CH-15-16 Psychological Disorders – Psychology: Perspectives and Connections : Chapter Notes

This Document Contains Chapters 15 to 16 Chapter 15: Psychological Disorders BRIEF CHAPTER OUTLINE Defining Psychological Disorders Neurodevelopmental Disorders Subtypes of Neurodevelopmental Disorders Causes of Neurodevelopmental Disorders Schizophrenia Major Symptoms of Schizophrenia Nature and Nurture Explanations of Schizophrenia Maternal Infections and Schizophrenia Schizophrenia and the Brain Neurochemistry of Schizophrenia Challenging Assumptions in the Discovery of Dopamine Depressive Disorders Nature and Nurture Explanations of Depression Bipolar Disorder Causes of Bipolar Disorder Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Social Phobia (Social Anxiety Disorder) Agoraphobia Specific Phobias Nature and Nurture Explanations of Anxiety Disorder Obsessive-Compulsive Disorder Causes of Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder Dissociative Disorders Dissociative Identity Disorder Causes of Dissociative Disorders Somatic Symptom Disorders Personality Disorders Odd-Eccentric Personality Disorders Dramatic-Emotional Personality Disorders Anxious-Fearful Personality Disorders Nature and Nurture Explanations of Personality Disorders Psychology in the Real World: Can Internet Use Become an Addiction? Bringing It All Together: Making Connections in Psychological Disorders: Creativity and Mental Health Chapter Review EXTENDED CHAPTER OUTLINE DEFINING PSYCHOLOGICAL DISORDERS • The first official attempt at diagnosing mental disorders in the United States came in 1952 with the publication of the Diagnostic and Statistical Manual (DSM). • The DSM is currently in its fifth edition (DSM-5) • The DSM-5 defines a mental disorder as a syndrome—a set of related conditions—of clinically significant disturbances of thoughts, feelings, or behaviors. More specifically, they argue for the “4 Ds” of determining whether something is a mental disorder. There has to be: o disturbance of thought, emotion, or behavior, o dysfunction of biological or developmental processes, o distress or disability in everyday life (especially relationships, work, or other activities), and o deviant (different from the norm) thought, emotion, or behavior, but only if also dysfunctional. Deviance alone is not enough. • Psychological disorders are distinguished by their clinically significant disturbance of psychological processes of thought, emotion, and behavior. • Distressing behavior leads to real discomfort or anguish, either in the person directly or in others. • Dysfunctional behavior interferes with everyday functioning and occasionally can be a risk to oneself or others. Dysfunctional also implies that it prevents the person from participating in everyday social relationships, holding a regular job, or being productive in other ways. • Deviant literally means “different from the norm,” or different from what most people do. It is important to point out, as the DSM-5 does, that deviant behavior can be classified as disordered only if it is also dysfunctional. • More than previous editions, the DSM-5 tries to expand beyond the U.S. perspective by aiming to be consistent with international standards for disorder classification and discussing the rates of prevalence of certain disorders in different countries around the world. Some disorders are found only in certain cultures, and others are usually found in certain other cultures. • Mental disorders are common. • People sometimes experience comorbidity. Comorbidity is the occurrence of two or more disorders at the same time. • CONNECTION: Dementia and Alzheimer’s disease are cognitive disorders related to age. Other disorders, such as sleep disorders, can occur at any time in a person’s life (Chapter 5). NEURODEVELOPMENTAL DISORDERS • Although most clinical diagnoses are reserved for adults (older than 18), a number of disorders are prominent in childhood. o The DSM-5 refers to these as neurodevelopmental disorders, and includes intellectual disabilities (formerly mental retardation) and learning disabilities. Subtypes of Neurodevelopmental Disorders • Attention deficit hyperactivity disorder (ADHD) is a childhood disorder characterized by inability to focus attention for more than a few minutes, to remain still and quiet, to do careful work. • Autistic spectrum disorder (ASD) is a childhood disorder characterized by severe language and social impairment along with repetitive habits and inward-focused behaviors; it is formally known as autism. o ADS covers a wide range of disorders from severe disability to high functioning (often called Asperger’s syndrome). o Children with ASD have difficulty with joint attention, the ability to make eye contact with others and to look in the same direction as someone else. Causes of Neurodevelopmental Disorders • The neurodevelopmental disorders often stem from genetic factors that may be triggered by environmental conditions. • For ADHD and conduct disorder, one of the environmental factors is whether the mother smokes while pregnant. Yet, smoking during pregnancy leads to conduct and impulse problems only if the child has one form of a dopamine gene but not another. • Brain activity in general is less pronounced in people with ADHD than in those without it. An understimulated brain explains the “paradoxical” effects of giving children with ADHD a stimulant to calm them down. The stimulant elevates their abnormally low nervous system activity and they require less stimulation and activity from the outside. • Head size is a marker of possible autism spectrum disorder. Often the brain is smaller than normal at birth but grows much faster during the first few years of life than the brains of nonautistic children. The brain of a 5-year-old with ASD is the same size as that of a typical 13-year-old. In addition, the frontal lobes, where much processing of social information occurs, are less well connected in children with ASD than in normal children. • A promising theory about the origins of autism spectrum disorder is based on the mirror neurons. Mirror neurons fire both when a person performs a particular behavior (such as reaching for an object) and when he or she simply watches someone else performing the same behavior. o Mirror neurons are thought to be involved in many, if not most, social behaviors, such as observational learning, imitation, and even language learning. Because children with ASD are deficient in these skills, neuroscientists predicted that mirror neurons malfunction in autistic children. SCHIZOPHRENIA • Psychotic disorders are psychological disorders of thought and perception, characterized by an inability to distinguish real from imagined perceptions. • Schizophrenia involves profound disturbances in thought and emotion and in particular, impairments in perception such as hallucinations. • According to the National Institute of Mental Health approximately 1% of the American population is afflicted with this disorder at any given time, making schizophrenia much less common than depression. Genetically, however, if a first-degree relative (biological parent, sibling, or child) has the disorder, the odds of a person having the disorder rise to 10%. Major Symptoms of Schizophrenia • For a diagnosis of schizophrenia, at least one of the following symptoms must persist for one month. Moreover, at least one of these symptoms must come from the first three (delusions, hallucinations, or disorganized speech): o delusions, o hallucinations, o disorganized speech, o grossly disorganized or catatonic behavior (immobile and unresponsive, though awake), and o negative symptoms (such as not speaking or being unable to experience emotion). • Symptoms of schizophrenia fall into three major categories. These categories are positive, negative, and cognitive. • Positive symptoms mean the presence of some behavior(s). Positive symptoms include: bizarre perceptual experiences associated with schizophrenia, including hallucinations, delusional thinking, and disorganized thought and speech. o Hallucinations are convincing sensory experiences that occur in the absence of an external stimulus. Auditory hallucinations are the most common form of hallucination in schizophrenia, typically taking the form of hearing voices in one’s head. o Delusions are a false belief system, often an exaggerated claim, that a person holds in spite of evidence to the contrary. • Negative symptoms mean the absence of some behavior(s). Negative symptoms include: nonresponsiveness, emotional flatness, immobility or the striking of strange poses (catatonia), reduction of speaking, and inability to complete tasks. • People with schizophrenia show cognitive symptoms, including problems with working memory, attention, verbal and visual learning and memory, reasoning and problem solving, speed of processing, and disordered speech. o Word salad is a term for the speech of people with schizophrenia, which may follow grammatical rules but be nonsensical in terms of content. Nature and Nurture Explanations of Schizophrenia • Schizophrenia offers a perfect illustration of the dynamic interplay between biology and experience in the development of a psychological disorder. Historically, this explanation has been called the diathesis–stress model. Stage one is the biological-genetic foundation or disposition, and stage two is an environmental event that occurs at some point after conception, such as maternal infection, chronic stress, or using certain drugs at certain critical points in development. • The heritability rates are 70% to 85%, suggesting the disorder is due largely to genetic influences. • Scientists have identified as many as 19 genes that contribute. • The more abuse and neglect children experience in their early home life, the more likely they are to suffer from schizophrenia later in life. Maternal Infections and Schizophrenia • Prenatal exposure to infections and diseases such as influenza, rubella, toxoplasmosis, and herpes has been linked to increased risk of schizophrenia and deficits in brain development. Schizophrenia and the Brain • Abnormal brain development before birth may be responsible for many of the brain dysfunctions that are characteristic of schizophrenia. • One mechanism by which maternal infections, for instance, may increase the risk of schizophrenia is by affecting the path neurons take when they migrate during fetal brain growth. • One of the most widely recognized brain abnormalities is a dysfunctional prefrontal cortex and its working memory. In people with schizophrenia, there is evidence of both reduced and excessive activity in that area. • The genes in the prefrontal cortex that regulate how synapses function are dysfunctional in people with schizophrenia compared to those without the disease. • Often the hippocampus is smaller in people with schizophrenia, compared to those without the disorder. • Brain problems may also stem from problems in communication among groups of neurons. • CONNECTION: During fetal development, the brain is extremely vulnerable to toxins (Chapter 5). Neurochemistry of Schizophrenia • For decades, the prevailing view on the neurochemistry of schizophrenia was the dopamine hypothesis, which states that people with schizophrenia have an excess of dopamine activity in certain areas of the brain. • The dopamine hypothesis was based on two findings. o Nobel laureate Arvid Carlsson discovered that amphetamines stimulate dopamine release and therefore may mimic the hallucinations and delusions of schizophrenia. o Early antipsychotic drugs that block dopamine receptors were somewhat effective at treating positive symptoms. Challenging Assumptions in the Discovery of Dopamine • The dopamine hypothesis states that people with schizophrenia have an excess of dopamine activity in certain areas of the brain. • There are some problems with the dopamine hypothesis: (1) dopamine effectively treats only positive symptoms, and it is not entirely effective, and (2) only a minority of the people who receive traditional drug treatment find it effective in managing their symptoms. • Researchers became aware that another set of recreational drugs induced schizophrenia-like symptoms and these drugs did not directly involve dopamine. These drugs included PCP and ketamine. They impaired the functioning of glutamate and one of its receptors, NMDA. • Glutamate is a major excitatory neurotransmitter that regulates the release of dopamine. • Glutamate deficiencies may also explain many of the symptoms of schizophrenia. • Glutamate plays a role in learning, memory, neural processing, and brain development. It also amplifies certain neural signals making some stimuli more important than others, therefore playing a role in selective attention. • Glutamate may explain why people with schizophrenia have trouble with selective attention, cognitive control, and working memory. DEPRESSIVE DISORDERS • According to the DSM-5, there are several forms of depressive disorders. What most people refer to as “depression” is formally called a major depressive disorder. Major depression is a chronic condition characterized by enduring changes in mood, motivation, and sense of self-worth. • To be diagnosed with a major depressive disorder, one must have at least five of nine symptoms associated with major depression according to DSM-5, which must continue for at least two consecutive weeks. These symptoms are: o depressed (sad, listless) mood that stays low all day for several days, o reduced interest or pleasure in doing anything, o significant change in body weight (indicating dieting or overeating), o sleep disturbances, o sluggishness or restlessness, o daily fatigue or loss of energy, o daily feelings of worthlessness, self-reproach, or excessive guilt, o lack of ability to concentrate or think clearly, and o recurrent thoughts of death or suicidal ideation. • Most importantly the symptoms must impact daily functioning and be a source of distress. • One of the milder forms is persistent depressive disorder (PDD). PDD was previously called dysthymia. Most of the symptoms are the same as in a major depressive disorder, but they are less intense in PDD. The depressive mood, however, lasts most of the day and most of the time, for at least two years. Nature and Nurture Explanations of Depression • The reason some people develop depression can be explained with the diathesis-stress model. • Abusive and extremely stressful environments increase one’s risk for depression later in life. • In humans, stressful events, especially social rejection, start a host of biological reactions, including activating the hypothalamic–pituitary–adrenal (HPA) system, which increases the likelihood of developing depression. • The physiological effects of depression may even be observable at the sub-cellular level. The mitochondria are structures inside cells (in this case inside neurons) that play a key role in cell metabolism. • People who are deficient in the neurotransmitters serotonin and neuropeptide Y (NPY) are most susceptible to depression after experiencing extremely stressful situations. • The personality traits of anxiety, neuroticism, and negative emotionality are most associated with vulnerability to depression. BIPOLAR DISORDER • Bipolar disorder is a mood disorder characterized by substantial mood fluctuations, cycling between very low (depressive) and very high (manic) episodes. At one time, this disorder was called “manic-depression.” • Manic episodes typically involve increased energy, sleeplessness, euphoria, irritability, delusions of grandeur, increased sex drive, and “racing” thoughts that last at least one week. • Hypomanic episodes are nearly the same symptoms but shorter in duration • There is a useful mnemonic for remembering the symptoms of mania is D-I-G-F-A-S-T. D = Distractibility I = Indiscretion G = Grandiosity F = Flight of ideas A = Activity increased S = Sleep (decreased need for) T = Talkativeness • The DSM-5 distinguishes between two kinds of bipolar disorder, depending on the severity of the mania. Bipolar I is more severe because it involves meeting the criteria for mania (at least seven days). Bipolar II is less severe because it involves meeting the criteria for hypomania (at least four days). Hypo means “below,” so hypomania is not as severe as mania. The degree of depression is the same in bipolar I and II, but the mania is less severe in bipolar II than in I. • People with either form of bipolar disorder often find the initial onset of the manic phase pleasant, especially compared to the dullness and despair of the depressive phase. Unfortunately, the symptoms quickly become quite unpleasant and frightening. The manic upswing spirals out of control, often leading to frenetic activity, excessive energy, and grandiose thinking, in which sufferers think they have relationships with important people or has expertise in areas where he or she has none. • Cyclothymia is a relatively mild but long-lasting form of bipolar disorder. Causes of Bipolar Disorder • Multiple biological and environmental factors interact. • Fetuses exposed to large amounts of alcohol may suffer permanent effects, including increased risks for bipolar disorder as well as depression, schizophrenia, alcoholism, intellectual disabilities, and drug abuse. • There are many variations of genes that play a role in the development of the disorder. • If one identical twin develops bipolar disorder then there is a 40–70% chance that the other twin will also develop the disorder. Even if the chance is 70% that both twins have the disorder, that still suggests that life events, such as stress and trauma, also play a role in the development of bipolar disorder. • Abnormalities in the brains of people who suffer from bipolar disorder may be a cause or result of the biochemical, genetic, and environmental elements that contribute to the disorder. The prefrontal cortex, the amygdala, the hippocampus, and the basal ganglia all may play a role. Overactivity in many of these regions is evident. There may also be problems with connectivity. • Neurochemistry is also important to bipolar disorder. In both the manic and depressed phases, serotonin levels are low. Low serotonin, however, may be coupled with high levels of norepinephrine in the manic phase and with low levels in the depressed phase. • In addition, thyroid hormones, which control metabolism, are sometimes present in either abnormally high or low levels in people with bipolar disorder. ANXIETY DISORDERS • Fear and anxiety are normal reactions to danger or future threat. These emotions create bodily changes—such as increased heart rate—that support useful responses to danger. For some, fear and anxiety can get out of hand, occurring repeatedly in response to imagined threat and sometimes persisting for days. Generalized Anxiety Disorder • Generalized anxiety disorder (GAD) is a common anxiety disorder, characterized by a pervasive and excessive hard-to-control state of anxiety or worry that lasts at least 6 months. Females are twice as likely as males to have GAD. Unlike those suffering from other anxiety disorders, people with GAD often have been anxious throughout their lives and cannot recall when they began to feel that way. Panic Disorder • Panic attacks are brief episodes of anxiety associated with a perception of threat and occurring because of fear of danger, an inability to escape, embarrassment, or specific objects. • Panic disorder consists of frequent panic attacks and pervasive and persistent fear, worry, embarrassment, and concern about having future panic attacks. • Although about 10% of the U.S. population has experienced a panic attack in the past 12 months, only about 2% to 3% of the population has panic disorder. Social Phobia (Social Anxiety Disorder) • A phobia is a persistent and unreasonable fear of a particular object, situation, or activity. • Social phobia (social anxiety disorder) is an anxiety disorder involving fear of humiliation in the presence of others, characterized by intense self-consciousness about appearance or behavior or both. • People with social phobia are most afraid of embarrassing or humiliating themselves, of being evaluated negatively by others, and of having their faults continually observed by everyone. • Unfortunately, the high degree of anxious arousal produced by social phobia may lead the person to act very nervously and thus, in a self-fulfilling way, exhibit behaviors that do indeed attract other people’s attention. Agoraphobia • Agoraphobia is an anxiety disorder involving fear of being in places from which escape might be difficult or in which help might not be available should a panic attack occur. The primary “fear” in agoraphobia is not of being out in public, but of not being able to escape. Panic attacks are associated with agoraphobia in about one-third of the cases. Specific Phobias • In the United States, up to 9% of the population has a specific phobia for a particular object or situation. Examples include: spiders (arachnophobia), heights, flying, enclosed spaces (claustrophobia), doctors and dentists, or snakes. Specific phobias are marked by an intense and immediate fear, even panic, when confronted with very particular situations or objects; even thinking about those situations or objects may set off the fear reaction. Nature and Nurture Explanations of Anxiety Disorders • Anxiety disorders, and most other psychological disorders, result from the interplay between biological and environmental factors. Instead of offering either biological or social theories of disorders, we present integrated nature–nurture (diathesis-stress) explanations. • Three biological factors that make people vulnerable to anxiety disorders are deficiencies in the neurotransmitter GABA, their genetic heritage, and their personality. • Deficiencies in GABA lead to excessive activation in certain brain regions, especially the limbic structures associated with fear. The fact that major medications for treating anxiety disorders work on GABA receptors is further evidence for GABA’s role in anxiety. • Genetic heritability estimates for generalized anxiety, panic disorder, and agoraphobia range from 30% to 40%. • As for personality, people who are high in neuroticism, prone to worry, anxiety, and nervousness are more likely to develop anxiety disorders than are people who are low in neuroticism. The degree of extraversion may play a role in some anxiety disorders as well. OBSESSIVE-COMPULSIVE DISORDER • Obsessive-compulsive disorder (OCD) is an anxiety disorder in which obsessive thoughts lead to compulsive behaviors. • An obsession is an unwanted thought, word, phrase, or image that persistently and repeatedly comes into a person’s mind and causes distress. • A compulsion is a repetitive behavior performed in response to uncontrollable urges or according to a ritualistic set of rules. In short, obsessions are thought disturbances, whereas compulsions are repetitive behaviors. • OCD most often involves either cleaning, checking, or counting behaviors that interfere with everyday functioning. People who suffer from OCD often know that their thoughts are irrational, or at least that their compulsive behaviors are excessive, but they cannot stop themselves. In some cases, compulsive behaviors stem from superstitions. Causes of OCD • Some scientists argue that the brain circuit that connects the caudate, the anterior cingulate cortex (ACC), and limbic structures (e.g., the amygdala and hypothalamus) is working overtime in OCD. • The overactive ACC creates a perpetual feeling that something is wrong, which the limbic system structures translate into anxiety. In turn, anxiety stimulates more intrusive thoughts, which sometimes become compulsive actions. • The cycle goes on endlessly, due to the hyperactivity of the brain circuit—which is stuck in the “on” position. This circuit involving the ACC, caudate nucleus, and limbic structures supports the obsessive thinking and compulsive responding. POST-TRAUMATIC STRESS DISORDER • Post-Traumatic Stress Disorder (PTSD) is a type of trauma and stressor-related disorder that involves intrusive and persistent cognitive, emotional, and physiological symptoms triggered by catastrophic or horrifying events. • People suffering from PTSD experience a number of intrusive symptoms that last for at least 1 month. These may include recurring intrusive thoughts, feelings, or memories of the traumatic event, either while awake or dreaming, and flashbacks. Flashbacks are vivid reactions in which the person feels as if he or she is experiencing the traumatic event all over again. • War veterans are at increased risk, not only for PTSD but also for depression, drug abuse, and suicide after returning home. • People of all ages can experience post-traumatic stress symptoms. o Compared to healthy controls, children with post-traumatic stress symptoms show reduced brain activity in the hippocampus while performing a verbal memory task. DISSOCIATIVE DISORDERS • Dissociative disorders are psychological disorders characterized by extreme splits or gaps in memory, identity, or consciousness. • These disorders lack a clear physical cause, such as brain injury, and often stem from extreme stress or abusive experiences, especially during childhood. Dissociative Identity Disorder • Dissociative identity disorder (DID) is a dissociative disorder in which a person develops at least two distinct personalities, each with its own memories, thoughts, behaviors, and emotions. • The diagnosis of DID is somewhat controversial, with some psychiatrists even claiming the diagnosis is not real but rather is produced unintentionally by therapists themselves. Causes of Dissociative Disorders • People who suffer from dissociative disorders have one characteristic in common. That characteristic is that they lived through a highly traumatic experience. Most explanations of dissociative disorder view it as a coping strategy that has gone awry. SOMATIC SYMPTOM DISORDERS • A somatic symptom disorder is a psychological disorder in which a person complains of multiple physical disorders that cause disruption and that persist for at least 6 months. • This disorder has two main criteria: o one or more distressing somatic symptoms that disrupt daily life; and o excessive thoughts, feelings, or behaviors related to bodily symptoms. • Illness anxiety disorder is the fear of somatic symptom but without any somatic symptoms. o The person with this disorder will also frequently and excessively check for the symptoms. • With the Internet and easy access to medical information, more and more people are self-diagnosing without evidence of real symptoms and without professional evaluations. People who self-diagnose primarily from information found on the Internet are referred to informally as cyberchondriacs. PERSONALITY DISORDERS • Personality disorders are patterns of cognition, emotion, and behavior that develop in late childhood or adolescence and are maladaptive and inflexible. • There are three distinct clusters of personality disorders—odd-eccentric, dramatic-emotional, and anxious-fearful. Odd-Eccentric Personality Disorders • There are three odd-eccentric personality disorders. • Schizoid personality disorder is when people do not want close relationships; are emotionally aloof, reclusive, and humorless; and want to live a solitary life. • Schizotypal personality disorder is when people are isolated and asocial. In addition they have very odd thoughts, perceptual distortions, and beliefs. • Paranoid personality disorder is when people are extremely suspicious and mistrustful of other people, in ways that are both unwarranted and not adaptive. Dramatic-Emotional Personality Disorders • There are four dramatic-emotional personality disorders. • Histrionic personality disorder is when people want very much to be the center of attention and often behave in very dramatic, seductive, flamboyant, and exaggerated ways. • Borderline personality disorder is when people have out-of-control emotions, are very afraid of being abandoned by others, and vacillate between idealizing and despising those who are close to them. • Narcissistic personality disorder is when people have an extremely positive and arrogant self-image, and most of their time and attention are self-focused. • Antisocial personality disorder is marked by extremely impulsive, deceptive, violent, ruthless, and callous behaviors. People with antisocial personality disorder are most likely to engage in criminal, deceptive, and violent behaviors. Indeed, although only about 3% of the population has this disorder, between 45% and 75% of male prison inmates are diagnosed with the disorder. Only about 20% of female prisoners are diagnosed with antisocial personality disorder. Anxious-Fearful Personality Disorders • There are three anxious-fearful personality disorders. • Avoidant personality disorder is when people are so afraid of being criticized that they avoid interacting with others and become socially isolated. • Dependent personality disorder is when people fear being rejected. They have such a strong need to be cared for that they form clingy and dependent relationships with others. • Obsessive-compulsive personality disorder is when people are very rigid in their habits, extremely perfectionistic in how things have to be done, and frequently very rigid list makers and rule followers. This personality disorder is similar to the clinical disorder with the same name but is more general and it does not have true obsessions and compulsions. Nature and Nurture Explanations of Personality Disorders • Research on murderers has identified a cluster of traits possessed by most of these violent criminals. These are being male, coming from abusive and neglectful households, having at least one psychological disorder, and having suffered some kind of injury to the head or brain. • Research on brain development suggests that living under a constant threat of abuse and stress changes the neural connectivity in the brain, making it less likely to develop many complex synaptic connections, especially in the frontal lobes. Being in a constant state of fear often leads to neural systems that are primed for unusually high levels of anxiety, impulsive behavior, and a state of constant alertness. These are all conditions that might lead to violent or criminal behaviors. • CONNECTION: Neuroplasticity occurs when neurons and hence brain structure and function change as a result of input from the environment (Chapter 3). • CONNECTION: How does our first environment—the womb—shape the expression of our genes (Chapter 3)? PSYCHOLOGY IN THE REAL WORLD: CAN INTERNET USE BECOME AN ADDICTION? • Some people just can’t stay off-line. For many people, this, in itself, may not be a serious problem. In some cases, however, people are online all day; they check their Facebook or Twitter feeds dozens or even hundreds of times a day; and they cannot continue their work or activities around the home without logging on. For them, Internet use has become so intrusive that it adversely affects their professional and personal lives in the real world. • As with all disorders, something becomes a problem once it causes clinically significant disruptions of everyday life. For the first time, the DSM-5 includes the category “Internet Gaming Disorder.” Due to insufficient and inconclusive evidence it is classified as a “Condition for Further Study.” Any five of nine criteria must be present during a 12-month period for a diagnosis to be made: o preoccupation with Internet games (not Internet gambling), o withdrawal symptoms when games are taken away (e.g., irritability, sadness, anxiety), o tolerance, that is, more and more time is needed to be satisfied, o unsuccessful attempts to stop or control one’s habit, o loss of interest in previous hobbies and entertainment, o continued excessive use despite knowing of their psychological problems, o deceives family, friends, and therapists about how much one plays games, o use of Internet games to cope with or escape from a negative mood, and o has jeopardized or lost a significant relationship, job, or educational/career opportunity due to Internet gaming activity. • Some of these criteria are, in fact, signs of addiction, namely tolerance, mood regulation, and disruption of relationships, job, or school. Moreover, researchers have suggested that some people do experience behavioral withdrawal symptoms, such as emotions of irritation and anger, when the computer or smartphone is not available. • Whether computer and online gaming meet the criteria for mental disorder remains to be seen. We do know, however, that overuse has negative effects (e.g., impaired cognition and impaired task performance while multitasking). • If serious disruptions in people’s lives (and occasional deaths) continue to result from excessive and compulsive Internet gaming use, then the next edition of the DSM may list it as an official mental disorder. MAKING CONNECTIONS IN PSYCHOLOGICAL DISORDERS: CREATIVITY AND MENTAL HEALTH • Creative figures throughout history have experienced some psychological condition so often that many people think the two are connected. The term mad genius reflects this belief. Evidence for a Relationship Between Creativity and Psychological Disorders • Arnold Ludwig examined the lifetime rates of psychological disorders across the professions and over lifetimes. • Lifetime rates for any psychiatric illness are remarkably high for people in the arts—87% of poets, 77% of fiction writers, 74% of actors, 73% of visual artists, 72% of nonfiction writers, 68% of musical performers, and 60% of musical composers are affected by some type of psychiatric disorder. Keep in mind that the rate in the general population for any disorder is 46%. This study clearly indicates a higher prevalence of disorder in creative artists than in people in the general population. Which Disorders Affect Creative Artists? Autism Spectrum Disorder and Creativity • Most savants do not produce great works of original genius because their amazing feats of calculation and recall are not original, nor do they create something significant. Some savant prodigies do produce truly creative works of art, usually math analyses, musical compositions, drawings, or painting. • Asperger’s syndrome, or high-functioning autism, has been associated with creative ability in science, math, and engineering. • Children with Asperger’s are more than twice as likely as normal children to have a father or grandfather who was an engineer. Psychotic Symptoms and Creativity • Having unusual thoughts is common to both creative people and those with schizophrenia. • It is the milder psychotic symptoms, however, that are most strongly associated with creativity. • Each of the following groups manifest unusual thought processes that are milder than those of schizophrenia—first-degree relatives of individuals with schizophrenia, people with Schizotypal personality disorder, and those who score high on the normal personality dimension of psychoticism. • Having a lot of ideas come to mind quickly can lead to many unusual associations that may be creative, but they may also be so unusual as to be similar to the bizarre associations seen in people with schizophrenia. • People in these groups are more likely to have unusual thought processes that develop into creative achievements that other people recognize to be important and significant. Depression and Creativity • Across 16 professions, the lifetime rate of depression was 30%, with poets (77%), fiction writers (59%), and visual artists (50%) having the highest rates. • Poets are 20 times more likely to commit suicide, a key indicator for depression, than most people. • Although highly creative artists and writers may suffer from depression more than most people, depressive episodes themselves do not generate much creative output. Recall that a complete lack of motivation is a common symptom of depression, so lower productivity would follow. However, the experiences one has while depressed might inspire and motivate the creation of works of art. Bipolar Disorder and Creativity • Actors (17%), poets (13%), architects (13%), and nonfiction writers (11%) all exceed a 10% lifetime rate of bipolar disorder—10 times the rate in the general population. • There is a positive relationship between bipolar disorder and creative thought. Some studies have shown that highly creative people are more likely than noncreative people to have bipolar disorder but others show the opposite. The manic phase is more likely to generate creative behavior than the depressive phase. • CONNECTION: Creative thinking requires novelty and connections among ideas (Chapter 10). KEY TERMS agoraphobia: an anxiety disorder involving fear of being in places from which escape might be difficult or in which help might not be available should a panic attack occur. antisocial personality disorder: personality disorder marked by extremely impulsive, deceptive, violent, ruthless, and callous behaviors. attention deficit hyperactivity disorder (ADHD): childhood disorder characterized by inability to focus attention for more than a few minutes, to remain still and quiet, to do careful work. autistic spectrum disorder: characterized by severe language and social impairment combined with repetitive habits and inward-focused behaviors. avoidant personality disorder: the person is so afraid of being criticized that they avoid interacting with others and become socially isolated. bipolar disorder: mood disorder characterized by substantial mood fluctuations, cycling between very low (depressive) and very high (manic) moods. borderline personality disorder: personality disorder characterized by out-of-control emotions, are very afraid of being abandoned by others, and vacillate between idealizing those close to them and despising them. cognitive symptoms (of schizophrenia): problems with working memory, attention, verbal and visual learning and memory, reasoning and problem solving, processing, and speech. comorbidity: occurrence of two or more disorders at the same time. compulsion: a repetitive behavior performed in response to uncontrollable urges or according to a ritualistic set of rules. cyclothymia: a relatively mild but long lasting form of bipolar disorder. delusion: false beliefs, often exaggerated claims, that a person holds in spite of evidence to the contrary. dependent personality disorder: personality disorder characterized by fear rejection and a strong need to be cared for that they form very clingy relationships with others. depressive disorder: the highest-order category of the depressive disorders; it subsumes all forms of depression, including major depressive disorder and persistent depressive disorder. diathesis-stress model: explanation for the origin of psychological disorders as a combination of biological predispositions (diathesis) plus stress or an abusive environment. dissociative disorders: extreme splits or gaps in memory, identity, or consciousness. dissociative identity disorder (DID): disorder in which the sufferer develops at least two distinct personalities, each with a unique set of memories, behaviors, thoughts, and emotions. generalized anxiety disorder (GAD): pervasive and excessive state of anxiety lasting at least 6 months. hallucinations: convincing sensory experiences that occur in the absence of an external stimulus. histrionic personality disorders: personality disorder in which the sufferer wants to be the center of attention and often behave in very dramatic, seductive, flamboyant, and exaggerated ways. hypomanic episodes: consists of the same symptoms as manic episodes (e.g., increased energy, sleeplessness, euphoria, irritability, delusions of grandeur, increased sex drive, and "racing" thoughts) but shorter in duration. illness anxiety disorder: fear of somatic symptom but without any somatic symptoms. joint attention: ability to make eye contact with others and to look in the same direction that someone else is looking. major depressive disorder: a disorder characterized by pervasive low mood, lack of motivation, low energy, and feelings of worthlessness and guilt that last for at least two consecutive weeks. manic episodes: typically involve increased energy, sleeplessness, euphoria, irritability, delusions of grandeur, increased sex drive, and “racing” thoughts. narcissistic personality disorders: personality disorder characterized by extremely positive and arrogant self-images; most of the sufferer’s time and attention is self-focused. negative symptoms (of schizophrenia): symptoms of schizophrenia which include nonresponsiveness, emotional flatness, immobility catatonia, problems with speech, and inability to complete tasks. obsession: an unwanted thought, word, phrase, or image that persistently and repeatedly comes into a person’s mind and causes distress. obsessive-compulsive disorder (OCD): an anxiety disorder that is manifested in both thought and behavior. panic attacks: associated with perceptions of threat and can occur for a number of reasons: fear of danger, inability to escape, embarrassment, or specific objects. panic disorder: involves panic attacks and the persistent worry, embarrassment, and concern about having more attacks. paranoid personality disorder: personality disorder in which the sufferer is extremely suspicious and mistrustful of other people, in ways that are both unwarranted and maladaptive. persistent depressive disorder: form of depression that is milder in intensity, but longer in duration, than major depressive disorder. personality disorders: maladaptive and inflexible patterns of cognition, emotion, and behavior that generally develop in late childhood or adolescence and continue into adulthood. phobia: an ongoing and irrational fear of a particular object, situation, or activity. positive symptoms (of schizophrenia): the perceptual experiences associated with schizophrenia, including hallucinations, delusional thinking, and disorganized thought and speech. post-traumatic stress disorder (PTSD): a type of trauma and stressor related disorder that involves intrusive and persistent cognitive, emotional, and physiological symptoms triggered by catastrophic or horrifying events. psychotic disorders: primarily disorders of thought and perception, and are characterized by an inability to distinguish real from imagined perceptions. schizoid personality disorder: personality disorder in which the sufferer does not want close relationships; is emotionally aloof, reclusive, and humorless; and wants to live a solitary life. schizophrenia: disorder involves profound disturbances in thought and emotion. schizotypal personality disorder: personality disorder in which the sufferer is isolated and asocial and has very odd thoughts, perceptual distortions, and beliefs. social phobia or social anxiety disorder: a pronounced fear of humiliation in the presence of others; marked by severe self-consciousness about appearance or behavior or both. somatic symptom disorder: occurs when a person complains of multiple physical disorders that have no known medical or physical basis. syndrome: a set of related conditions. word salad: term for the speech of people with schizophrenia, which may follow grammatical rules but be nonsensical in terms of content. MAKING THE CONNECTIONS (Some of the connections are found in the text. Other connections may be useful for lecture or discussion.) Defining Psychological Disorders CONNECTION: Dementia and Alzheimer’s disease are neurocognitive disorders related to age. Other disorders, such as sleep disorders, can occur at any time in a person’s life (Chapters 5 and Chapter 6). o Activity: Check out the livestrong.com website (http://www.livestrong.com/article/5951-psychological-disorders-elderly/) on psychological disorders in the elderly. CONNECTION: How does our first environment, the womb, shape the expression of our genes? (Chapter 3) o Discussion: Ask students what they think about the diathesis stress model. It indeed explains why some veterans seemingly have no difficulty and others have significant difficulty, or why some victims of trauma seem to bounce back more quickly. CONNECTION: Development, language development in particular, occurs rapidly during critical periods, when we are biologically most receptive to a specific kind of input from the environment (Chapter 9). o Discussion: This is also evidence for the diathesis stress model. You may also want to point out to students that this is one of the limitations of co-relational designs. That is, there could also be a third factor variable here in terms of the kinds of parents who abuse. Ask students what kinds of factors or stressors may lead to abuse. Depressive Disorders CONNECTION: A person can inherit one form of a gene, or allele—say, for red hair—from one parent and a different form—maybe for brown hair—from the other parent (Chapter 3). o Discussion: Ask students how concepts of dominant and recessive genes might influence the impact of genetic contributions to depression. Schizophrenia CONNECTION: During fetal development the brain is extremely vulnerable to all kinds of toxins (Chapter 5). o Discussion: You may want to introduce students to the neurodevelopmental hypothesis, which argues that early brain development gone awry may be causal in the development of schizophrenia. See biology online for a brief overview: http://www.biology-online.org/articles/advances_neurobiology_schizophrenia/neurodevelopmental_hypothesis_schizophrenia.html. Psychotic Symptoms and Creativity CONNECTION: Psychoticism can be measured in degrees. Normal people vary considerably in their scores on psychoticism measures (Chapter 13). Creative thinking requires novelty and connections among ideas (Chapter 10). o Discussion: See http://www.trans4mind.com/personality/EPQ.html for an overview of traits Eysenk argued were parts of psychoticism. Eysenk has done considerable research on creativity and psychoticism and may be one of the leaders in this area. Personality Disorders CONNECTION: Neuroplasticity occurs when neurons and hence brain structure and function change as a result of input from the environment (Chapter 3). o Activity: Have students check out the article in Psychology Today (2008) on the revolution of neuroscience and psychology (http://www.psychologytoday.com/blog/enlightened-living/200806/neuroplasticity-the-revolution-in-neuroscience-and-psychology-part-i) Making Connections CONNECTION: Creative thinking requires novelty and connections among ideas (Chapter 10). o Activity: Have students read more about illness anxiety disorder, at the Encyclopedia of Mental Disorders (http://www.minddisorders.com/Flu-Inv/Hypochondriasis.html) and discuss how creativity factors into this disorder. INNOVATIVE INSTRUCTION 1. Defining Psychopathology: You may want to point out to students that defining a disorder is no easy feat. For example, do you go with statistically unusual? If so, then how do you deal with intelligence? The bottom 2.5% are in the DSM as intellectually challenged but the top 2.5% (the gifted portion) are not. Should they be? Then what do you do about disorders that are high in the general population, like substance abuse? Students generally have no problem brainstorming ideas about what abnormal is, but it is easy to challenge most of them. For example, let’s use unusual behaviors. Are behaviors you don’t see frequently necessarily abnormal? What if a student took of his or her shirt and started dancing on a table in a bar? It’s not something you see every day, but as the tabloids show us, it’s not something that people think is necessarily “abnormal.” However, if it happened in class… Another factor is cultural influences. It is important to remind students that speaking in tongues in a Pentecostal church is fine but in another setting, it’s probably not. 2. PTSD: Ask students about what kinds of events other than war can lead to PTSD. Point out that being a victim of a violent crime, for example, could lead to similar effects. What kinds of effects could this have on everyday life? 3. Phobias: Ask students what they have a phobic response to. You may want to point out that having one phobia in a subtype—say animal types—increases the probability of having another phobia in the same subtype (e.g., fear of spiders and snakes). You may want to show this clip of unusual phobias http://www.youtube.com/watch?v=9rl7Lr6eDLc 4. Abuse and brain damage: Remind students that perhaps being abused as a child may affect the development of the brain increasing activity level. That is, neglect and abuse no doubt affect the way the brain becomes wired. For example, let’s take poor feeding habits. Would poor food choices affect the development of the brain? Further, witnessing extreme abuse of others or being in an aggression-charged environment would have effects on behavior as well. 5. Autism Spectrum Disorders: You may want to point out that the increase is most likely due to several factors—increased awareness, a broadening of the definition into “spectrum,” a need to “label” a child to procure government-provided services for children with delays, and many others. Ask students to brainstorm other possible reasons for why the numbers have jumped. 6. Psychoticism can be measured in degrees. Normal people vary considerably in their scores on psychoticism measures (Chapter 13). Creative thinking requires novelty and connections among ideas (Chapter 10). 7. See http://www.trans4mind.com/personality/EPQ.html for an overview of traits Eysenck argued were parts of psychoticism. Eysenck has done considerable research on creativity and psychoticism. 8. Ask students what they think about the DID diagnosis. Do they think it’s possible? This is a good time to remind students about Loftus’s work on repressed memories. 9. As discussed in Chapter 10, some people who have autism or Asperger’s syndrome are called savants for their extreme giftedness in one domain, such as music or math. At this point, most students are thinking that this sounds great. Students tend to idolize actors, writers, musicians, and artists. Remind students that although they show great creativity, the data overall supports that these increases in ability in one area are tied to severe deficits in other areas. For example, although it may sound to them that savants have these great spikes, they often cannot complete many aspects of independent living without help. That is, depressive stages and autism are severely debilitating. You may also want to remind them that most schizophrenics are not like John Nash; they are homeless and in a vicious cycle of non-treatment and severe symptoms. 10. Assign students to take a quick quiz to test their knowledge: http://www.psywww.com/selfquiz/ch12mcq.htm 11. Have students do a literature review of the recent supposed “causes” of autism and then write a paragraph. You may want to pick a few and show that research has yet to show any definitive causal factor. 12. Have students watch Girl Interrupted and write a two-paragraph synopsis of the disorders seen in the film. 13. Have a speaker from the counseling department at your university come and speak to your class. As college students are at the peak age for the development of many disorders, counselors can answer student questions and review the support available at your university. This may also increase students’ awareness of diversity and disability. 14. Students love to talk about dissociative states! Remind them that there is little evidence here but it is also hard to falsify claims. Have them do a little Internet research and bring to class one example they found for either a “pro” or a “con.” This should lead to a lively discussion. 15. Those most likely to develop anxiety disorders are people with a genetic predisposition to anxiety, low levels of GABA, or the personality trait of neuroticism and who also experience chronic stress environments or abuse. Ask students to discuss the issue of biology being destiny. If they know that their partner has a history of a psychological disorder somewhere in his/her bloodline, should they panic about reproducing? 16. Do you think a person can be addicted to technology? If a person is spending 10 or more hours on line and it is interfering with their daily life, is that a problem? Is it a problem if a person constantly checks their phone? Be sure and have students defend their answer. This question often provides some lively debate, especially if a class has generational differences. Suggested Media 1. The Aviator, a biography of Howard Hughes. 2. Any episode of Monk will demonstrate OCD. 3. Girl Interrupted is based on Susanna Kaysen’s book and real-life experience as a patient in the mid-1960s. 4. Show Sybil as an example of DID. 5. A clip from NOVA on epigenetics in identical twins: http://www.pbs.org/wgbh/nova/sciencenow/3411/02.html 6. A brief clip with interviews of people with schizophrenia: http://www.youtube.com/watch?v=f4R6jln_eZg&feature=related’ 7. The brain and schizophrenia: http://www.youtube.com/watch?v=DL8mOHCIb_w 8. Medications and schizophrenia: http://www.youtube.com/watch?v=80skOLGG2dI 9. A clip of a doctor living with manic depression at Johns Hopkins: http://www.youtube.com/watch?v=CxRLap9xLag 10. The Learning Resources Organization has free copies of an Abnormal Psychology Video set. You have to register first, but then you can play it in the classroom: http://www.learner.org/resources/series60.html 11. Show Temple Grandin, a biography on a woman with autism. 12. Copycat is an example of panic attacks and agoraphobia. 13. As Good As It Gets is an example of OCD. 14. A Beautiful Mind is an example of schizophrenia. 15. Three Faces of Eve is an example of DID and a forerunner to Sybil. 16. Understanding Mental Illness and Schizophrenia (Information Television Network) 17. Discovering Psychology—Psychopathology (Annenberg). 18. Bipolar: The Right Diagnosis (ABC). 19. ADHD (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.). 20. Symptoms of Schizophrenia (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.). 21. John Nash, A Beautiful Mind (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.). 22. Depression Theories and Treatment (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.). 23. Bipolar Disorder (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.). 24. Obsessive-Compulsive Disorder (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.). 25. Borderline Personality Disorder (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.). 26. Ellen Saks talks about her life with schizophrenia: http://www.ted.com/talks/elyn_saks_seeing_mental_illness 27. The Soloist (2009) (schizophrenia). Concept Clips (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.) 1. Abnormality 2. Major Depressive Disorder Suggested Websites 1. An Internet dictionary of abnormal terms: http://www.mentalhealth.com/p20-grp.html 2. Links to pages for most of the disorders: http://www.healthyplace.com/site/disorders_list.asp 3. DSM-5 information http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683251/ 4. Journal of Abnormal Psychology—some free articles: http://www.apa.org/journals/abn/ 5. A great overview of psychology (and the abnormal page is great): http://www.psywww.com/index.html 6. National Institute of Mental Health (NIMH): http://www.nimh.nih.gov/ 7. ICD-10 website—free access: http://www.who.int/classifications/icd/en/ 8. Temple Grandin, PhD’s website: http://www.templegrandin.com/ 9. National Alliance for the Mentally Ill http://www.nami.org/ 10. Anxiety Disorders Association website: http://www.adaa.org/ 11. A great biological site on anxiety disorder: http://www.brainexplorer.org/brain_disorders/Focus_Panic_disorder.shtml 12. Schizophrenia Home Page: http://schizophrenia.com/ Suggested Readings American Psychiatric Association APA. (2013). Diagnostic and statistical manual of mental disorders. Angst, J. (2013). Bipolar disorders in DSM-5: Strengths, problems and perspectives. International Journal of Bipolar Disorders http://www.journalbipolardisorders.com/content/pdf/2194-7511-1-12.pdf Eysenck, H. J. (1983). The roots of creativity: Cognitive ability or personality trait? Roeper Review, 5, 10–12. Eysenck, H. J. (1993). Creativity and personality: Suggestions for a theory. Psychological Inquiry, 4, 147–178. Freedman, R. (2010). The madness within us: Schizophrenia as a neuronal process. Oxford University Press. Glenn, A. L., et al. (2007). Early temperamental and psychophysiological precursors of adult psychopathic personality. Journal of Abnormal Psychology. 116, 508–515. Heath, A. C., & Martin, N. G. (1990). Psychoticism as a dimension of personality: A multivariate genetic test of Eysenck and Eysenck's psychoticism construct. Journal of Personality and Social Psychology, 58, 111–121. Kendell, R., & Jablensky, A. (2003). Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry, 160(1), 4–12. Krueger, R. F., Watson, D., Barlow, D. H., et al. (2005). Toward a dimensionally based taxonomy of psychopathology. Journal of Abnormal Psychology, 114, 491–493. Nathan, D. (2011). Sybil exposed: The extraordinary story behind the famous multiple personality case. Free Press Redfield-Jamison, K. (1997). An unquiet mind: A memoir of moods and madness. Vintage. Redfield-Jamison, K. (2000). Night falls fast: Understanding suicide. Vintage. Regier, D. S., Narrow, W. E., First, M. B., & Marshall, T. (2002). The APA classification of mental disorders: future perspectives. Psychopathology, 35(2–3), 166–170. Saks, E. R. (2007). The center cannot hold: My journey through madness. Hyperion. Smith, D. (2013). Monkey mind: A memoir of anxiety. Simon & Schuster. Chapter 16: Treatment of Psychological Disorders BRIEF CHAPTER OUTLINE Biomedical Treatments for Psychological Disorders Drug therapies Drug Treatments for Schizophrenia Drug Treatments for Depressive and Anxiety Disorders Psychosurgery Electric and Magnetic Therapies Electroconvulsive Therapy Repetitive Transcranial Magnetic Stimulation Deep Brain Stimulation Challenging Assumptions in the Treatment of Severe Depression Effectiveness of Biomedical Treatments Psychological Treatments for Psychological Disorders Psychoanalytic Therapy Humanistic/Positive Therapy Behavior Therapies Cognitive and Cognitive-Behavioral Treatments Group Therapy Effectiveness of Psychological Treatments Technology-Based Treatments of Psychological Disorders Effectiveness of Technology-Based Therapy Combined Approaches Drugs and Psychotherapy Integrative Therapy Mindfulness Training and Psychotherapy Effectiveness of Combined Approaches Psychology in the Real World: How to Choose a Therapist Emerging Therapies Preventing Disorders Bringing It All Together: Making Connections in the Treatment of Psychological Disorders: Approaches to the Treatment of OCD and Anxiety Disorders Chapter Review EXTENDED CHAPTER OUTLINE • Mental health professionals rely on four major forms of treatment to help people with mental disorders. These treatments are: (1) biomedical, (2) psychological, (3) technology based, and (4) combined therapies. BIOMEDICAL TREATMENTS FOR PSYCHOLOGICAL DISORDERS • Four major forms of treatment exist: biologically based, psychologically based, and integrative. o Biomedical treatments include drugs, surgery, electric and magnetic treatments. o Psychological treatments include psychoanalytic/psychodynamic, humanistic, cognitive, and behavioral therapies. o Technology-based treatments are therapies making use of technology or the internet (e.g., virtual reality therapies). o Combined approaches combine either drugs and psychotherapies or different variations of psychotherapy, or combine less traditional approaches, such as meditation, with other more traditional techniques. • Most mental health practitioners rely on all four forms of treatment. Each treatment provider works from a perspective based on training, personal interests, and experience. Drug Therapies Drug Treatments for Schizophrenia • Drug treatments are typically the first choice of treatment for schizophrenia. • Phenothiazines help diminish hallucinations, confusion, agitation, and paranoia in people with schizophrenia, but also have adverse side effects. These drugs block dopamine receptors in the brain. • Traditional antipsychotics such as phenothiazines and haloperidol were the first medications used to manage psychotic symptoms. Unfortunately, they have many unpleasant side effects, including fatigue, visual impairments, and a condition called tardive dyskinesia. Tardive dyskinesia is repetitive, involuntary movements of jaw, tongue, face, and mouth (such as grimacing and lip smacking) and body tremors. • Atypical antipsychotics are newer antipsychotics that do not have these side effects. Many physicians now consider the atypical antipsychotics the first line of treatment for schizophrenia. These drugs preferentially block a different type of dopamine receptor than the traditional antipsychotics do, which makes them less likely to create tardive dyskinesia. • CONNECTION: Schizophrenia and other disorders can be caused in part by genes that are expressed only under specific environmental circumstances (Chapter 15). • CONNECTION: Do you need a caffeinated beverage to get you going in the morning and more throughout the day to stay alert? People who require more and more caffeine or other drugs, including prescription drugs, have developed a drug tolerance (Chapter 6). Drug Treatments for Depressive and Anxiety Disorders • There are six major categories of drugs used to treat mood and anxiety disorders: monoamine oxidase (MAO) inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, barbiturates, and lithium. • Monoamine oxidase (MAO) inhibitors were the first pharmaceuticals used to treat depression. These drugs reduce the action of the enzyme monoamine oxidase, which breaks down monoamine neurotransmitters (including norepinephrine, epinephrine, dopamine, and serotonin) in the brain. By inhibiting the action of this enzyme, MAO inhibitors allow more of these neurotransmitters to stay active in the synapse for a longer time, which presumably improves mood. o Unfortunately, MAO inhibitors have many serious side effects and interactions. A new transdermal patch may help overcome some of these side effects. • Tricyclic antidepressants work by blocking the reuptake of both serotonin and norepinephrine almost equally; hence, they work by making more of these neurotransmitters available in the brain. The tricyclics produce unpleasant side effects, however, such as dry mouth, weight gain, irritability, confusion, and constipation. They are still popular for treating depression and are also used for chronic pain management, ADHD, and bedwetting. • Selective serotonin reuptake inhibitors (SSRIs) make more serotonin available in the synapse, as depressed people have typically low levels of serotonin. SSRIs are among the most widely prescribed psychotherapeutic drugs in the United States today. o Serotonin, like all neurotransmitters, is released from the presynaptic neuron into the synapse. It then binds with serotonin-specific receptor sites on the postsynaptic neuron to stimulate the firing of that neuron. Normally, neurotransmitters that do not bind with the postsynaptic neuron will be either taken back up into the presynaptic neuron (a process called reuptake) or destroyed by enzymes in the synapse. The SSRIs inhibit the reuptake process, thereby allowing more serotonin to be received and used by the postsynaptic neuron. o By allowing more serotonin to be used, the SSRIs alleviate some of the symptoms of depression. o Although prescribed primarily for depression, they are also prescribed for the treatment of certain anxiety disorders, especially OCD, as well as disorders of impulse control, such as compulsive gambling. There are fewer side effects with SSRIs. Some side effects can occur and include agitation, insomnia, nausea, and difficulty in achieving orgasm. o CONNECTION: Deficiencies in either the amount or the utilization of serotonin in certain parts of the brain are often found in people with depression (Chapter 15). • Benzodiazepines and barbiturates are prescribed for anxiety because they have calming effects. Unfortunately, they can be addictive. • Lithium is a salt that is prescribed for its ability to stabilize the mania associated with bipolar disorder. It is not known how lithium works. It appears, however, to influence many neurotransmitter systems in the brain, including glutamate. Glutamate is the major excitatory neurotransmitter in the brain, which appears to play a substantial role in schizophrenia. Taking lithium can be unpleasant and dangerous, as it can cause diarrhea, nausea, tremors, cognitive problems, kidney failure, brain damage, and even adverse cardiac effects. Due to its toxicity physicians often prefer to prescribe other drugs. Currently the atypical antipsychotics are often prescribed. Psychosurgery • Prefrontal lobotomy is a form of psychosurgery that is no longer preformed. In a lobotomy the connections between the prefrontal lobes and the lower portion of the brain are severed. • The belief was that this would disconnect the thinking and emotional areas of the brain. However, prefrontal lobotomies produced profound personality changes, often leaving the patient listless or subject to seizures. Some patients were even reduced to a vegetative state. • After the introduction of the traditional antipsychotic medications, the lobotomy fell out of favor. Today a few, highly constrained forms of brain surgery are occasionally performed, but only as a last resort after other forms of treatment have been unsuccessful. Electric and Magnetic Therapies Electroconvulsive Therapy • Electroconvulsive therapy (ECT) involves passing an electrical current through a person’s brain in order to induce a seizure. This is a treatment of last resort. • Research eventually demonstrated, however, that ECT did not treat the symptoms of schizophrenia effectively at all, and it disappeared as a viable therapy for years. It resurfaced later as a treatment for people with severe cases of depression. • Standard ECT treatment involves up to 12 sessions over the course of several weeks. During these sessions, electric currents (60 to 140 volts) are passed through the brain for 1/3 to 1/2 second. Although some people report immediate relief of their depressive symptoms, it creates some permanent memory loss and other types of cognitive damage because it actually destroys some brain tissue. Repetitive Transcranial Magnetic Stimulation • Repetitive transcranial magnetic stimulation (TMS) is a treatment for severe depression. Physicians expose particular brain structures to bursts of high-intensity magnetic fields instead of electricity. Like ECT, repetitive transcranial magnetic stimulation is usually reserved for people with severe depression who have not responded well to other forms of therapy. Deep Brain Stimulation • Deep brain stimulation is a promising new treatment for various psychological disorders including depression. • Electrodes are implanted into the brain to allow electrical stimulation of specific brain regions and clusters of neurons. • Deep brain stimulation has shown promise in the treatment of anorexia and Alzheimer's disease. Challenging Assumptions in the Treatment of Severe Depression • Neurologist Helen Mayberg discovered what appears to be a neural switch that activates depression. The path led Mayberg to discover how a brain region called Brodmann’s Area 25 may control depression. • Mayberg applied deep brain stimulation to 12 people with severe depression that did not respond to traditional treatments. The patients responded positively. • Area 25 was hyperactive in the depressed patients. • Finding over-activity challenged previous assumptions that the brain areas of depressed people were underactive. • Figures 16.4 and 16.5 illustrate the brain areas and the pacemaker implanted in the chest to send electrical signals to the brain. • Most people who have had the procedure experience dramatic improvements or complete elimination of their depression. A few, however, do not. • Research is currently ongoing. Effectiveness of Biomedical Treatments • The SSRIs and tricyclics show comparable effectiveness in the treatment of depression and are preferable to MAO inhibitors. They have the fewest adverse side effects and are better tolerated for long-term use. • According to a large-scale meta-analysis, most widely used prescription antidepressants may be beneficial to those with severe depression but no better than placebos for people with mild to moderate depression. • Lithium is still widely used for treatment of mania. Lithium does appear to have long-term effectiveness in treating bipolar disorder. • The evidence for lithium's effectiveness for acute mania is weak. • Lithium does not appear to be superior to antipsychotic medications. • Both traditional and atypical antipsychotic drugs work best on the positive symptoms of schizophrenia, such as hallucinations and delusions, but are generally less effective on the negative symptoms, such as flattened affect, and the cognitive confusion that is characteristic of the disorder. o Clozapine (Clorazil) does appear to be somewhat effective in treating the negative symptoms, but diabetes is a potentially serious side effect. o Keeping patients on the drugs seems to be an issue; up to 74% who use traditional and atypical antipsychotics discontinue treatment. • ECT is regarded as a treatment of last resort for severely depressed people who have not responded to any other therapy. PSYCHOLOGICAL TREATMENTS FOR PSYCHOLOGICAL DISORDERS • Psychotherapy is the use of psychological techniques to modify maladaptive behaviors or thought patterns, or both, and to help patients develop insight into their own behavior. Psychoanalytic Therapy • Psychoanalytic therapy is the original form of “talk therapy.” It is oriented toward major personality change with a focus on uncovering unconscious motives, especially through dream interpretation. Sessions tend to meet 3 to 5 times a week. Currently classical, or Freudian, psychoanalysis is relatively rare. • Free association is a Freudian technique that involves the client recounting a dream and then takes one image or idea and saying whatever comes to mind, regardless of how threatening, disgusting, or troubling it may be. After this has been done with the first image, the process is repeated until the client has made associations with all the recalled dream images. Ideally, somewhere in the chain of free associations is a connection that unlocks the key to the dream. • Symbols are dream images that are thought of as representing or being symbolic of something else. • Transference is another Freudian concept where the client reacts to a person in a present relationship as though that person were someone from the client’s past. • Some psychoanalytic techniques may lead to catharsis. Catharsis is the process of releasing intense, often unconscious, emotions in a therapeutic setting. Humanistic/Positive Therapy • Humanistic/positive therapies try to help the client reach his or her greatest potential. • Client-centered therapy was developed by Carl Rogers. The main idea of client-centered therapy is that people are not well because there is a gap between who they are and who they would ideally like to be. • Unconditional positive regard states that the therapist must show genuine liking and empathy for the client, regardless of what he or she has said or done. • Positive psychotherapy focuses explicitly on increasing a person’s happiness, well-being, and positive emotions. o Gratitude training involves daily exercises in noticing and finding things in life for which one is grateful and thankful. Behavior Therapies • In behavior therapies the application of classical and operant conditioning principles are used to treat psychological disorders. They focus on changing behavior. • The token economy is a technique where desirable behaviors are reinforced with a token, such as a small chip or fake coin, which can then be exchanged for privileges. o Recent uses include treatment of substance abuse by people with schizophrenia. Each time the patients did not use drugs, they were rewarded with small amounts of money. Coupled with problem-solving and social-skills training, this token system helped control substance abuse in hospitalized patients with schizophrenia, who are generally very hard to treat. • Systematic desensitization is used to treat simple phobias. Systematic desensitization pairs relaxation with gradual exposure to a phobic object. The therapist helps the client learn relaxation techniques that he or she can use when experiencing anxiety. o Systematic desensitization involves three levels of exposure to a phobic object.  In imagined exposure people simply imagine contact with the phobic object.  In virtual reality exposure virtual reality software allows clients to simulate flying or other objects of fear.  In vivo exposure exposes the client makes real-life contact with a phobic object. • Flooding (implosion therapy) is a form of in vivo exposure in which the client experiences extreme exposure to the phobic object. • CONNECTION: Principles of classical and operant conditioning, including the powerful effect of reinforcement on learning, are the foundation of many behavioral therapies (Chapter 8). Cognitive and Cognitive-Behavioral Treatments • Cognitive therapy is any type of psychotherapy that works to restructure irrational thought patterns. o The therapist helps the client identify irrational thought patterns and then challenges these thoughts. o This therapy is structured and problem-oriented. The goal is to fix problematic thought patterns. o Cognitive therapy involves a collaborative effort by the therapist and client. • Cognitive-behavioral therapy (CBT) is an approach that combines techniques for restructuring irrational thoughts with operant and classical conditioning techniques to shape desirable behaviors. o This is a short-term psychological treatment that has been successfully applied to disorders as varied as depression, phobias, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, and substance abuse. o CBT teaches skills to diminish depressogenic thinking that tends to help generate or support depressed moods. CBT has revolutionized the treatment of many psychological disorders. Group Therapies • In group therapy several people who share a common problem all meet regularly with a therapist to help themselves and one another. The therapist acts as a facilitator. Group therapies often follow a structured process with clear treatment goals. • Support groups are meetings of people who share a common situation (e.g., a disorder, a disease, or coping with an ill family member). They meet regularly to share experiences, usually without programmatic treatment goals. They usually have a facilitator, a regular meeting time, and an open format. • Groups can be categorized in terms of their focus, such as eating disorders, substance abuse, treatment of OCD, or coping with bereavement, and may be time limited or ongoing. Effectiveness of Psychological Treatments • It is increasingly believed that therapists need to make treatment choices based on empirical evidence of the treatments efficacy. • Evidence-based therapies are treatments based on empirical evidence of their efficacy • Current meta-analyses of the effectiveness of psychotherapy continue to show most forms of therapy are effective. Few significant differences exist in effectiveness between general psychotherapy, cognitive-behavioral therapy, and psychodynamic therapy. This is known as the dodo bird verdict. • In some cases, the usefulness of psychotherapy depends on the nature of the disorder being treated and the state of the patient’s mental health. • Some conditions are more responsive to psychological interventions than others (e.g., personality disorders are best helped with psychodynamic psychotherapy and long-term group therapy improves basic life skills of schizophrenics). • People experiencing depressive disorders are much more responsive to psychological approaches than are people suffering from schizophrenic disorders. • Systematic desensitization is effective for treating a simple phobia but is inappropriate for treating depression. • Cognitive therapy (CT) and cognitive-behavioral therapy have shown perhaps the greatest effectiveness of any form of psychotherapy for treating various psychological disorders (especially for certain cases of depression and anxiety disorders). o Some research suggests that CT is as effective as antidepressants in treating severe depression. • Behavioral treatments, such as systematic desensitization, are very effective for treatment of certain anxiety disorders, especially simple phobias, including performance anxiety and public speaking. TECHNOLOGY-BASED TREATMENTS OF PSYCHOLOGICAL DISORDERS • Technology-based therapies make use of technology or the Internet to complement current therapies or make psychotherapeutic techniques available to people who might otherwise not have access to it or seek it out. • Virtual reality therapies use virtual (digital simulation) environments that create therapeutic situations that might be hard to create otherwise; used for treatment of phobia and PTSD. • The Internet is used in treatments including Second Life (an online, virtual environment where people interact in real time with others). The character you use is called an avatar (hence the name “avatar therapy”). Effectiveness of Technology-Based Therapy • Second Life offers people with social anxiety, those who avoid therapy because it requires them to get out of house and go in new environment, a “safe” form of psychotherapy, because they are not directly observed or exposed to ridicule and embarrassing situations. • There is evidence that electronic distribution can work effectively for certain anxiety symptoms, including measures of panic disorder. COMBINED APPROACHES Drugs and Psychotherapy • Drugs can modify some of the debilitating effects of a disorder enough so that the patient can function well enough to learn techniques that might help in changing his or her problematic thinking and behavior. • This approach works best for depressive and anxiety disorders, in which thinking is not severely impaired. Integrative Therapies • The majority of clinical psychologists report that they use an integrative approach to treatment. • In integrative therapy clinicians are trained in many methods. They use those that seem most appropriate given the situation. They are not loyal to any particular orientation or treatment. This is an eclectic approach to psychotherapy. • Prolonged exposure therapy is an integrative treatment program for people who have post-traumatic stress disorder. It combines CBT with methods of the imagined exposure form of systematic desensitization and relaxation. Mindfulness Training and Psychotherapy • Some recently developed therapies integrate the nontraditional practice of mindfulness meditation with psychotherapeutic techniques to treat psychological disorders. In mindfulness meditation, the mediator is trained to note thoughts as they occur, without clinging to them. • Mindfulness-based cognitive therapy (MBCT) is an approach that combines elements of CBT with mindfulness meditation to help people with depression learn to recognize and restructure negative thought patterns. • Meditation-based therapies have been used with some success in the treatment of positive and negative symptoms of schizophrenia. • A new approach in the treatment of schizophrenic symptoms focuses on changing relationship with voices rather than trying to make them go away. • CONNECTION: Mindfulness meditation practices help people become aware of everything that occurs in the mind and recognize it for what it is: a thought, an emotion, or a sensation that will arise and dissipate (Chapter 6). • Dialectical behavior therapy (DBT) is a treatment that integrates elements of CBT with exercises aimed at developing mindfulness without meditation. Effectiveness of Integrative Approaches • Few systematic studies have examined the effectiveness of integrative therapy. • A 14-month study of mental health in more than 500 children examined the relative effectiveness of medication, behavioral treatment, and the combination of the two approaches in treating a variety of disorders. For AD/HD, for example, the combination of drugs and behavioral therapy was superior to behavioral intervention and better than medication alone for most outcome measures. • Clinical research shows that prolonged exposure therapy (an integrative CBT approach) is effective at substantially reducing symptoms of PTSD. • The advantage of mindfulness-based cognitive therapy compared with standard cognitive therapy is that it works when the person is in a nondepressive state, and so it might help prevent relapse. • Borderline personality disorder has long been considered nearly untreatable. DBT is quite effective in reducing self-inflicted harmful behaviors, lowering scores on depression questionnaires, decreasing dysfunctional patterns associated with substance abuse, and increasing the likelihood of staying in treatment. PSYCHOLOGY IN THE REAL WORLD: HOW TO CHOOSE A THERAPIST • About 50% of the adult population at some point in their life will suffer from some form of psychological disorder but only a subset of that will seek therapy. Reasons for this include the stigma of going to see a therapist and the belief that friends and family are enough to help them. • The first step in selecting a therapist is to know the different types of therapists and what they can and cannot do.  Psychiatrists are medical doctors so they can prescribe medication. They usually treat the most severe disorders.  Clinical psychologists are trained to help people with moderate to severe psychological disorders. They are often trained in PhD (doctorate of philosophy) programs, but also in PsyD programs (doctorate of psychology). They often focus on past experiences as causes for current problems.  Counselors (usually those with Ed.D. or master’s degree) work in social settings and help people adjust to normal work- and family-related difficulties. They focus on the present rather than the past.  Social workers have a master’s degree in social work (MSW) and are trained in clinical practice.  Marriage and Family Therapists (MFT) have a master’s degree in clinical psychology and help couples and families deal with conflict. • Individuals should look for someone who has experience in the area in which you are having difficulty. • Individuals should also make sure the therapist is licensed and in good standing. • The relationship with the therapist is very important so individuals should trust their gut feelings on people. • Individuals need to know the therapist’s approach. • Finally, it is always helpful to ask for a referral. EMERGING THERAPIES • There are some new therapies on the horizon that are showing promise in the treatment of psychological disorders. • Optogenetics is a treatment that uses a combination of light stimulation and genetics to manipulate the activity of individual neurons. This has been used in treating OCD and chemical dependency. It may offer precise access to specific brain areas. • Another potential new therapy is the regulation of specific genes involved in various mental disorders. This is still in the early stage of research in animals. • A few studies have shown that after Botox injections to the glabellar region people feel less depressed. This is because of feedback to the brain from the facial muscles involving some negative emotions is reduced. PREVENTING DISORDERS • Prevention focuses on identifying risk factors for disorders, targeting at-risk populations, and offering training programs that decrease the likelihood of disorders occurring. • Most preventative programs focus on depression. • Many prevention programs focus on children because interventions earlier in life increase the likelihood of making a difference. • According to Van Voorhees and colleagues (2008), several characteristics put teens at risk for a depressive episode: being female, being of a nonwhite race, ethnicity, having low-income status, being in poor health, and experiencing parental conflict. • Poverty, unemployment, life stress, and a pessimistic outlook put one at risk of depression so prevention programs often focus on ways to deal with stress. • The Penn Resiliency Program (PRP) is designed to prevent depression and other psychological disorders by developing resilience and skills for coping with stress, problem solving (flexibility in the face of adverse or challenging circumstances), and cognitive restructuring (learning to change one’s perspective on events). BRINGING IT ALL TOGETHER: MAKING CONNECTIONS IN THE TREATMENT OF PSYCHOLOGICAL DISORDERS: APPROACHES TO THE TREATMENT OF OCD AND ANXIETY DISORDERS • OCD and the anxiety disorders are a diverse group of conditions. Mental health practitioners employ a wide variety of treatment strategies to help people with these disorders. Drug Therapies • There are two main categories of drug therapies for OCD and the anxiety disorders: antidepressants and antianxiety medications. Antidepressants • Many doctors prescribe SSRIs for the treatment of OCD, anxiety disorders, social phobia, post-traumatic stress disorder (PTSD), and panic disorder. People who take SSRIs for these disorders report that these medications help them avoid getting caught up in certain thoughts that otherwise would snowball into anxiety. Anti-Anxiety Medications • Beta-blockers are drugs that block the action of neurotransmitters, such as norepinephrine, to quickly calm the aroused sympathetic nervous system. These medications calm the physiological symptoms of anxiety, by bringing down heart rate, blood pressure, and rate of breathing. • The benzodiazepines (e.g., Valium) also calm the physiological arousal caused by anxiety and are widely prescribed for social phobias, panic disorder, and generalized anxiety disorder. • Newer antianxiety medications such as buspirone are less likely to create withdrawal symptoms, but require longer and constant usage. Psychotherapeutic Treatments • Cognitive-behavioral therapy (CBT) helps people with anxiety disorder identify irrational thoughts and undo thinking patterns that support fear; it also helps them modify their responses to anxiety-provoking situations. • Group CBT has been effective for treating social phobia. • Traditional psychodynamic therapies for anxiety disorders viewed anxiety as the main symptom of what was then commonly called neurosis. According to Freud, neurosis most often stemmed from repressed thoughts, feelings, and impulses that usually originated in childhood experiences. o Free association, dream interpretation, defense mechanisms, and catharsis are typically used to alleviate these symptoms. • Systematic desensitization is used for the treatment of specific phobias. Combined and Integrative Therapies and Anxiety • Medication can help people get “over the hump” of crippling symptoms so that a nondrug therapy has a chance to work. • There is evidence that integrative psychotherapeutic approaches offer potential relief from a range of anxiety disorders. As already noted, OCD may be treated with mindfulness meditation practices and cognitive therapy. Dialectical behavior therapy (DBT), which was developed to treat borderline personality disorder, has been used effectively to treat post-traumatic stress disorder. KEY TERMS atypical antipsychotics: newer antipsychotic drugs, which do not create tardive dyskinesia. Examples include Clozapine (Clozaril), olanzapine (Zyprexa), and risperidone (Risperdal). barbiturates: another class of drug for anxiety; has sedative, calming effects. These drugs can be addictive and carry risk of overdose. behavior therapies: therapies that apply the principles of classical and operant conditioning to treat psychological disorders. benzodiazepines: (Valium, Librium) a class of drugs prescribed for anxiety; has calming effects and can be addictive, but less dangerous than the barbiturates. catharsis: the process of releasing intense, often unconscious, emotions in a therapeutic setting. client-centered therapy: a form of humanistic therapy developed by Carl Rogers, in which the therapist must show genuine liking and empathy for the client, regardless of what he or she has said or done. cognitive-behavioral therapy: an approach that combines techniques for restructuring irrational thoughts with operant and classical conditioning techniques to shape desirable behaviors. cognitive therapy: any type of psychotherapy that works to restructure irrational thought patterns. defense mechanisms: processes that operate unconsciously and involve defending against anxiety and threats to the ego. dialectical behavior therapy (DBT): a program developed for the treatment of borderline personality disorder, which integrates elements of CBT with exercises aimed at developing mindfulness without meditation. dodo bird verdict: the finding that most forms of therapy are effective and few significant differences exist in effectiveness among standard therapies. electroconvulsive therapy (ECT): involves passing an electrical current through a person’s brain in order to induce a seizure; currently in limited use for treatment of severe depression. evidence-based therapies: treatments based on empirical evidence of their efficacy. flooding: an extreme form of in vivo exposure in which the client experiences extreme exposure to the phobic object. free association: a psychotherapeutic technique in which the client recounts a dream and then takes one image or idea and says whatever comes to mind, regardless of how threatening, disgusting, or troubling it may be. This process is repeated until the client has made associations with all the recalled dream images. group therapy: therapeutic settings in which several people who share a common problem all meet regularly with a therapist to help themselves and one another; the therapist acts as a facilitator. integrative therapy: also called “eclectic,” this is an approach to treatment in which the therapist is not loyal to any particular orientation or treatment, but rather draws on use of those that seem most appropriate given the situation. lithium: a salt that is prescribed for its ability to stabilize the mania associated with bipolar disorder. mindfulness-based cognitive therapy (MBCT): an approach that combines elements of CBT with mindfulness meditation to help people with depression learn to not cling to negative thought patterns. monoamine oxidase (MAO) inhibitors: one of the first classes of pharmaceuticals used to treat depression; these reduce the action of the enzyme monoamine oxidase, which breaks down monoamine neurotransmitters (including norepinephrine, epinephrine, dopamine, and serotonin) in the brain. optogenetics: a treatment that uses a combination of light stimulation and genetics to manipulate the activity of individual neurons. phenothiazines: the first class of drugs used to treat schizophrenia; helps diminish hallucinations, confusion, agitation, and paranoia; creates adverse side effects, including tardive dyskinesia. prefrontal lobotomy: a form of psychosurgery, in which the connections between the prefrontal lobes and the lower portion of the brain are severed. psychoanalytic therapy: oriented toward major personality change with a focus on uncovering unconscious motives, especially through dream interpretation. psychodynamic psychotherapy: therapy aimed at uncovering unconscious motives that underlie psychological problems. psychotherapy: the use of psychological techniques to modify maladaptive behaviors or thought patterns, or both, and to help patients develop insight into their own behavior. repetitive transcranial magnetic stimulation: physicians expose particular brain structures to bursts of high-intensity magnetic fields instead of electricity; usually reserved for people with severe depression. selective serotonin reuptake inhibitors (SSRIs): drugs that make more serotonin available in the synapse. Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), and Celexa (citalopram) are a few of the more widely used SSRIs; used primarily for depression and some anxiety disorders. support groups: meetings of people who share a common situation, be it a disorder, a disease, or coping with an ill family member. They meet regularly with each other to share experiences; these groups usually have a facilitator and an open format. systematic desensitization: a behavioral therapy technique, often used for phobias, in which the therapist pairs relaxation with gradual exposure to a phobic object, generating a hierarchy of increasing contact with the feared object, ranging from mild to extreme. tardive dyskinesia: a side effect from the extended use of traditional antipsychotics; consists of repetitive, involuntary movements of jaw, tongue, face, and mouth (such as grimacing and lip-smacking) and body tremors. technology-based therapies: make use of technology or the Internet to complement current therapies or make psychotherapeutic techniques available to people who might otherwise not have access to it or seek it out. token economies: a behavioral technique in which desirable behaviors are reinforced with a token, such as a small chip or fake coin, which can then be exchanged for privileges. traditional antipsychotics: historically, these were the first medications used to manage psychotic symptoms. transference: occurs in psychotherapy when the client reacts to a person in a present relationship as though that person were someone from the client’s past. tricyclic antidepressants: drugs used for treating depression. Examples include imipramine and amitriptyline, marketed under the trade names Elavil and Anafranil. They are also used in chronic pain management, to treat ADHD, and also as a treatment for bedwetting. virtual reality therapies: use virtual (digital simulation) environments that create therapeutic situations that might be hard to create otherwise. MAKING THE CONNECTIONS (Some of the connections are found in the text. Other connections may be useful for lecture or discussion.) Drug Treatments for Mood and Anxiety Disorders CONNECTION: Deficiencies in either the amount or the utilization of serotonin in certain parts of the brain are often found in people with depression (Chapter 15). • Discussion: Remind students that this is why the SSRIs are the post popular class of drugs for treating this disorder. Although researchers know how the drugs work, they are unsure as to why they work. CONNECTION: Do you need a caffeinated beverage to get you going in the morning--and more throughout the day to stay alert? People who require more and more caffeine or other drugs, including prescription drugs, have developed a drug tolerance (Chapter 6). • Discussion: This may contribute to folks with mental health issues not wanting to take their medications. Not only do most people never want to have to take a pill every day, but the side effects and the constant readjustment can wear on patients. Ask students what they think could be effective ways to get patients to take their medications. Drug Treatments for Schizophrenia CONNECTION: Schizophrenia and other disorders can be caused in part by genes that are expressed only under specific environmental circumstances • Discussion: Remind students of the diathesis-stress model discussed in Chapter 15. The diathesis or gene needs to be there and then stressors or experiences in the environment “select” the disorder. Behavioral Treatments CONNECTION: Principles of classical and operant conditioning, including the powerful effect of reinforcement on learning, are the foundation of many behavioral therapies (Chapter 8). • Discussion: You may want to point out to students examples you provided back in Chapter 8 of the Shi Tzu dog bite and how that could lead to a fear. Also remind them of how little Peter was “backward conditioned” by pairing the CS with a new favorable stimulus. This is an effective behavioral strategy. Mindfulness Training Combined with Psychotherapy CONNECTION: Mindfulness meditation practices help people become aware of everything that occurs in the mind and recognize it for what it is: a thought, an emotion, or a sensation that will arise and dissipate (Chapter 6). • Discussion: Have students take a look at the following article from Physorg.com on research done at Harvard, Yale, and MIT on the relationship between brain size and meditation: http://www.physorg.com/news10312.html INNOVATIVE INSTRUCTION 1. ECT: You may want to discuss with students ECT. Perhaps show a brief clip of it from One Flew Over the Cuckoo’s Nest and ask students what they think about it still being used today. Remind students that this is reserved for the most intensive cases as a last resort. 2. Talk Therapies: Students often get confused on the differences here. Remind students that the difference in most approaches stems from theoretical beliefs (e.g., psychodynamic stems from a belief of internal conflicts that are unconscious, behavioral from learning, etc.). This will directly correspond to the type of therapy and the methods used. What types of therapies have students seen in movies or TV? Is one form represented to a greater extent than others? What would it mean in terms of most insurance policies that only pay for 10 to 15 visits a year? 3. Psychopharmaceuticals: Ask students what they think about the now widespread use of psychopharmaceuticals. Maybe begin the discussion with, “How many of you know someone taking an antidepressant or anti-anxiety medication?” This should allow a segue into a discussion on if this is because it is needed or perhaps trendy. That is, if movie stars are found with benzodiazapans and antidepressives, what message does that send to impressionable youth? 4. Medication: Remind students of the controversy in medicating children for disorders like ADHD. You may want to show Frontline: The Medicated Child (http://www.pbs.org/wgbh/pages/frontline/medicatedchild/) to get the discussion going. Ask them if they think children should receive medication for a disorder. You may want to remind them that unlike cholesterol, blood sugars, or HIV, the disorders commonly found in children (like ADHD) cannot be tested for in a clear manner. This is where the controversy lies. Further, how does this carry over to adults? 5. Behaviorism: You may want to inform students that the reason behavioral and cognitive behavioral therapies are so popular now is: 1) their efficacy; 2) they are relatively short in duration; and thus, 3) they are less expensive. Ask students to generate examples of how a disorder could be learned and then how the behavioral perspective not only explains the disorder but also how it could be “fixed” therapeutically. 6. Assign students to take a quick quiz to test their knowledge: http://www.psywww.com/selfquiz/ch12mcq.htm 7. Go to http://www.deltabravo.net/custody/rorschach.php and print one or more of the Rorschach inkblots for use in class. Ask students to write down what they think they see. Then ask for a few students to volunteer their answers. What do they think about this methodology? Could it be used diagnostically? You may want to end with a brief discussion on how this measure lacks both reliability and validity. 8. Have students go to http://consensus.nih.gov/1998/1998AttentionDeficitHyperactivityDisorder110html.htm and read the article on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder from NIH. This is a 10-year-old article on ADHD. Have students then find one new source from the last 10 years and write one paragraph summarizing the initial article and a second on the current article. Then have them write a third paragraph on where the field should go from here. 9. Based on all the material we have covered in this text on abuse and epigenisis and disorders, have students try to integrate it all. Have them start at http://www.health.am/ab/more/psychological_therapy_can_help_maltreated_children/ for an article on abused kids and therapy. Have them write a short paper synthesizing material from the text discussing abuse and neglect, and how it affects the brain and leads to a greater risk of mental health issues. 10. There is a growing movement in the United States to allow clinical psychologists to prescribe medication. Three states, Louisiana, Illinois, and New Mexico, allow script-writing privileges after completing an additional requirement. What is your opinion of this change? Do you believe that clinical psychologists should be allowed to write prescriptions? Why or why not? Why do you think that the American Medical Association might not support this change? Suggested Media 1. One Flew Over the Cuckoo’s Nest. A classic depiction of a mental health center. 2. A brief audio clip of Freud in 1938: http://www.youtube.com/watch?v=_sm5YFnEPBE. 3. History of psychoanalysis and the case of Anna O: http://www.youtube.com/watch?v=AUB85lSj4pM. 4. Frontline: The Medicated Child: http://www.pbs.org/wgbh/pages/frontline/medicatedchild/. 5. Dr. Sherwin Nuland discussing electroshock therapy: http://www.ted.com/index.php/talks/sherwin_nuland_on_electroshock_therapy.html. 6. Martin Seligman on positive psychology: http://www.ted.com/index.php/talks/martin_seligman_on_the_state_of_psychology.html. 7. Harvard psychologist Dan Gilbert on happiness: http://www.ted.com/index.php/talks/dan_gilbert_asks_why_are_we_happy.html 8. Virtual Therapy for Agoraphobia (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.) 9. Using Soccer as Therapy (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.) Concept Clip (McGraw-Hill Connect for Feist and Rosenberg, 3rd ed.) 1. Cognitive Therapy Suggested Websites 1. Article on mediation and brain change: http://www.washingtonpost.com/wp-dyn/articles/A43006-2005Jan2.html 2. fMRI studies on monks: http://www.urbandharma.org/udharma8/monkstudy.html 3. A great site on most of the disorders: http://www.brainphysics.com/ 4. Department of Health’s site on alternative therapies: http://healthpsych.psy.vanderbilt.edu/alternative_therapy.htm 5. NIMH on childhood and adolescent mental health: http://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml 6. A great website for therapies: http://www.psychwww.com/resource/bytopic/therapies.html 7. WebMD on different disorders and therapies: http://www.webmd.com/anxiety-panic/guide/mental-health-psychotherapy 8. MBCT organization: http://www.mbct.com/. 9. Mayo Clinic's Website on ECT: http://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/basics/definition/prc-20014161 10. History of psychosurgery http://www.cerebromente.org.br/n02/historia/psicocirg_i.htm Suggested Readings Acton, G. S. (1998). Classification of psychopathology: The nature of language. Journal of Mind and Behavior, 19, 243–256. Bauer, M. S., & Mitchner, L. (2004). What is a “mood stabilizer”? An evidence-based response. American Journal of Psychiatry, 161, 3–18. Beck, A. T., Rush, A. J., & Shaw, B. F. (1979). Cognitive therapy of depression. New York: Guilford Press. Bond, G., Drake, R. E., Becker, & Mueser, K. (1999). Effectiveness of psychiatric rehabilitation approaches for employment of people with severe mental illness. Journal of Disability Policy Studies, 10, 18–52. Dickerson, F. B. (2000). Cognitive behavioral psychotherapy for schizophrenia: A review of recent empirical studies. Schizophrenia Research 43, 71–90. Frank, E., Kupfer, D. J., Perel, J. M., Cornes, C., Jarrett, D. B., Mallinger, A. G., Thase, M. E., McEachran, A. B., & Grochoconski, V. J. (1990). Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry 47, 1093–1099. Freud, S. (1910). The origin and development of psychoanalysis. American Journal of Psychology, 21, 181–218. Hoagwood, K., Jensen, P. S., Petti, T., & Burns, B. J. (1996). Outcomes of mental health care for children and adolescents: A comprehensive conceptual model. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1055–1063. Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psychological, educational, and behavioral treatment. American Psychologist, 48, 1181–1209. Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M., Piacentini, J., Schwab-Stone, M. E., Lahey, B. B., Bourdon, K., Jensen, P. S., Bird, H. R., Canino, G., & Regier, D. A. (1996). The NIMH diagnostic interview schedule for children, version 2.3 (DISC 2.3): description, acceptability, prevalence, rates, and performance in the MECA study. Journal of the Academy of Child and Adolescent Psychiatry, 35(7), 865–877. Von Korff, M., Katon, W., Bush, T., Lin, E. H., Simon, G. E., Saunders, K., Ludman, E., Walker, E., & Unutzer, J. (1998). Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosomatic Medicine, 60, 143–149. Instructor Manual for Psychology: Perspectives and Connections Gregory J. Feist, Erika Rosenberg 9780077861872, 9781260397031