psychodynamic, cognitive, group, and family 30% of attempters who do not receive treatment try again, 16% of treated attempters try again What is Suicide Prevention Suicide prevention programs Suicide hot lines Paraprofessionals – ppl trained in counseling but no formal degree Crisis intervention Help suicidal people see their situations more accurately Prevention Centers Establish a positive relationship Understanding and clarifying the problem Assessing suicide potential Lethality scale Assessing and mobilizing the caller’s resources Formulating a plan Do Suicide Prevention Programs Work Not known Only a small percentage of suicidal people contact prevention centers Prevention programs seem to reduce the number of suicides among these high-risk people who do call ~ 2% of these callers later committed suicide compared to 6% of others in same group Chapter 9 – Eating Disorders Anorexia Nervosa Refusal to maintain more than 85% of normal body weight, intense fears of becoming overweight, distorted view of weight and shape, stop menstruating (females) Restricting-type anorexia nervosa - at least half reduce weight by restricting their intake of food Binge-eating/purging-type anorexia nervosa – lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics 90-95% of cases occur in females Normal onset 14-18 yrs .5-2% lifetime prevalence for females in western countries, on the increase Develops when people take diets too far, may follow stressful event 2-6% of victims die The Clinical Picture Goal is to become thin, motivation is fear Preoccupied with food, may be caused by food deprivation Think in distorted ways Overestimate their actual proportions/body size more than normal Common to display psychological problems Depression Anxiety Low self-esteem May also experience Insomnia Sleep disturbances Substances Display obsessive compulsive patterns Perfectionistic Medical Problems Amenorrhea Lower body temp, lower blood pressure, body swelling, reduced bone mineral density, slow HR Metabolic and electrolyte imbalances also possible (bad(death by heart failure or circulatory collapse) Rough, dry, cracked skin; nails become brittle; hands and feet may be cold and blue due to poor nutrition Bulimia Nervosa a disorder also know as binge-purge syndrome – engage in repeated episodes of uncontrollable overeating or binges perform inappropriate compensatory behaviors, such as forcing themselves to vomit; misusing laxatives, diuretics, or enemas; fasting; or exercising excessively 90-95% females Begins in early adolescence (15-21 yrs) Lasts for several years with periodic letup Wt of ppl with bulimia nervosa usually stays within a normal range Binge-eating disorder – pattern of binge eating without vomiting or other inappropriate compensatory behaviors (observed in a number of overweight ppl) 2-7% of severely overweight ppl Bulimia nervosa 5% lifetime prevalence for women in western countries Binges Ppl with bulimia nervosa may have 2-40 binge episodes per week, usual number is around 10 for 3 months (binge eating disorder is 6 months) Consume more than 1,000 calories (often >3,000) Binges are usually preceded by feelings of great tension Person feels irritable, “unreal”, and powerless to control an overwhelming need to eat “forbidden” foods Binge may be experienced as pleasurable in the sense that it relieves the unbearable tension Followed by feelings of extreme self-blame, shame, guilt, and depression, as well as fear of gaining wt and being discovered Compensatory Behaviors Vomiting Fails to prevent the absorption of half of the calories consumed during a binge Repeated vomiting affects one’s general ability to feel full ( greater hunger and more frequent and intense binges Laxatives or diuretics Fail to undo the caloric effects of bingeing Cycle develops in which purging allows more bingeing, and bingeing requires more purging Pattern typically begins during or after a period of intense dieting Often one that has been successful and received praise Normal subjects placed on a very strict diets also develop a tendency to binge Bulimia Nervosa vs. Anorexia nervosa Similar Both typically begin after a period of dieting by ppl who are fearful of becoming obese driven to become thin preoccupied with food, wt, and appearance struggling with feelings of depression, anxiety and the need to be perfect Individuals of both are at a heightened risk of self-harm or attempts at suicide Substance abuse my accompany either Ppl believe that they weigh too much and look too heavy regardless of their actual wt or appearance Marked by disturbed attitudes towards eating Different Bulimia nervosa tend to be more concerned about pleasing others, being attractive to others, having intimate relationships more sexually experienced and active display fewer of the obsessive qualities that drive ppl with restricting-type anorexia nervosa have long histories of mood swings, become easily frustrated or bored, have trouble coping effectively or controlling their impulses ruled by strong emotions may change friends and relationships frequently borderline personality disorder only half of women are amenorrheic or have very irregular menstrual periods, compared to almost all of those with anorexia nervosa have bad teeth may experience dangerous potassium deficiencies ( weakness, intestinal disorders, kidney disease, or heart damage What Causes Eating Disorders? multidimensional risk perspective identify several key factors that place individuals at risk for the disorder Societal Pressures Western standards of female attractiveness have contributed to increases in eating disorders Noticeable shift toward preference for a thin female frame in recent decades Professionals in fashion models, actors, dancers, and certain athletes are more prone than others to eating disorders 9% of female college athletes, 50% admit to eating behaviors that put them to risk 20% of gymnasts surveyed had an eating disorder Dieting and preoccupation with thinness have increased in all classes and minority groups, as has the prevalence of eating disorders Cruel jokes about obesity are fare on tv and in movies, books, and magazines Half of elementary school girls have tried to lose wt and 61% of middle school girls are currently dieting Family Environment Half or the families of ppl with eating disorders have a long history of emphasizing thinness, physical appearance, and dieting Salvador Minuchin – enmeshed family pattern Family members are overinvolved in each other’s affairs Can be affectionate and loyal Can be clingy and foster dependency Parents that are too involved allow little room for individuality and independence In fact, families of ppl with either anorexia or bulimia nervosa vary widely Ego deficiencies and Cognitive Disturbances Disturbed mother-child interactions lead to serious ego deficiencies in the child and severe cognitive disturbances that foster disordered eating patterns Effective parents Accurately attend to their child’s biological and emotional needs Ineffective parents Fail to attend to their children’s needs, inappropriately respond to demands (ie giving food in time of fear, or comfort in time of hunger) Child may grow up confused and unaware of their own internal needs Unable to rely on internal signals, these children turn instead to external guides, such as parents Parents of teens with eating disorders tend to define their children’s needs rather than allow the children to define their own needs People with eating disorders perceive internal cues, including emotional cues, inaccurately Mood Disorders Symptoms of depression – esp bulimia nervosa Mood disorders may set the stage for eating disorders Four kinds of evidence Many more ppl with an eating disorder qualify for a clinical diagnosis or major depressive disorder Close relatives of ppl with eating disorders seem to have a higher rate of mood disorders Many ppl with eating disorders, esp bulimia nervosa, have low activity of serotonin Ppl with eating disorders are often helped by same antidepressant drugs that reduce depression Pressure and pain of having an eating disorder may cause a mood disorder Biological Factors Relatives of ppl with eating disorders are up to 6x more likely to develop a disorder Identical twins have a 23% bulimia 47% anorexia concordance rate compared to 9% of faternal Serotonin – link between eating disorders and the genes responsible for production of serotonin Abnormal serotonin activity causes the body to crave and binge on high CHO foods (some people may have predisposition for this) Hypothalamus – wt thermostat LH – produces hunger VMH – reduces hunger Glucagons-like-peptide-1 (GLP-1) – appetite suppressant Brian also triggers bodily changes that make it harder to lose wt and easier to gain wt are also in affect How Are Eating Disorders Treated? Two goals Correct as quickly as possible the dangerous eating pattern Address the broader psychological and situational factors Treatments for Anorexia nervosa How Are Proper Weight and Normal Eating Restored? Now is often offered in outpatient settings Life-threatening cases, clinicians may need to force tube and intravenous feedings Behavioral wt-restoration approaches have clinicians use rewards whenever patients eat properly or gain wt Combination of supportive nursing care, nutritional counseling, and high-calorie diet Nurses gradually increase a patient’s diet over the course of several weeks to more than 2,500 calories a day (8-12 wks) How are Lasting Changes Achieved? Ppl with anorexia nervosa must overcome their underlying psychological problems Therapists typically provide both therapy and education Individual, group, and family approaches used Building Independence and Self-awareness One treatment is to help patients recognize their need for independence and teach them more appropriate ways to exercise control Teach them to better identify and trust their internal sensations and feelings Correcting Disturbed Cognitions Treatment focuses on changing their attitudes about eating and weight Guide clients to identify, challenge, and change maladaptive assumptions Educate clients about the body distortions typical of anorexia nervosa and help them see that their own assessments of their size are incorrect Changing Family Interactions Therapist meets with the family as a whole, points out troublesome family patterns, and helps the members make appropriate changes Family therapy can be helpful in the treatment of this disorder What is the Aftermath of Anorexia Nervosa Wt is often quickly restored Most begin menstruate again Death rate seems to be falling Deaths that do occur are usually caused by suicide, starvation, infection, GI problems, or electrolyte imbalance ~20% remain seriously troubled for years Recovery not always permanent Anorexic behaviors recurs in at least one-third of recovered patients, usually triggered by new stresses Those who were ill continue to experience certain emotional problems, particularly depression, social anxiety, and obsessiveness The more wt persons have lost and the more time that has passed before they entered treatment, the poorer the recovery rate Individuals who had psychological or sexual problems before the onset of the disorder tend to have poorer recovery rates Teenagers seem to have a better recovery rate Females have a better recovery rate than males Treatments for Bulimia Nervosa Treatment programs often offered in eating disorder clinics Immediate goal is to eliminate binge-purge patterns and establish good eating habits and the more general goal of eliminating the underlying causes of bulimic patterns Emphasize education as much as therapy Often combine several treatment strategies; insight therapy, behavioral therapy, antidepressant drugs therapy, and group therapy Individual Insight Therapy Cognitive therapy – help clients recognize and change their maladaptive attitudes toward food, eating, wt, and shape Identify and challenge the negative thoughts that regularly precede their urge to binge Change their perfectionistic standards, sense of helplessness, and low self-concept Helps as many as 65% Often tried first Interpersonal psychotherapy Seeks to improve interpersonal functioning Self care manuals Psychodynamic therapy – not helpful Behavioral therapy Supplement to cognitive therapy Keep diaries of their eating behavior, changes in sensations of hunger and fullness, rise and fall of other feelings Helps them to observe their eating patterns more objectively and recognize the emotions that trigger their desire to binge Exposure and response prevention Eat particular kinds and amounts of food and then prevent them from vomiting Antidepressant Medications Seems to work best in combination with other forms of therapy Group therapy At least somewhat helpful in as many as 75% of cases, esp when combined What is the Aftermath of Bulimia Nervosa Untreated can last for years Treatment produces immediate, significant improvements in ~40% of clients, moderate in another 40%, 20% show little to no improvement 10 yrs after treatment 89% have recovered (70%fully, 19% partially) Relapses are usually triggered by a new life stress Almost one third relapse within two years of treatment, usually within six months Relapse is more likely among persons who had longer histories of bulimia nervosa, histories of substance abuse, and continue to be lonely or to distrust others after treatment Chapter 10 – Substance-Related Disorders Substance-related Disorders drug – any substance other than food that affects our bodies or minds may cause temporary changes in behavior, emotion, or thought, lead to intoxication also cause long term problems maladaptive patterns or behavior and changes in body’s physical responses Substance abuse – rely on drug excessively and chronically and in doing so damage their family and social relationships, occupation, put themselves at danger Tolerance – need for increasing doses of a drug in order get desired effect Withdrawal – unpleasant and dangerous symptoms (ie cramps, anxiety attacks, sweating, nausea) that occur when individuals suddenly stop taking or cut back on the drug 9.4% of US adults display substance abuse or dependence, 26% of them receive tx Depressants slow the activity of the CNS, Reduce tension an inhibitions, may interfere with persons judgment, motor activity, and concentration Alcohol 2/3 of US have a drink from time to time 2:1 M:F heavy drinkers Binds to neurons that normally receive GABA (inhibitory), helps GABA shut down neurons 13% of an oz is metabolized by liver in an hour Alcohol Abuse and Dependence 6.6% of world pop fall in to long-term pattern of alcohol abuse or dependence in given year, 8% affected overall 13% alcohol use disorder lifetime prevalence in US adults, 2:1 M:F Prevalence same for whites, AA, and Hispanics in US Earlier onset for whites and Hispanics, Later onset for AA Native Americans have highest rate, lowest for asian americans Alcohol Abuse Long-term heavy drinkers have damage in various regions of their brains ( impariements in their short-term memory, speed of thinking, attention skills, and balance Alcohol Dependence Body builds up a tolerance for alcohol and need to drink greater amounts to feel its effects Experience withdrawal when stop drinking Hands, tounge, eyelids shake, feel weak and nauseated, sweat and vomit, rapid HR, increase in bp, may become anxious, depressed, trouble sleeping, irritable Delirium Tremens – terrifying visual hallucinations that begin within 3 days after stop or reduce drinking Run course in 2-3 days May have seizures, lose consciousness, suffer a stroke, or die What is the Personal and Social Impact of Alcoholism Plays a role in more than 1/3 of all suicides, homicides, assaults, rapes, and accidental deaths (41% of all fatal automobile accidents) Affect on children Children of alcoholic parents exhibit higher rates of psychological problems - anxiety, depression, phobias, conduct disorder, ADD, and substance related disorders during their lifetimes Lower self-esteem, poor communication skills, poor sociability, and marital problems Physical health damage Cirrhosis – liver becomes scarred and dysfunctional Damage to heart and lower the immune system’s ability to fight off cancer and bacterial infections and to resist onset of AIDS after infection Nutritional Problmes Chronic drinkers become malnourished, weak, and prone to disease Korsakoff’s syndrome – disease marked by extreme confusion, memory loss, and other neurological symptoms – cannot remember the past or learn new info and may make up for memory loss by confabulating – reciting made-up events to fill the gaps Fetal alcohol syndrome Pattern of abnormalitites that can include mental retardation, hyperactivity, head and face deformities, heart defects, and slow growth Drinking during pregnancy often leads to miscarriage – 11% of pregnant women have drank alcohol in last month, 4% binge Sedative-Hypnotic Drugs Produce feelings of relaxation and drowsiness Low dosages has calming or sedative effect, high doses induce sleep Barbiturates Originally prescribed as an antianxiety and to help people sleep Low doses is similar to alcohol, synergistic with GABA Large doses become intoxicated similar to alcohol Can halt breathing, lower bp, and lead to coma and death Danger of barbiturate dependence is tha the lethal dose of the drug remains the same even while the body is building up a tolerance for its sedating effects Withdrawal symptoms Nausea, anxiety, sleep problems, can cause convulsions Benzodiazepines Antianxiety drug Increases GABA’s activity Relieve anxiety without making people as drowsy as other kinds of sedative-hypnotics Less likely to slow a person’s breathing, so less likely to cause death in event of an overdose Opioids Opium Oldest form Morphine Pain reliever, commonly used for soilders ( large dependence in population in past Heroin Used as a “wonder drug” Even more addictive than the other opioids Synthetic opioids Methadone Codeine Narcotics(natural and synthesized) Can be smoked, inhaled, snorted, injected by needle just beneath skin, or directly into bloodstream Injection brings a rush followed by a “high or nod” Leaves users feel relaxed, happy, and unconcerned about food, sex, or other bodily needs How they work Depress the CNS, particularly the centers that help control emotion Attach to brain receptor sites that normally receive endorphins Can also cause nausea, narrowing of the pupils, and constipation Heroin Abuse and Dependence Withdrawal symptoms Anxiety, restlessness, sweating, rapid breating, Later include severe twitching, aches, fever, vomiting, diarrhea, loss of appetite, high bp, and wt loss of up to 15lbs due to loss of fluids Symptoms peak by day 3, disappear around day 8 1% prevalence in US What are the Dangers of Heroin Abuse Overdose – closes down the respiratory center in the brain HIV rates as has as 60% in some areas among heroin dependents Stimulants Substances that increase the activity of the CNS, resulting in increased bp and HR, greater alertness, and speeded-up behavior and thinking Cocaine Brings a euphoric rush of well-being and confidence, in high doses can be “orgasmic” Stimulates higher centers of the CNS, makes users feel excited, energetic, talkative and even euphoric Also stimulates other centers of CNS producing faster HR, higher BP, faster and deeper breathing, and further arousal and wakefulness Increases supplies of NT dopamine, also increases activity of norepi and serotonin in some areas of brain High doses produce cocaine intoxication Poor muscle coordination, grandiosity, bad judgment, anger, aggression, compulsive behavior, anxiety, and confusion May experience hallucinations or delusions, or both ( cocaine-induced psychotic disorder As stimulant effects subside User experiences a depression-like letdown, “crashing”, May include headaches, dizziness, and fainting Aftereffects usually disappear within 24 hours Cocaine Abuse and Dependence Regular use may cause short-term memory and attention deficiencies Dependence may also develop Tolerance is developed 1% of people dependent in given year, 3% lifetime prevalence Free-basing Cocaine basic alkaloid is “freed” from processed cocaine (crack) Sold at more economic price What are the Dangers of Cocaine Greatest danger is overdose First stimulates respiratory center, then depresses it to the point in which breathing stops Can produce heart irregularities or brain seizures that bring breathing or heart functioning to a sudden stop Risk of miscarriage and abnormalities in immune functioning, attention and learning, thyroid size, and dopamine and serotonin activity in the brain of fetus/infant Amphetamines Stimulant drugs that are manufactured in a laboratory Taken in a pill or capsule form, can be injected for quicker effect Can be taken in forms as “ice” and “crank” counterparts of free-base cocaine Increase energy and alertness and lower appetite when taken in small doses Produce rush, intoxication and psychosis in high doses Can cause emotional letdown as leave the body Stimulate the CNS by increasing the release of the NT dopamine, norepi, and serotonin Tolerance builds quickly, high risk of dependence Less than .5% of US pop display abuse in given year 1.5-2% lifetime prevalence Hallucinogens, Cannabis, and Combinations of Substances Hallucinogens - produce delusions, hallucinations, and other sensory changes Cannabis – produce sensory changes but also have depressant and stimulant effects Hallucinogens Substances that cause powerful changes in sensory perceptions, from strengthening a person’s normal perceptions to inducing illusions and hallucinations Psychedelic drugs – LSD, mescaline, psilocybin, MDMA LSD Brings a state of hallucinogen intoxication, marked by a general strengthening of perceptions, particularly visual perceptions, along with psychological and physical changes – things turn purple, objects seem distorted Hallucinosis – may hear sounds more clearly, feel tingling or numbness in the limbs, or confuse the sensation of hot and cold May causes senses to cross – colors may be “heard” Can induce strong emotions, from joy to anxiety or depression, bring back long-forgotten thoughts and feelings Produces symptoms by binding to some of the neurons that normally receive serotonin, and change activity at those sites Neurons that help brain send visual info and control emotions 14% of US pop has used the drug at least once, 1.6% in last year Usually do not develop tolerance or have withdrawal symptoms Long-term risks May develop psychosis or a mood or anxiety disorder Cannabis When smoked, produces a mixture of hallucinogenic, depressant, and stimulant effects Low doses smoker has feelings of joy and relaxation and may become either quiet or talkative Can become anxious, suspicious or irritated Many report sharpened perceptions and fascination with sounds and sights around them, time slows down Marijuana Abuse and Dependence Regular users can become physically dependent Develop a tolerance for it and may experience flulike symptoms, restlessness, and irritability when they stop smoking 1.9% of US pop display abuse in giver year, 5% lifetime prevalence 4x more powerful now than it was 40yrs ago Is Marijuana Dangerous Can cause panic reactions similar to the ones caused by hallucinogens, fear you are losing your mind People high often fail to remember information, especially anything that has been recently learned Higher bloodflow in brain of chronic users Heavy smokers no improvement after quitting Lung disease Reproduction handicaps for men and women Cannabis and Society: A Rocky Relationship Some states legalized it for medical use, but supreme court ruled physicians can be prosecuted for prescribing it Canada giving it a try Combinations of Substances Synergistic effect Different drugs that are in the body at the same time may multiply, or potentate each others effects Easy to overdose Opposite, or antagonistic actions Very dangerous, one may interfere with the others disposal system Polysubstance-related disorders 90% of persons who use one illegal drug are also using another to some extent What Causes Substance-Related Disorders? The Sociocultural View People are most likely to develop patterns of substance abuse or dependence when they live under stressful socioeconomic conditions High levels of unemployment correlate with higher rates of alcoholism likely to appear in families and social environments where substance use is valued, or at least accepted Psychodynamic View People who abuse substance have powerful dependency Parents fail to satisfy a young child’s need for nurturance, child is likely to group up depending excessively on others If search for outside support includes experimentation with a drug, person will develop a relationship with the drug People respond to their early deprivations by developing a substance abuse personality ( more prone to drug abuse problems later in life The Behavioral and Cognitive Views Behaviorists Operant condition Temporary reduction of tension or raising of spirits produced by a drug has a rewarding effect, thus increasing the likelihood that the user will seek this rxn again Classical conditioning Objects present at time drugs are taken may act as classically conditioned stimuli ie sight of a bong Cognitive Such rewards eventually produce an expectancy that substances will be rewarding and this expectation helps motivate individual to increase drug use at times of tension Both People “medicate” themselves when they feel tense Higher rates seen in people with PTSD and mood disorders The Biological View Genetic Predisposition 54% concordance rate for identical twins compared to 28% for fraternal Adoptees whose biological parents were alcoholics are more likely to become alcoholics than adoptees whose parents aren’t alcoholics Dopamine-2 receptor gene Biochemical Factors Negative feedback, take a drug that mimics a NT, body releases less of that NT, withdrawal the time it takes the body to release the proper amount of the NT again depressant use reduces natural GABA levels, opioid use reduces endorphin, stimulant use reduces dopamine production Reward deficiency syndrome – people who abuse drug, their reward center is not redily activated by the usual events in their lives, so they turn to drugs to stimulate their pleasure pathways How are Substance-Related Disorders Treated? Psychodynamic Therapies Therapists guide clients to uncover and resolve the underlying needs and conflicts that led to the disorder Help clients change their substance-related styles of living Not very effective, needs to be combined with other methods Behavioral Therapies Aversion therapy Pair unpleasant stimulus with drug, ie an electrical shock, or nausea with alcohol Covert sensitization – imagine bad things while thinking about doing the drug ie maggots in beer Contingency management – rewards for remaining drug free for certain amount of time Good fro short-term treatment Limited success when sole form of treatment, best when in combination of biological or cognitive approaches Cognitive-Behavioral therapies Behavioral self-control training (BSCT) Clients keep track of their own drinking behavior, note times, locations, emotions, bodily changes, ect Teach coping strategies to avoid/deal with situations, relaxation techniques, assertiveness skills Teach to set limits Relapse-prevention training Similar to BSCT Taught to plan ahead of time how many drinks are appropriate, what to drink, and under what circumstances Majority achieve success only after repeated efforts at RPT Biological Treatments Rarely bring long-term improvements, can be helpful when combined with other approaches Detox Systematic and medically supervised withdrawal from a drug Relapse rates tend to be high for those who fail to receive a follow-up from of tx-psychological, biological, Sociocultural-after successful detox Antagonist Drugs Block or change the effects of the addictive drug Antabuse does nothing on its own but when combined with alcohol causes nausea Must be carefully regulated due to risk of putting person in severe withdrawl Drug Maintenance Therapy Methadone maintenance programs People with a heroin addection are given methadone as a substitute for heroin Try to ease person off drug Methadone withdrawal lasts longer than heroin withdrawal Sociocultural Therapies Self-help and Residential Treatment Progams AA Residential Treatment Centers or Therapeutic communities Where people formerly dependent on drugs live, work and socialize in a drug-free environment while undergoing individual, group, and family therapies and making a transition back to community life Culture- And Gender-sensitive Programs Try to be sensitive to the special Sociocultural pressures faced by drug abusers who are poor, homeless, or members or minority groups Women often require tx methods different from those designed for men Community Prevention Programs Most effective approach to supstance-related disorders is to prevent them School – “DARE” Programs may focus on individual, family, peer group, school, or community at large Sleep and Sleep Disorders among the Old and Not So Old REM Resembles both deep sleep and wakefulness Body is immobilized despite small movements and muscle twitches Eyes dart back and forth Increased blood flow to brain, increased brain-wave activity Time for dreaming Dyssomnias – disturbances in the amount, quality, or timing of sleep Parasomnias – abnormal events that occur during sleep Insomnia Difficulty falling asleep or maintaining sleep More than 20% of pop May be caused by anxiety, depression, medical ailments, pain or medication effects Sleep Disorders in the Elderly At least 40% over 65 experience insomnia With old age spend less time in deep sleep, more time in REM Sleep apnea 10% of elderly Respiratory problem in which persons are periodically deprived of oxygen, causes them to wake up Occurs in the overweight who are heavy snorers Sleep Disorders Throughout the Life Span Hypersomnia – heightened need for sleep and excessive sleepiness Narcolepsy – sudden bouts of REM during waking hours Affects 135,000 ppl, 1/2000 ppl Triggered by strong emotions Circadian rhythm sleep disorder – experience excessive sleepiness or insomnia as a result of a mismatch between their own sleep-wake pattern and the sleep-wake schedule of most other ppl in their environment Typical in 3rd shift workers Nightmare disorder – nightmares become frequent and cause such great distress that the individual must receive treatment Most common of the parasomnias Increase with stress Sleep Terror disorder – awaken suddenly during the first third of their evening sleep, screaming gin extreme fear and agitation Most common in children and disappear during adolescence Sleep walking disorder – usually children, repeatedly leave their beds and walk around without being conscious of the episode or remembering it Occur in the firs third of night Able to perform complex activities Chapter 11 Sexual Dysfunctions Sexual dysfunctions – disorders in which people cannot respond normally in key areas of sexual functioning, make it difficult or impossible to enjoy sexual intercourse 31% males, 43% females life time prevalence in US Human sexual cycle: desire, excitement, orgasm, and resolution Disorders of Desire Desire phase – consists of urge to have sex, sexual fantasies, and sexual attraction to others Hypoactive sexual desire – lack of interest in sex, low level of sexual activity When ppl with hypoactive sexual desire do have sex, their physical responses may be normal and they may enjoy the experience 16% of men, 33% of women DSM IV – deficient or absent sexual fantasies and desire for sexual activity Sexual aversion – find sex distinctly unpleasant or repulsive, sexual advances may sicken, disgust, or frighten them Rare in men and somewhat more common in women Biological Causes High levels of hormone prolactin, low level of male sex hormone testosterone, and either a high or low level of female sex hormone estrogen can lead to low sex drive Long term physical illness can lower sex drive Pain meds, several illegal drugs (cocaine, marijuana, amphetamines, heroin) may lower sex drive At low levels alcohol can raise sex drive, high levels can lower it Psychological causes General increase in anxiety or anger may reduce sexual desire in men and women Attitudes, fears, or memories can contribute to desire dysfunction Fear of losing control, pregnancy may play a factor Mild depression, and OCD symptoms may interfere with sexual desire Sociocultural causes Situational pressures – divorce, death in the family, job stress, infertility difficulties, having a baby, problems in their relationship all may play a factor Youthfulness and attractiveness – old men might not find old women hot Trauma of sexual molestation or can produce fears, attitudes, ect leading to dysfunctions (esp sexual aversion) Disorders of Excitement Excitement phase – marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breating…erection in men, swelling of the clitoris and labia, as well as lubrication of the vagina in women Female Sexual Arousal Disorder Sexual arousal disorder – persistenetly unable to attain or maintain proper lubrication or genital swelling during sexual activity More than 10% of women Male erectile Disorder ED – persistently fail to attain or maintain an adequate erection during sexual activity 10% male pop. Most men with ED are over 50 Experienced by 5-9% of 40yr olds 15% of 60 yr olds Half of all men experience ED during intercourse at least some of the time Biological Causes Same hormones that cause hypoactive sexual desire could be at work Vascular problems more common Damage to the nervous system as a result of diabetes, spinal cord injuries, multiple sclerosis, kidney failure, or treatment withy an artificial kidney machine Medications, and other substances can interfere with erections (ie alcohol, smoking) Nocturnal penile tumescence Erections typically occur during REM sleep (~2-5 hrs of erection a night) Snap-gauge Useful to determine if causes are biological Psychological causes Performance anxiety and the spectator role Once a man begins to experience erectile problems, he becomes fearful about failing again. Instead of relaxing and enjoying the sensations of sexual pleasure, he remains distanced from the activity, watching himself and focusing on the goal of reaching erection Sociocultural Causes Men under finical stress more likely to develop ED than others Two relationship patterns that can lead to ED Wife provides too little physical stimulation for aging husband who has aged and now needs more arousal time A couple that believes that only intercourse can give the wife an orgasm Disorder of Orgasm Orgasm phase – individual’s sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract Premature Ejaculation Persistently reaches orgasm and ejaculates with very little sexual stimulation 29% of men some time Duration of intercourse in our society has increased Typical of young, sexually inexperienced men who have not learned control May be related to anxiety, hurried masturbation, or poor recognition of one’s own sexual arousal Male Orgasmic Disorder Repeatedly cannot reach orgasm or is very delayed in reaching orgasm after normal sexual excitement Low testosterone level, certain neurological diseases and some head or spinal cord injuries can interfere with ejaculation Serotonin-enhancing antidepressants may interfere Spectator role Female Orgasmic Disorder Rarely reach orgasm or generally experience a very delayed one 24% of women, 1/3 postmenopausal 10% women never had an orgasm, 9% rarely Women who are more sexually assertive tend to experience less problems Biological Causes Diabetes can damage nervous system in ways that interfere with arousal, lubrication… Multiple sclerosis and other neurological diseases, drugs and medications that affect men may be the same Postmenopausal changes in skin sensitivity Psychological Causes Psychodynamic – memories of childhood traumas and relationships Sociocultural Causes Society’s recurrent message to women that they should hold back and deny their sexuality, leads to less permissive sexual attitudes in women Strict religious up bringing Stressful events, traumas, or relationships may help produce the fears, ect that lead to these dysfunctions Likelihood may be linked to how much emotional involvement was experienced during first intercourse Disorders of Sexual Pain Vaginismus Involuntary contractions of the muscles around the outer third of the vagina prevent entry of the penis Usually a learned fear response Some women experience painful intercourse because of an infection of the vagina or urinary tract Need to receive medical treatment for these conditions Dyspareunia Experiences severe pain in the genitals during sexual activity 14% of women, 3% of men Sufferers typically enjoy sex and get aroused but are limited by the pain Psychosocial factors alone are rarely responsible for it Treatments for Sexual Dysfunctions Psychodynamic therapy typically unsuccessful Behavioral therapies also failed William Masters and Virginia Johnson’s “Human Sexual Inadequacy” revolutionized therapy What are the General Features of Sex Therapy Modern sex therapy is short-term and instructive, typically 15-20 sessions Centers on specific sexual problems rather than broad personality issues Following techniques normally applied 1) Assessment and conceptualization of the problem Medical examination Sex history interview 2) Mutual Responsibility Both partners share the sexual problem 3) Education about sexuality Teach about physiology and techniques of sexual activity 4) Attitude change Examine and change any beliefs about sexuality that are preventing sexual arousal and pleasure 5) Elimination of performance anxiety and the spectator role Sensate focus, or nondemand pleasuring 6) Increasing sexual and general communication skills Use sensate-focus session at home Give instructions in nonthreatening manner 7) Changing destructive lifestyles and marital interactions 8) Addressing physical and medical factors What Techniques are Applied to Particular Dysfunctions Hypoactive Sexual desire and Sexual Aversion Hypoactive sexual desire and sexual aversion are hard to treat Affectual awareness – patients visualize sexual scenes in order to discover any feeling of anxiety, vulnerability, and other negative emotions they may have concerning sex Self-instruction training – help change their negative reactions to sex Behavioral approach Keep a desire diary Read books and view films with erotic content, and to fantasize about sex Hormone treatment may be used Erectile Disorder Focus on reducing a man’s performance anxiety or increasing his stimulation or both Tease Technique – partner keep caressing the man, if gets an erection, partner stops until erection gone. Repeat Exercise reduces pressure on the man to perform Blue bombers Male Orgasmic Disorder Aim to reduce performance anxiety and increase stimulation Masturbate before intercourse Drug treatment to increase arousal of the sympathetic nervous system Premature Ejaculation Behavioral procedures Stop-start/pause techniques Drug treatments (antidepressants) Female Arousal and Orgasmic Disorders Cognitive-Behavioral Techniques Direct masturbation training Wisest course may be to educate women that they are normal Vaginismus Practice controlling vaginal muscle activity Behavioral exposure treatment – penetrate her self then eventually partner Dyspareunia Learn intercourse positions that avoid putting pressure on the injured area What are the Current Trends in Sex Therapy More open to the ppl that are treated (don’t have to be married) Narrow approach of any kind probably cannot fully address the complex factors that cause most sexual problems Paraphilias Disorders in which individuals repeatedly have intense sexual urges or fantasies or display sexual behaviors that involve nonhuman objects, children, nonconsenting adults, or the experience of suffering or humiliation Need to last 6 months For some, urges, fantasies, or behaviors must also cause great distress or interfere with one’s social life or job performance in order for a diagnosis to be applied But performance of the sexual behavior indicates a disorder even if the individual experiences no distress or impairment (ie pedophilia) Often come to the attention of clinicians whey they get into trouble with the law Biological interventions most common today Antiandrogens that lower the production of testosterone Medications that lower impulsivity may be used as well Fetishism Recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve nonliving objects Pyschodynamic view Defense mechanism to avoid anxiety produced by normal sexual contact Treatment no good Behaviorists Acquired through classical conditioning Treat through aversion therapy Shock therapy Covert sensitization Pair pleasurable stimuli with adverse stimuli Masturbatory satiation Masturbates to orgasm about sexually appropriate object, then switches to fetish object for hour more ( suppose to lead to boredom Orgasmic reorientation Teaches individuals to respond to more appropriate sources of sexual stimulation Switch-a-roo Transvestic Fetishism Recurrent need or desire to dress in clothes of the opposite sex in order to achieve sexual arousal Begins in childhood or adolescence Development seems to follow behavioral principles of operant conditioning (parent rewards child for cross dressing) Exhibitionism Recurrent urges to expose genitals to another person of the opposite sex, has sexually arousing fantasies of doing so Wants to provoke shock or surprise Urge to exhibit typically becomes stronger when person has free time or is under significant stress Begins before 18, most common in males Typically immature in dealing with the other sex, difficulty in interpersonal relationships Treatment Aversion therapy, masturbatory satiation, possibly combined with reorientation, social skills training, or insight therapy Voyeurism Recurrent and intense urges to secretly observe unsuspecting people as they undress or to spy on couples having intercourse Begins before 15 yrs Vulnerability of the people being observed and the probability that they would feel humiliated if they knew they were under observation are often part of the individuals enjoyment Also risk of being discovered Psychodynamic – ppl seeking by their actions to gain power over others, feel inadequate or are sexually or socially shy Behaviorists – learned behavior that can be traced to a chance and secret observation of sexually arousing scene Frotteurism Repeated and intense sexual urges to touch and rub against a nonconsenting person, or has sexually arousing fantasies of doing so Behavior decreases after 25 Pedophilia Gains sexual gratification by watching, touching, or engaging in sexual acts with prepubescent children, usually 13 yrs old or younger Satisfied by child porn or may actually carry out acts Boys and girls can be victims, 2/3 are girls Disorder is developed during adolescences, some were sexually abused themselves, neglected, excessively punished, or deprived of genuinely close relationships Ppl are often immature in their social and sexual skills may be underdeveloped, thoughts of normal sexual relationships fill them with anxiety Most display at least one additional psychological disorder May be related to biochemical or brain structure abnormality Most offenders are imprisoned Cognitive-behavioral treatment – relapse-prevention training, learn strategies to avoid situations or coping with them better Sexual Masochism Intensely sexually aroused by the act or thought of being humiliated, beaten, bound, or otherwise made to suffer Only those who are very upset or impaired by their fantasies receive this diagnosis Hypoxyphilia – people strangle or smother themselves for enjoyment Usually males, as young as 10 Seems to developed through the behavioral process of classical conditioning Sexual Sadism Usually male, intensely sexually aroused by the thought or act of inflicting suffering on others by dominating, restraining, blindfolding, cutting, ect the victim About control over sexual victim Many carry out sadistic acts with a consenting partner, some nonconsenting though Behaviorists Classical conditioning at work May be learned through modeling Psychodynamic and cognitive theorists Underlying feelings of sexual inadequacy; inflict pain in order to gain a sense of power Biological studies Possible abnormalities in the endocrine system Treatment Aversion therapy (clockwork orange) Relapse-prevention therapy may be useful A word of Caution Except when people are hurt by them, paraphilic behaviors should not be considered disorders at all (homosexuality use to be considered one) Gender Identity Disorder Disorder in which people persistently feel that a vast mistake has been made – been assigned the wrong sex 2:1 M:F Different from transvestic fetishism People with GID feel uncomfortable in their sex’s clothing, cross dressing isn’t for sexual arousal GID people try to take full role of opposite sex Childhood pattern usually disappears by adolescence or adulthood, but in some cases it develops into adult GID Most children with the disorder do not become transsexual adults Cluster of cells in hypothalamus called bed nucleus of stria terminals smaller in transsexual men – similar to female size Treatments Hormone treatment – change physical characteristics Sex-change/reassignment Surgery Women – bilateral mastectomy and hysterectomy, phalloplasty 1 in 30,000 men, 1 in 100,000 women Chapter 12 – Schizophrenia Schizophrenia psychosis – loss of contact with reality may have hallucinations (false sensory perceptions) or delusions (false beliefs) or may withdraw into a private world Prevalence: 1% world wide 1/3 attempt suicide, 15% of sufferers succeed Equal number of men and women Disorder begins earlier in men and may be more severe 2.4 % AA recive diagnosis compared to 1.4 white Americans Diagnostic biases, economic factors, or both More frequent in low SES Stress and poverty could cause the disorder Downward drift theory – schizophrenia causes people to have problems resulting in them falling in social class The Clinical Picture of Schizophrenia Symptoms of Z vary greatly, and so do its triggers, course, and responsiveness to treatment What are the Symptoms of Schizophrenia Positive Symptoms – pathological excesses Delusions – idea that they believe wholeheartedly but that have no basis in fact Delusions of persecution most common Believe they are being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized Delusions of reference Attach special and personal meaning to the actions of others or to various objects or events Delusions of grandeur Believe themselves to be great inventors, religious saviors, or other specially empowered persons Delusions of control Believe their feelings, thoughts, and actions are being controlled by other people Disorganized Thinking and Speech May not be able to think logically and may speak in peculiar ways Formal thought disorder Cause sufferer great confusion and make communication extremely difficult. Loose associations or derailment Rapidly shift from one topic to another, believing that their incoherent statements make sense Neologisms Made-up words that typically have meaning only to the person using them Perseveration They repeat their words and statements again and again Clang Use rhyme, to think or express themselves Heightened Perceptions and Hallucinations Perceptions and attention of some people with Z seem to intensify Problems may develop years before the onset of the actual disorder Hallucinations Perceptions that occur in the absence of external stimuli May involve any of the senses Auditory hallucinations are by far the most common kind in Z People with auditory hallucinations actually produce the nerve signals of sound in their brain, “hear” them, and then believe that external sources are responsible Broca’s area – region of the brain that helps people produce speech More blood flow in Broca’s area while patients were experiencing auditory hallucinations Increased activity near the surfaces of their brains in the tissues of the brains’s hearing center when “hear” voices Hallucinations and delusional ideas often occur together Inappropriate Affect Emotions that are unsuited to the situation Person may smile when making a serious statement or on being told terrible news Inappropriate shifts in mood Negative Symptoms – pathological deficits Poverty of Speech Alogia – poverty of speech, a reduction in speech or speech content Think and say very little Blunted and Flat Affect Blunted affect – show less anger, sadness, joy, and other feelings than most people Flat affect – show almost no emotions at all Their faces are still, their eye contact is poor, and their voices are monotonous Anhedonia – general lack of pleasure Blunted or flat affect may reflect an inability to express emotion Subjects with Z showed less facial expression than average ppl, but reported feeling just as much positive and negative emotion and in fact displayed greater skin arousal Loss of Volition Avolition – apathy, feeling drained of energy and of interest in normal goals and unable to start or follow through course of action Ambivalence – conflicting feelings about most things Social Withdrawal May withdraw from their social environment and attend only to their own ideas and fantasies Seems also to lead to a breakdown of social skills, including the ability to recognize other peoples needs accurately Psychomotor symptoms Awkward movements or repeated grimaces and odd gestures Catatonia Catatonic stupor – stop responding to their environment, remaining motionless and silent for long stretches of time Catatonic rigidity – maintain a rigid, upright posture for hours and resist efforts to be moved Catatonic excitement – a different form of catatonia in which they move excitedly, sometimes with wild waving of the arms and legs What is the Course of schizophrenia Usually appears between the person’s late teens and mid 30’s Three phases Prodromal phase – symptoms are not yet obvious, but persons are beginning to deteriorate May withdraw socially, may speak in vague or odd ways, develop strange ideas, or express little emotion Active phase – symptoms become apparent Sometimes this phase is triggered by stress in person’s life Residual phase – they return to a prodromal-like level of functioning Striking symptoms of the active phase lessen, but some negative symptoms, such as blunted emotions may remain ¼ or more patients recover completely from Z, majority continue to have at least some residual problems for the rest of their lives Each of the phases may last for days or for years Fuller recovery from Z is more likely in persons who functioned quite well before the disorder, whose disorder was first triggered by stress, came on abruptly, or developed during middle age Relapses more likely when individuals are under great stress or pressure Diagnosing Schizophrenia Diagnosis only after symptoms of the disorder continue for six months or more Must show a deterioration in their work, social relations, and ability to care for themselves 5 types of schizophrenia Disorganized type of Z – confusion, incoherence, and flat or inappropriate affect Attention and perception problems, extreme social withdrawal, and odd mannerisms or grimaces are common Catatonic type of Z – psychomotor disturbance of some sort (catatonic variation of some sort) Paranoid type of Z – have an organized system of delusions and auditory hallucination that may guide their lives Undifferentiated type of Z – category is somewhat vague, it has been assigned to a wide assortment of unusual patterns Residual type of Z – ppl with this pattern may continue to display blunted or inappropriate emotions, as well as social withdrawal, eccentric behavior, and some illogical thinking How do Theorists Explain Schizophrenia Biological View – most supported Genetic Factors Diathesis-stress perspective – certain ppl inherit a biological predisposition to Z and develop the disorder later when they face extreme stress Are Relatives Vulnerable – more closely related the relatives are to the person with Z, the greater their likelihood of developing the disorder Is an Identical Twin at Greater Risk than a Fraternal Twin 48% concordance in identical twins, 17% in fraternal Are the Biological Relatives of an Adoptee Vulnerable Biological relatives of adoptees with Z are more likely to experience Z or a related disorder What do Genetic Linkage and Molecular Biology Suggest Possible gene defects on chromosomes 1, 6, 6, 10, 12, 15, 18, 22 and X chromosome, each of which may help predispose individuals to develop Z Biochemical Abnormalities Dopamine Hypothesis Certain neurons that use the NT dopamine fire too often and transmit too many messages, thus producing the symptoms of the disorder Antipsychotic drugs help remove the symptoms of Z (dopamine antagonist) Phenothiazines Often produce troublesome muscular tremors, symptoms that are identical the Parkinsons’s disease Drug may reduce dopamine activity People with Parkinson’s disease develop Z symptoms if they take too much L-dopa (dopamine synergist), a medication that raises dopamine levels Other drugs that act with dopamine such as amphetamines can cause a syndrome very similar to Z (amphetamine psychosis) Antipsychotic drugs bind to D-2 receptors Atypical antipsychotics New drugs bind not only to D-2 dopamine receptors, but also to D-1 receptors and to receptors for other NT such as serotonin Z may be related to abnormal activity or interactions of both dopamine and serotonin Abnormal Brain Structure Linked to cases dominated by negative symptoms Enlarged ventricles- the brain cavities that contain CSF Experience poorer social adjustments prior to the disorder and greater cognitive disturbances Enlarged ventricles may be a sign that nearby parts of the brain have not developed properly or have been damaged Smaller temporal and frontal lobes Abnormal blood flow Possible problems in the hippocampus, amygdale, and thalamus, among other brain areas Viral Problems Abnormalities may result from exposure to viruses before birth Interrupt proper brain development in fetus’s brain Winter birth rate is 5-8% higher among ppl with schizophrenia than among other persons Antibodies to particular virus in the blood of 40% of subjects with Z biological factors merely set the stage for Z, while key psychological and Sociocultural factors must be present for the disorder to appear Psychological Views The Psychodynamic Explanation – 2 processes 1) regression to a pre-ego stage and 2) effort to restablish ego control Schizophrenogenic mothers - cold or unnurturing parents may set Z in motion, may appear to be self-sacrificing but are actually using their children to meet their own needs Most people with Z don’t have mothers like this Some believe that biological abnormalities leave certain persons particularly prone to extreme regression/unconscious acts that may contribute to Z The Cognitive View During hallucinations and related perceptual difficulties the brains of ppl with Z are actually producing strange sensations Further features emerge when person attempts to understand their unusual experiences First turn to friends to explain odd voices/visions, friends deny existence of such, sufferes conclude that others are trying to hide the truth Not proved Sociocultural Views Social Labeling Features of Z are influenced by the diagnosis itself Self-fulfilling prophecy to the diagnosis Family dysfunctioning Z often linked to family stress Parents of ppl with Z often Display more conflict Have greater difficulty communicating with one another Are more critical of and over involved with their children than other parents Expressed emotion – frequently express criticism, disapproval, and hostility toward each other and intrude on one another’s privacy Ppl trying to recover from Z are 4x more likely to relapse if they live with such a family Also the case that ppl with Z greatly disrupt family life How are Schizophrenia and Other Severe Mental Disorders Treated? Institutional Care in the Past Ppl with Z were institutionalized in a public mental hospital Shifted to State hospitals that were suppose to protect patients from the stresses of daily life and provide therapists Funding was unable to keep up Patients transferred to back or chronic wards if they failed to improve “advanced” tx included medical approaches such as lobotomy Institutional Care Takes a Turn for the Better Milieu therapy Institutions can help patients by creating a social climate that builds productive activities, self-respect, and individual responsibility, given right to run their own lives and make their own decisions Atmosphere of mutual respect, support and openness Greater improvements over programs offering primarily custodial care Still used in combination with other therapies Token Economy Operant conditioning Patients rewarded when they behave acceptably, use rewards to redeem desirable items Does help reduce psychotic and related behaviors Ethical limitations – what can ethically be held back from ppl Are psychotic thoughts and perceptions improving or simply the patients ability to imitate normal behavior No longer as popular Antipsychotic Drugs Conventional drugs – neuroleptic drugs Eliminate many of Z symptoms – block dopamine D-2 receptor Produce undesired movement effects similar to the symptoms of neurological diseases How effective are Antipsychotic Drugs? Reduce symptoms in majority of patients with Z More effective than approaches Max level of improvements within the first six months of tx Reduce positive symptoms better than negative symptoms Patients often dislike the powerful side effects of the drugs Unwanted Effects of conventional Antipsychotic Drugs Disturbing movement problems – extrapyramidal effects Severe muscle tremors Bizarre movemtns of the face, neck, tounge, and back Restlessness and discomfort in their limbs Symptoms can be reversed if an anti-parkinsonian drug is also taken Tardive Dyskinesia Appears after a year of taking antipsychotic Includes involuntary writhing or ticklike movements of the tounge, mouth, face or whole body; involuntary chewing, sucking, and lip smacking, and jerky movements of the arms, and legs, or entire body Difficult or impossible to eliminate Physicians now prescribe lowest possible doses that achieve effects, stop meds shortly after patients begin functioning normally New Antipsychotic Drugs - “Atypical” antipsychotic drugs Biological operations differs from conventional drugs Received at fewer D-2 receptors and more D-1 and D-4 and serotonin receptors Appear to be more effective than conventional drugs Help 85% over 65% Reduces positive as well as negative symptoms Fewer extrapyramidal symptoms and do not seem to produce tardive dyskinesia Psychotherapy Insight therapy Individual or group formats Level of experience of therapist more important than orientation best ones take active role, set limits, express opinions, challenge patients statements, provide guidance, display empathy, and gain trust Family Therapy 25% of those recovering form Z live with family members Recovery may be greatly affected by the behaviors and reactions of the relatives at home Expressed emotion – bad Family members may be greatly affected by the social withdrawal and unusual behaviors of a relative with schizophrenia Family therapy teaches more realistic expectations and to become more tolerant, less guilt-ridden, and more willing to try new patterns of communication Good with drug therapy Social Therapy Includes techniques that address social and personal difficulties in the clients’ lives Offer practical advice; work with clients on problem solving, decision making, and social skills – help find work financial assistance and proper housing Does help ppl stay out of the hospital The Community Approach Community Mental Helth Act – patients are to receive a range of mental health services (in/out patient treatments, emergency care, preventive care and after care) in their communities rather than being transported to institutions far from home Deinstitutionalization from state institutions into the community Quality of community care is still inadequate – revolving door What are the features of Effective Community Care Assertive community treatment - need medication, psychotherapy, help in handling daily pressure and responsibilities, guidance in making decisions, training in social skills, residential supervision, and vocational counseling Coordinated Services Community mental health center – directly supply meds, therapy, emergency care, and coordinate the services offered by other community agencies Very important for mentally ill chemical abusers Short-term hospitalization First try to treat on an outpatient basis, short term hospitalization if this fails, then are released for aftercare Partial Hospitalization Day centers/day hospitals – care during the day then patients return home at night Semihospital or residential crisis center – provide 24-hour nursing care for ppl with severe mental disorders Supervised Residences Halfway houses – group of ppl suffering from mental illness live with a paraprofessional Houses run with milieu therapy, emphasizes mutual support, resident responsibility, and self-government Occupational Training Sheltered workshop – supervised workplace for employees who are not ready for competitive or complicated jobs Not consistently available to ppl with severe mental disorders Fewer than 15% How has Community Treatment Failed? Fewer than half of all ppl who need help receive appropriate community mental health services 40-60% of ppl with Z and other severe mental disorders receive no tx at all Poor coordination of services Various mental health agencies in a community often fail to communicate with one another Case managers – coordinate help services for patient, provide counseling Shortage of services Number of community programs available to ppl with severe mental disorders falls short Community health centers generally fail to provide adequate services for ppl with severe mental disorders, tend to devote efforts to ppl with less disabling problems ie anxiety disorders Most mental health professionals prefer to work with ppl with less severe and short term problems Economic problems causes shortage of help Economic responsibility falls on local governments and nonprofit organizations Much of money available to ppl with severe mental disabilities goes to social security disability income What are the Consequences of Inadequate Community Treatment Many receive help from family Page 367 ~250,000-550,000 homeless ppl in US, about 1/3 are Z Chapter 13 – Personality Disorders Personality Disorder Personality traits – we tend to react in our own predictable and consistent ways Personalities are also flexible, people who suffer from personality disorders lack this flexibility Personality disorder – very rigid pattern of inner experience and outward behavior. Seen in most interactions, lasts for years Rigid traits lead to psychological pain, and social or occupational problems Can bring pain to others Personality disorders become recognizable in adolescence or early adulthood, sometimes during childhood 9-13% of adults Axis II disorders – not typically marked by changes in intensity or periods of clear improvement Personality disorders complicates a person’s chances for a successful recovery from psychological problems “Odd” Personality Disorders Paranoid Personality Disorder Deeply distrust other people and are suspicious of their motives Believes everyone wants to harm them Avoid close relationships Find “hidden” meanings in everything, usually belittling or threatening Quick to challenge the trustworthiness of acquaintances Although inaccurate, their suspicions are usually not delusional People with this disorder are critical of weakness and fault in others, but unable to recognize their own mistakes Extremely sensitive to criticism .5-3% of adults How do Theorists Explain Paranoid Personality Disorder Psychodynamic theories Demanding parents, particularly distant, rigid fathers and overcontrolling, rejecting mothers Come to view the environment as unfriendly, must always be on the alert bc cannot trust others Cognitive theorists Maladaptive assumptions such as “people are evil” Biological theories Genetic cause Treatments for Paranoid Personality Disorder Do not typically see themselves as needing help Distrust their therapists Limited effect and moves very slowly Object relations therapists See past patient’s anger and work on his/her “deep wish for a satisfying relationship” Behavioral and Cognitive therapists Control their anxiety and improve their skills at solving interpersonal problems Develop more realistic interpretations of other people’s words and actions Drug therapy Limited help Schizoid Personality Disorder Persistently avoid social relationships and demonstrate little emotion Don’t have close ties with other people, genuinely prefer to be alone, wk social skills Focus mainly on themselves and are generally unaffected by praise or criticism Less than 1% of the population Little more common in men than in women Ho Do Theorists Explain Schizoid Personality Disorder Psychodynamic Has roots in an unsatisfied need for human contact Parents are believed to have been unaccepting, even abusive of their children Suffers are unable to give or receive love, cope by avoiding all relationships Cognitive Deficiencies in their thinking Thoughts tend to be vague and empty Have trouble scanning their environment to arrive at accurate perceptions Unable to pick up emotional signals from others Children have language problems Treatments for Schizoid Personality Disorder Social withdrawal prevents seeking treatment (go in for other problems ie alcoholism) Clients remain emotionally distant from therapist Limited progress at best Drug therapy limited help Schizotypal Personality Disorder Extreme e discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities Ideas of reference- beliefs that unrelated events pertain to them in some important way Bodily illusions – such as sensing an external “force” or presence Great difficulty keeping their attention focused Anxious around others, seek isolation and have few close friends Many feel intensely lonely More severe than paranoid and schizoid personality disorders 2-4% of adults, slightly more males than females How do Theorists Explain Schizotypal Personality Disorder Linked to family conflicts and psychological disorders in parents Defects in attention and STM may be at work High activity of NT dopamine, enlarged brain ventricles, smaller temporal lobes and loss of gray matter Possible genetic base Treatments for Schizotypal Personality Disorder Need to help clients “reconnect” with the world and recognize the limits of their thinking and their powers Increase positive social contacts, ease loneliness, reduce overstimulation, and help the individuals become more aware of their personal feelings Evaluate their unusual thoughts or perceptions objectively and ignore the inappropriate ones Antipsychotic drugs in low doses help “Dramatic” Personality Disorders Antisocial Personality Disorder “psychopaths” or “sociopaths”, persistently disregard and violate others’ rights Most linked to adult criminal behavior Display some patterns of misbehavior before they are 15 Lie repeatedly Impulsive, taking action without thinking of the consequences Irritable, aggressive, quick to start fights Recklessness, little regard for their own safety or for that of others Self-centered, likely to have trouble maintaining close relationships Lack moral conscious 3.5% of ppl in US meet criteria 4x more common in men than women Criminal behavior declines after the age 40 High rates of alcoholism and other substance-related disorders How do Theorists Explain Antisocial Personality Disorder Psychodynamic Absence of parental love during infancy, leading to lack of basic trust Children respond to the early inadequacies by becoming emotionally distant, they bond with others through the use of power and destructiveness Behavioral Maladaptive behavior may be learned through modeling or imitation Parents may unintentionally reward child’s aggressive behavior by giving in to restore peace Biological These people experience less anxiety than others May lack key ingredient for learning Subjects are not influenced much by punishment Do to under arousal, may take risks and see thrills others wouldn’t Treatments for Antisocial Personality Disorder ¼ receive treatment Major obstacle is individuals’ lack of conscience or desire to change Most in therapy have been forced to be there, 70% leave prematurely Most treatments have little or no impact Borderline Personality Disorder Display great instability, including major shifts in mood, an unstable self-image, and impulsivity Relationships very unstable Swing in and out of very depressive, anxious, and irritable states that last from a few hours to a few days or more Often direct their impulsive anger inward and inflict bodily harm on themselves Physical discomfort helps relieve emotional suffering More common conditions seen in clinical practice ( hurt themselves, go to hospital, referenced to help 70% attempt suicide at least once in their lives, 6-10% succeed Most suicidal in adolescents Often form intense, conflict-ridden relationships with individuals who do not necessarily share their feelings Violate boundaries of relationships Become furious when their expectations are not met, remain very attached though Rapid shifts in goals, aspirations, friends, and even sexual orientations 1.5-2.5% of general population 75% of diagnosed are women How Do Theorists Explain Borderline Personality Disorder Psychodynamic Early lack of acceptance by parents may lead to a loss of self-esteem, increased dependence, and an inability to cope with separation Common to have history of neglect or abuse, multiple parent substitutes, divorce, death, or traumas Biological Lower brain serotonin activity Close relatives are 5x more likely to also have disorder than general population Biosocial Theory Combination of internal forces (ie controlling arousal levels and emotion) and external forces (ie way emotions are punished or disregarded) Sociocultural Likely to emerge in cultures the change rapidly (ie ours) Treatments for Borderline Personality Disorder Psychotherapy can lead to some degree of improvement Therapist needs to find balance between empathizing with dependency and anger and challenging his/her way of thinking Many clients violate boundaries of client-therapist relationship Dialectical Behavior Therapy (DBT) Combines techniques for the cognitive and behavioral Aim to help clients increase their ability to tolerate distress, learn new social skills, respond more effectively to life situations The relationship between the client and therapist is emphasized Persons treated with DBT attempt suicide and self-harming behavior less Better adherence Drugs Antidepressants, antibipolar, antianxiety, and antipsychotic help Combination of psychotherapy and drugs best Histrionic Personality Disorder Extremely emotional Always “on stage”, change themselves to attract and impress an audience Vain, self-centered, demanding, and unable to delay gratification for long Overreact to any minor event that prevents drawing attention Diagnosis goes to women more, “hysterical wife” How do Theorists Explain Histrionic Personality Disorder Psychodynamic Experienced unhealthy relationships in which cold and controlling parents left them feeling unloved and afraid of abandonment Cognitive Lack of substance and extreme suggestibility found in ppl with this disorder Less and less interested in knowing about the world at large because they are so self-focused and emotional Rely on hunches or others to provide them with direction Hold general assumptions that they are helpless to care for themselves, constantly seek out others who will meet their needs Treatments for Histrionic Personality Disorder Often seek out treatment on their own Very difficult clients, display needy demands, tantrums, seductiveness Pretend to have important insights or to experience change to please therapist Cognitive Change their beliefs that they are helpless Psychodynamic Aim to help clients recognize their excessive dependency, find inner satisfaction, and become independent Drug Less successful, can relieve depressive symptoms Narcissistic personality Disorder Generally grandiose, need much admiration, feel no empathy with others Convinced of their own great success, power, or beauty, they can expect constant attention and admiration from those around Exaggerate their achievements and talents, expecting others to recognize them as superior, often appear arrogant Very choosy about friends, make favorable first impressions, yet rarely maintain long-term relationships Take advantage of others to achieve their own ends Believe others envy them React to criticism or frustration with bouts of rage or humiliation, or cold indifference, or extremely pessimistic and felled with depression <1% of adults, 75% males How do Theorists Explain Narcissistic Personality Disorder Psychodynamic Problem begins with cold, rejecting parents Spend their lives defending against feeling unsatisfied, rejected, unworthy, and wary of the world Repeatedly tell themselves that they are actually perfect and desirable, also by seeking admiration from others Believe that others are unavailable to them Behavioral and cognitive May develop when people are treated too positively Over admiring parents teach them to overvalue their self worth Western cultures are particularly prone Treatments for Narcissistic Personality Disorder More difficult to treat Commonly come in due to depression Try to manipulate the therapist into supporting their sense of superiority Psychodynamic therapists try to have clients recognize their basic insecurities and defenses Cognitive therapists try to redirect the clients’ focus onto the opinions of others, teach them to interpret criticism more rationally, increase their ability to empathize and change their all-or-nothing style of thinking Limited success in all approaches “Anxious” Personality Disorders Avoidant personality disorder Very uncomfortable and restrained in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation Actively avoid occasions for social contact Not so much poor social skills as the dread of criticism, disapproval, or rejection Timid in social situations, afraid of saying something foolish Believe themselves to be unappealing or inferior to others Exaggerate the potential difficulties of new situations, seldom take risks Usually have few or no close friends, but yearn for intimate relationships, frequently feel depressed and lonely People with social phobia fear social situations, people with avoidant personality disorder fear close social relationships 1-2% of adults, men and women equal How do Theorists Explain Avoidant Personality Disorder Psychodynamic Focus on general sense of shame Trace shame to childhood experiences such as early bowel and bladder accidents Parents may have repeatedly punished or ridiculed the child Lead to feelings of unlovable throughout life and distrusting the love of others Cognitive Harsh criticism and rejection in early childhood may lead ppl to assume that others in their environment will always judge them negatively Expect rejection, misinterpret the reactions of others to fit that expectation Treatments for Avoidant Personality Disorder Keeping them in therapy may be a challenge, many avoid the sessions Often distrust the therapist’s sincerity and start to fear his or her rejection Key task of therapist is to gain the individuals trust Psychodynamic Help clients recognize and resolve the unconscious conflicts that may be operating Cognitive Change their distressing beliefs and thoughts, improve self-image Behavioral Provide social skills training as well as exposure treatments that require ppl to gradually increase social contacts Drugs may help relieve social anxiety Dependent Personality Disorder Have persistent, excessive need to be taken care of Clinging and obedient, fearing separation from parents, spouse, or other close relationship Feel completely helpless and devastated when a close relationship ends, quickly seek out another relationship to fill the void Seldom disagree with others and allow even important decisions to be made for them Overly sensitive to disapproval and keep trying to meet other people’s wishes Risk for depressive, anxiety, and eating disorders, prone to suicidal thoughts 2% of population, equal in men and women How do Theorists Explain Dependent Personality Disorder Very similar to depression Freud Conflicts during the oral stage of development set the stage for a lifelong need for nurturance, thus heightening the likelihood of dependent personality Parental loss, rejection, or separation may prevent normal experiences of attachment Over involved, protective parents create dependency, insecurity, ect. Behaviorists Parents unintentionally reward their children’s clinging and loyal behavior, punish acts of independence Cognitive 2 maladaptive attitudes 1) I am inadequate and helpless to deal with the world 2) I must find a person to provide protection so I can cope Dichotomous thinking (black and white) may also play a role Treatments for Dependent Personality Disorder Clients place all responsibility for their well-being on the clinician Task is to help patients accept responsibility for themselves Couples/family therapy together or separate Psychodynamic Focuses on transference of dependency needs onto the therapist Behavioral Provide assertiveness training, help clients better express their own wishes in relationships Cognitive Challenge and change their assumptions on incompetence and helplessness Obsessive-Compulsive Personality Disorder So focused on order, perfection, and control that they lose all of their flexibility, openness, and efficiency ( impairs productivity Neglect leisure activities, unreasonably high standards for themselves Afraid of making mistakes, may be reluctant to make decisions Rigid and stubborn, esp in morals, ethics, and values Trouble expressing much affection, and their relationships are sometimes stiff and superficial 2-5% of population White, educated, married, and employed most often Men 2x more likely than women Closely related to the anxiety disorder Other personality disorders are more common among those with the anxiety disorder How do Theorists Explain Obsessive-Compulsive Personality Disorder Freudian Anal-regressive – overly harsh toilet training during the anal stage, become filled with anger, remain fixated at this stage Resist both their anger and their instincts to have bowel movements ( become extremely orderly and restrained Cognitive Illogical thinking processes help keep it going Dichotomous (black and white) thinking produce rigidity and perfectionism Tend to misread or exaggerate the potential outcomes of mistakes Treatments for Obsessive-Compulsive Personality Disorder Clients usually do not believe that there is anything wrong with them ( not likely to seek treatment Psychodynamic Help the recognize, experience, and accept their underlying feelings and insecurities, accept personal limitations Cognitive Focus on helping clients to change their dichotomous thinking, perfectionism, indecisiveness, procrastination, and chronic worring Drug therapy no good What Problems are Posed by the DSM-IV-TR Categories easy to misdiagnose, validity and accuracy problems diagnoses often rely heavily on the impressions of the individual clinician High similarity between personality disorders People with quite different personalities may qualify fo the same personality disorder diagnosis Passive-aggressive personality disorder – pattern of negative attitudes and resistance to the demands of others Removed from DSM-IV Are There Better Ways to Classify Personality Disorders? categories rather than dimensions are currently used problematic traits are either there or not personality disorder is either displayed or not a person who suffers from a particular personality disorder is not markedly troubled by personality traits outside that disorder Should personality disorders be looked in degree instead of type of disfunction Base on continuum The Big Five Theory of personality and personality Disorders Neuroticism Anxiety and hostility Extroversion Optimism and friendliness Openness to experiences Agreeableness Conscientiousness Alternative Dimensional Approaches Alternative dimensional models have been proposed - 12 broad factors Chapter 14 – Disorders of Childhood and Adolescence Childhood and Adolescence Children of all cultures typically experience at least some emotional and behavioral problems as they encounter new people and situations Worry is common Half of all children in US have multiple fears esp concerning school, health, and personal safety Physical and sexual changes, social, academic pressures, personal doubts and temptations may cause many teenagers to feel anxious, confused, and depressed 1/5 of all children and adolescents in NA also experience a diagnosable psychological disorder Boys outnumber girls Oppositional Defiant Disorder and Conduct Disorder Oppositional defiant disorder – hostile and disobedient, display negative behaviors 8% of children More common in boys before puberty, equal in after puberty Conduct disorder – more sever problem, repeatedly violate the basic rights of others Often aggressive and may be physically cruel Begins between 7-15 yrs 10% of children, ¾ of these boys Mild conduct disorder often improves over time, severe cases can continue into adult hood and develop into antisocial personality disorder Most individuals who display conduct disorder display oppositional defiant disorder first More than 1/3 kids with conduct disorder also show ADHD Several kinds of conduct disorder Overt-destructive pattern – openly aggressive and confrontational behaviors Overt-nondestructive – open offensive but nonconfrontational behaviors such as lying Covert-destructive – secretive destructive behaviors such as violating peoples property, breaking and entering, and setting fires Covert-nondestructive – secretly commit nonaggressive behaviors, such as being truant from school Relational aggression – socially isolated and tend to commit social misdeeds such as slandering others, spreading rumors, and manipulating friendships More common among girls than boys Juvenile delinquents – children between 8-18 who break the law What are the Causes of Conduct Disorder Linked to genetic and biological factors, drug abuse, poverty, traumatic events, and exposure to violent peers or community violence Troubled parent-child relationships, inadequate parenting, family conflict, marital conflict, and family hostility Children whose parents reject, leave, coerce, or abuse them or fail to provide appropriate and consistent supervision are more likely to develop conduct problems Children are more prone when their parents are antisocial, display excessive anger, or have substance-related, mood, or Z disorders How do Clinicians Treat Conduct Disorder Aggressive behaviors become locked in with age, best treated before 13 Sociocultural Treatments Parent-child interaction therapy – used with preschoolers Teach parents to work with their child positively, set appropriate limits, act consistently, be fair in their discipline decisions, establish more appropriate expectations regarding the child Also teach child better social skills Parent management training – school age children Parents are taught more effective ways to deal with their children Parents and children meet together in behavior-oriented family therapy Target particular behaviors for change How to stop rewarding unwanted behaviors, and reward proper behaviors consistently Treatment foster care – delinquents Children sent to live in foster home in community by juvenile justice system Children, foster parents, and biological parents all receive training and tx interventions Juvenile training centers Frequently serve to strengthen delinquent behavior rather than resocialize young offenders Child-focused Treatments Problem-solving skills training Combine modeling, practice, role-playing, and systematic rewards to help teach children constructive thinking and positive social behaviors Anger Coping and Coping Power Program Children with conduct problems participate in group sessions that teach them to manage their anger and other emotions more effectively, solve problems, build social skills, set goals, handle peer pressure Stimulant drugs – Ritalin Help reduce aggressive behaviors at home and at school Prevention Change unfavorable social conditions before a conduct disorder is able to develop Attention-Deficit/Hyperactivity Disorder ADHD – great difficulty attending to tasks or behave overactively and impulsively or both Symptoms often feed into one another Hard to attend to the task or show good judgment Half also have learning or communication problems, many perform poorly in school 80% misbehave, often quite seriously 5% of kids, 90% boys Many show lessening of symptoms as they move into mid-adolescence 60% continue to have ADHD as adults Symptoms of restlessness and overactivity are not usually as apparent in adult cases What are the Causes of ADHD Biological factors Abnormal activity of NT dopamine Abnormalities in the frontal-striatal regions of the brain High levels of stress and to family dysfunctioning Sociocultural ADHD symptoms and a diagnosis of ADHD may themselves create social problems and produce additional symptoms in the child Children who are hyperactive tend to be viewed particularly negatively by their peers and by their parents, and they often view themselves negatively as well Not caused by food additives, or environmental toxins How do Clinicians Assess ADHD Observe behavior in several settings (home, school, with friends) Symptoms have to be present in all settings Obtain reports from parents and teachers Diagnostic interviews, ratings scales, and psychological tests can be helpful How is ADHD Treated Ritalin (methylphenidate) Stimulant drugs have a quieting effect on most children with ADHD and increases their ability to solve problems, perform academically, and control aggression Don’t know the long term affects Don’t know if results are applicable to minority children (most research has been done on whites) Behavioral therapy Parents and teachers learn how to reward attentiveness or self-control, use token economy program Effective when combined with drug therapy Good for children, adolescents, and adults The Sociocultural Landscape: ADHD and Race AA and Hispanics are less likely than whites to receive ADHD diagnosis or undergo tx for this disorder Minorities are less likely to be treated with stimulants or combination of stimulants and behavioral therapy Poorer children less likely than wealthy to be identified as having ADHD and less likely to receive tx Attribute learning deficits in poor and minorities to intelligence instead of disorder Elimination Disorders Inappropriate passing of bodily waste at an age in which it should be controlled Enuresis Repeated involuntary (sometimes intentional) bed-wetting or wetting of one’s clothes Children must be at least 5 Problem may be triggered by stressful events 10% at 5, 3-5% at 10, 1% at 15 Psychodynamic theorists Symptom of broader anxiety and underlying conflicts Family theorists Disturbed family interactions Behaviorists Improper or coercive toilet training Biological Small bladder capacity or weak bladder muscles Behavioral therapy Bell-and-battery technique Foil sheet placed underneath child, when drop of urine hits foil bell sounds Pairs full bladder with waking Dry-Bed training Receive training in cleanliness and bladder retention, are awakened periodically during the night, practice going to the bathroom, and are appropriately rewarded Encopresis Repeated defecating into one’s clothing, less common than enuresis Seldom occurs at night during sleep Involuntary, starts after age of 4 1% of 5 yr olds More common in boys than girls Cases may stem form biological factors, stress, improper toilet training, or a combination of these factors Children normally have history of constipation, may contribute to impaired intestinal functioning Tx Behavioral, medical, and dietary approaches Family therapy also helpful Long-Term Disorders That Begin in Childhood Pervasive Developmental Disorders Marked by impaired social interactions, unusual communications, and inappropriate responses to stimuli in the environment Autistic Disorder Extremely unresponsive to others, uncommunicative, repetitive, and rigid Appear before 3 yrs 80% of cases in boys 90% remain severely disabled into adulthood Highest functioning adults with autism have problems displaying closeness and empathy and have limited interests and activities What are the Features of Autism Individuals lack responsiveness Extreme aloofness, lack of interest in other ppl, low empathy, inability to share attention with others Language and communication problems ~half fail to speak or develop language skills May have problems naming objects, using abstract language, employing a proper tone, speaking spontaneously, using language for conversational purposes, or understanding speech Echolalia – exact echoing of phrases, but no sign of understanding Delayed echolalia – repeat a sentence days after they heard it Pronoun reversal – substitute words like “I” with “you” Limited imaginative play or very repetitive and rigid behavior Unable to play in a varied, spontaneous way or include others in their play No desire to imitate or be like others Perseveration of sameness Very upset at minor changes of objects, persons, or routines, and resist any efforts to change their own repetitive behaviors Fascinated by movements – ie watch a spinning fan for hours Self-stimulatory behaviors Motor movements – unusual motions ie jump, flap arms, swist hands and fingers, rock, spin, make faces Self-injurious behaviors – lunging into or banging their heads against a wall, pulling their hair, or biting themselves Seem overstimulated by sights and sounds and to be trying to block them out, while at other times seem understimulated and performing self-stimulatory actions Asperger’s Disorder Significant social impairments yet manage to maintain appropriate levels of cognitive function and language Similar kinds of social deficits, odd interests, and restricted and repetitive behavior that characterize individuals with autism, but often have normal intellectual, adaptive, and language skills Want to fit in and interact with others, but poor in social functioning makes it hard for them to do so Appear awkward and unaware of social rules Three subtypes Rule boys – want to have set rules that governs their lives Logic boys – interested in the reasons behind rules, rules alone aren’t sufficient, want to know how the world works Emotion boys – run by feelings, have more tantrums, hard to sway them with rules or reason, often act out More common than autism, again 80% boys What are the Causes of Pervasive Developmental Disorders? Sociocultural causes Family dysfunction and social stresses primary causes of autism Personality characteristics of the parents Create unfavorable climate for development, very intelligent yet cold “refrigerator parents Social and environmental stress Not supported by research Psychological Causes Central perceptual or cognitive disturbance makes normal communication impossible Fail to develop a theory of mind Don’t have an awareness that other ppl base their behaviors on their own beliefs, intentions, and other mental states, not on information they have no way of knowing Biological Causes Genetic factor in disorder High prevalence among siblings Chromosomal abnormalities Prenatal difficulties or birth complications Greater prevalence when mother had rubella Cerebellum abnormalities Increased brain volume and white matter Abnormalities in the limbic system, brain stem nuclei, and amygdala Reduced activity in the brain’s temporal and frontal lobes when performing language and motor tasks Multiple biological causes may be at work How Do Clinicians and Educators Treat Pervasive Developmental Disorders Behavioral therapy Modeling Demonstrate desired behavior and guide ppl with disorder to imitate Operant conditioning Reinforce such behaviors, first by shaping them – breaking them down so they can be learned step by step – and then rewarding each step clearly and consistently Often produce new, more functional behaviors Best when started at younger ages Asperger’s Cognitive social integration therapy – taught to be more flexible with regard to social rules, problem solving and behavioral choices Communication Training Half remain speechless Taught other forms of communication ie sign language and simultaneous communication Augmentative communication systems – ie communication boards Child-initiated interactions Teachers try to identify intrinsic reinforces rather than trivial ones like food Children first encouraged to choose items that they are interested in, and they then learn to initiate questions Parent Training Train parents so that they can apply behavioral techniques at home Behavioral gains by trained parents are typically equal to or greater than those generated by parents Community Integration Teach self-help, self-management, and living, social, and work skills as early as possible to help the children function better in their communities Group homes and sheltered workshops Mental Retardation – developmental disability Prevalence: 3/100, 3/5 M Intellectual functioning that is well below average, in combination with poor adaptive behavior, in addition to a low IQ Great difficulty in communication, home living, self-directing, work, or safety Appear before 18 Assessing Intelligence IQ not always reliable (.5 correlation between IQ and school performance) May be SES or culturally biased Assessing Adaptive Functioning Some ppl with low IQ are capable of managing their lives and functioning independently, others are not What are the Characteristics of Mental Retardation Person learns very slow Difficulty in attention, short term memory, planning, and language Four levels by DSM-IV Mild: 50-70 Moderate: 35-49 Severe: 20-34 Profound: below 20 American association of Mental Retardation prefers to distinguish by level of support person needs Intermittent, limited, extensive, or pervasive Mild Retardation 80-85% Educably retarded Typical normal development, limitations become more apparent as academic and social demands increase Seems to improve with age, capable of jobs in unskilled and semiskilled areas Mainly caused by Sociocultural and psychological causes, particularly poor and unstimulating environments, inadequate parent-child interactions and insufficient learning experiences during early years Biological factors may also be acting Mother’s drinking, drug use, malnutrition during pregnancy Moderate, Severe, and Profound Retardation Moderate 10% Diagnosis earlier in life, clear deficits in language development and play during their preschool years Deficits in numbers and reading Adult can manage to acquire fair degree of communication skill, learn to care for themselves, benefit from vocational training, and can work in unskilled or semi skilled jobs Severe 3-4% Demonstrate basic motor and communication deficits during infancy, string only 2-3 words together Require careful supervision, profit some what from vocational training, and can perform only basic work tasks in structured and sheltered environments Profound 1-2% Very noticeable at birth or early infancy Need a very structured environment with close supervision and considerable help, What are the Causes of Moderate, Severe, and Profound Mental Retardation Chromosomal Causes Downs syndrome 1/1000 births, rate increases if mother over 35 Small head, flat face, slanted eyes, high cheekbones, possible protruding tongue Able to display same range of personality characteristics as others, affectionate with family members Has three 21st chromosome, not two IQ: 35-55 Age early, dementia as approach 40 Fragile X chromosome Mild to moderate degrees of dysfunctioning Language, possibly behavioral impairments Metabolic Causes Body’s breakdown or production of chemicals is disturbed Caused by pairing of two defective recessive genes PKU 1/17,000 Tay-Sachs High prevalence in European Jewish community (1/900 couples at risk) Prenatal and Birth-related Causes Cretinism Too little iodine in mothers diet Fetal alcohol syndrome Rubella or syphilis during pregnancy Anoxia Less than 3.5 lbs at birth Childhood problems Particularly if occur before age 6 Poisonings, serious head injuries caused by accident or abuse, excessive exposure to x-rays, excessive use of some drugs Lead poising, mercury, radiation, nitrite Meningitis and encephalitis Interventions for People with Mental Retardation Quality of life attained by people with mental retardation depends largely on sociocultural factors Where and who they live with, how educated, growth opportunities available Try to improve self-image, self esteem What is the Proper Residence Use to be state schools Now smaller institutions and other community residence Today vast majority live in at home Normalization – provide normal living conditions, flexible routines, common developmental experiences Which educational programs work best Best when begins early Special education and mainstreaming/inclusion equally effective Operant conditioning Token economy When is therapy needed Up to 25% have psychological disorders other than mental retardation Low self esteem, interpersonal problems, and difficulties adjusting to community life How can opportunities for personal, social, and occupational, Growth be increased Allow them to grow and make many of their own choices Dating skills programs Sheltered workshops

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