Abnormal Psychology

Discovering Psychology Series
Abnormal Psychology
2nd edition
Alexis Bridley, Ph.D.

Lee W. Daffin Jr., Ph.D.
Washington State University
Version 2.00
August 2020
Contact Information about this OER:
1. Dr. Lee Daffin, Associate Professor of Psychology – [email protected]
2. Dr. Alexis Bridley - Adjunct Instructor – [email protected]

Table of Contents
Preface
Record of Changes
Part I. Setting the Stage
• Module 1: What is Abnormal Psychology? 1-1
• Module 2: Models of Abnormal Psychology 2-1
• Module 3: Clinical Assessment, Diagnosis, and Treatment 3-1
Part II. Mental Disorders – Block 1
• Module 4: Mood Disorders 4-1
• Module 5: Trauma- and Stressor-Related Disorders 5-1
• Module 6: Dissociative Disorders 6-1
Part III. Mental Disorders – Block 2
• Module 7: Anxiety Disorders 7-1
• Module 8: Somatic Symptom and Related Disorders 8-1
• Module 9: Obsessive-Compulsive and Related Disorders 9-1
Part IV. Mental Disorders – Block 3
• Module 10: Eating Disorders 10-1
• Module 11: Substance-Related and Addictive Disorders 11-1

Part V. Mental Disorders – Block 4
• Module 12: Schizophrenia Spectrum and Other Psychotic Disorders 12-1
• Module 13: Personality Disorders 13-1
Part VI. Mental Disorders – Block 5
• Module 14: Neurocognitive Disorders 14-1
• Module 15: Contemporary Issues in Psychopathology 15-1
Glossary
References
Index
Record of Changes
Edition As of Date Changes Made
1.0 Fall 2017 Initial writing; feedback pending
1.01 Spring 2018 Addition of Modules 2, 3, and 15
1.02 Summer 2018 Addition of Index, Glossary, and Preface; made minor edits based
on student feedback.
1.03 Summer 2019 Proofreading edits
2.00 August 2020 Proofreading edits and overall improvements such as end of
section summaries and review questions. Added a Tokens of
Appreciation page. Added lecture slides courtesy of Arizona State
University.
Tokens of Appreciation
August 20, 2020
Alexis and I want to offer a special thank you to Ms. Celeste Ernst, undergraduate within the
online Bachelor of Science degree in Psychology program, for her edits of the 1st edition during
the spring 2020. Her changes, and our own, are integrated into the 2nd edition of the book and are
a dramatic improvement over the 1st edition. Thank you, Celeste.
We would also like to extend a special thank you to Madeleine Stewart and Matt Meier, PsyD.,
of the Department of Psychology at Arizona State University for the development of the lecture
slides for this book. They did this work unsolicited and produced top quality presentations which
we will include in a password protected page, along with additional ancillaries such as an
Instructor’s Manual and test banks, in the very near future (i.e. hopefully by mid fall semester at
the latest but the slides in August) and for Instructors (Not students. Sorry). Thank you again for
your excellent work, Madeleine and Matt. It is more appreciated than you could ever imagine.
And now to our reader. We hope you enjoy the book and please, if you see any issues whether
typographical, factual, or just want to suggest some type of addition to the material or another
way to describe a concept, general formatting suggestion, etc. please let us know. The beauty of
Open Education Resources (OER) is that we can literally make a minor change immediately and
without the need for expensive printings of a new edition. And it’s available for everyone right
away. If you have suggestions, please email them to either Alexis or myself (Lee Daffin) using
the emails on the title page.
Enjoy the 2nd edition of Abnormal Psychology.
Lee Daffin
On behalf of, Alexis Bridley

2nd edition as of August 2020
Topics Covered:
1. What is Abnormal Psychology?
2. Models of Abnormal Psychology
3. Clinical Assessment, Diagnosis, and Treatment

Module 1:
What is Abnormal Psychology?
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Module 1: What is Abnormal Psychology?
Module Overview
Cassie is an 18-year-old female from suburban Seattle, WA. She was a successful student
in high school, graduating valedictorian and obtaining a National Merit Scholarship for her
performance on the PSAT during her junior year. She was accepted to a university on the
opposite side of the state, where she received additional scholarships giving her a free ride for
her entire undergraduate education. Excited to start this new chapter in her life, Cassie’s parents
begin the 5-hour commute to Pullman, where they will leave their only daughter for the first time
in her life.
The semester begins as it always does in late August. Cassie meets the challenge with
enthusiasm and does well in her classes for the first few weeks of the semester, as expected.
Sometime around Week 6, her friends notice she is despondent, detached, and falling behind in
her work. After being asked about her condition, she replies that she is “just a bit homesick,” and
her friends accept this answer as it is a typical response to leaving home and starting college for
many students. A month later, her condition has not improved but worsened. She now regularly
shirks her responsibilities around her apartment, in her classes, and on her job. Cassie does not
hang out with friends like she did when she first arrived for college and stays in bed most of the
day. Concerned, Cassie’s friends contact Health and Wellness for help.
Cassie’s story, though hypothetical, is true of many Freshmen leaving home for the first
time to earn a higher education, whether in rural Washington state or urban areas such as
Chicago and Dallas. Most students recover from this depression and go on to be functional
members of their collegiate environment and accomplished scholars. Some students learn to cope
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on their own while others seek assistance from their university’s health and wellness center or
from friends who have already been through the same ordeal. These are normal reactions.
However, in cases like Cassie's, the path to recovery is not as clear. Instead of learning how to
cope, their depression increases until it reaches clinical levels and becomes an impediment to
success in multiple domains of life such as home, work, school, and social circles.
In Module 1, we will explore what it means to display abnormal behavior, what mental
disorders are, and how society views it both today and has throughout history. Then we will
review research methods used by psychologists in general and how they are adapted to study
abnormal behavior/mental disorders. We will conclude with an overview of what mental health
professionals do.
Module Outline
• 1.1. Understanding Abnormal Behavior
• 1.2. Classifying Mental Disorders
• 1.3. The Stigma of Mental Illness
• 1.4. The History of Mental Illness
• 1.5. Research Methods in Psychopathology
• 1.6. Mental Health Professionals, Societies, and Journals
Module Learning Outcomes
• Explain what it means to display abnormal behavior.
• Clarify how mental health professionals classify mental disorders.
• Describe the effect of stigma on those who have a mental illness.
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• Outline the history of mental illness.
• Describe the research methods used to study abnormal behavior and mental illness.
• Identify types of mental health professionals, societies they may join, and journals
they can publish their work in.
1.1. Understanding Abnormal Behavior
Section Learning Objectives
• Describe the disease model and its impact on the field of psychology throughout
history.
• Describe positive psychology.
• Define abnormal behavior.
• Explain the concept of dysfunction as it relates to mental illness.
• Explain the concept of distress as it relates to mental illness.
• Explain the concept of deviance as it relates to mental illness.
• Explain the concept of dangerousness as it relates to mental illness.
• Define culture and social norms.
• Clarify the cost of mental illness on society.
• Define abnormal psychology, psychopathology, and mental disorders.
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1.1.1. Understanding Abnormal Behavior
To understand what abnormal behavior is, we first have to understand what normal
behavior is. Normal really is in the eye of the beholder, and most psychologists have found it
easier to explain what is wrong with people then what is right. How so?
Psychology worked with the disease model for over 60 years, from about the late 1800s
into the middle part of the 19th century. The focus was simple – curing mental disorders - and
included such pioneers as Freud, Adler, Klein, Jung, and Erickson. These names are synonymous
with the psychoanalytical school of thought. In the 1930s, behaviorism, under B.F. Skinner,
presented a new view of human behavior. Simply, human behavior could be modified if the
correct combination of reinforcements and punishments were used. This viewpoint espoused the
dominant worldview of the time – mechanism – which presented the world as a great machine
explained through the principles of physics and chemistry. In it, human beings serve as smaller
machines in the larger machine of the universe.
Moving into the mid to late 1900s, we developed a more scientific investigation of
mental illness, which allowed us to examine the roles of both nature and nurture and to develop
drug and psychological treatments to “make miserable people less miserable.” Though this was
an improvement, there were three consequences as pointed out by Martin Seligman in his 2008
TED Talk entitled, “The new era of positive psychology.” These are:
• “The first was moral; that psychologists and psychiatrists became victimologists,
pathologizers; that our view of human nature was that if you were in trouble, bricks
fell on you. And we forgot that people made choices and decisions. We forgot
responsibility. That was the first cost.”
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• “The second cost was that we forgot about you people. We forgot about improving
normal lives. We forgot about a mission to make relatively untroubled people
happier, more fulfilled, more productive. And "genius," "high-talent," became a dirty
word. No one works on that.”
• “And the third problem about the disease model is, in our rush to do something about
people in trouble, in our rush to do something about repairing damage, it never
occurred to us to develop interventions to make people happier -- positive
interventions.”
Starting in the 1960s, figures such as Abraham Maslow and Carl Rogers sought to
overcome the limitations of psychoanalysis and behaviorism by establishing a "third force"
psychology, also known as humanistic psychology. As Maslow said,
The science of psychology has been far more successful on the negative than on the
positive side; it has revealed to us much about man’s shortcomings, his illnesses, his sins,
but little about his potentialities, his virtues, his achievable aspirations, or his full
psychological height. It is as if psychology had voluntarily restricted itself to only half its
rightful jurisdiction, and that the darker, meaner half. (Maslow, 1954, p. 354).
Humanistic psychology instead addressed the full range of human functioning and focused on
personal fulfillment, valuing feelings over intellect, hedonism, a belief in human perfectibility,
emphasis on the present, self-disclosure, self-actualization, positive regard, client centered
therapy, and the hierarchy of needs. Again, these topics were in stark contrast to much of the
work being done in the field of psychology up to and at this time.
In 1996, Martin Seligman became the president of the American Psychological
Association (APA) and called for a positive psychology or one that had a more positive
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conception of human potential and nature. Building on Maslow and Roger’s work, he ushered in
the scientific study of such topics as happiness, love, hope, optimism, life satisfaction, goal
setting, leisure, and subjective well-being. Though positive and humanistic psychology have
similarities, their methodology was much different. While humanistic psychology generally
relied on qualitative methods, positive psychology utilizes a quantitative approach and aims to
help people make the most out of life’s setbacks, relate well to others, find fulfillment in
creativity, and find lasting meaning and satisfaction
(http://www.positivepsychologyinstitute.com.au/what_is_positive_psychology.html).
So, to understand what normal behavior is, do we look to positive psychology for an
indication, or do we first define abnormal behavior and then reverse engineer a definition of what
normal is? Our preceding discussion gave suggestions about what normal behavior is, but could
the darker elements of our personality also make up what is normal to some extent? Possibly.
The one truth is that no matter what behavior we display, if taken to the extreme, it can become
disordered – whether trying to control others through social influence or helping people in an
altruistic fashion. As such, we can consider abnormal behavior to be a combination of personal
distress, psychological dysfunction, deviance from social norms, dangerousness to self and
others, and costliness to society.
1.1.2. How do we determine what abnormal behavior is?
In the previous section we showed that what we might consider normal behavior is
difficult to define. Equally challenging is understanding what abnormal behavior is, which may
be surprising to you. A publication which you will become intimately familiar with throughout
this book, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental
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Disorders 5th edition (DSM-5), states that though "no definition can capture all aspects of all
disorders in the range contained in the DSM-5" certain aspects are required. These include:
• Dysfunction – Includes “clinically significant disturbance in an individual’s
cognition, emotion regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes underlying mental functioning”
(pg. 20). Abnormal behavior, therefore, has the capacity to make well-being difficult
to obtain and can be assessed by looking at an individual’s current performance and
comparing it to what is expected in general or how the person has performed in the
past. As such, a good employee who suddenly demonstrates poor performance may
be experiencing an environmental demand leading to stress and ineffective coping
mechanisms. Once the demand resolves itself, the person’s performance should return
to normal according to this principle.
• Distress – When the person experiences a disabling condition “in social,
occupational, or other important activities” (pg. 20). Distress can take the form of
psychological or physical pain, or both concurrently. Alone though, distress is not
sufficient enough to describe behavior as abnormal. Why is that? The loss of a loved
one would cause even the most “normally” functioning individual pain. An athlete
who experiences a career-ending injury would display distress as well. Suffering is
part of life and cannot be avoided. And some people who exhibit abnormal behavior
are generally positive while doing so.
• Deviance – Closer examination of the word abnormal indicates a move away from
what is normal, or the mean (i.e., what would be considered average and in this case
in relation to behavior), and so is behavior that infrequently occurs (sort of an outlier
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in our data). Our culture, or the totality of socially transmitted behaviors, customs,
values, technology, attitudes, beliefs, art, and other products that are particular to a
group, determines what is normal. Thus, a person is said to be deviant when he or she
fails to follow the stated and unstated rules of society, called social norms. Social
norms changes over time due to shifts in accepted values and expectations. For
instance, homosexuality was taboo in the U.S. just a few decades ago, but today, it is
generally accepted. Likewise, PDAs, or public displays of affection, do not cause a
second look by most people unlike the past when these outward expressions of love
were restricted to the privacy of one’s own house or bedroom. In the U.S., crying is
generally seen as a weakness for males. However, if the behavior occurs in the
context of a tragedy such as the Vegas mass shooting on October 1, 2017, in which 58
people were killed and about 500 were wounded while attending the Route 91
Harvest Festival, then it is appropriate and understandable. Finally, consider that
statistically deviant behavior is not necessarily negative. Genius is an example of
behavior that is not the norm.
Though not part of the DSM conceptualization of what abnormal behavior is, many
clinicians add dangerousness to this list when behavior represents a threat to the safety of the
person or others. It is important to note that having a mental disorder does not imply a person is
automatically dangerous. The depressed or anxious individual is often no more a threat than
someone who is not depressed, and as Hiday and Burns (2010) showed, dangerousness is more
the exception than the rule. Still, mental health professionals have a duty to report to law
enforcement when a mentally disordered individual expresses intent to harm another person or
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themselves. It is important to point out that people seen as dangerous are also not automatically
mentally ill.
1.1.3. The Costs of Mental Illness
This leads us to wonder what the cost of mental illness is to society. The National
Alliance on Mental Illness (NAMI) indicates that depression is the number one cause of
disability across the world “and is a major contributor to the global burden of disease.” Serious
mental illness costs the United States an estimated $193 billion in lost earnings each year. They
also point out that suicide is the 10th leading cause of death in the U.S., and 90% of those who
die due to suicide have an underlying mental illness. Regarding children and teens, 37% of
students with a mental disorder age 14 and older drop out of school, which is the highest dropout
rate of any disability group, and 70% of youth in state and local juvenile justice systems have at
least one mental disorder. Source: https://www.nami.org/Learn-More/Mental-Health-By-the-
Numbers. In terms of worldwide impact, the World Economic Forum used 2010 data to estimate
$2.5 trillion in global costs in 2010 and projected costs of $6 trillion by 2030. The costs for
mental illness are greater than the combined costs of cancer, diabetes, and respiratory disorders
(Whiteford et al., 2013). And finally, “The Social Security Administration reports that in 2012,
2.6 and 2.7 million people under age 65 with a mental illness-related disability received SSI and
SSDI payments, respectively, which represents 43 and 27 percent of the total number of people
receiving such support, respectively” (Source:
https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mental-health-awareness-
month-by-the-numbers.shtml). So as you can see, the cost of mental illness is quite staggering
for both the United States and other countries.
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Check this out: Seven Facts about America’s Mental Health-Care System
https://www.washingtonpost.com/news/wonk/wp/2012/12/17/seven-facts-about-
americas-mental-health-care-system/?utm_term=.12de8bc56941
1.1.4. Definition of abnormal psychology or psychopathology
Our discussion so far has concerned what normal and abnormal behavior is. We saw that
the study of normal behavior falls under the providence of positive psychology. Similarly, the
scientific study of abnormal behavior, with the intent to be able to predict reliably, explain,
diagnose, identify the causes of, and treat maladaptive behavior, is what we refer to as abnormal
psychology. Abnormal behavior can become pathological and has led to the scientific study of
psychological disorders, or psychopathology. From our previous discussion we can fashion the
following definition of a psychological or mental disorder: mental disorders are characterized
by psychological dysfunction, which causes physical and/or psychological distress or impaired
functioning, and is not an expected behavior according to societal or cultural standards.
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You should have learned the following in this section:

• Abnormal behavior is a combination of personal distress, psychological
dysfunction, deviance from social norms, dangerousness to self and others,
and costliness to society.
• Abnormal psychology is the scientific study of abnormal behavior, with the
intent to be able to predict reliably, explain, diagnose, identify the causes
of, and treat maladaptive behavior.
• The study of psychological disorders is called psychopathology.
• Mental disorders are characterized by psychological dysfunction, which
causes physical and/or psychological distress or impaired functioning, and
is not an expected behavior according to societal or cultural standards.
Section 1.1 Review Questions
1. What is the disease model and what problems existed with it? What was to
overcome its limitations?
2. Can we adequately define normal behavior? What about abnormal
behavior?
3. What aspects are part of the American Psychiatric Association’s definition
of abnormal behavior?
4. What is abnormal behavior? Psychopathology?
5. How do we define mental disorders?
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1.2. Classifying Mental Disorders
• Define and exemplify classification.
• Define nomenclature.
• Define epidemiology.
• Define the presenting problem and clinical description.
• Differentiate prevalence, incidence, and any subtypes.
• Define comorbidity.
• Define etiology.
• Define course.
• Define prognosis.
• Define treatment.
Classification is not a foreign concept and as a student you have likely taken at least one
biology class that discussed the taxonomic classification system of Kingdom, Phylum, Class,
Order, Family, Genus, and Species revolutionized by Swedish botanist, Carl Linnaeus. You
probably even learned a witty mnemonic such as ‘King Phillip, Come Out For Goodness Sake’
to keep the order straight. The Library of Congress uses classification to organize and arrange
their book collections and includes such categories as B – Philosophy, Psychology, and Religion;
H – Social Sciences; N – Fine Arts; Q – Science; R – Medicine; and T – Technology.
Simply, classification is how we organize or categorize things. The second author’s wife
has been known to color-code her DVD collection by genre, movie title, and release date. It is
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useful for us to do the same with abnormal behavior, and classification provides us with a
nomenclature, or naming system, to structure our understanding of mental disorders in a
meaningful way. Of course, we want to learn as much as we can about a given disorder so we
can understand its cause, predict its future occurrence, and develop ways to treat it.
Epidemiology is the scientific study of the frequency and causes of diseases and other
health-related states in specific populations such as a school, neighborhood, a city, country, and
the world. Psychiatric or mental health epidemiology refers to the occurrence of mental
disorders in a population. In mental health facilities, we say that a patient presents with a specific
problem, or the presenting problem, and we give a clinical description of it, which includes
information about the thoughts, feelings, and behaviors that constitute that mental disorder. We
also seek to gain information about the occurrence of the disorder, its cause, course, and
treatment possibilities.
Occurrence can be investigated in several ways. First, prevalence is the percentage of
people in a population that has a mental disorder or can be viewed as the number of cases
divided by the total number of people in the sample. For instance, if 20 people out of 100 have
bipolar disorder, then the prevalence rate is 20%. Prevalence can be measured in several ways:
• Point prevalence indicates the proportion of a population that has the characteristic
at a specific point in time. In other words, it is the number of active cases.
• Period prevalence indicates the proportion of a population that has the characteristic
at any point during a given period of time, typically the past year.
• Lifetime prevalence indicates the proportion of a population that has had the
characteristic at any time during their lives.
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According to the National Survey on Drug Use and Health (NSDUH), in 2015 there was
an estimated 9.8 million U.S. adults aged 18 years or older with a serious mental illness, or 4%
of all U.S. adults, and 43.4 million adults aged 18 years or older with any mental illness, or
17.9% of all U.S. adults.
Source: https://www.nimh.nih.gov/health/statistics/prevalence/index.shtml
Incidence indicates the number of new cases in a population over a specific period. This
measure is usually lower since it does not include existing cases as prevalence does. If you wish
to know the number of new cases of social phobia during the past year (going from say Aug 21,
2015 to Aug 20, 2016), you would only count cases that began during this time and ignore cases
before the start date, even if people are currently afflicted with the mental disorder. Incidence is
often studied by medical and public health officials so that causes can be identified, and future
cases prevented.
Finally, comorbidity describes when two or more mental disorders are occurring at the
same time and in the same person. The National Comorbidity Survey Replication (NCS-R) study
conducted by the National Institute of Mental Health (NIMH) and published in the June 6, 2005
issue of the Archives of General Psychiatry, sought to discover trends in prevalence, impairment,
and service use during the 1990s. The first study, conducted from 1980 to 1985, surveyed 20,000
people from five different geographical regions in the U.S. A second study followed from 1990-
1992 and was called the National Comorbidity Survey (NCS). The third study, the NCS-R, used
a new nationally representative sample of the U.S. population, and found that 45% of those with
one mental disorder met the diagnostic criteria for two or more disorders. The authors also found
that the severity of mental illness, in regard to disability, is strongly related to comorbidity, and
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that substance use disorders often result from disorders such as anxiety and bipolar mood
disorders. The implications of this are significant as services to treat substance abuse and mental
disorders are often separate, despite the disorders appearing together.
The etiology is the cause of the disorder. There may be social, biological, or
psychological explanations for the disorder which need to be understood to identify the
appropriate treatment. Likewise, the effectiveness of a treatment may give some hint at the cause
of the mental disorder. More on this later.
The course of the disorder is its particular pattern. A disorder may be acute, meaning that
it lasts a short time, or chronic, meaning it persists for a long time. It can also be classified as
time-limited, meaning that recovery will occur after some time regardless of whether any
treatment occurs.
Prognosis is the anticipated course the mental disorder will take. A key factor in
determining the course is age, with some disorders presenting differently in childhood than
adulthood.
Finally, we will discuss several treatment strategies in this book in relation to specific
disorders, and in a general fashion in Module 3. Treatment is any procedure intended to modify
abnormal behavior into normal behavior. The person suffering from the mental disorder seeks
the assistance of a trained professional to provide some degree of relief over a series of therapy
sessions. The trained mental health professional may prescribe medication or utilize
psychotherapy to bring about this change. Treatment may be sought from the primary care
provider, in an outpatient facility, or through inpatient care or hospitalization at a mental hospital
or psychiatric unit of a general hospital.
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• Classification, or how we organize or categorize things, provides us with a
nomenclature, or naming system, to structure our understanding of mental
disorders in a meaningful way.
• Epidemiology is the scientific study of the frequency and causes of
diseases and other health-related states in specific populations.
• Prevalence is the percentage of people in a population that has a mental
disorder or can be viewed as the number of cases divided by the total
number of people in the sample.
• Incidence indicates the number of new cases in a population over a specific
period.
• Comorbidity describes when two or more mental disorders are occurring at
the same time and in the same person.
• The etiology is the cause of a disorder while the course is its particular
pattern and can be acute, chronic, or time-limited.
• Prognosis is the anticipated course the mental disorder will take.
1. What is the importance of classification for the study of mental disorders?

2. What information does a clinical description include?
3. In what ways is occurrence investigated?
4. What is the etiology of a mental illness?
5. What is the relationship of course and prognosis to one another?
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1.3. The Stigma of Mental Illness
• Clarify the importance of social cognition theory in understanding why people do not
seek care.
• Define categories and schemas.
• Define stereotypes and heuristics.
• Describe social identity theory and its consequences.
• Differentiate between prejudice and discrimination.
• Contrast implicit and explicit attitudes.
• Explain the concept of stigma and its three forms.
• Define courtesy stigma.
• Describe what the literature shows about stigma.
In the previous section, we discussed the fact that care can be sought out in a variety of
ways. The problem is that many people who need care never seek it out. Why is that? We
already know that society dictates what is considered abnormal behavior through culture and
social norms, and you can likely think of a few implications of that. But to fully understand
society’s role in why people do not seek care, we need to determine the psychological processes
underlying this phenomenon in the individual.
Social cognition is the process through which we collect information from the world
around us and then interpret it. The collection process occurs through what we know as sensation
– or detecting physical energy emitted or reflected by physical objects. Detection occurs courtesy
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of our eyes, ears, nose, skin and mouth; or via vision, hearing, smell, touch, and taste,
respectfully. Once collected, the information is relayed to the brain through the neural impulse
where it is processed and interpreted, or meaning is added to this raw sensory data which we call
perception.
One way meaning is added is by taking the information we just detected and using it to
assign people to categories, or groups. For each category, we have a schema, or a set of beliefs
and expectations about a group of people, believed to apply to all members of the group, and
based on experience. You might think of them as organized ways of making sense of experience.
So it is during our initial interaction with someone that we collect information about him/her,
assign the person to a category for which we have a schema, and then use that to affect how we
interact with her or him. First impressions, called the primacy effect, are important because even
if we obtain new information that should override an incorrect initial assessment, the initial
impression is unlikely to change. We call this the perseverance effect, or belief perseverance.
Stereotypes are special types of schemas that are very simplistic, very strongly held, and
not based on firsthand experience. They are heuristics, or mental shortcuts, that allow us to
assess this collected information very quickly. One piece of information, such as skin color, can
be used to assign the person to a schema for which we have a stereotype. This can affect how we
think or feel about the person and behave toward them. Again, human beings tend to imply
things about an individual solely due to a distinguishing feature and disregard anything
inconsistent with the stereotype.
Social identity theory (Tajfel, 1982; Turner, 1987) states that people categorize their
social world into meaningfully simplistic representations of groups of people. These
representations are then organized as prototypes, or “fuzzy sets of a relatively limited number of
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category-defining features that not only define one category but serve to distinguish it from other
categories” (Foddy and Hogg, as cited in Foddy et al., 1999). We construct in-groups and out-
groups and categorize the self as an in-group member. The self is assimilated into the salient in-
group prototype, which indicates what cognitions, affect, and behavior we may exhibit.
Stereotyping, out-group homogeneity, in-group/out-group bias, normative behavior, and
conformity are all based on self-categorization.
How so? Out-group homogeneity occurs when we see all members of an outside group as
the same. This leads to a tendency to show favoritism to, and exclude or hold a negative view of,
members outside of, one’s immediate group, called the in-group/out-group bias. The negative
view or set of beliefs about a group of people is what we call prejudice, and this can result in
acting in a way that is negative against a group of people, called discrimination. It should be
noted that a person can be prejudicial without being discriminatory since most people do not act
on their attitudes toward others due to social norms against such behavior. Likewise, a person or
institution can be discriminatory without being prejudicial. For example, when a company
requires that an applicant have a certain education level or be able to lift 80 pounds as part of
typical job responsibilities. Individuals without a degree or ability to lift will be removed from
consideration for the job, but this discriminatory act does not mean that the company has
negative views of people without degrees or the inability to lift heavy weight. You might even
hold a negative view of a specific group of people and not be aware of it. An attitude we are
unaware of is called an implicit attitude, which stands in contrast to explicit attitudes, which are
the views within our conscious awareness.
We have spent quite a lot of space and time understanding how people gather information
about the world and people around them, process this information, use it to make snap
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judgements about others, form groups for which stereotypes may exist, and then potentially hold
negative views of this group and behave negatively toward them as a result. Just one piece of
information can be used to set this series of mental events into motion. Outside of skin color, the
label associated with having a mental disorder can be used. Stereotypes about people with a
mental disorder can quickly and easily transform into prejudice when people in a society
determine the schema to be correct and form negative emotions and evaluations of this group
(Eagly & Chaiken, 1993). This, in turn, can lead to discriminatory practices such as an employer
refusing to hire, a landlord refusing to rent an apartment, or avoiding a romantic relationship, all
due to the person having a mental illness.
Overlapping with prejudice and discrimination in terms of how people with mental
disorders are treated is stigma, or when negative stereotyping, labeling, rejection, and loss of
status occur. Stigma takes on three forms as described below:
• Public stigma – When members of a society endorse negative stereotypes of people
with a mental disorder and discriminate against them. They might avoid them
altogether, resulting in social isolation. An example is when an employer
intentionally does not hire a person because their mental illness is discovered.
• Label avoidance –To avoid being labeled as “crazy” or “nuts” people needing care
may avoid seeking it altogether or stop care once started. Due to these labels, funding
for mental health services could be restricted and instead, physical health services
funded.
• Self-stigma – When people with mental illnesses internalize the negative stereotypes
and prejudice, and in turn, discriminate against themselves. They may experience
shame, reduced self-esteem, hopelessness, low self-efficacy, and a reduction in
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coping mechanisms. An obvious consequence of these potential outcomes is the why
try effect, or the person saying ‘Why should I try and get that job? I am not worthy of
it’ (Corrigan, Larson, & Rusch, 2009; Corrigan, et al., 2016).
Another form of stigma that is worth noting is that of courtesy stigma or when stigma
affects people associated with a person who has a mental disorder. Karnieli-Miller et al. (2013)
found that families of the afflicted were often blamed, rejected, or devalued when others learned
that a family member had a serious mental illness (SMI). Due to this, they felt hurt and betrayed,
and an important source of social support during a difficult time had disappeared, resulting in
greater levels of stress. To cope, some families concealed their relative’s illness, and some
parents struggled to decide whether it was their place to disclose their child’s condition. Others
fought with the issue of confronting the stigma through attempts at education versus just ignoring
it due to not having enough energy or desiring to maintain personal boundaries. There was also a
need to understand the responses of others and to attribute it to a lack of knowledge, experience,
and/or media coverage. In some cases, the reappraisal allowed family members to feel
compassion for others rather than feeling put down or blamed. The authors concluded that each
family “develops its own coping strategies which vary according to its personal experiences,
values, and extent of other commitments” and that “coping strategies families employ change
over-time.”
Other effects of stigma include experiencing work-related discrimination resulting in
higher levels of self-stigma and stress (Rusch et al., 2014), higher rates of suicide especially
when treatment is not available (Rusch, Zlati, Black, and Thornicroft, 2014; Rihmer & Kiss,
2002), and a decreased likelihood of future help-seeking intention (Lally et al., 2013). The results
of the latter study also showed that personal contact with someone with a history of mental
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illness led to a decreased likelihood of seeking help. This is important because 48% of the
university sample stated that they needed help for an emotional or mental health issue during the
past year but did not seek help. Similar results have been reported in other studies (Eisenberg,
Downs, Golberstein, & Zivin, 2009). It is also important to point out that social distance, a result
of stigma, has also been shown to increase throughout the life span, suggesting that anti-stigma
campaigns should focus on older people primarily (Schomerus, et al., 2015).
One potentially disturbing trend is that mental health professionals have been shown to
hold negative attitudes toward the people they serve. Hansson et al. (2011) found that staff
members at an outpatient clinic in the southern part of Sweden held the most negative attitudes
about whether an employer would accept an applicant for work, willingness to date a person who
had been hospitalized, and hiring a patient to care for children. Attitudes were stronger when
staff treated patients with a psychosis or in inpatient settings. In a similar study,
Martensson, Jacobsson, and Engstrom (2014) found that staff had more positive attitudes
towards persons with mental illness if their knowledge of such disorders was less stigmatized;
their workplaces were in the county council where they were more likely to encounter patients
who recover and return to normal life in society, rather than in municipalities where patients
have long-term and recurrent mental illness; and they have or had one close friend with mental
health issues.
To help deal with stigma in the mental health community, Papish et al. (2013)
investigated the effect of a one-time contact-based educational intervention compared to a four-
week mandatory psychiatry course on the stigma of mental illness among medical students at the
University of Calgary. The curriculum included two methods requiring contact with people
diagnosed with a mental disorder: patient presentations, or two one-hour oral presentations in
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which patients shared their story of having a mental illness, and "clinical correlations" in which a
psychiatrist mentored students while they interacted with patients in either inpatient or outpatient
settings. Results showed that medical students held a stigma towards mental illness and that
comprehensive medical education reduced this stigma. As the authors stated, “These results
suggest that it is possible to create an environment in which medical student attitudes towards
mental illness can be shifted in a positive direction.” That said, the level of stigma was still
higher for mental illness than it was for the stigmatized physical illness, type 2 diabetes mellitus.
What might happen if mental illness is presented as a treatable condition? McGinty,
Goldman, Pescosolido, and Barry (2015) found that portraying schizophrenia, depression, and
heroin addiction as untreated and symptomatic increased negative public attitudes towards
people with these conditions. Conversely, when the same people were portrayed as successfully
treated, the desire for social distance was reduced, there was less willingness to discriminate
against them, and belief in treatment effectiveness increased among the public.
Self-stigma has also been shown to affect self-esteem, which then affects hope, which
then affects the quality of life among people with SMI. As such, hope should play a central role
in recovery (Mashiach-Eizenberg et al., 2013). Narrative Enhancement and Cognitive Therapy
(NECT) is an intervention designed to reduce internalized stigma and targets both hope and self-
esteem (Yanos et al., 2011). The intervention replaces stigmatizing myths with facts about illness
and recovery, which leads to hopefulness and higher levels of self-esteem in clients. This may
then reduce susceptibility to internalized stigma.
Stigma leads to health inequities (Hatzenbuehler, Phelan, & Link, 2013), prompting calls
for stigma change. Targeting stigma involves two different agendas: The services agenda
attempts to remove stigma so people can seek mental health services, and the rights agenda tries
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to replace discrimination that “robs people of rightful opportunities with affirming attitudes and
behavior” (Corrigan, 2016). The former is successful when there is evidence that people with
mental illness are seeking services more or becoming better engaged. The latter is successful
when there is an increase in the number of people with mental illnesses in the workforce who are
receiving reasonable accommodations. The federal government has tackled this issue with
landmark legislation such as the Patient Protection and Affordable Care Act of 2010, Mental
Health Parity and Addiction Equity Act of 2008, and the Americans with Disabilities Act of
1990. However, protections are not uniform across all subgroups due to “1) explicit language
about inclusion and exclusion criteria in the statute or implementation rule, 2) vague statutory
language that yields variation in the interpretation about which groups qualify for protection, and
3) incentives created by the legislation that affect specific groups differently” (Cummings,
Lucas, and Druss, 2013). More on this in Module 15.

• Stigma is when negative stereotyping, labeling, rejection, and loss of status occur
and take the form of public or self-stigma, and label avoidance.
1. How does social cognition help us to understand why stigmatization occurs?

2. Define stigma and describe its three forms. What is courtesy stigma?
3. What are the effects of stigma on the afflicted?
4. Is stigmatization prevalent in the mental health community? If so, what can be
done about it?
5. How can we reduce stigmatization?
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1.4. The History of Mental Illness
• Describe prehistoric and ancient beliefs about mental illness.
• Describe Greco-Roman thought on mental illness.
• Describe thoughts on mental illness during the Middle Ages.
• Describe thoughts on mental illness during the Renaissance.
• Describe thoughts on mental illness during the 18th and 19th centuries.
• Describe thoughts on mental illness during the 20th and 21st centuries.
• Describe the status of mental illness today.
• Outline the use of psychoactive drugs throughout time and their impact.
• Clarify the importance of managed health care for the treatment of mental illness.
• Define and clarify the importance of multicultural psychology.
• State the issue surrounding prescription rights for psychologists.
• Explain the importance of prevention science.
As we have seen so far, what is considered abnormal behavior is often dictated by the
culture/society a person lives in, and unfortunately, the past has not treated the afflicted very
well. In this section, we will examine how past societies viewed and dealt with mental illness.
1.4.1. Prehistoric and Ancient Beliefs
Prehistoric cultures often held a supernatural view of abnormal behavior and saw it as the
work of evil spirits, demons, gods, or witches who took control of the person. This form of
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demonic possession often occurred when the person engaged in behavior contrary to the
religious teachings of the time. Treatment by cave dwellers included a technique called
trephination, in which a stone instrument known as a trephine was used to remove part of the
skull, creating an opening. Through it, the evil spirits could escape, thereby ending the person’s
mental affliction and returning them to normal behavior. Early Greek, Hebrew, Egyptian, and
Chinese cultures used a treatment method called exorcism in which evil spirts were cast out
through prayer, magic, flogging, starvation, having the person ingest horrible tasting drinks, or
noisemaking.
1.4.2. Greco-Roman Thought
Rejecting the idea of demonic possession, Greek physician Hippocrates (460-377 B.C.)
said that mental disorders were akin to physical ailments and had natural causes. Specifically,
they arose from brain pathology, or head trauma/brain dysfunction or disease, and were also
affected by heredity. Hippocrates classified mental disorders into three main categories –
melancholia, mania, and phrenitis (brain fever) – and gave detailed clinical descriptions of each.
He also described four main fluids or humors that directed normal brain functioning and
personality – blood which arose in the heart, black bile arising in the spleen, yellow bile or choler
from the liver, and phlegm from the brain. Mental disorders occurred when the humors were in a
state of imbalance such as an excess of yellow bile causing frenzy and too much black bile
causing melancholia or depression. Hippocrates believed mental illnesses could be treated as any
other disorder and focused on the underlying pathology.
Also noteworthy was the Greek philosopher Plato (429-347 B.C.), who said that the
mentally ill were not responsible for their actions and should not be punished. It was the
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responsibility of the community and their families to care for them. The Greek physician Galen
(A.D. 129-199) said mental disorders had either physical or psychological causes, including fear,
shock, alcoholism, head injuries, adolescence, and changes in menstruation.
In Rome, physician Asclepiades (124-40 BC) and philosopher Cicero (106-43 BC)
rejected Hippocrates’ idea of the four humors and instead stated that melancholy arises from
grief, fear, and rage; not excess black bile. Roman physicians treated mental disorders with
massage or warm baths, the hope being that their patients would be as comfortable as they could
be. They practiced the concept of contrariis contrarius, meaning opposite by opposite, and
introduced contrasting stimuli to bring about balance in the physical and mental domains. An
example would be consuming a cold drink while in a warm bath.
1.4.3. The Middle Ages – 500 AD to 1500 AD
The progress made during the time of the Greeks and Romans was quickly reversed
during the Middle Ages with the increase in power of the Church and the fall of the Roman
Empire. Mental illness was yet again explained as possession by the Devil and methods such as
exorcism, flogging, prayer, the touching of relics, chanting, visiting holy sites, and holy water
were used to rid the person of demonic influence. In extreme cases, the afflicted were exposed to
confinement, beatings, and even execution. Scientific and medical explanations, such as those
proposed by Hippocrates, were discarded.
Group hysteria, or mass madness, was also seen when large numbers of people displayed
similar symptoms and false beliefs. This included the belief that one was possessed by wolves or
other animals and imitated their behavior, called lycanthropy, and a mania in which large
numbers of people had an uncontrollable desire to dance and jump, called tarantism. The latter
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was believed to have been caused by the bite of the wolf spider, now called the tarantula, and
spread quickly from Italy to Germany and other parts of Europe where it was called Saint
Vitus’s dance.
Perhaps the return to supernatural explanations during the Middle Ages makes sense
given events of the time. The black death (bubonic plague) killed up to a third, or according to
other estimates almost half, of the population. Famine, war, social oppression, and pestilence
were also factors. The constant presence of death led to an epidemic of depression and fear. Near
the end of the Middle Ages, mystical explanations for mental illness began to lose favor, and
government officials regained some of their lost power over nonreligious activities. Science and
medicine were again called upon to explain psychopathology.
1.4.4. The Renaissance - 14th to 16th centuries
The most noteworthy development in the realm of philosophy during the Renaissance
was the rise of humanism, or the worldview that emphasizes human welfare and the uniqueness
of the individual. This perspective helped continue the decline of supernatural views of mental
illness. In the mid to late 1500s, German physician Johann Weyer (1515-1588) published his
book, On the Deceits of the Demons, that rebutted the Church’s witch-hunting handbook, the
Malleus Maleficarum, and argued that many accused of being witches and subsequently
imprisoned, tortured, and/or burned at the stake, were mentally disturbed and not possessed by
demons or the Devil himself. He believed that like the body, the mind was susceptible to illness.
Not surprisingly, the book was vehemently protested and banned by the Church. It should be
noted that these types of acts occurred not only in Europe, but also in the United States. The most
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famous example, the Salem Witch Trials of 1692, resulted in more than 200 people accused of
practicing witchcraft and 20 deaths.
The number of asylums, or places of refuge for the mentally ill where they could receive
care, began to rise during the 16th century as the government realized there were far too many
people afflicted with mental illness to be left in private homes. Hospitals and monasteries were
converted into asylums. Though the intent was benign in the beginning, as the facilities
overcrowded, the patients came to be treated more like animals than people. In 1547, the
Bethlem Hospital opened in London with the sole purpose of confining those with mental
disorders. Patients were chained up, placed on public display, and often heard crying out in pain.
The asylum became a tourist attraction, with sightseers paying a penny to view the more violent
patients, and soon was called “Bedlam” by local people; a term that today means “a state of
uproar and confusion” (https://www.merriam-webster.com/dictionary/bedlam).
1.4.5. Reform Movement – 18th to 19th centuries
The rise of the moral treatment movement occurred in Europe in the late 18th century
and then in the United States in the early 19th century. The earliest proponent was Francis Pinel
(1745-1826), the superintendent of la Bicetre, a hospital for mentally ill men in Paris. Pinel
stressed respectful treatment and moral guidance for the mentally ill while considering their
individual, social, and occupational needs. Arguing that the mentally ill were sick people, Pinel
ordered that chains be removed, outside exercise be allowed, sunny and well-ventilated rooms
replace dungeons, and patients be extended kindness and support. This approach led to
considerable improvement for many of the patients, so much so, that several were released.
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Following Pinel’s lead, William Tuke (1732-1822), a Quaker tea merchant, established a
pleasant rural estate called the York Retreat. The Quakers believed that all people should be
accepted for who they are and treated kindly. At the retreat, patients could work, rest, talk out
their problems, and pray (Raad & Makari, 2010). The work of Tuke and others led to the passage
of the Country Asylums Act of 1845, which required that every county provide asylum to the
mentally ill. This sentiment extended to English colonies such as Canada, India, Australia, and
the West Indies as word of the maltreatment of patients at a facility in Kingston, Jamaica spread,
leading to an audit of colonial facilities and their policies.
Reform in the United States started with the figure largely considered to be the father of
American psychiatry, Benjamin Rush (1745-1813). Rush advocated for the humane treatment of
the mentally ill, showing them respect, and even giving them small gifts from time to time.
Despite this, his practice included treatments such as bloodletting and purgatives, the invention
of the “tranquilizing chair,” and reliance on astrology, showing that even he could not escape
from the beliefs of the time.
Due to the rise of the moral treatment movement in both Europe and the United States,
asylums became habitable places where those afflicted with mental illness could recover.
Regrettably, its success was responsible for its decline. The number of mental hospitals greatly
increased, leading to staffing shortages and a lack of funds to support them. Though treating
patients humanely was a noble endeavor, it did not work for some patients and other treatments
were needed, though they had not been developed yet. Staff recognized that the approach worked
best when the facility had 200 or fewer patients, but waves of immigrants arriving in the U.S.
after the Civil War overwhelmed the facilities, and patient counts soared to 1,000 or more.
Prejudice against the new arrivals led to discriminatory practices in which immigrants were not
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afforded the same moral treatments as native citizens, even when the resources were available to
treat them.
The moral treatment movement also fell due to the rise of the mental hygiene
movement, which focused on the physical well-being of patients. Its leading proponent in the
United States was Dorothea Dix (1802-1887), a New Englander who observed the deplorable
conditions suffered by the mentally ill while teaching Sunday school to female prisoners. Over
the next 40 years, from 1841 to 1881, she motivated people and state legislators to do something
about this injustice and raised millions of dollars to build over 30 more appropriate mental
hospitals and improve others. Her efforts even extended beyond the U.S. to Canada and
Scotland.
Finally, in 1908 Clifford Beers (1876-1943) published his book, A Mind that Found
Itself, in which he described his struggle with bipolar disorder and the “cruel and inhumane
treatment people with mental illnesses received. He witnessed and experienced horrific abuse at
the hands of his caretakers. At one point during his institutionalization, he was placed in a
straightjacket for 21 consecutive nights” (http://www.mentalhealthamerica.net/our-history). His
story aroused sympathy from the public and led him to found the National Committee for Mental
Hygiene, known today as Mental Health America, which provides education about mental illness
and the need to treat these people with dignity. Today, MHA has over 200 affiliates in 41 states
and employs 6,500 affiliate staff and over 10,000 volunteers.
“In the early 1950s, Mental Health America issued a call to asylums
across the country for their discarded chains and shackles. On April 13,
1953, at the McShane Bell Foundry in Baltimore, Md., Mental Health
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America melted down these inhumane bindings and recast them into a
sign of hope: the Mental Health Bell.
Now the symbol of Mental Health America, the 300-pound Bell serves as
a powerful reminder that the invisible chains of misunderstanding and
discrimination continue to bind people with mental illnesses. Today, the
Mental Health Bell rings out hope for improving mental health and
achieving victory over mental illnesses.”
For more information on MHA, please visit: http://www.mentalhealthamerica.net/
1.4.6. 20th – 21st Centuries
The decline of the moral treatment approach in the late 19th century led to the rise of two
competing perspectives – the biological or somatogenic perspective and the psychological or
psychogenic perspective.
1.4.6.1. Biological or Somatogenic Perspective. Recall that Greek physicians Hippocrates
and Galen said that mental disorders were akin to physical disorders and had natural causes.
Though the idea fell into oblivion for several centuries, it re-emerged in the late 19th century for
two reasons. First, German psychiatrist Emil Kraepelin (1856-1926) discovered that symptoms
occurred regularly in clusters, which he called syndromes. These syndromes represented a
unique mental disorder with a distinct cause, course, and prognosis. In 1883 he published his
textbook, Compendium der Psychiatrie (Textbook of Psychiatry), and described a system for
classifying mental disorders that became the basis of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders (DSM) that is currently in its 5th edition
(published in 2013).
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Secondly, in 1825, the behavioral and cognitive symptoms of advanced syphilis were
identified to include a belief that everyone is plotting against you or that you are God (a delusion
of grandeur), and were termed general paresis by French physician A.L.J. Bayle. In 1897,
Viennese psychiatrist Richard von Krafft-Ebbing injected patients suffering from general paresis
with matter from syphilis spores and noted that none of the patients developed symptoms of
syphilis, indicating they must have been previously exposed and were now immune. This led to
the conclusion that syphilis was the cause of the general paresis. In 1906, August von
Wassermann developed a blood test for syphilis, and in 1917 a cure was found. Julius von
Wagner-Jauregg noticed that patients with general paresis who contracted malaria recovered
from their symptoms. To test this hypothesis, he injected nine patients with blood from a soldier
afflicted with malaria. Three of the patients fully recovered while three others showed great
improvement in their paretic symptoms. The high fever caused by malaria burned out the
syphilis bacteria. Hospitals in the United States began incorporating this new cure for paresis
into their treatment approach by 1925.
Also noteworthy was the work of American psychiatrist John P. Grey. Appointed as
superintendent of the Utica State Hospital in New York, Grey asserted that insanity always had a
physical cause. As such, the mentally ill should be seen as physically ill and treated with rest,
proper room temperature and ventilation, and a nutritive diet.
The 1930s also saw the use of electric shock as a treatment method, which was stumbled
upon accidentally by Benjamin Franklin while experimenting with electricity in the early 18th
century. He noticed that after suffering a severe shock his memories had changed, and in
published work, he suggested physicians study electric shock as a treatment for melancholia.
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1.4.6.2. Psychological or Psychogenic Perspective. The psychological or psychogenic
perspective states that emotional or psychological factors are the cause of mental disorders and
represented a challenge to the biological perspective. This perspective had a long history but did
not gain favor until the work of Viennese physician Franz Anton Mesmer (1734-1815).
Influenced heavily by Newton’s theory of gravity, he believed that the planets also affected the
human body through the force of animal magnetism and that all people had a universal magnetic
fluid that determined how healthy they were. He demonstrated the usefulness of his approach
when he cured Franzl Oesterline, a 27-year-old woman suffering from what he described as a
convulsive malady. Mesmer used a magnet to disrupt the gravitational tides that were affecting
his patient and produced a sensation of the magnetic fluid draining from her body. This
procedure removed the illness from her body and provided a near-instantaneous recovery. In
reality, the patient was placed in a trancelike state which made her highly suggestible. With other
patients, Mesmer would have them sit in a darkened room filled with soothing music, into which
he would enter dressed in a colorful robe and pass from person to person touching the afflicted
area of their body with his hand or a rod/wand. He successfully cured deafness, paralysis, loss of
bodily feeling, convulsions, menstrual difficulties, and blindness.
His approach gained him celebrity status as he demonstrated it at the courts of English
nobility. However, the medical community was hardly impressed. A royal commission was
formed to investigate his technique but could not find any proof for his theory of animal
magnetism. Though he was able to cure patients when they touched his “magnetized” tree, the
result was the same when “non-magnetized” trees were touched. As such, Mesmer was deemed a
charlatan and forced to leave Paris. His technique was called mesmerism, better known today as
hypnosis.
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The psychological perspective gained popularity after two physicians practicing in the
city of Nancy in France discovered that they could induce the symptoms of hysteria in perfectly
healthy patients through hypnosis and then remove the symptoms in the same way. The work of
Hippolyte-Marie Bernheim (1840-1919) and Ambroise-Auguste Liebault (1823-1904) came to
be part of what was called the Nancy School and showed that hysteria was nothing more than a
form of self-hypnosis. In Paris, this view was challenged by Jean Charcot (1825-1893), who
stated that hysteria was caused by degenerative brain changes, reflecting the biological
perspective. He was proven wrong and eventually turned to their way of thinking.
The use of hypnosis to treat hysteria was also carried out by fellow Frenchman Pierre
Janet (1859-1947), and student of Charcot, who believed that hysteria had psychological, not
biological causes. Namely, these included unconscious forces, fixed ideas, and memory
impairments. In Vienna, Josef Breuer (1842-1925) induced hypnosis and had patients speak
freely about past events that upset them. Upon waking, he discovered that patients sometimes
were free of their symptoms of hysteria. Success was even greater when patients not only
recalled forgotten memories but also relived them emotionally. He called this the cathartic
method, and our use of the word catharsis today indicates a purging or release, in this case, of
pent-up emotion.
By the end of the 19th century, it had become evident that mental disorders were caused
by a combination of biological and psychological factors, and the investigation of how they
develop began. Sigmund Freud’s development of psychoanalysis followed on the heels of the
work of Bruner, and others who came before him.
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1.4.7. Current Views/Trends
1.4.7.1. Mental illness today. An article published by the Harvard Medical School in
March 2014 called “The Prevalent and Treatment of Mental Illness Today” presented the results
of the National Comorbidity Study Replication of 2001-2003, which included a sample of more
than 9,000 adults. The results showed that nearly 46% of the participants had a psychiatric
disorder at some time in their lives. The most commonly reported disorders were:
• Major depression – 17%
• Alcohol abuse – 13%
• Social anxiety disorder – 12%
• Conduct disorder – 9.5%
Also of interest was that women were more likely to have had anxiety and mood disorders while
men showed higher rates of impulse control disorders. Comorbid anxiety and mood disorders
were common, and 28% reported having more than one co-occurring disorder (Kessler,
Berglund, et al., 2005; Kessler, Chiu, et al., 2005; Kessler, Demler, et al., 2005).
About 80% of the sample reported seeking treatment for their disorder, but with as much
as a 10-year gap after symptoms first appeared. Women were more likely than men to seek help
while whites were more likely than African and Hispanic Americans (Wang, Berglund, et al.,
2005; Wang, Lane, et al., 2005). Care was sought primarily from family doctors, nurses, and
other general practitioners (23%), followed by social workers and psychologists (16%),
psychiatrists (12%), counselors or spiritual advisers (8%), and complementary and alternative
medicine providers (CAMs; 7%).
In terms of the quality of the care, the article states:
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Most of this treatment was inadequate, at least by the standards applied in
the survey. The researchers defined minimum adequacy as a suitable
medication at a suitable dose for two months, along with at least four visits
to a physician; or else eight visits to any licensed mental health
professional. By that definition, only 33% of people with a psychiatric
disorder were treated adequately, and only 13% of those who saw general
medical practitioners.
In comparison to the original study conducted from 1991-1992, the use of mental health services
has increased over 50% during this decade. This may be attributed to treatment becoming more
widespread and increased attempts to educate the public about mental illness. Stigma, discussed
in Section 1.3, has reduced over time, diagnosis is more effective, community outreach programs
have increased, and most importantly, general practitioners have been more willing to prescribe
psychoactive medications which themselves are more readily available now. The article
concludes, “Survey researchers also suggest that we need more outreach and voluntary
screening, more education about mental illness for the public and physicians, and more effort to
treat substance abuse and impulse control disorders.” We will explore several of these issues in
the remainder of this section, including the use of psychiatric drugs and deinstitutionalization,
managed health care, private psychotherapy, positive psychology and prevention science,
multicultural psychology, and prescription rights for psychologists.
For more on the Harvard article, please see:
https://www.health.harvard.edu/mind-and-mood/the-prevalence-and-treatment-of-mental-illness-today
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1.4.7.2. Use of psychiatric drugs and deinstitutionalization. Beginning in the 1950s,
psychiatric or psychotropic drugs were used for the treatment of mental illness and made an
immediate impact. Though drugs alone cannot cure mental illness, they can improve symptoms
and increase the effectiveness of treatments such as psychotherapy. Classes of psychiatric drugs
include anti-depressants used to treat depression and anxiety, mood-stabilizing medications to
treat bipolar disorder, anti-psychotic drugs to treat schizophrenia, and anti-anxiety drugs to treat
generalized anxiety disorder or panic disorder
Frank (2006) found that by 1996, psychotropic drugs were used in 77% of mental health
cases and spending on these drugs grew from $2.8 billion in 1987 to about $18 billion in 2001
(Coffey et al., 2000; Mark et al., 2005), representing over a sixfold increase. The largest classes
of psychotropic drugs are anti-psychotics and anti-depressants, followed closely by anti-anxiety
medications. Frank, Conti, and Goldman (2005) point out, “The expansion of insurance coverage
for prescription drugs, the introduction and diffusion of managed behavioral health care
techniques, and the conduct of the pharmaceutical industry in promoting their products all have
influenced how psychotropic drugs are used and how much is spent on them.” Is it possible then
that we are overprescribing these mediations? Davey (2014) provides ten reasons why this may
be so, including leading suffers from believing that recovery is in their hands but instead in the
hands of their doctors; increased risk of relapse; drug companies causing the “medicalization of
perfectly normal emotional processes, such as bereavement” to ensure their survival; side effects;
and a failure to change the way the person thinks or the socioeconomic environments that may be
the cause of the disorder. For more on this article, please see:
https://www.psychologytoday.com/blog/why-we-worry/201401/overprescribing-drugs-treat-
mental-health-problems. Smith (2012) echoed similar sentiments in an article on inappropriate
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prescribing. He cites the approval of Prozac by the Food and Drug Administration (FDA) in
1987 as when the issue began and the overmedication/overdiagnosis of children with ADHD as a
more recent example.
A result of the use of psychiatric drugs was deinstitutionalization, or the release of
patients from mental health facilities. This shifted resources from inpatient to outpatient care and
placed the spotlight back on the biological or somatogenic perspective. When people with
severe mental illness do need inpatient care, it is typically in the form of short-term
hospitalization.
1.4.7.3. Managed health care. Managed health care is a term used to describe a type of
health insurance in which the insurance company determines the cost of services, possible
providers, and the number of visits a subscriber can have within a year. This is regulated through
contracts with providers and medical facilities. The plans pay the providers directly, so
subscribers do not have to pay out-of-pocket or complete claim forms, though most require co-
pays paid directly to the provider at the time of service. Exactly how much the plan costs
depends on how flexible the subscriber wants it to be; the more flexibility, the higher the cost.
Managed health care takes three forms:
• Health Maintenance Organizations (HMO) – Typically only pay for care within the
network. The subscriber chooses a primary care physician (PCP) who coordinates the
majority of their care. The PCP refers the subscriber to specialists or other health care
providers as is necessary. This is the most restrictive option.
• Preferred Provider Organizations (PPO) - Usually pay more if the subscriber obtains
care within the network, but if care outside the network is sought, they cover part of
the cost.
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• Point of Service (POS) – These plans provide the most flexibility and allow the
subscriber to choose between an HMO or a PPO each time care is needed.
Regarding the treatment needed for mental illness, managed care programs regulate the
pre-approval of treatment via referrals from the PCP, determine which mental health providers
can be seen, and oversee which conditions can be treated and what type of treatment can be
delivered. This system was developed in the 1980s to combat the rising cost of mental health
care and took responsibility away from single practitioners or small groups who could charge
what they felt was appropriate. The actual impact of managed care on mental health services is
still questionable at best.
1.4.7.4. Multicultural psychology. As our society becomes increasingly diverse, medical
practitioners and psychologists alike have to take into account the patient’s gender, age, race,
ethnicity, socioeconomic (SES) status, and culture and how these factors shape the individual’s
thoughts, feelings, and behaviors. Additionally, we need to understand how the various groups,
whether defined by race, culture, or gender, differ from one another. This approach is called
multicultural psychology.
In August 2002, the American Psychological Association’s (APA) Council of
Representatives put forth six guidelines based on the understanding that “race and ethnicity can
impact psychological practice and interventions at all levels” and the need for respect and
inclusiveness. They further state, “psychologists are in a position to provide leadership as agents
of prosocial change, advocacy, and social justice, thereby promoting societal understanding,
affirmation, and appreciation of multiculturalism against the damaging effects of individual,
institutional, and societal racism, prejudice, and all forms of oppression based on stereotyping
and discrimination.” The guidelines from the 2002 document are as follows:
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• “Guideline #1: Psychologists are encouraged to recognize that, as cultural beings,
they may hold attitudes and beliefs that can detrimentally influence their perceptions
of and interactions with individuals who are ethnically and racially different from
themselves.
• Guideline #2: Psychologists are encouraged to recognize the importance of
multicultural sensitivity/responsiveness, knowledge, and understanding about
ethnically and racially different individuals.
• Guideline #3: As educators, psychologists are encouraged to employ the constructs of
multiculturalism and diversity in psychological education.
• Guideline #4: Culturally sensitive psychological researchers are encouraged to
recognize the importance of conducting culture–centered and ethical psychological
research among persons from ethnic, linguistic, and racial minority backgrounds.
• Guideline #5: Psychologists strive to apply culturally-appropriate skills in clinical and
other applied psychological practices.
• Guideline #6: Psychologists are encouraged to use organizational change processes to
support culturally informed organizational (policy) development and practices.”
Source: https://apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx
This type of sensitivity training is vital because bias based on ethnicity, race, and culture
has been found in the diagnosis and treatment of autism (Harrison et al., 2017; Burkett, 2015),
borderline personality disorder (Jani et al., 2016), and schizophrenia (Neighbors et al., 2003;
Minsky et al., 2003). Despite these findings, Schwartz and Blankenship (2014) state, “It should
also be noted that although clear evidence supports a longstanding trend in differential diagnoses
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according to consumer race, this trend does not imply that one race (e.g., African Americans)
actually demonstrate more severe symptoms or higher prevalence rates of psychosis compared
with other races (e.g., Euro-Americans). Because clinicians are the diagnosticians and
misinterpretation, bias or other factors may play a role in this trend caution should be used when
making inferences about actual rates of psychosis among ethnic minority persons.” Additionally,
white middle-class help seekers were offered appointments with psychotherapists almost three
times as often as their black working-class counterparts. Women were offered an appointment
time in their preferred time range more than men were, though average appointment offer rates
were similar between genders (Kugelmass, 2016). These findings collectively show that though
we are becoming more culturally sensitive, we have a lot more work to do.
1.4.7.5. Prescription rights for psychologists. To reduce inappropriate prescribing as
described in 1.4.7.2, it has been proposed to allow appropriately trained psychologists the right to
prescribe. Psychologists are more likely to utilize both therapy and medication, and so can make
the best choice for their patient. The right has already been granted in New Mexico, Louisiana,
Guam, the military, the Indian Health Services, and the U.S. Public Health Services. Measures in
other states “have been opposed by the American Medical Association and American Psychiatric
Association over concerns that inadequate training of psychologists could jeopardize patient
safety. Supporters of prescriptive authority for psychologists are quick to point out that there is
no evidence to support these concerns” (Smith, 2012).
1.4.7.6. Prevention science. As a society, we used to wait for a mental or physical health
issue to emerge, then scramble to treat it. More recently, medicine and science has taken a
prevention stance, identifying the factors that cause specific mental health issues and
implementing interventions to stop them from happening, or at least minimize their deleterious
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effects. Our focus has shifted from individuals to the population. Mental health promotion
programs have been instituted with success in schools (Shoshani & Steinmetz, 2014; Weare &
Nind, 2011; Berkowitz & Beer, 2007), in the workplace (Czabała, Charzyńska, & Mroziak, B.,
2011), with undergraduate and graduate students (Conley et al., 2017; Bettis et al., 2016), in
relation to bullying (Bradshaw, 2015), and with the elderly (Forsman et al., 2011). Many
researchers believe it is the ideal time to move from knowledge to action and to expand public
mental health initiatives (Wahlbeck, 2015). The growth of positive psychology in the late 1990s
has further propelled this movement forward. For more on positive psychology, please see
Section 1.1.1.
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• Some of the earliest views of mental illness saw it as the work of evil
spirts, demons, gods, or witches who took control of the person, and in the
Middle Ages it was seen as possession by the Devil and methods such as
exorcism, flogging, prayer, the touching of relics, chanting, visiting holy
sites, and holy water were used to rid the person of demonic influence.
• During the Renaissance, humanism was on the rise which emphasized
human welfare and the uniqueness of the individual and led to an increase
in the number of asylums as places of refuge for the mentally ill.
• The 18th to 19th centuries saw the rise of the moral treatment movement
followed by the mental hygiene movement.
• The psychological or psychogenic perspective states that emotional or
psychological factors are the cause of mental disorders and represented a
challenge to the biological perspective which said that mental disorders
were akin to physical disorders and had natural causes.
• Psychiatric or psychotropic drugs used to treat mental illness became
popular beginning in the 1950s and led to deinstitutionalization or a shift
from inpatient to outpatient care.
1. How has mental illness been viewed across time?

2. Contrast the moral treatment and mental hygiene movements.
3. Contrast the biological or somatogenic perspective with that of the
psychological or psychogenic perspective.
4. Discuss contemporary trends in relation to the use of drugs to treat mental
illness, deinstitutionalization, managed health care, multicultural
psychology, prescription rights for psychologists, and prevention science.
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1.5. Research Methods in Psychopathology
• Define the scientific method.
• Outline and describe the steps of the scientific method, defining all key terms.
• Identify and clarify the importance of the three cardinal features of science.
• List the five main research methods used in psychology.
• Describe observational research, listing its advantages and disadvantages.
• Describe case study research, listing its advantages and disadvantages.
• Describe survey research, listing its advantages and disadvantages.
• Describe correlational research, listing its advantages and disadvantages.
• Describe experimental research, listing its advantages and disadvantages.
• State the utility and need for multimethod research.
1.5.1. The Scientific Method
Psychology is the “scientific study of behavior and mental processes.” We will spend
quite a lot of time on the behavior and mental processes part throughout this book and in relation
to mental disorders. Still, before we proceed, it is prudent to further elaborate on what makes
psychology scientific. It is safe to say that most people outside of our discipline or a sister
science would be surprised to learn that psychology utilizes the scientific method at all. That may
be even truer of clinical psychology, especially in light of the plethora of self-help books found
at any bookstore. But yes, the treatment methods used by mental health professionals are based
on empirical research and the scientific method.

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As a starting point, we should expand on what the scientific method is.
The scientific method is a systematic method for gathering knowledge about the world
around us.
The keyword here is systematic, meaning there is a set way to use it. What is that way? Well,
depending on what source you look at, it can include a varying number of steps. I like to use the
following:
Table 1.1: The Steps of the Scientific Method
Step Name Description

0 Ask questions and be To study the world around us, you have to wonder about it.
willing to wonder. This inquisitive nature is the hallmark of critical thinking —
our ability to assess claims made by others and make
objective judgments that are independent of emotion and
anecdote and based on hard evidence —and a requirement to
be a scientist.
1 Generate a research Through our wonderment about the world around us and why
question or identify a events occur as they do, we begin to ask questions that
problem to investigate. require further investigation to arrive at an answer. This
investigation usually starts with a literature review, or when
we conduct a literature search through our university library
or a search engine such as Google Scholar to see what
questions have been investigated already and what answers
have been found, so that we can identify gaps or holes in this
body of work.
2 Attempt to explain the We now attempt to formulate an explanation of why the
phenomena we wish to event occurs as it does. This systematic explanation of a
study. phenomenon is a theory and our specific, testable prediction
is the hypothesis. We will know if our theory is correct
because we have formulated a hypothesis that we can now
test.
3 Test the hypothesis. It goes without saying that if we cannot test our hypothesis,
then we cannot show whether our prediction is correct or not.
Our plan of action of how we will go about testing the
hypothesis is called our research design. In the planning
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stage, we will select the appropriate research method to

answer our question/test our hypothesis.
4 Interpret the results. With our research study done, we now examine the data to
see if the pattern we predicted exists. We need to see if a
cause and effect statement can be made, assuming our
method allows for this inference. More on this in Section 2.3.
For now, it is essential to know that statistics have two
forms. First, there are descriptive statistics which provide a
means of summarizing or describing data and presenting the
data in a usable form. You likely have heard of mean or
average, median, and mode. Along with standard deviation
and variance, these are ways to describe our data. Second,
there are inferential statistics that allow for the analysis of
two or more sets of numerical data to determine the
statistical significance of the results. Significance is an
indication of how confident we are that our results are due to
our manipulation or design and not chance.
5 Draw conclusions We need to interpret our results accurately and not overstate
carefully. our findings. To do this, we need to be aware of our biases
and avoid emotional reasoning so that they do not cloud our
judgment. How so? In our effort to stop a child from
engaging in self-injurious behavior that could cause
substantial harm or even death, we might overstate the
success of our treatment method.
6 Communicate our Once we have decided on whether our hypothesis was
findings to the broader correct or not, we need to share this information with others
scientific community. so that they might comment critically on our methodology,
statistical analyses, and conclusions. Sharing also allows for
replication or repeating the study to confirm its results.
Communication occurs via scientific journals, conferences,
or newsletters released by many of the organizations
mentioned in Module 1.6.
Science has at its root three cardinal features that we will see play out time and time
again throughout this book. They are:
1. Observation – To know about the world around us, we have to be able to see it firsthand.
When a mental disorder afflicts an individual, we can see it through their overt behavior.
An individual with depression may withdraw from activities he/she enjoys, those with
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social anxiety disorder will avoid social situations, people with schizophrenia may
express concern over being watched by the government, and individuals with dependent
personality disorder may leave major decisions to trusted companions. In these examples
and numerous others, the behaviors that lead us to a diagnosis of a specific disorder can
easily be observed by the clinician, the patient, and/or family and friends.
2. Experimentation – To be able to make causal or cause and effect statements, we must
isolate variables. We have to manipulate one variable and see the effect of doing so on
another variable. Let’s say we want to know if a new treatment for bipolar disorder is as
effective as existing treatments, or more importantly, better. We could design a study
with three groups of bipolar patients. One group would receive no treatment and serve as
a control group. A second group would receive an existing and proven treatment and
would also be considered a control group. Finally, the third group would receive the new
treatment and be the experimental group. What we are manipulating is what treatment the
groups get – no treatment, the older treatment, and the newer treatment. The first two
groups serve as controls since we already know what to expect from their results. There
should be no change in bipolar disorder symptoms in the no-treatment group, a general
reduction in symptoms for the older treatment group, and the same or better performance
for the newer treatment group. As long as patients in the newer treatment group do not
perform worse than their older treatment counterparts, we can say the new drug is a
success. You might wonder why we would get excited about the performance of the new
drug being the same as the old drug. Does it really offer any added benefit? In terms of a
reduction of symptoms, maybe not, but it could cost less money than the older drug and
that would be of value to patients.
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3. Measurement – How do we know that the new drug has worked? Simply, we can
measure the person’s bipolar disorder symptoms before any treatment was implemented,
and then again once the treatment has run its course. This pre-post test design is typical
in drug studies.
1.5.2. Research Methods
Step 3 called on the scientist to test his or her hypothesis. Psychology as a discipline uses
five main research designs. They are:
1.5.2.1. Naturalistic and laboratory observation. In terms of naturalistic observation,
the scientist studies human or animal behavior in its natural environment, which could include
the home, school, or a forest. The researcher counts, measures, and rates behavior in a systematic
way and, at times, uses multiple judges to ensure accuracy in how the behavior is being
measured. The advantage of this method is that you see behavior as it happens, and the
experimenter does not taint the data. The disadvantage is that it could take a long time for the
behavior to occur, and if the researcher is detected, then this may influence the behavior of those
being observed.
Laboratory observation involves observing people or animals in a laboratory setting.
The researcher might want to know more about parent-child interactions, and so, brings a mother
and her child into the lab to engage in preplanned tasks such as playing with toys, eating a meal,
or the mother leaving the room for a short time. The advantage of this method over the
naturalistic method is that the experimenter can use sophisticated equipment to record the session
and examine it later. The problem is that since the subjects know the experimenter is watching
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them, their behavior could become artificial. Clinical observation is a commonly employed
research method to study psychopathology; we will talk about it more throughout this course.
1.5.2.2. Case studies. Psychology can also utilize a detailed description of one person or
a small group based on careful observation. This was the approach the founder of
psychoanalysis, Sigmund Freud, took to develop his theories. The advantage of this method is
that you arrive at a detailed description of the investigated behavior, but the disadvantage is that
the findings may be unrepresentative of the larger population, and thus, lacking generalizability.
Again, bear in mind that you are studying one person or a tiny group. Can you possibly make
conclusions about all people from just one person, or even five or ten? The other issue is that the
case study is subject to researcher bias in terms of what is included in the final narrative and
what is left out. Despite these limitations, case studies can lead us to novel ideas about the cause
of abnormal behavior and help us to study unusual conditions that occur too infrequently to
analyze with large sample sizes and in a systematic way.
1.5.2.3. Surveys/Self-Report data. This is a questionnaire consisting of at least one scale
with some questions used to assess a psychological construct of interest such as parenting style,
depression, locus of control, or sensation-seeking behavior. It may be administered by paper and
pencil or computer. Surveys allow for the collection of large amounts of data quickly, but the
actual survey could be tedious for the participant and social desirability, when a participant
answers questions dishonestly so that he/she is seen in a more favorable light, could be an issue.
For instance, if you are asking high school students about their sexual activity, they may not give
genuine answers for fear that their parents will find out. You could alternatively gather this
information via an interview in a structured or unstructured fashion.
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1.5.2.4. Correlational research. This research method examines the relationship
between two variables or two groups of variables. A numerical measure of the strength of this
relationship is derived, called the correlation coefficient. It can range from -1.00, a perfect
inverse relationship in which one variable goes up as the other goes down, to 0 indicating no
relationship at all, to +1.00 or a perfect relationship in which as one variable goes up or down so
does the other. In terms of a negative correlation we might say that as a parent becomes more
rigid, controlling, and cold, the attachment of the child to parent goes down. In contrast, as a
parent becomes warmer, more loving, and provides structure, the child becomes more attached.
The advantage of correlational research is that you can correlate anything. The disadvantage is
that you can correlate anything, including variables that do not have any relationship with one
another. Yes, this is both an advantage and a disadvantage. For instance, we might correlate
instances of making peanut butter and jelly sandwiches with someone we are attracted to sitting
near us at lunch. Are the two related? Not likely, unless you make a really good PB&J, but then
the person is probably only interested in you for food and not companionship. The main issue
here is that correlation does not allow you to make a causal statement.
A special form of correlational research is the epidemiological study in which the
prevalence and incidence of a disorder in a specific population are measured (See Section 1.2 for
definitions).
1.5.2.5. Experiments. This is a controlled test of a hypothesis in which a researcher
manipulates one variable and measures its effect on another variable. The manipulated variable is
called the independent variable (IV), and the one that is measured is called the dependent
variable (DV). In the example under Experimentation in Section 1.5.1, the treatment for bipolar
disorder was the IV, while the actual intensity or number of symptoms serve as the DV. A
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common feature of experiments is a control group that does not receive the treatment or is not
manipulated and an experimental group that does receive the treatment or manipulation. If the
experiment includes random assignment, participants have an equal chance of being placed in
the control or experimental group. The control group allows the researcher (or teacher) to make a
comparison to the experimental group and make a causal statement possible, and stronger. In our
experiment, the new treatment should show a marked reduction in the intensity of bipolar
symptoms compared to the group receiving no treatment, and perform either at the same level as,
or better than, the older treatment. This would be the initial hypothesis made before starting the
experiment.
In a drug study, to ensure the participants' expectations do not affect the final results by
giving the researcher what he/she is looking for (in our example, symptoms improve whether the
participant is receiving treatment or not), we might use what is called a placebo, or a sugar pill
made to look exactly like the pill given to the experimental group. This way, participants all are
given something, but cannot figure out what exactly it is. You might say this keeps them honest
and allows the results to speak for themselves.
Finally, the study of mental illness does not always afford us a large sample of
participants to study, so we have to focus on one individual using a single-subject experimental
design. This differs from a case study in the sheer number of strategies available to reduce
potential confounding variables, or variables not originally part of the research design but
contribute to the results in a meaningful way. One type of single-subject experimental design is
the reversal or ABAB design. Kuttler, Myles, and Carson (1998) used social stories to reduce
tantrum behavior in two social environments in a 12-year old student diagnosed with autism,
Fragile-X syndrome, and intermittent explosive disorder. Using an ABAB design, they found
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that precursors to tantrum behavior decreased when the social stories were available (B) and
increased when the intervention was withdrawn (A). A more recent study (Balakrishnan & Alias,
20174) also established the utility of social stories as a social learning tool for children with
autism spectrum disorder (ASD) using an ABAB design. During the baseline phase (A), the four
student participants were observed, and data recorded on an observation form. During the
treatment phase (B), they listened to the social story and data was recorded in the same manner.
Upon completion of the first B, the students returned to A, which was followed one more time by
B and the reading of the social story. Once the second treatment phase ended, the participation
was monitored again to obtain the outcome. All students showed improvement during the
treatment phases in terms of the number of positive peer interactions, but the number of
interactions reduced in the absence of social stories. From this, the researchers concluded that the
social story led to the increase in positive peer interactions of children with ASD.
1.5.2.6. Multi-method research. As you have seen above, no single method alone is
perfect. All have strengths and limitations. As such, for the psychologist to provide the most
precise picture of what is affecting behavior or mental processes, several of these approaches are
typically employed at different stages of the research study. This is called multi-method
research.
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• The scientific method is a systematic method for gathering knowledge about
the world around us.
• A systematic explanation of a phenomenon is a theory and our specific,
testable prediction is the hypothesis.
• Replication is when we repeat the study to confirm its results.
• Psychology’s five main research designs are observation, case studies,
surveys, correlation, and experimentation.
• No single research method alone is perfect - all have strengths and
limitations.
1. What is the scientific method and what steps make it up?

2. Differentiate theory and hypothesis.
3. What are the three cardinal features of science and how do they relate to the
study of mental disorders?
4. What are the five main research designs used by psychologists? Define each
and then state its strengths and limitations.
5. What is the advantage of multi-method research?
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1.6. Mental Health Professionals, Societies, and Journals
• Identify and describe the various types of mental health professionals.
• Clarify what it means to communicate findings.
• Identify professional societies in clinical psychology.
• Identify publications in clinical psychology.
1.6.1. Types of Professionals
There are many types of mental health professionals that people may seek out for
assistance. They include:
Table 1.2: Types of Mental Health Professionals
Name Degree Function/Training Can they prescribe

Required medications?
Clinical Ph.D. Trained to make diagnoses and can Only in select states
Psychologist provide individual and group therapy
School Masters Trained to make diagnoses and can No

Psychologist or Ph.D. provide individual and group therapy
but also works with school staff
Counseling Ph.D. Deals with adjustment issues primarily No

Psychologist and less with mental illness
Clinical Social M.S.W. Trained to make diagnoses and can No

Worker or Ph.D. provide individual and group therapy
and is involved in advocacy and case
management. Usually in hospital
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settings.
Psychiatrist M.D. or Has specialized training in the Yes

Ph.D. diagnosis and treatment of mental
disorders
Psychiatric Nurse R.N. Has specialized treatment in the care Yes

Practitioner and treatment of psychiatric patients
Occupational B.S. Trained to assist individuals suffering No

Therapist from physical or psychological
handicaps and help them acquire
needed resources
Pastoral Counselor Clergy Trained in pastoral education and can No

make diagnoses and can provide
individual and group therapy
Drug Abuse and/or B.S. or Trained in alcohol and drug abuse and No
Alcohol Counselor higher can make diagnoses and can provide
individual and group therapy
Child/Adolescent M.D. or Specialized training in the diagnosis Yes

Psychiatrist Ph.D. and treatment of mental illness in
children
Marital and Family Masters Specialized training in marital and No

Therapist family therapy; Can make diagnoses
and can provide individual and group
therapy
For more information on types of mental health professionals, please visit:
http://www.mentalhealthamerica.net/types-mental-health-professionals
1.6.2. Professional Societies and Journals
One of the functions of science is to communicate findings. Testing hypotheses,
developing sound methodology, accurately analyzing data, and drawing sound conclusions are
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important, but you must tell others what you have done too. This is accomplished by joining
professional societies and submitting articles to peer-reviewed journals. Below are some of the
organizations and journals relevant to applied behavior analysis.
1.6.2.1. Professional Societies
• Society of Clinical Psychology – Division 12 of the American Psychological
Association
• Website – https://div12.org/
• Mission Statement – “The mission of the Society of Clinical Psychology is
to represent the field of Clinical Psychology through encouragement and
support of the integration of clinical psychological science and practice in
education, research, application, advocacy and public policy, attending to
the importance of diversity.”
• Publications – Clinical Psychology: Science and Practice and the

newsletter Clinical Psychology: Science and Practice (quarterly)
• Other Information – Members and student affiliates may join one of eight
divisions such as emergencies and crises, clinical psychology of women,
assessment, and clinical geropsychology
• Society of Clinical Child and Adolescent Psychology – Division 53 of the
American Psychological Association
• Website – https://www.clinicalchildpsychology.org/
• Mission Statement – “Our mission is to serve children, adolescents and
families with the best possible clinical care based on psychological
science. SCCAP strives to integrate scientific and professional aspects of

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clinical child and adolescent psychology, in that it promotes scientific
inquiry, training, and clinical practice related to serving children and their
families.”
• Publication – Journal of Clinical Child and Adolescent Psychology
• American Academy of Clinical Psychology
• Website – https://www.aacpsy.org/
• Mission Statement – The American Academy of Clinical Psychology
seeks to “recognize and promote advanced competence within
Professional Psychology,” “provide a professional community that
encourages communication between and among Members and Fellows of
the Academy,” “provide opportunities for advanced education in
Professional Psychology,” and “expand awareness and availability of
AACP Members and Fellows to the public through promotion and
education.”
• Publication – Bulletin of the American Academy of Clinical Psychology
(newsletter)
• The Society for a Science of Clinical Psychology (SSCP)
• Website – http://www.sscpweb.org/
• Mission Statement – “The Society for a Science of Clinical Psychology
(SSCP) was established in 1966. Its purpose is to affirm and continue to
promote the integration of the scientist and the practitioner in training,
research, and applied endeavors. Its members represent a diversity of
interests and theoretical orientations across clinical psychology. The

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common bond of the membership is a commitment to empirical research
and the ideal that scientific principles should play a role in training,
practice, and establishing public policy for health and mental health
concerns. SSCP has organizational affiliations with both the American
Psychological Association (Section III of Division 12) and the Association
for Psychological Science.”
• Other Information – Offers ten awards ranging from early career award,
outstanding mentor award, outstanding student teacher award, and
outstanding student clinician award.
• American Society of Clinical Hypnosis
• Website – http://www.asch.net/
• Mission Statement – “To provide and encourage education programs to
further, in every ethical way, the knowledge, understanding, and
application of hypnosis in health care; to encourage research and scientific
publication in the field of hypnosis; to promote the further recognition and
acceptance of hypnosis as an important tool in clinical health care and
focus for scientific research; to cooperate with other professional societies
that share mutual goals, ethics and interests; and to provide a professional
community for those clinicians and researchers who use hypnosis in their
work.”
• Publication – American Journal of Clinical Hypnosis
• Other Information – Offers certification in clinical hypnosis
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1.6.2.2. Professional Journals
• Clinical Psychology: Science and Practice
• Website – http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1468-
2850
• Published by – American Psychological Association, Division 12
• Description – “Clinical Psychology: Science and Practice presents
cutting-edge developments in the science and practice of clinical
psychology and related mental health fields by publishing scholarly
articles, primarily involving narrative and systematic reviews as well as
meta-analyses related to assessment, intervention, and service delivery.”
• Journal of Clinical Child and Adolescent Psychology
• Website – https://www.clinicalchildpsychology.org/JCCAP
• Published by – American Psychological Association, Division 53
• Description – “It publishes original contributions on the following topics:
(a) the development and evaluation of assessment and intervention
techniques for use with clinical child and adolescent populations; (b) the
development and maintenance of clinical child and adolescent problems;
(c) cross-cultural and socio-demographic issues that have a clear bearing
on clinical child and adolescent psychology in terms of theory, research,
or practice; and (d) training and professional practice in clinical child and
adolescent psychology, as well as child advocacy.”
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• American Journal of Clinical Hypnosis
• Website -
http://www.asch.net/Public/AmericanJournalofClinicalHypnosis.aspx
• Published by – American Society of Clinical Hypnosis
• Description – “The Journal publishes original scientific articles and
clinical case reports on hypnosis, as well as reviews of related books and
abstracts of the current hypnosis literature.”

• Mental health professionals take on many different forms with different degree
requirements, training, and the ability to prescribe mediations.
• Telling others what we have done is achieved by joining professional societies and
submitting articles to peer-reviewed journals.
1. Provide a general overview of the types of mental professionals and the degree,
training, and ability to prescribe medications that they have.
2. Briefly outline professional societies and journals related to clinical psychology
and related disciplines.
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Module Recap
In Module 1, we undertook a relatively lengthy discussion of what abnormal behavior is
by first looking at what normal behavior is. What emerged was a general set of guidelines
focused on mental illness as causing dysfunction, distress, deviance, and at times, being
dangerous for the afflicted and others around him/her. Then we classified mental disorders in
terms of their occurrence, cause, course, prognosis, and treatment. We acknowledged that mental
illness is stigmatized in our society and provided a basis for why this occurs and what to do
about it. This involved a discussion of the history of mental illness and current views and trends.
Psychology is the scientific study of behavior and mental processes. The word scientific
is key as psychology adheres to the strictest aspects of the scientific method and uses five main
research designs in its investigation of mental disorders – observation, case study, surveys,
correlational research, and experiments. Various mental health professionals use these designs,
and societies and journals provide additional means to communicate findings or to be good
consumers of psychological inquiry.
It is with this foundation in mind that we move to examine models of abnormality in
Module 2.
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Module 2:
Models of Abnormal Psychology
2-1
Module 2: Models of Abnormal Psychology
Module Overview
In Module 2, we will discuss three models of abnormal behavior to include the biological,
psychological, and sociocultural models. Each is unique in its own right and no single model can
account for all aspects of abnormality. Hence, we advocate for a multi-dimensional and not a
uni-dimensional model.
Module Outline
• 2.1. Uni- vs. Multi-Dimensional Models of Abnormality
• 2.2. The Biological Model
• 2.3. Psychological Perspectives
• 2.4. The Sociocultural Model
• Differentiate uni- and multi-dimensional models of abnormality.
• Describe how the biological model explains mental illness.
• Describe how psychological perspectives explain mental illness.
• Describe how the sociocultural model explains mental illness.
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2.1. Uni- vs. Multi-Dimensional Models of Abnormality
• Define the uni-dimensional model.
• Explain the need for a multi-dimensional model of abnormality.
• Define model.
• List and describe the models of abnormality.
2.1.1. Uni-Dimensional
To effectively treat a mental disorder, we have to understand its cause. This could be a
single factor such as a chemical imbalance in the brain, relationship with a parent,
socioeconomic status (SES), a fearful event encountered during middle childhood, or the way in
which the individual copes with life’s stressors. This single factor explanation is called a uni-
dimensional model. The problem with this approach is that mental disorders are not typically
caused by a solitary factor, but multiple causes. Admittedly, single factors do emerge during a
person’s life, but as they arise, the factors become part of the individual. In time, the cause of the
person’s psychopathology is due to all of these individual factors.
2.1.2. Multi-Dimensional
So, it is better to subscribe to a multi-dimensional model that integrates multiple causes
of psychopathology and affirms that each cause comes to affect other causes over time. Uni-
dimensional models alone are too simplistic to explain the etiology of mental disorders fully.
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Before introducing the current main models, it is crucial to understand what a model is.
In a general sense, a model is defined as a representation or imitation of an object
(dictionary.com). For mental health professionals, models help us to understand mental illness
since diseases such as depression cannot be touched or experienced firsthand. To be considered
distinct from other conditions, a mental illness must have its own set of symptoms. But as you
will see, the individual does not have to present with the entire range of symptoms. For example,
five out of nine symptoms may be enough to be diagnosed as having dysthymia, paranoid
schizophrenia, avoidant personality disorder, or illness anxiety disorder. There will be some
variability in terms of what symptoms are displayed, but in general, all people with a specific
psychopathology have symptoms from that group.
We can also ask the patient probing questions, seek information from family members,
examine medical records, and in time, organize and process all of this information to better
understand the person’s condition and potential causes. Models aid us with doing all of this. Still,
we must remember that the model is a starting point for the researcher, and due to this, it
determines what causes might be investigated at the exclusion of other causes. Often, proponents
of a given model find themselves in disagreement with proponents of other models. All forget
that there is no individual model that completely explains human behavior, or in this case,
abnormal behavior, and so each model contributes in its own way. Here are the models we will
examine in this module:
• Biological – includes genetics, chemical imbalances in the brain, the functioning of
the nervous system, etc.
• Psychological – includes learning, personality, stress, cognition, self-efficacy, and
early life experiences. We will examine several perspectives that make up the
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psychological model to include psychodynamic, behavioral, cognitive, and
humanistic-existential.
• Sociocultural – includes factors such as one’s gender, religious orientation, race,
ethnicity, and culture.

• The uni-dimensional model proposes a single factor as the cause of
psychopathology while the multi-dimensional model integrates multiple
causes of psychopathology and affirms that each cause comes to affect other
causes over time.
• There is no individual model that completely explains human behavior and so
each model contributes in its own way.
1. What is the problem with a uni-dimensional model of psychopathology?

2. Discuss the concept of a model and identify those important to understanding
psychopathology.
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2.2. The Biological Model
• Describe how communication in the nervous system occurs.
• List the parts of the nervous system.
• Describe the structure of the neuron and all key parts.
• Outline how neural transmission occurs.
• Identify and define important neurotransmitters.
• List the major structures of the brain.
• Clarify how specific areas of the brain are involved in mental illness.
• Describe the role of genes in mental illness.
• Describe the role of hormonal imbalances in mental illness.
• Describe the role of viral infections in mental illness.
• Describe commonly used treatments for mental illness.
• Evaluate the usefulness of the biological model.
Proponents of the biological model view mental illness as being a result of a malfunction
in the body to include issues with brain anatomy or chemistry. As such, we will need to establish
a foundation for how communication in the nervous system occurs, what the parts of the nervous
system are, what a neuron is and its structure, how neural transmission occurs, and what the parts
of the brain are. All while doing this, we will identify areas of concern for psychologists focused
on the treatment of mental disorders.
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2.2.1. Brain Structure and Chemistry
2.2.1.1. Communication in the nervous system. To truly understand brain structure and
chemistry, it is a good idea to understand how communication occurs within the nervous system.
See Figure 2.1 below. Simply:
1. Receptor cells in each of the five sensory systems detect energy.
2. This information is passed to the nervous system due to the process of transduction
and through sensory or afferent neurons, which are part of the peripheral nervous
system.
3. The information is received by brain structures (central nervous system) and
perception occurs.
4. Once the information has been interpreted, commands are sent out, telling the body
how to respond (Step E), also via the peripheral nervous system.
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Figure 2.1. Communication in the Nervous System
Please note that we will not cover this process in full, but just the parts relevant to our
topic of psychopathology.
2.2.1.2. The nervous system. The nervous system consists of two main parts – the
central and peripheral nervous systems. The central nervous system (CNS) is the control center
for the nervous system, which receives, processes, interprets, and stores incoming sensory
information. It consists of the brain and spinal cord. The peripheral nervous system consists of
everything outside the brain and spinal cord. It handles the CNS’s input and output and divides
into the somatic and autonomic nervous systems. The somatic nervous system allows for
voluntary movement by controlling the skeletal muscles and carries sensory information to the
CNS. The autonomic nervous system regulates the functioning of blood vessels, glands, and
internal organs such as the bladder, stomach, and heart. It consists of sympathetic and
parasympathetic nervous systems. The sympathetic nervous system is involved when a person
is intensely aroused. It provides the strength to fight back or to flee (fight-or-flight instinct).
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Eventually, the response brought about by the sympathetic nervous system must end. The
parasympathetic nervous system calms the body.
Figure 2.2. The Structure of the Nervous System
2.2.1.3. The neuron. The fundamental unit of the nervous system is the neuron, or nerve
cell (See Figure 2.3). It has several structures in common with all cells in the body. The nucleus
is the control center of the body and the soma is the cell body. In terms of distinctive structures,
these focus on the ability of a neuron to send and receive information. The axon sends
signals/information to neighboring neurons while the dendrites, which resemble little trees,
receive information from neighboring neurons. Note the plural form of dendrite and the singular
form of axon; there are many dendrites but only one axon. Also of importance to the neuron is
the myelin sheath or the white, fatty covering which: 1) provides insulation so that signals from
adjacent neurons do not affect one another and, 2) increases the speed at which signals are
transmitted. The axon terminals are the end of the axon where the electrical impulse becomes a
chemical message and passes to an adjacent neuron.

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Though not neurons, glial cells play an important part in helping the nervous system to be
the efficient machine that it is. Glial cells are support cells in the nervous system that serve five
main functions:
1. They act as a glue and hold the neuron in place.
2. They form the myelin sheath.
3. They provide nourishment for the cell.
4. They remove waste products.
5. They protect the neuron from harmful substances.
Finally, nerves are a group of axons bundled together like wires in an electrical cable.
Figure 2.3. The Structure of the Neuron
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2.2.1.4. Neural transmission. Transducers or receptor cells in the major organs of our
five sensory systems – vision (the eyes), hearing (the ears), smell (the nose), touch (the skin), and
taste (the tongue) – convert the physical energy that they detect or sense, and send it to the brain
via the neural impulse. How so? See Figure 2.4 below. We will cover this process in three parts.
Part 1. The Axon and Neural Impulse
The neural impulse follows the following steps:
• Step 1 – Neurons waiting to fire are said to be in resting potential and polarized, or
having a negative charge inside the neuron and a positive charge outside.
• Step 2 – If adequately stimulated, the neuron experiences an action potential and
becomes depolarized. When this occurs, voltage-gated ion channels open, allowing
positively charged sodium ions (Na+) to enter. This shifts the polarity to positive on
the inside and negative outside. Note that ions are charged particles found both inside
and outside the neuron.
• Step 3 – Once the action potential passes from one segment of the axon to the next,
the previous segment begins to repolarize. This occurs because the Na channels close
and potassium (K) channels open. K+ has a positive charge, so the neuron becomes
negative again on the inside and positive on the outside.
• Step 4 – After the neuron fires, it will not fire again no matter how much stimulation
it receives. This is called the absolute refractory period. Think of it as the neuron
ABSOLUTELY will not fire, no matter what.
• Step 5 – After a short time, the neuron can fire again, but needs greater than normal
levels of stimulation to do so. This is called the relative refractory period.
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• Step 6 - Please note that this process is cyclical. We started at resting potential in Step
1 and end at resting potential in Step 6.
Part 2. The Action Potential
Let's look at the electrical portion of the process in another way and add some detail.
Figure 2.4. The Action Potential
• Recall that a neuron is usually at resting potential and polarized. The charge inside is
-70mV at rest.
• If it receives sufficient stimulation, causing the polarity inside the neuron to rise from
-70 mV to -55mV (threshold of excitation), the neuron will fire or send an electrical
impulse down the length of the axon (the action potential or depolarization). It should
be noted that it either hits -55mV and fires, or it does not fire at all. This is the all-or-
nothing principle. The threshold must be reached.
• Once the electrical impulse has passed from one segment of the axon to the next, the
neuron begins the process of resetting called repolarization.
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• During repolarization the neuron will not fire no matter how much stimulation it
receives. This is called the absolute refractory period.
• The neuron next moves into a relative refractory period, meaning it can fire but needs
higher than normal levels of stimulation. Notice how the line has dropped below -
70mV. Hence, to reach -55mV and fire, it will need more than the normal gain of
+15mV (-70 to -55 mV).
• And then we return to resting potential, as you saw in Figure 2.4
Part 3. The Synapse
The electrical portion of the neural impulse is just the start. The actual code passes from
one neuron to another in a chemical form called a neurotransmitter. The point where this
occurs is called the synapse. The synapse consists of three parts – the axon of the sending
neuron, the space in between called the synaptic space, gap, or cleft, and the dendrite of the
receiving neuron. Once the electrical impulse reaches the end of the axon, called the axon
terminal, it stimulates synaptic vesicles or neurotransmitter sacs to release the neurotransmitter.
Neurotransmitters will only bind to their specific receptor sites, much like a key will only fit
into the lock it was designed for. You might say neurotransmitters are part of a lock-and-key
system. What happens to the neurotransmitters that do not bind to a receptor site? They might go
through reuptake, which is the process of the presynaptic neuron taking up excess
neurotransmitters in the synaptic space for future use or enzymatic degradation when enzymes
destroy excess neurotransmitters in the synaptic space.
2.2.1.5. Neurotransmitters. What exactly are some of the neurotransmitters which are so
critical for neural transmission, and are essential to our discussion of psychopathology?
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• Dopamine – controls voluntary movements and is associated with the reward
mechanism in the brain
• Serotonin – regulates pain, sleep cycle, and digestion; leads to a stable mood, so low
levels leads to depression
• Endorphins – involved in reducing pain and making the person calm and happy
• Norepinephrine – increases the heart rate and blood pressure and regulates mood
• GABA – blocks the signals of excitatory neurotransmitters responsible for anxiety
and panic
• Glutamate – associated with learning and memory
The critical thing to understand here is that there is a belief in the realm of mental health
that chemical imbalances are responsible for many mental disorders. Chief among these are
neurotransmitter imbalances. For instance, people with Seasonal Affective Disorder (SAD) have
difficulty regulating serotonin. More on this throughout the book as we discuss each disorder.
2.2.1.6. The brain. The central nervous system consists of the brain and spinal cord; the
former we will discuss briefly and in terms of key structures which include:
• Medulla – regulates breathing, heart rate, and blood pressure
• Pons – acts as a bridge connecting the cerebellum and medulla and helps to transfer
messages between different parts of the brain and spinal cord
• Reticular formation – responsible for alertness and attention
• Cerebellum – involved in our sense of balance and for coordinating the body’s
muscles so that movement is smooth and precise. Involved in the learning of certain
kinds of simple responses and acquired reflexes.
• Thalamus – the major sensory relay center for all senses except smell
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• Hypothalamus – involved in drives associated with the survival of both the
individual and the species. It regulates temperature by triggering sweating or
shivering and controls the complex operations of the autonomic nervous system
• Amygdala – responsible for evaluating sensory information and quickly determining
its emotional importance
• Hippocampus – our “gateway” to memory. Allows us to form spatial memories so
that we can accurately navigate through our environment and helps us to form new
memories about facts and events
• The cerebrum has four distinct regions in each cerebral hemisphere. First, the
frontal lobe contains the motor cortex, which issues orders to the muscles of the
body that produce voluntary movement. The frontal lobe is also involved in emotion
and in the ability to make plans, think creatively, and take initiative. The parietal
lobe contains the somatosensory cortex and receives information about pressure, pain,
touch, and temperature from sense receptors in the skin, muscles, joints, internal
organs, and taste buds. The occipital lobe contains the visual cortex for receiving and
processing visual information. Finally, the temporal lobe is involved in memory,
perception, and emotion. It contains the auditory cortex which processes sound.
Of course, this is not an exhaustive list of structures found in the brain but gives you a
pretty good idea of function and which structure is responsible for it. What is important to mental
health professionals is some disorders involve specific areas of the brain. For instance,
Parkinson’s disease is a brain disorder that results in a gradual loss of muscle control and arises
when cells in the substantia nigra, a long nucleus considered to be part of the basal ganglia,
stop making dopamine. As these cells die, the brain fails to receive messages about when and
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how to move. In the case of depression, low levels of serotonin are responsible, at least partially.
New evidence suggests “nerve cell connections, nerve cell growth, and the functioning of nerve
circuits have a major impact on depression… and areas that play a significant role in depression
are the amygdala, the thalamus, and the hippocampus.” Also, individuals with borderline
personality disorder have been shown to have structural and functional changes in brain areas
associated with impulse control and emotional regulation, while imaging studies reveal
differences in the frontal cortex and subcortical structures for those suffering from OCD.
Check out the following from Harvard Health for more on depression and the brain as a
cause: https://www.health.harvard.edu/mind-and-mood/what-causes-depression
2.2.2. Genes, Hormonal Imbalances, and Viral Infections
2.2.2.1. Genetic issues and explanations. DNA, or deoxyribonucleic acid, is our heredity
material. It exists in the nucleus of each cell, packaged in threadlike structures known as
chromosomes, for which we have 23 pairs or 46 total. Twenty-two of the pairs are the same in
both sexes, but the 23rd pair is called the sex chromosome and differs between males and
females. Males have X and Y chromosomes while females have two Xs. According to the
Genetics Home Reference website as part of NIH’s National Library of Medicine, a gene is “the
basic physical and functional unit of heredity” (https://ghr.nlm.nih.gov/primer/basics/gene). They
act as the instructions to make proteins, and it is estimated by the Human Genome Project that
we have between 20,000 and 25,000 genes. We all have two copies of each gene, one inherited
from our mother and one from our father.
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Recent research has discovered that autism, ADHD, bipolar disorder, major depression,
and schizophrenia all share genetic roots. They “were more likely to have suspect genetic
variation at the same four chromosomal sites. These included risk versions of two genes that
regulate the flow of calcium into cells.” Likewise, twin and family studies have shown that
people with first-degree relatives suffering from OCD are at higher risk to develop the disorder
themselves. The same is true of borderline personality disorder.
WebMD adds, “Experts believe many mental illnesses are linked to abnormalities in
many genes rather than just one or a few and that how these genes interact with the environment
is unique for every person (even identical twins). That is why a person inherits a susceptibility to
a mental illness and doesn't necessarily develop the illness. Mental illness itself occurs from the
interaction of multiple genes and other factors–such as stress, abuse, or a traumatic event–which
can influence, or trigger, an illness in a person who has an inherited susceptibility to it”
(https://www.webmd.com/mental-health/mental-health-causes-mental-illness#1).
For more on the role of genes in the development of mental illness, check out this article
from Psychology Today:
https://www.psychologytoday.com/blog/saving-normal/201604/what-you-need-know-
about-the-genetics-mental-disorders
2.2.2.2. Hormonal imbalances. The body has two coordinating and integrating systems,
the nervous system and the endocrine system. The main difference between these two systems is
the speed with which they act. The nervous system moves quickly with nerve impulses moving
in a few hundredths of a second. The endocrine system moves slowly with hormones, released
by endocrine glands, taking seconds, or even minutes, to reach their target. Hormones are
important to psychologists because they manage the nervous system and body tissues at certain
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stages of development and activate behaviors such as alertness or sleepiness, sexual behavior,
concentration, aggressiveness, reaction to stress, and a desire for companionship. The pituitary
gland is the “master gland” which regulates other endocrine glands. It influences blood pressure,
thirst, contractions of the uterus during childbirth, milk production, sexual behavior and interest,
body growth, the amount of water in the body’s cells, and other functions as well. The pineal
gland helps regulate the sleep-wake cycle while the thyroid gland regulates the body’s energy
levels by controlling metabolism and the basal metabolic rate (BMR). It regulates the body’s rate
of metabolism and so how energetic people are.
Of importance to mental health professionals are the adrenal glands, located on top of
the kidneys, and which release cortisol to help the body deal with stress. Elevated levels of this
hormone can lead to several problems, including increased weight gain, interference with
learning and memory, reduced bone density, high cholesterol, and an increased risk of
depression. Similarly, the overproduction of the hormone melatonin can lead to SAD.
For more on the link between cortisol and depression, check out this article:
https://www.psychologytoday.com/blog/the-athletes-way/201301/cortisol-why-the-stress-
hormone-is-public-enemy-no-1
2.2.2.3. Viral infections. Infections can cause brain damage and lead to the development
of mental illness or exacerbate existing symptoms. For example, evidence suggests that
contracting strep infection can lead to the development of OCD, Tourette’s syndrome, and tic
disorder in children (Mell, Davis, & Owens, 2005; Giedd et al., 2000; Allen et al., 1995;
https://www.psychologytoday.com/blog/the-perfectionists-handbook/201202/can-infections-
result-in-mental-illness). Influenza epidemics have also been linked to schizophrenia (Brown et
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al., 2004; McGrath and Castle, 1995; McGrath et al., 1994; O'callaghan et al., 1991) though
more recent research suggests this evidence is weak at best (Selten & Termorshuizen, 2017;
Ebert & Kotler, 2005).
2.2.3. Treatments
2.2.3.1. Psychopharmacology and psychotropic drugs. One option to treat severe
mental illness is psychotropic medications. These medications fall under five major categories.
Antidepressants are used to treat depression, but also anxiety, insomnia, and pain. The most
common types of antidepressants are SSRIs or selective serotonin reuptake inhibitors and include
Citalopram, Paroxetine, and Fluoxetine (Prozac). Possible side effects include weight gain,
sleepiness, nausea and vomiting, panic attacks, or thoughts about suicide or dying.
Anti-anxiety medications help with the symptoms of anxiety and include benzodiazepines
such as Clonazepam, Alprazolam, and Lorazepam. “Anti-anxiety medications such as
benzodiazepines are effective in relieving anxiety and take effect more quickly than the
antidepressant medications (or buspirone) often prescribed for anxiety. However, people can
build up a tolerance to benzodiazepines if they are taken over a long period of time and may need
higher and higher doses to get the same effect.” Side effects include drowsiness, dizziness,
nausea, difficulty urinating, and irregular heartbeat, to name a few.
Stimulants increase one’s alertness and attention and are frequently used to treat ADHD.
They include Lisdexamfetamine, the combination of dextroamphetamine and amphetamine, and
Methylphenidate. Stimulants are generally effective and produce a calming effect. Possible side
effects include loss of appetite, headache, motor or verbal tics, and personality changes such as
appearing emotionless.
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Antipsychotics are used to treat psychosis or “conditions that affect the mind, and in
which there has been some loss of contact with reality, often including delusions (false, fixed
beliefs) or hallucinations (hearing or seeing things that are not really there).” They can be used to
treat eating disorders, severe depression, PTSD, OCD, ADHD, and Generalized Anxiety
Disorder. Common antipsychotics include Chlorpromazine, Perphenazine, Quetiapine, and
Lurasidone. Side effects include nausea, vomiting, blurred vision, weight gain, restlessness,
tremors, and rigidity.
Mood stabilizers are used to treat bipolar disorder and, at times, depression,
schizoaffective disorder, and disorders of impulse control. A common example is Lithium; side
effects include loss of coordination, hallucinations, seizures, and frequent urination.
For more information on psychotropic medications, please visit:
https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml
The use of these drugs has been generally beneficial to patients. Most report that their
symptoms decline, leading them to feel better and improve their functioning. Also, long-term
hospitalizations are less likely to occur as a result, though the medications do not benefit the
individual in terms of improved living skills.
2.2.3.2. Electroconvulsive therapy. According to Mental Health America,
“Electroconvulsive therapy (ECT) is a procedure in which a brief application of electric stimulus
is used to produce a generalized seizure.” Patients are placed on a padded bed and administered a
muscle relaxant to avoid injury during the seizures. Annually, approximately 100,000 undergo
ECT to treat conditions such as severe depression, acute mania, suicidality, and some forms of
schizophrenia. The procedure is still the most controversial available to mental health
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professionals due to “its effectiveness vs. the side effects, the objectivity of ECT experts, and the
recent increase in ECT as a quick and easy solution, instead of long-term psychotherapy or
hospitalization” (http://www.mentalhealthamerica.net/ect). Its popularity has declined since the
1960s and 1970s.
2.2.3.3. Psychosurgery. Another option to treat mental disorders is to perform brain
surgeries. In the past, we have conducted trephination and lobotomies, neither of which are used
today. Today’s techniques are much more sophisticated and have been used to treat
schizophrenia, depression, and some personality and anxiety disorders. However, critics cite
obvious ethical issues with conducting such surgeries as well as scientific issues.
For more on psychosurgery, check out this article from Psychology Today:
https://www.psychologytoday.com/articles/199203/psychosurgery
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2.2.4. Evaluation of the Model
The biological model is generally well respected today but suffers a few key issues. First,
consider the list of side effects given for psychotropic medications. You might make the case that
some of the side effects are worse than the condition they are treating. Second, the viewpoint that
all human behavior is explainable in biological terms, and therefore when issues arise, they can
be treated using biological methods, overlooks factors that are not fundamentally biological.
More on that over the next two sections.

• Proponents of the biological model view mental illness as being a result of a
malfunction in the body to include issues with brain anatomy or chemistry.
• Neurotransmitter imbalances and problems with brain structures/areas can
result in mental disorders.
• Many disorders have genetic roots, are a result of hormonal imbalances, or
caused by viral infections such as strep.
• Treatments related to the biological model include drugs, ECT, and
psychosurgery.
1. Briefly outline how communication in the nervous system occurs.

2. What happens at the synapse during neural transmission? Why is this
important to a discussion of psychopathology?
3. How is the anatomy of the brain important to a discussion of
psychopathology?
4. What is the effect of genes, hormones, and viruses on the development of
mental disorders?
5. What treatments are available to clinicians courtesy of the biological model of
psychopathology?
6. What are some issues facing the biological model?
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2.3. Psychological Perspectives
• Describe psychodynamic theory.
• Outline the structure of personality and how it develops over time.
• Describe ways to deal with anxiety.
• Clarify what psychodynamic techniques are used.
• Evaluate the usefulness of psychodynamic theory.
• Describe learning.
• Outline respondent conditioning and the work of Pavlov and Watson.
• Outline operant conditioning and the work of Thorndike and Skinner.
• Outline observational learning/social-learning theory and the work of Bandura.
• Evaluate the usefulness of the behavioral model.
• Define the cognitive model.
• Exemplify the effect of schemas on creating abnormal behavior.
• Exemplify the effect of attributions on creating abnormal behavior.
• Exemplify the effect of maladaptive cognitions on creating abnormal behavior.
• List and describe cognitive therapies.
• Evaluate the usefulness of the cognitive model.
• Describe the humanistic perspective.
• Describe the existential perspective.
• Evaluate the usefulness of humanistic and existential perspectives.
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2.3.1. Psychodynamic Theory
In 1895, the book, Studies on Hysteria, was published by Josef Breuer (1842-1925) and
Sigmund Freud (1856-1939), and marked the birth of psychoanalysis, though Freud did not use
this actual term until a year later. The book published several case studies, including that of Anna
O., born February 27, 1859 in Vienna to Jewish parents Siegmund and Recha Pappenheim, strict
Orthodox adherents who were considered millionaires at the time. Bertha, known in published
case studies as Anna O., was expected to complete the formal education typical of upper-middle-
class girls, which included foreign language, religion, horseback riding, needlepoint, and piano.
She felt confined and suffocated in this life and took to a fantasy world she called her “private
theater.” Anna also developed hysteria, including symptoms such as memory loss, paralysis,
disturbed eye movements, reduced speech, nausea, and mental deterioration. Her symptoms
appeared as she cared for her dying father, and her mother called on Breuer to diagnosis her
condition (note that Freud never actually treated her). Hypnosis was used at first and relieved her
symptoms, as it had done for many patients (See Module 1). Breuer made daily visits and
allowed her to share stories from her private theater, which she came to call “talking cure” or
“chimney sweeping.” Many of the stories she shared were actually thoughts or events she found
troubling and reliving them helped to relieve or eliminate the symptoms. Breuer’s wife,
Mathilde, became jealous of her husband’s relationship with the young girl, leading Breuer to
terminate treatment in June of 1882 before Anna had fully recovered. She relapsed and was
admitted to Bellevue Sanatorium on July 1, eventually being released in October of the same
year. With time, Anna O. did recover from her hysteria and went on to become a prominent
member of the Jewish Community, involving herself in social work, volunteering at soup
kitchens, and becoming ‘House Mother’ at an orphanage for Jewish girls in 1895. Bertha (Anna
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O.) became involved in the German Feminist movement, and in 1904 founded the League of
Jewish Women. She published many short stories; a play called Women’s Rights, in which she
criticized the economic and sexual exploitation of women; and wrote a book in 1900 called The
Jewish Problem in Galicia, in which she blamed the poverty of the Jews of Eastern Europe on
their lack of education. In 1935, Bertha was diagnosed with a tumor, and in 1936, she was
summoned by the Gestapo to explain anti-Hitler statements she had allegedly made. She died
shortly after this interrogation on May 28, 1936. Freud considered the talking cure of Anna O. to
be the origin of psychoanalytic therapy and what would come to be called the cathartic method.
For more on Anna O., please see:
https://www.psychologytoday.com/blog/freuds-patients-serial/201201/bertha-pappenheim-
1859-1936
2.3.1.1. The structure of personality. Freud’s psychoanalysis was unique in the history
of psychology because it did not arise within universities as most major schools of thought did;
rather, it emerged from medicine and psychiatry to address psychopathology and examine the
unconscious. Freud believed that consciousness had three levels – 1) consciousness which was
the seat of our awareness, 2) preconscious that included all of our sensations, thoughts,
memories, and feelings, and 3) the unconscious, which was not available to us. The contents of
the unconscious could move from the unconscious to preconscious, but to do so, it had to pass a
Gate Keeper. Content that was turned away was said to be repressed.
According to Freud, our personality has three parts – the id, superego, and ego, and from
these our behavior arises. First, the id is the impulsive part that expresses our sexual and
aggressive instincts. It is present at birth, completely unconscious, and operates on the pleasure
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principle, resulting in selfishly seeking immediate gratification of our needs no matter what the
cost. The second part of personality emerges after birth with early formative experiences and is
called the ego. The ego attempts to mediate the desires of the id against the demands of reality,
and eventually, the moral limitations or guidelines of the superego. It operates on the reality
principle, or an awareness of the need to adjust behavior, to meet the demands of our
environment. The last part of the personality to develop is the superego, which represents
society’s expectations, moral standards, rules, and represents our conscience. It leads us to adopt
our parent’s values as we come to realize that many of the id’s impulses are unacceptable. Still,
we violate these values at times and experience feelings of guilt. The superego is partly
conscious but mostly unconscious, and part of it becomes our conscience. The three parts of
personality generally work together well and compromise, leading to a healthy personality, but if
the conflict is not resolved, intrapsychic conflicts can arise and lead to mental disorders.
Personality develops over five distinct stages in which the libido focuses on different
parts of the body. First, libido is the psychic energy that drives a person to pleasurable thoughts
and behaviors. Our life instincts, or Eros, are manifested through it and are the creative forces
that sustain life. They include hunger, thirst, self-preservation, and sex. In contrast, Thanatos,
our death instinct, is either directed inward as in the case of suicide and masochism or outward
via hatred and aggression. Both types of instincts are sources of stimulation in the body and
create a state of tension that is unpleasant, thereby motivating us to reduce them. Consider
hunger, and the associated rumbling of our stomach, fatigue, lack of energy, etc., that motivates
us to find and eat food. If we are angry at someone, we may engage in physical or relational
aggression to alleviate this stimulation.
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2.3.1.2. The development of personality. Freud’s psychosexual stages of personality
development are listed below. Please note that a person may become fixated at any stage,
meaning they become stuck, thereby affecting later development and possibly leading to
abnormal functioning, or psychopathology.
1. Oral Stage – Beginning at birth and lasting to 24 months, the libido is focused on the
mouth. Sexual tension is relieved by sucking and swallowing at first, and then later by
chewing and biting as baby teeth come in. Fixation is linked to a lack of confidence,
argumentativeness, and sarcasm.
2. Anal Stage – Lasting from 2-3 years, the libido is focused on the anus as toilet
training occurs. If parents are too lenient, children may become messy or
unorganized. If parents are too strict, children may become obstinate, stingy, or
orderly.
3. Phallic Stage – Occurring from about age 3 to 5-6 years, the libido is focused on the
genitals, and children develop an attachment to the parent of the opposite sex and are
jealous of the same-sex parent. The Oedipus complex develops in boys and results in
the son falling in love with his mother while fearing that his father will find out and
castrate him. Meanwhile, girls fall in love with the father and fear that their mother
will find out, called the Electra complex. A fixation at this stage may result in low
self-esteem, feelings of worthlessness, and shyness.
4. Latency Stage – From 6-12 years of age, children lose interest in sexual behavior, so
boys play with boys and girls with girls. Neither sex pays much attention to the
opposite sex.
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5. Genital Stage – Beginning at puberty, sexual impulses reawaken and unfulfilled
desires from infancy and childhood can be satisfied during lovemaking.
2.3.1.3. Dealing with anxiety. The ego has a challenging job to fulfill, balancing both the
will of the id and the superego, and the overwhelming anxiety and panic this creates. Ego-
defense mechanisms are in place to protect us from this pain but are considered maladaptive if
they are misused and become our primary way of dealing with stress. They protect us from
anxiety and operate unconsciously by distorting reality. Defense mechanisms include the
following:
• Repression – When unacceptable ideas, wishes, desires, or memories are blocked
from consciousness such as forgetting a horrific car accident that you caused.
Eventually, though, it must be dealt with or the repressed memory can cause
problems later in life.
• Reaction formation – When an impulse is repressed and then expressed by its
opposite. For example, you are angry with your boss but cannot lash out at him, so
you are super friendly instead. Another example is having lustful thoughts about a
coworker than you cannot express because you are married, so you are extremely
hateful to this person.
• Displacement – When we satisfy an impulse with a different object because focusing
on the primary object may get us in trouble. A classic example is taking out your
frustration with your boss on your wife and/or kids when you get home. If you lash
out at your boss, you could be fired. The substitute target is less dangerous than the
primary target.
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• Projection – When we attribute threatening desires or unacceptable motives to
others. An example is when we do not have the skills necessary to complete a task,
but we blame the other members of our group for being incompetent and unreliable.
• Sublimation – When we find a socially acceptable way to express a desire. If we are
stressed out or upset, we may go to the gym and box or lift weights. A person who
desires to cut things may become a surgeon.
• Denial – Sometimes, life is so hard that all we can do is deny how bad it is. An
example is denying a diagnosis of lung cancer given by your doctor.
• Identification – When we find someone who has found a socially acceptable way to
satisfy their unconscious wishes and desires, and we model that behavior.
• Regression – When we move from a mature behavior to one that is infantile. If your
significant other is nagging you, you might regress by putting your hands over your
ears and saying, “La la la la la la la la…”
• Rationalization – When we offer well-thought-out reasons for why we did what we
did, but these are not the real reason. Students sometimes rationalize not doing well in
a class by stating that they really are not interested in the subject or saying the
instructor writes impossible-to-pass tests.
• Intellectualization – When we avoid emotion by focusing on the intellectual aspects
of a situation such as ignoring the sadness we are feeling after the death of our mother
by focusing on planning the funeral.
For more on defense mechanisms, please visit:
https://www.psychologytoday.com/blog/fulfillment-any-age/201110/the-essential-guide-
defense-mechanisms
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2.3.1.4. Psychodynamic techniques. Freud used three primary assessment techniques—
free association, transference, and dream analysis—as part of psychoanalysis, or psychoanalytic
therapy, to understand the personalities of his patients and expose repressed material. First, free
association involves the patient describing whatever comes to mind during the session. The
patient continues but always reaches a point when he/she cannot or will not proceed any further.
The patient might change the subject, stop talking, or lose his/her train of thought. Freud said this
resistance revealed where issues persisted.
Second, transference is the process through which patients transfer attitudes he/she held
during childhood to the therapist. They may be positive and include friendly, affectionate
feelings, or negative, and include hostile and angry feelings. The goal of therapy is to wean
patients from their childlike dependency on the therapist.
Finally, Freud used dream analysis to understand a person’s innermost wishes. The
content of dreams includes the person’s actual retelling of the dreams, called manifest content,
and the hidden or symbolic meaning called latent content. In terms of the latter, some symbols
are linked to the person specifically, while others are common to all people.
2.3.1.5. Evaluating psychodynamic theory. Freud’s psychodynamic theory made a lasting
impact on the field of psychology but also has been criticized heavily. First, Freud made most of
his observations in an unsystematic, uncontrolled way, and he relied on the case study method.
Second, the participants in his studies were not representative of the broader population. Despite
Freud's generalization, his theory was based on only a few patients. Third, he relied solely on
the reports of his patients and sought no observer reports. Fourth, it is difficult to empirically
study psychodynamic principles since most operate unconsciously. This begs the question of
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how we can really know that they exist. Finally, psychoanalytic treatment is expensive and time
consuming, and since Freud’s time, drug therapies have become more popular and successful.
Still, Sigmund Freud developed useful therapeutic tools for clinicians and raised awareness about
the role the unconscious plays in both normal and abnormal behavior.
2.3.2. The Behavioral Model
2.3.2.1. What is learning? The behavioral model concerns the cognitive process of
learning, which is any relatively permanent change in behavior due to experience and practice.
Learning has two main forms – associative learning and observational learning. First, associative
learning is the linking together of information sensed from our environment. Conditioning, or a
type of associative learning, occurs when two separate events become connected. There are two
forms: classical conditioning, or linking together two types of stimuli, and operant conditioning,
or linking together a response with its consequence. Second, observational learning occurs
when we learn by observing the world around us.
We should also note the existence of non-associative learning or when there is no linking
of information or observing the actions of others around you. Types include habituation, or
when we simply stop responding to repetitive and harmless stimuli in our environment such as a
fan running in your laptop as you work on a paper, and sensitization, or when our reactions are
increased due to a strong stimulus, such as an individual who experienced a mugging and now
panics when someone walks up behind him/her on the street.
Behaviorism is the school of thought associated with learning that began in 1913 with the
publication of John B. Watson’s article, “Psychology as the Behaviorist Views It,” in the journal
Psychological Review (Watson, 1913). Watson believed that the subject matter of psychology
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was to be observable behavior, and to that end, psychology should focus on the prediction and
control of behavior. Behaviorism was dominant from 1913 to 1990 before being absorbed into
mainstream psychology. It went through three major stages – behaviorism proper under Watson
and lasting from 1913-1930 (discussed as classical/respondent conditioning), neobehaviorism
under Skinner and lasting from 1930-1960 (discussed as operant conditioning), and
sociobehaviorism under Bandura and Rotter and lasting from 1960-1990 (discussed as social
learning theory).
2.3.2.2. Respondent conditioning. You have likely heard about Pavlov and his dogs, but
what you may not know is that this was a discovery made accidentally. Ivan Petrovich Pavlov
(1906, 1927, 1928), a Russian physiologist, was interested in studying digestive processes in
dogs in response to being fed meat powder. What he discovered was the dogs would salivate
even before the meat powder was presented. They would salivate at the sound of a bell, footsteps
in the hall, a tuning fork, or the presence of a lab assistant. Pavlov realized some stimuli
automatically elicited responses (such as salivating to meat powder) and other stimuli had to be
paired with these automatic associations for the animal or person to respond to it (such as
salivating to a bell). Armed with this stunning revelation, Pavlov spent the rest of his career
investigating the learning phenomenon.
The important thing to understand is that not all behaviors occur due to reinforcement and
punishment as operant conditioning says. In the case of respondent conditioning, stimuli exert
complete and automatic control over some behaviors. We see this in the case of reflexes. When a
doctor strikes your knee with that little hammer, your leg extends out automatically. Another
example is how a baby will root for a food source if the mother’s breast is placed near their
mouth. And if a nipple is placed in their mouth, they will also automatically suck via the sucking
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reflex. Humans have several of these reflexes, though not as many as other animals due to our
more complicated nervous system.
Respondent conditioning (also called classical or Pavlovian conditioning) occurs when
we link a previously neutral stimulus with a stimulus that is unlearned or inborn, called an
unconditioned stimulus. In respondent conditioning, learning happens in three phases:
preconditioning, conditioning, and postconditioning. See Figure 2.5 for an overview of Pavlov’s
classic experiment.
Preconditioning. Notice that preconditioning has both an A and a B panel. All this stage
of learning signifies is that some learning is already present. There is no need to learn it again, as
in the case of primary reinforcers and punishers in operant conditioning. In Panel A, food makes
a dog salivate. This response does not need to be learned and shows the relationship between an
unconditioned stimulus (UCS) yielding an unconditioned response (UCR). Unconditioned means
unlearned. In Panel B, we see that a neutral stimulus (NS) produces no response. Dogs do not
enter the world knowing to respond to the ringing of a bell (which it hears).
Conditioning. Conditioning is when learning occurs. By pairing a neutral stimulus and
unconditioned stimulus (bell and food, respectively), the dog will learn that the bell ringing (NS)
signals food coming (UCS) and salivate (UCR). The pairing must occur more than once so that
needless pairings are not learned such as someone farting right before your food comes out and
now you salivate whenever someone farts (…at least for a while. Eventually the fact that no food
comes will extinguish this reaction but still, it will be weird for a bit).
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Figure 2.5. Pavlov’s Classic Experiment
Postconditioning. Postconditioning, or after learning has occurred, establishes a new and
not naturally occurring relationship of a conditioned stimulus (CS; previously the NS) and
conditioned response (CR; the same response). So the dog now reliably salivates at the sound of
the bell because he expects that food will follow, and it does.
Watson and Rayner (1920) conducted one of the most famous studies in psychology.
Essentially, they wanted to explore “the possibility of conditioning various types of emotional
response(s).” The researchers ran a series of trials in which they exposed a 9-month-old child,
known as Little Albert, to a white rat. Little Albert made no response outside of curiosity (NS–
NR not shown). Panel A of Figure 2.6 shows the naturally occurring response to the stimulus of
a loud sound. On later trials, the rat was presented (NS) and followed closely by a loud sound
(UCS; Panel B). After several conditioning trials, the child responded with fear to the mere
presence of the white rat (Panel C).

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Figure 2.6. Learning to Fear
As fears can be learned, so too they can be unlearned. Considered the follow-up to
Watson and Rayner (1920), Jones (1924; Figure 2.7) wanted to see if a child who learned to be
afraid of white rabbits (Panel B) could be conditioned to become unafraid of them. Simply, she
placed the child in one end of a room and then brought in the rabbit. The rabbit was far enough
away so as not to cause distress. Then, Jones gave the child some pleasant food (i.e., something
sweet such as cookies [Panel C]; remember the response to the food is unlearned, i.e., Panel A).
The procedure in Panel C continued with the rabbit being brought a bit closer each time until,
eventually, the child did not respond with distress to the rabbit (Panel D).
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Figure 2.7. Unlearning Fears
This process is called counterconditioning, or the reversal of previous learning.
Another respondent conditioning way to unlearn a fear is called flooding or exposing the
person to the maximum level of stimulus and as nothing aversive occurs, the link between CS
and UCS producing the CR of fear should break, leaving the person unafraid. That is the idea, at
least. So, if you were afraid of clowns, you would be thrown into a room full of clowns. Hmm….
Finally, respondent conditioning has several properties:
• Respondent Generalization – When many similar CSs or a broad range of CSs elicit
the same CR. An example is the sound of a whistle eliciting salivation much the same
as a ringing bell, both detected via audition.
• Respondent Discrimination – When a single CS or a narrow range of CSs elicits a
CR, i.e., teaching the dog to respond to a specific bell and ignore the whistle. The
whistle would not be followed by food, eventually leading to….
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• Respondent Extinction – When the CS is no longer paired with the UCS. The sound
of a school bell ringing (new CS that was generalized) is not followed by food (UCS),
and so eventually, the dog stops salivating (the CR).
• Spontaneous Recovery – When the CS elicits the CR after extinction has occurred.
Eventually, the school bell will ring, making the dog salivate. If no food comes, the
behavior will not continue. If food appears, the salivation response will be re-
established.
2.3.2.3. Operant conditioning. Influential on the development of Skinner’s operant
conditioning, Thorndike (1905) proposed the law of effect or the idea that if our behavior
produces a favorable consequence, in the future when the same stimulus is present, we will be
more likely to make the response again, expecting the same favorable consequence. Likewise, if
our action leads to dissatisfaction, then we will not repeat the same behavior in the future. He
developed the law of effect thanks to his work with a puzzle box. Cats were food deprived the
night before the experimental procedure was to occur. The next morning, researchers placed a
hungry cat in the puzzle box and set a small amount of food outside the box, just close enough to
be smelled. The cat could escape the box and reach the food by manipulating a series of levers.
Once free, the cat was allowed to eat some food before being promptly returned to the box. With
each subsequent escape and re-insertion into the box, the cat became faster at correctly
manipulating the levers. This scenario demonstrates trial and error learning or making a
response repeatedly if it leads to success. Thorndike also said that stimulus and responses were
connected by the organism and this led to learning. This approach to learning was called
connectionism.
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Operant conditioning is a type of associate learning which focuses on consequences that
follow a response or behavior that we make (anything we do, say, or think/feel) and whether it
makes a behavior more or less likely to occur. This should sound much like what you just read
about in terms of Thorndike’s work. Skinner talked about contingencies or when one thing
occurs due to another. Think of it as an If-Then statement. If I do X, then Y will happen. For
operant conditioning, this means that if I make a behavior, then a specific consequence will
follow. The events (response and consequence) are linked in time.
What form do these consequences take? There are two main ways they can present
themselves.
o Reinforcement – Due to the consequence, a behavior/response is strengthened
and more likely to occur in the future.
o Punishment – Due to the consequence, a behavior/response is weakened and less
likely to occur in the future.
Reinforcement and punishment can occur as two types – positive and negative. These
words have no affective connotation to them, meaning they do not imply good or bad. Positive
means that you are giving something – good or bad. Negative means that something is being
taken away – good or bad. Check out the figure below for how these contingencies are arranged.
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Figure 2.8. Contingencies in Operant Conditioning
Let’s go through each:
• Positive Punishment (PP) – If something bad or aversive is given or added, then the
behavior is less likely to occur in the future. If you talk back to your mother and she
slaps your mouth, this is a PP. Your response of talking back led to the consequence
of the aversive slap being given to your face. Ouch!!!
• Positive Reinforcement (PR) – If something good is given or added, then the
behavior is more likely to occur in the future. If you study hard and receive an A on
your exam, you will be more likely to study hard in the future. Similarly, your parents
may give you money for your stellar performance. Cha Ching!!!
• Negative Reinforcement (NR) – This is a tough one for students to
comprehend because the terms seem counterintuitive, even though we experience NR
all the time. NR is when something bad or aversive is taken away or subtracted due to
your actions, making it that you will be more likely to make the same behavior in the
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future when the same stimulus presents itself. For instance, what do you do if you
have a headache? If you take Tylenol and the pain goes away, you will likely take
Tylenol in the future when you have a headache. NR can either result in current
escape behavior or future avoidance behavior. What does this mean? Escape occurs
when we are presently experiencing an aversive event and want it to end. We make a
behavior and if the aversive event, like the headache, goes away, we will repeat the
taking of Tylenol in the future. This future action is an avoidance event. We might
start to feel a headache coming on and run to take Tylenol right away. By doing so,
we have removed the possibility of the aversive event occurring, and this behavior
demonstrates that learning has occurred.
• Negative Punishment (NP) – This is when something good is taken away or
subtracted, making a behavior less likely in the future. If you are late to class and
your professor deducts 5 points from your final grade (the points are something good
and the loss is negative), you will hopefully be on time in all subsequent classes.
The type of reinforcer or punisher we use is crucial. Some are naturally occurring, while
others need to be learned. We describe these as primary and secondary reinforcers and punishers.
Primary refers to reinforcers and punishers that have their effect without having to be learned.
Food, water, temperature, and sex, for instance, are primary reinforcers, while extreme cold or
hot or a punch on the arm are inherently punishing. A story will illustrate the latter. When I was
about eight years old, I would walk up the street in my neighborhood, saying, “I’m Chicken
Little and you can’t hurt me.” Most ignored me, but some gave me the attention I was seeking, a
positive reinforcer. So I kept doing it and doing it until one day, another kid grew tired of hearing
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about my other identity and punched me in the face. The pain was enough that I never walked up
and down the street echoing my identity crisis for all to hear. This was a positive punisher that
did not have to be learned, and definitely not one of my finer moments in life.
Secondary or conditioned reinforcers and punishers are not inherently reinforcing or
punishing but must be learned. An example was the attention I received for saying I was Chicken
Little. Over time I learned that attention was good. Other examples of secondary reinforcers
include praise, a smile, getting money for working or earning good grades, stickers on a board,
points, getting to go out dancing, and getting out of an exam if you are doing well in a class.
Examples of secondary punishers include a ticket for speeding, losing television or video game
privileges, ridicule, or a fee for paying your rent or credit card bill late. Really, the sky is the
limit with reinforcers in particular.
In operant conditioning, the rule for determining when and how often we will reinforce
the desired behavior is called the reinforcement schedule. Reinforcement can either occur
continuously meaning every time the desired behavior is made the subject will receive some
reinforcer, or intermittently/partially meaning reinforcement does not occur with every behavior.
Our focus will be on partial/intermittent reinforcement.
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Figure 2.9. Key Components of Reinforcement Schedules
Figure 2.9 shows that that are two main components that make up a reinforcement
schedule – when you will reinforce and what is being reinforced. In the case of when, it will be
either fixed or at a set rate, or variable and at a rate that changes. In terms of what is being
reinforced, we will either reinforce responses or time. These two components pair up as follows:
• Fixed Ratio schedule (FR) – With this schedule, we reinforce some set number of
responses. For instance, every twenty problems (fixed) a student gets correct (ratio),
the teacher gives him an extra credit point. A specific behavior is being reinforced –
getting problems correct. Note that if we reinforce each occurrence of the behavior,
the definition of continuous reinforcement, we could also describe this as an FR1
schedule. The number indicates how many responses have to be made, and in this
case, it is one.
• Variable Ratio schedule (VR) – We might decide to reinforce some varying number
of responses, such as if the teacher gives him an extra credit point after finishing
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between 40 and 50 correct problems. This approach is useful if the student is learning
the material and does not need regular reinforcement. Also, since the schedule
changes, the student will keep responding in the absence of reinforcement.
• Fixed Interval schedule (FI) – With a FI schedule, you will reinforce after some set
amount of time. Let’s say a company wanted to hire someone to sell their product. To
attract someone, they could offer to pay them $10 an hour 40 hours a week and give
this money every two weeks. Crazy idea, but it could work. Saying the person will be
paid every indicates fixed, and two weeks is time or interval. So, FI.
• Variable Interval schedule (VI) – Finally, you could reinforce someone at some
changing amount of time. Maybe they receive payment on Friday one week, then
three weeks later on Monday, then two days later on Wednesday, then eight days later
on Thursday, etc. This could work, right? Not for a job, but maybe we could say we
are reinforced on a VI schedule if we are.
Finally, four properties of operant conditioning – extinction, spontaneous recovery,
stimulus generalization, and stimulus discrimination – are important. These are the same four
discussed under respondent conditioning. First, extinction is when something that we do, say,
think/feel has not been reinforced for some time. As you might expect, the behavior will begin to
weaken and eventually stop when this occurs. Does extinction happen as soon as the anticipated
reinforcer is removed? The answer is yes and no, depending on whether we are talking about
continuous or partial reinforcement. With which type of schedule would you expect a person to
stop responding to immediately if reinforcement is not there? Continuous or partial?
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The answer is continuous. If a person is used to receiving reinforcement every time they
perform a particular behavior, and then suddenly no reinforcer is delivered, he or she will cease
the response immediately. Obviously then, with partial, a response continues being made for a
while. Why is this? The person may think the schedule has simply changed. ‘Maybe I am not
paid weekly now. Maybe it changed to biweekly and I missed the email.’ Due to this endurance,
we say that intermittent or partial reinforcement shows resistance to extinction, meaning the
behavior does weaken, but gradually.
As you might expect, if reinforcement occurs after extinction has started, the behavior
will re-emerge. Consider your parents for a minute. To stop some undesirable behavior you made
in the past, they likely took away some privilege. I bet the bad behavior ended too. But did you
ever go to your grandparent’s house and grandma or grandpa—or worse, BOTH—took pity on
you and let you play your video games (or something equivalent)? I know my grandmother used
to. What happened to that bad behavior that had disappeared? Did it start again and your parents
could not figure out why?
Additionally, you might have wondered if the person or animal will try to make the
response again in the future even though it stopped being reinforced in the past. The answer is
yes, and one of two outcomes is possible. First, the response is made, and nothing happens. In
this case, extinction continues. Second, the response is made, and a reinforcer is delivered. The
response re-emerges. Consider a rat trained to push a lever to receive a food pellet. If we stop
providing the food pellets, in time, the rat will stop pushing the lever. If the rat pushes the lever
again sometime in the future and food is delivered, the behavior spontaneously recovers. Hence,
this phenomenon is called spontaneous recovery.
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2.3.2.4. Observational learning. There are times when we learn by simply watching
others. This is called observational learning and is contrasted with enactive learning, which is
learning by doing. There is no firsthand experience by the learner in observational learning,
unlike enactive. As you can learn desirable behaviors such as watching how your father bags
groceries at the grocery store (I did this and still bag the same way today), you can learn
undesirable ones too. If your parents resort to alcohol consumption to deal with stressors life
presents, then you also might do the same. The critical part is what happens to the person
modeling the behavior. If my father seems genuinely happy and pleased with himself after
bagging groceries his way, then I will be more likely to adopt this behavior. If my mother or
father consumes alcohol to feel better when things are tough, and it works, then I might do the
same. On the other hand, if we see a sibling constantly getting in trouble with the law, then we
may not model this behavior due to the negative consequences.
Albert Bandura conducted pivotal research on observational learning, and you likely
already know all about it. Check out Figure 2.10 to see if you do. In Bandura’s experiment,
children were first brought into a room to watch a video of an adult playing nicely or
aggressively with a Bobo doll, which provided a model. Next, the children are placed in a room
with several toys in it. The room contains a highly prized toy, but they are told they cannot play
with it. All other toys are allowed, including a Bobo doll. Children who watched the aggressive
model behaved aggressively with the Bobo doll while those who saw the gentle model, played
nice. Both groups were frustrated when deprived of the coveted toy.
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Figure 2.10. Bandura’s Classic Experiment
According to Bandura, all behaviors are learned by observing others, and we model our
actions after theirs, so undesirable behaviors can be altered or relearned in the same way.
Modeling techniques change behavior by having subjects observe a model in a situation that
usually causes them some anxiety. By seeing the model interact nicely with the fear evoking
stimulus, their fear should subside. This form of behavior therapy is widely used in clinical,
business, and classroom situations. In the classroom, we might use modeling to demonstrate to a
student how to do a math problem. In fact, in many college classrooms, this is exactly what the
instructor does. In the business setting, a model or trainer demonstrates how to use a computer
program or run a register for a new employee.
However, keep in mind that we do not model everything we see. Why? First, we cannot
pay attention to everything going on around us. We are more likely to model behaviors by
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someone who commands our attention. Second, we must remember what a model does to imitate
it. If a behavior is not memorable, it will not be imitated. We must try to convert what we see
into action. If we are not motivated to perform an observed behavior, we probably will not show
what we have learned.
2.3.2.5. Evaluating the behavioral model. Within the context of psychopathology, the
behavioral perspective is useful because explains maladaptive behavior in terms of learning gone
awry. The good thing is that what is learned can be unlearned or relearned through behavior
modification, the process of changing behavior. To begin, an applied behavior analyst identifies
a target behavior, or behavior to be changed, defines it, works with the client to develop goals,
conducts a functional assessment to understand what the undesirable behavior is, what causes it,
and what maintains it. With this knowledge, a plan is developed and consists of numerous
strategies to act on one or all of these elements – antecedent, behavior, and/or consequence. The
strategies arise from all three learning models. In terms of operant conditioning, strategies
include antecedent manipulations, prompts, punishment procedures, differential reinforcement,
habit reversal, shaping, and programming. Flooding and desensitization are typical respondent
conditioning procedures used with phobias, and modeling arises from social learning theory and
observational learning. Watson and Skinner defined behavior as what we do or say, but later
behaviorists added what we think or feel. In terms of the latter, cognitive behavior modification
procedures arose after the 1960s and with the rise of cognitive psychology. This led to a
cognitive-behavioral perspective that combines concepts from the behavioral and cognitive
models, the latter discussed in the next section.
Critics of the behavioral perspective point out that it oversimplifies behavior and often
ignores inner determinants of behavior. Behaviorism has also been accused of being mechanistic
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and seeing people as machines. This criticism would be true of behaviorism’s first two stages,
though sociobehaviorism steered away from this proposition and even fought against any
mechanistic leanings of behaviorists.
The greatest strength or appeal of the behavioral model is that its tenets are easily tested
in the laboratory, unlike those of the psychodynamic model. Also, a large number of treatment
techniques have been developed and proven to be effective over the years. For example,
desensitization (Wolpe, 1997) teaches clients to respond calmly to fear-producing stimuli. It
begins with the individual learning a relaxation technique such as diaphragmatic breathing. Next,
a fear hierarchy, or list of feared objects and situations, is constructed in which the individual
moves from least to most feared. Finally, the individual either imagines (systematic) or
experiences in real life (in-vivo) each object or scenario from the hierarchy and uses the
relaxation technique while doing so. This represents the individual pairings of a feared object or
situation and relaxation. So if there are 10 objects/situations in the list, the client will experience
ten such pairings and eventually be able to face each without fear. Outside of phobias,
desensitization has been shown to be effective in the treatment of Obsessive-Compulsive
Disorder symptoms (Hakimian and Souza, 2016) and limitedly with the treatment of depression
when co-morbid with OCD (Masoumeh and Lancy, 2016).
2.3.3. The Cognitive Model
2.3.3.1. What is it? As noted earlier, the idea of people being machines, called
mechanism, was a key feature of behaviorism and other schools of thought in psychology until
about the 1960s or 1970s. In fact, behaviorism said psychology was to be the study of observable
behavior. Any reference to cognitive processes was dismissed as this was not overt, but covert
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according to Watson and later Skinner. Of course, removing cognition from the study of
psychology ignored an important part of what makes us human and separates us from the rest of
the animal kingdom. Fortunately, the work of George Miller, Albert Ellis, Aaron Beck, and
Ulrich Neisser demonstrated the importance of cognitive abilities in understanding thoughts,
behaviors, and emotions, and in the case of psychopathology, show that people can create their
problems by how they come to interpret events experienced in the world around them. How so?
2.3.3.2. Schemas and cognitive errors. First, consider the topic of social cognition or
the process of collecting and assessing information about others. So what do we do with this
information? Once collected or sensed (sensation is the cognitive process of detecting the
physical energy given off or emitted by physical objects), the information is sent to the brain
through the neural impulse. Once in the brain, it is processed and interpreted. This is where
assessing information about others comes in and involves the cognitive process of perception,
or adding meaning to raw sensory data. We take the information just detected and use it to assign
people to categories, or groups. For each category, we have a schema, or a set of beliefs and
expectations about a group of people, presumed to apply to all members of the group, and based
on experience.
Can our schemas lead us astray or be false? Consider where students sit in a class. It is
generally understood that the students who sit in the front of the class are the overachievers and
want to earn an A in the class. Those who sit in the back of the room are underachievers who
don’t care. Right? Where do you sit in class, if you are on a physical campus and not an online
student? Is this correct? What about other students in the class that you know? What if you found
out that a friend who sits in the front row is a C student but sits there because he cannot see the
screen or board, even with corrective lenses? What about your friend or acquaintance in the
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back? This person is an A student but does not like being right under the nose of the professor,
especially if he/she tends to spit when lecturing. The person in the back could also be shy and
prefer sitting there so that s/he does not need to chat with others as much. Or, they are easily
distracted and sits in the back so that all stimuli are in front of him/her. Again, your schema
about front row and back row students is incorrect and causes you to make certain assumptions
about these individuals. This might even affect how you interact with them. Would you want
notes from the student in the front or back of the class?
2.3.3.3. Attributions and cognitive errors. Second, consider the very interesting social
psychology topic attribution theory, or the idea that people are motivated to explain their own
and other people’s behavior by attributing causes of that behavior to personal reasons or
dispositional factors that are in the person themselves or linked to some trait they have; or
situational factors that are linked to something outside the person. Like schemas, the attributions
we make can lead us astray. How so? The fundamental attribution error occurs when we
automatically assume a dispositional reason for another person’s actions and ignore situational
factors. In other words, we assume the person who cut us off is an idiot (dispositional) and do not
consider that maybe someone in the car is severely injured and this person is rushing them to the
hospital (situational). Then there is the self-serving bias, which is when we attribute our success
to our own efforts (dispositional) and our failures to external causes (situational). Our attribution
in these two cases is in error, but still, it comes to affect how we see the world and our subjective
well-being.
2.3.3.4. Maladaptive cognitions. Irrational thought patterns can be the basis of
psychopathology. Throughout this book, we will discuss several treatment strategies used to
change unwanted, maladaptive cognitions, whether they are present as an excess such as with
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paranoia, suicidal ideation, or feelings of worthlessness; or as a deficit such as with self-
confidence and self-efficacy. More specifically, cognitive distortions/maladaptive cognitions can
take the following forms:
• Overgeneralizing – You see a larger pattern of negatives based on one event.
• Mind Reading – Assuming others know what you are thinking without any evidence.
• What if? – Asking yourself ‘what if something happens,’ without being satisfied by
any of the answers.
• Blaming – You focus on someone else as the source of your negative feelings and do
not take any responsibility for changing yourself.
• Personalizing – Blaming yourself for adverse events rather than seeing the role that
others play.
• Inability to disconfirm – Ignoring any evidence that may contradict your maladaptive
cognition.
• Regret orientation – Focusing on what you could have done better in the past rather
than on improving now.
• Dichotomous thinking – Viewing people or events in all-or-nothing terms.
2.3.3.5. Cognitive therapies. According to the National Alliance on Mental Illness
(NAMI), cognitive behavioral therapy “focuses on exploring relationships among a person's
thoughts, feelings and behaviors. During CBT a therapist will actively work with a person to
uncover unhealthy patterns of thought and how they may be causing self-destructive behaviors
and beliefs.” CBT attempts to identify negative or false beliefs and restructure them. They add,
“Oftentimes someone being treated with CBT will have homework in between sessions where
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they practice replacing negative thoughts with more realistic thoughts based on prior experiences
or record their negative thoughts in a journal.” For more on CBT, visit:
https://www.nami.org/Learn-More/Treatment/Psychotherapy. Some commonly used strategies
include cognitive restructuring, cognitive coping skills training, and acceptance techniques.
First, you can use cognitive restructuring, also called rational restructuring, in which
maladaptive cognitions are replaced with more adaptive ones. To do this, the client must be
aware of the distressing thoughts, when they occur, and their effect on them. Next, help the client
stop thinking these thoughts and replace them with more rational ones. It’s a simple strategy, but
an important one. Psychology Today published a great article on January 21, 2013, which
described four ways to change your thinking through cognitive restructuring. Briefly, these
included:
1. Notice when you are having a maladaptive cognition, such as making “negative
predictions.” Figure out what is the worst thing that could happen and what
alternative outcomes are possible.
2. Track the accuracy of the thought. If you believe focusing on a problem generates a
solution, then write down each time you ruminate and the result. You can generate a
percentage of times you ruminated to the number of successful problem-solving
strategies you generated.
3. Behaviorally test your thought. Try figuring out if you genuinely do not have time to
go to the gym by recording what you do each day and then look at open times of the
day. Add them up and see if making some minor, or major, adjustments to your
schedule will free an hour to get in some valuable exercise.
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4. Examine the evidence both for and against your thought. If you do not believe you do
anything right, list evidence of when you did not do something right and then
evidence of when you did. Then write a few balanced statements such as the one the
article suggests, “I’ve made some mistakes that I feel embarrassed about, but a lot of
the time, I make good choices.”
The article also suggested a few non-cognitive restructuring techniques, including
mindfulness meditation and self-compassion. For more on these, visit:
https://www.psychologytoday.com/blog/in-practice/201301/cognitive-restructuring
The second major CBT strategy is called cognitive coping skills training. This strategy
teaches social skills, communication, assertiveness through direct instruction, role playing, and
modeling. For social skills training, identify the appropriate social behavior such as making eye
contact, saying no to a request, or starting up a conversation with a stranger and determine
whether the client is inhibited from making this behavior due to anxiety. For communication,
decide if the problem is related to speaking, listening, or both and then develop a plan for use in
various interpersonal situations. Finally, assertiveness training aids the client in protecting their
rights and obtaining what they want from others. Those who are not assertive are often overly
passive and never get what they want or are unreasonably aggressive and only get what they
want. Treatment starts with determining situations in which assertiveness is lacking and
developing a hierarchy of assertiveness opportunities. Least difficult situations are handled first,
followed by more difficult situations, all while rehearsing and mastering all the situations present
in the hierarchy. For more on these techniques, visit http://cogbtherapy.com/cognitive-
behavioral-therapy-exercises/.
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Finally, acceptance techniques help reduce a client’s worry and anxiety. Life involves a
degree of uncertainty, and at times we must accept this. Techniques might include weighing the
pros and cons of fighting uncertainty or change. The disadvantages should outweigh the
advantages and help you to end the struggle and accept what is unknown. Chances are you are
already accepting the unknown in some areas of life, and identifying these can help you to see
why it is helpful in these areas, and how you can apply this in more difficult areas. Finally, does
uncertainty always lead to a negative end? We may think so, but a review of the evidence for and
against this statement will show that it does not and reduce how threatening it seems.
2.3.3.6. Evaluating the cognitive model. The cognitive model made up for an apparent
deficit in the behavioral model – overlooking the role cognitive processes play in our thoughts,
feelings, and behaviors. Right before his death, Skinner (1990) reminded psychologists that the
only thing we can truly know and study was the observable. Cognitive processes cannot be
empirically and reliably measured and should be ignored. Is there merit to this view? Social
desirability states that sometimes participants do not tell us the truth about what they are
thinking, feeling or doing (or have done) because they do not want us to think less of them or to
judge them harshly if they are outside the social norm. In other words, they present themselves in
a favorable light. If this is true, how can we know anything about controversial matters? The
person’s true intentions or thoughts and feelings are not readily available to us, or are covert, and
do not make for useful empirical data. Still, cognitive-behavioral therapies have proven their
efficacy for the treatment of OCD (McKay et al., 2015), perinatal depression (Sockol, 2015),
insomnia (de Bruin et al., 2015), bulimia nervosa (Poulsen et al., 2014), hypochondriasis
(Olatunji et al., 2014), and social anxiety disorder (Leichsenring et al., 2014) to name a few.
Other examples will be discussed throughout this book.
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2.3.4. The Humanistic and Existential Perspectives
2.3.4.1. The humanistic perspective. The humanistic perspective, or third force
psychology (psychoanalysis and behaviorism being the other two forces), emerged in the 1960s
and 1970s as an alternative viewpoint to the largely deterministic view of personality espoused
by psychoanalysis and the view of humans as machines advocated by behaviorism. Key features
of the perspective include a belief in human perfectibility, personal fulfillment, valuing self-
disclosure, placing feelings over intellect, an emphasis on the present, and hedonism. Its key
figures were Abraham Maslow, who proposed the hierarchy of needs, and Carl Rogers, who we
will focus on here.
Rogers said that all people want to have positive regard from significant others in their
life. When the individual is accepted as they are, they receive unconditional positive regard and
become a fully functioning person. They are open to experience, live every moment to the fullest,
are creative, accepts responsibility for their decisions, do not derive their sense of self from
others, strive to maximize their potential, and are self-actualized. Their family and friends may
disapprove of some of their actions but overall, respect and love them. They then realize their
worth as a person but also that they are not perfect. Of course, most people do not experience this
but instead are made to feel that they can only be loved and respected if they meet certain
standards, called conditions of worth. Hence, they experience conditional positive regard. Their
self-concept becomes distorted, now seen as having worth only when these significant others
approve, leading to a disharmonious state and psychopathology. Individuals in this situation are
unsure of what they feel, value, or need leading to dysfunction and the need for therapy. Rogers
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stated that the humanistic therapist should be warm, understanding, supportive, respectful, and
accepting of his/her clients. This approach came to be called client-centered therapy.
2.3.4.2. The existential perspective. This approach stresses the need for people to re-
create themselves continually and be self-aware, acknowledges that anxiety is a normal part of
life, focuses on free will and self-determination, emphasizes that each person has a unique
identity known only through relationships and the search for meaning, and finally, that we
develop to our maximum potential. Abnormal behavior arises when we avoid making choices, do
not take responsibility, and fail to actualize our full potential. Existential therapy is used to treat
substance abuse, “excessive anxiety, apathy, alienation, nihilism, avoidance, shame, addiction,
despair, depression, guilt, anger, rage, resentment, embitterment, purposelessness, psychosis, and
violence. They also focus on life-enhancing experiences like relationships, love, caring,
commitment, courage, creativity, power, will, presence, spirituality, individuation, self-
actualization, authenticity, acceptance, transcendence, and awe.” For more information, please
visit: https://www.psychologytoday.com/therapy-types/existential-therapy
2.3.4.3. Evaluating the humanistic and existential perspectives. The biggest criticism
of these models is that the concepts are abstract and fuzzy and so very difficult to research.
Rogers did try to investigate his propositions scientifically, but most other humanistic-existential
psychologists rejected the use of the scientific method. They also have not developed much in
the way of theory, and the perspectives tend to work best with people suffering from adjustment
issues and not as well with severe mental illness. The perspectives do offer hope to people
suffering tragedy by asserting that we control our destiny and can make our own choices.
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• According to Freud, consciousness had three levels (consciousness,
preconscious, and the unconscious), personality had three parts (the id,
ego, and superego), personality developed over five stages (oral, anal,
phallic, latency, and genital), there are ten defense mechanisms to protect
the ego such as repression and sublimation, and finally three assessment
techniques (free association, transference, and dream analysis) could be
used to understand the personalities of his patients and expose repressed
material.
• The behavioral model concerns the cognitive process of learning, which is
any relatively permanent change in behavior due to experience and
practice, and has two main forms – associative learning to include classical
and operant conditioning and observational learning.
• Respondent conditioning (also called classical or Pavlovian conditioning)
occurs when we link a previously neutral stimulus with a stimulus that is
unlearned or inborn, called an unconditioned stimulus.
• Operant conditioning is a type of associate learning which focuses on
consequences that follow a response or behavior that we make (anything
we do, say, or think/feel) and whether it makes a behavior more or less
likely to occur.
• Observational learning is learning by watching others and modeling
techniques change behavior by having subjects observe a model in a
situation that usually causes them some anxiety.
• The cognitive model focuses on schemas, cognitive errors, attributions,
and maladaptive cognitions and offers strategies such as CBT, cognitive
restructuring, cognitive coping skills training, and acceptance.
• The humanistic perspective focuses on positive regard, conditions of
worth, and the fully functioning person while the existential perspective
stresses the need for people to re-create themselves continually and be
self-aware, acknowledges that anxiety is a normal part of life, focuses on
free will and self-determination, emphasizes that each person has a unique
identity known only through relationships and the search for meaning, and
finally, that we develop to our maximum potential.
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1. What are the three parts of personality according to Freud?

2. What are the five psychosexual stages according to Freud?
3. List and define the ten defense mechanisms proposed by Freud.
4. What are the three assessment techniques used by Freud?
5. What is learning and what forms does it take?
6. Describe respondent conditioning.
7. Describe operant conditioning.
8. Describe observational learning and modeling.
9. How does the cognitive model approach psychopathology?
10. How does the humanistic perspective approach psychopathology?
11. How does the existential perspective approach psychopathology?
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2.4. The Sociocultural Model
• Describe the sociocultural model.
• Clarify how socioeconomic factors affect mental illness.
• Clarify how gender factors affect mental illness.
• Clarify how environmental factors affect mental illness.
• Clarify how multicultural factors affect mental illness.
• Evaluate the sociocultural model.
Outside of biological and psychological factors on mental illness, race, ethnicity, gender,
religious orientation, socioeconomic status, sexual orientation, etc. also play a role, and this is
the basis of the sociocultural model. How so? We will explore a few of these factors in this
section.
2.4.1. Socioeconomic Factors
Low socioeconomic status has been linked to higher rates of mental and physical illness
(Ng, Muntaner, Chung, & Eaton, 2014) due to persistent concern over unemployment or under-
employment, low wages, lack of health insurance, no savings, and the inability to put food on the
table, which then leads to feeling hopeless, helpless, and dependency on others. This situation
places considerable stress on an individual and can lead to higher rates of anxiety disorders and
depression. Borderline personality disorder has also been found to be higher in people in low-
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income brackets (Tomko et al., 2012) and group differences for personality disorders have been
found between African and European Americans (Ryder, Sunohara, and Kirmayer, 2015).
2.4.2. Gender Factors
Gender plays an important, though at times, unclear role in mental illness. Gender is not a
cause of mental illness, though differing demands placed on males and females by society and
their culture can influence the development and course of a disorder. Consider the following:
• Rates of eating disorders are higher among women than men, though both genders are
affected. In the case of men, muscle dysphoria is of concern and is characterized by
extreme concern over being more muscular.
• OCD has an earlier age of onset in girls than boys, with most people being diagnosed
by age 19.
• Females are at higher risk for developing an anxiety disorder than men.
• ADHD is more common in males than females, though females are more likely to
have inattention issues.
• Boys are more likely to be diagnosed with Autism Spectrum Disorder.
• Depression occurs with greater frequency in women than men.
• Women are more likely to develop PTSD compared to men.
• Rates of SAD (Seasonal Affective Disorder) are four times greater in women than
men. Interestingly, younger adults are more likely to develop SAD than older adults.
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Consider this…
In relation to men: “Men and women experience many of the same mental disorders
but their willingness to talk about their feelings may be very different. This is one of
the reasons that their symptoms may be very different as well. For example, some
men with depression or an anxiety disorder hide their emotions and may appear to be
angry or aggressive while many women will express sadness. Some men may turn to
drugs or alcohol to try to cope with their emotional issues.”
https://www.nimh.nih.gov/health/topics/men-and-mental-health/index.shtml
In relation to women: “Some women may experience symptoms of mental disorders

at times of hormone change, such as perinatal depression, premenstrual dysphoric
disorder, and perimenopause-related depression. When it comes to other mental
disorders such as schizophrenia and bipolar disorder, research has not found
differences in rates that men and women experiences these illnesses. But, women
may experience these illnesses differently – certain symptoms may be more common
in women than in men, and the course of the illness can be affected by the sex of the
individual.”
https://www.nimh.nih.gov/health/topics/women-and-mental-health/index.shtml
2.4.3. Environmental Factors
Environmental factors also play a role in the development of mental illness. How so?
• In the case of borderline personality disorder, many people report experiencing
traumatic life events such as abandonment, abuse, unstable relationships or
hostility, and adversity during childhood.
• Cigarette smoking, alcohol use, and drug use during pregnancy are risk factors for
ADHD.
• Divorce or the death of a spouse can lead to anxiety disorders.
• Trauma, stress, and other extreme stressors are predictive of depression.

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• Malnutrition before birth, exposure to viruses, and other psychosocial factors are
potential causes of schizophrenia.
• SAD occurs with greater frequency for those living far north or south from the
equator (Melrose, 2015). Horowitz (2008) found that rates of SAD are just 1% for
those living in Florida while 9% of Alaskans are diagnosed with the disorder.
Source: https://www.nimh.nih.gov/health/topics/index.shtml
2.4.4. Multicultural Factors
Racial, ethnic, and cultural factors are also relevant to understanding the development
and course of mental illness. Multicultural psychologists assert that both normal behavior and
abnormal behavior need to be understood in the context of the individual’s unique culture and
the group’s value system. Racial and ethnic minorities must contend with prejudice,
discrimination, racism, economic hardships, etc. as part of their daily life and this can lead to
disordered behavior (Lo & Cheng, 2014; Jones, Cross, & DeFour, 2007; Satcher, 2001), though
some research suggests that ethnic identity can buffer against these stressors and protect mental
health (Mossakowski, 2003). To address this unique factor, culture-sensitive therapies have
been developed and include increasing the therapist’s awareness of cultural values, hardships,
stressors, and/or prejudices faced by their client; the identification of suppressed anger and pain;
and raising the client’s self-worth (Prochaska & Norcross, 2013). These therapies have proven
efficacy for the treatment of depression (Kalibatseva & Leong, 2014) and schizophrenia (Naeem
et al., 2015).
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2.4.5. Evaluation of the Model
The sociocultural model has contributed significantly to our understanding of the nuances
of mental illness diagnosis, prognosis, course, and treatment for other races, cultures, genders,
ethnicities. In Module 3, we will discuss diagnosing and classifying abnormal behavior from the
perspective of the DSM 5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition).
Important here is that specific culture- and gender-related diagnostic issues are discussed for
each disorder, demonstrating increased awareness of the impact of these factors. Still, the
sociocultural model suffers from unclear findings and not allowing for the establishment of
causal relationships, reliance on more qualitative data gathered from case studies and
ethnographic analyses (one such example is Zafra, 2016), and an inability to make predictions
about abnormal behavior for individuals.

• The sociocultural model asserts that race, ethnicity, gender, religious orientation,
socioeconomic status, sexual orientation all play a role in the development and
treatment of mental illness.
1. How do socioeconomic, gender, environmental, and multicultural factors affect

mental illness and its treatment?
2. How effective is the sociocultural model at explaining psychopathology and its
treatment?
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Module Recap
In Module 2, we first distinguished uni- and multi-dimensional models of abnormality
and made a case that the latter was better to subscribe to. We then discussed biological,
psychological, and sociocultural models of abnormality. In terms of the biological model,
neurotransmitters, brain structures, hormones, genes, and viral infections were identified as
potential causes of mental illness and three treatment options were given. In terms of
psychological perspectives, Freud’s psychodynamic theory; the learning-related research of
Watson, Skinner, and Bandura and Rotter; the cognitive model; and the humanistic and
existential perspectives were discussed. Finally, the sociocultural model indicated the role of
socioeconomic, gender, environmental, and multicultural factors on abnormal behavior.
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Module 3:
Clinical Assessment, Diagnosis, and
Treatment
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Module 3: Clinical Assessment, Diagnosis, and Treatment
Module Overview
Module 3 covers the issues of clinical assessment, diagnosis, and treatment. We will
define assessment and then describe key issues such as reliability, validity, standardization, and
specific methods that are used. In terms of clinical diagnosis, we will discuss the two main
classification systems used around the world – the DSM-5 and ICD-10. Finally, we discuss the
reasons why people may seek treatment and what to expect when doing so.
Module Outline
• 3.1. Clinical Assessment of Abnormal Behavior
• 3.2. Diagnosing and Classifying Abnormal Behavior
• 3.3. Treatment of Mental Disorders – An Overview
• Describe clinical assessment and methods used in it.
• Clarify how mental health professionals diagnose mental disorders in a standardized
way.
• Discuss reasons to seek treatment and the importance of psychotherapy.
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3.1. Clinical Assessment of Abnormal Behavior
• Define clinical assessment.
• Clarify why clinical assessment is an ongoing process.
• Define and exemplify reliability.
• Define and exemplify validity.
• Define standardization.
• List and describe seven methods of assessment.
3.1.1. What is Clinical Assessment?
For a mental health professional to be able to effectively help treat a client and know that
the treatment selected worked (or is working), he/she first must engage in the clinical
assessment of the client, or collecting information and drawing conclusions through the use of
observation, psychological tests, neurological tests, and interviews to determine the person’s
problem and the presenting symptoms. This collection of information involves learning about the
client’s skills, abilities, personality characteristics, cognitive and emotional functioning, the
social context in terms of environmental stressors that are faced, and cultural factors particular to
them such as their language or ethnicity. Clinical assessment is not just conducted at the
beginning of the process of seeking help but throughout the process. Why is that?
Consider this. First, we need to determine if a treatment is even needed. By having a clear
accounting of the person’s symptoms and how they affect daily functioning, we can decide to
what extent the individual is adversely affected. Assuming a treatment is needed, our second
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reason to engage in clinical assessment will be to determine what treatment will work best. As
you will see later in this module, there are numerous approaches to treatment. These include
Behavior Therapy, Cognitive and Cognitive-Behavioral Therapy (CBT), Humanistic-
Experiential Therapies, Psychodynamic Therapies, Couples and Family Therapy, and biological
treatments (psychopharmacology). Of course, for any mental disorder, some of the
aforementioned therapies will have greater efficacy than others. Even if several can work well, it
does not mean a particular therapy will work well for that specific client. Assessment can help
figure this out. Finally, we need to know if the treatment we employed worked. This will involve
measuring before any treatment is used and then measuring the behavior while the treatment is in
place. We will even want to measure after the treatment ends to make sure symptoms of the
disorder do not return. Knowing what the person’s baselines are for different aspects of
psychological functioning will help us to see when improvement occurs.
In recap, obtaining the baselines happens in the beginning, implementing the treatment
plan that is agreed upon happens more so in the middle, and then making sure the treatment
produces the desired outcome occurs at the end. It should be clear from this discussion that
clinical assessment is an ongoing process.
3.1.2. Key Concepts in Assessment
The assessment process involves three critical concepts – reliability, validity, and
standardization. Actually, these three are important to science in general. First, we want the
assessment to be reliable or consistent. Outside of clinical assessment, when our car has an issue
and we take it to the mechanic, we want to make sure that what one mechanic says is wrong with
our car is the same as what another says, or even two others. If not, the measurement tools they
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use to assess cars are flawed. The same is true of a patient who is suffering from a mental
disorder. If one mental health professional says the person suffers from major depressive
disorder and another says the issue is borderline personality disorder, then there is an issue with
the assessment tool being used (in this case, the DSM and more on that in a bit). Ensuring that
two different raters are consistent in their assessment of patients is called interrater reliability.
Another type of reliability occurs when a person takes a test one day, and then the same test on
another day. We would expect the person’s answers to be consistent, which is called test-retest
reliability. For example, let’s say the person takes the MMPI on Tuesday and then the same test
on Friday. Unless something miraculous or tragic happened over the two days in between tests,
the scores on the MMPI should be nearly identical to one another. What does identical mean?
The score at test and the score at retest are correlated with one another. If the test is reliable, the
correlation should be very high (remember, a correlation goes from -1.00 to +1.00, and positive
means as one score goes up, so does the other, so the correlation for the two tests should be high
on the positive side).
In addition to reliability, we want to make sure the test measures what it says it measures.
This is called validity. Let’s say a new test is developed to measure symptoms of depression. It
is compared against an existing and proven test, such as the Beck Depression Inventory (BDI).
If the new test measures depression, then the scores on it should be highly comparable to the
ones obtained by the BDI. This is called concurrent or descriptive validity. We might even ask if
an assessment tool looks valid. If we answer yes, then it has face validity, though it should be
noted that this is not based on any statistical or evidence-based method of assessing validity. An
example would be a personality test that asks about how people behave in certain situations.
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Therefore, it seems to measure personality, or we have an overall feeling that it measures what
we expect it to measure.
Predictive validity is when a tool accurately predicts what will happen in the future. Let’s
say we want to tell if a high school student will do well in college. We might create a national
exam to test needed skills and call it something like the Scholastic Aptitude Test (SAT). We
would have high school students take it by their senior year and then wait until they are in
college for a few years and see how they are doing. If they did well on the SAT, we would
expect that at that point, they should be doing well in college. If so, then the SAT accurately
predicts college success. The same would be true of a test such as the Graduate Record Exam
(GRE) and its ability to predict graduate school performance.
Finally, we want to make sure that the experience one patient has when taking a test or
being assessed is the same as another patient taking the test the same day or on a different day,
and with either the same tester or another tester. This is accomplished with the use of clearly laid
out rules, norms, and/or procedures, and is called standardization. Equally important is that
mental health professionals interpret the results of the testing in the same way, or otherwise, it
will be unclear what the meaning of a specific score is.
3.1.3. Methods of Assessment
So how do we assess patients in our care? We will discuss observation, psychological
tests, neurological tests, the clinical interview, and a few others in this section.
3.1.3.1. Observation. In Section 1.5.2.1 we talked about two types of observation –
naturalistic, or observing the person or animal in their environment, and laboratory, or observing
the organism in a more controlled or artificial setting where the experimenter can use
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sophisticated equipment and videotape the session to examine it at a later time. One-way mirrors
can also be used. A limitation of this method is that the process of recording a behavior causes
the behavior to change, called reactivity. Have you ever noticed someone staring at you while
you sat and ate your lunch? If you have, what did you do? Did you change your behavior? Did
you become self-conscious? Likely yes, and this is an example of reactivity. Another issue is that
the behavior made in one situation may not be made in other situations, such as your significant
other only acting out at the football game and not at home. This form of validity is called cross-
sectional validity. We also need our raters to observe and record behavior in the same way or to
have high inter-rater reliability.
3.1.3.2. The clinical interview. A clinical interview is a face-to-face encounter between
a mental health professional and a patient in which the former observes the latter and gathers
data about the person’s behavior, attitudes, current situation, personality, and life history. The
interview may be unstructured in which open-ended questions are asked, structured in which a
specific set of questions according to an interview schedule are asked, or semi-structured, in
which there is a pre-set list of questions, but clinicians can follow up on specific issues that catch
their attention. A mental status examination is used to organize the information collected
during the interview and systematically evaluates the patient through a series of questions
assessing appearance and behavior. The latter includes grooming and body posture, thought
processes and content to include disorganized speech or thought and false beliefs, mood and
affect such that whether the person feels hopeless or elated, intellectual functioning to include
speech and memory, and awareness of surroundings to include where the person is and what the
day and time are. The exam covers areas not normally part of the interview and allows the
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mental health professional to determine which areas need to be examined further. The limitation
of the interview is that it lacks reliability, especially in the case of the unstructured interview.
3.1.3.3. Psychological tests and inventories. Psychological tests assess the client’s
personality, social skills, cognitive abilities, emotions, behavioral responses, or interests. They
can be administered either individually or to groups in paper or oral fashion. Projective tests
consist of simple ambiguous stimuli that can elicit an unlimited number of responses. They
include the Rorschach or inkblot test and the Thematic Apperception Test which asks the
individual to write a complete story about each of 20 cards shown to them and give details about
what led up to the scene depicted, what the characters are thinking, what they are doing, and
what the outcome will be. From the response, the clinician gains perspective on the patient’s
worries, needs, emotions, conflicts, and the individual always connects with one of the people on
the card. Another projective test is the sentence completion test and asks individuals to finish an
incomplete sentence. Examples include ‘My mother…’ or ‘I hope…’
Personality inventories ask clients to state whether each item in a long list of statements
applies to them, and could ask about feelings, behaviors, or beliefs. Examples include the MMPI
or Minnesota Multiphasic Personality Inventory and the NEO-PI-R, which is a concise measure
of the five major domains of personality – Neuroticism, Extroversion, Openness, Agreeableness,
and Conscientiousness. Six facets define each of the five domains, and the measure assesses
emotional, interpersonal, experimental, attitudinal, and motivational styles (Costa & McCrae,
1992). These inventories have the advantage of being easy to administer by either a professional
or the individual taking it, are standardized, objectively scored, and can be completed
electronically or by hand. That said, personality cannot be directly assessed, and so you do not
ever completely know the individual.
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3.1.3.4. Neurological tests. Neurological tests are used to diagnose cognitive
impairments caused by brain damage due to tumors, infections, or head injuries; or changes in
brain activity. Positron Emission Tomography or PET is used to study the brain’s chemistry. It
begins by injecting the patient with a radionuclide that collects in the brain and then having them
lie on a scanning table while a ring-shaped machine is positioned over their head. Images are
produced that yield information about the functioning of the brain. Magnetic Resonance Imaging
or MRI provides 3D images of the brain or other body structures using magnetic fields and
computers. It can detect brain and spinal cord tumors or nervous system disorders such as
multiple sclerosis. Finally, computed tomography or the CT scan involves taking X-rays of the
brain at different angles and is used to diagnose brain damage caused by head injuries or brain
tumors.
3.1.3.5. Physical examination. Many mental health professionals recommend the patient
see their family physician for a physical examination, which is much like a check-up. Why is
that? Some organic conditions, such as hyperthyroidism or hormonal irregularities, manifest
behavioral symptoms that are similar to mental disorders. Ruling out such conditions can save
costly therapy or surgery.
3.1.3.6. Behavioral assessment. Within the realm of behavior modification and applied
behavior analysis, we talk about what is called behavioral assessment, which is the
measurement of a target behavior. The target behavior is whatever behavior we want to change,
and it can be in excess and needing to be reduced, or in a deficit state and needing to be
increased. During the behavioral assessment we learn about the ABCs of behavior in which
Antecedents are the environmental events or stimuli that trigger a behavior; Behaviors are what
the person does, says, thinks/feels; and Consequences are the outcome of a behavior that either
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encourages it to be made again in the future or discourages its future occurrence. Though we
might try to change another person’s behavior using behavior modification, we can also change
our own behavior, which is called self-modification. The person does their own measuring and
recording of the ABCs, which is called self-monitoring. In the context of psychopathology,
behavior modification can be useful in treating phobias, reducing habit disorders, and ridding the
person of maladaptive cognitions.
3.1.3.7. Intelligence tests. Intelligence testing determines the patient’s level of cognitive
functioning and consists of a series of tasks asking the patient to use both verbal and nonverbal
skills. An example is the Stanford-Binet Intelligence test, which assesses fluid reasoning,
knowledge, quantitative reasoning, visual-spatial processing, and working memory. Intelligence
tests have been criticized for not predicting future behaviors such as achievement and reflecting
social or cultural factors/biases and not actual intelligence. Also, can we really assess
intelligence through one dimension, or are there multiple dimensions?
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• Clinical assessment is the collecting of information and drawing conclusions
through the use of observation, psychological tests, neurological tests, and
interviews.
• Reliability refers to consistency in measurement and can take the form of
interrater and test-retest reliability.
• Validity is when we ensure the test measures what it says it measures and
takes the forms of concurrent or descriptive, face, and predictive validity.
• Standardization is all the clearly laid out rules, norms, and/or procedures to
ensure the experience each participant has is the same.
• Patients are assessed through observation, psychological tests, neurological
tests, and the clinical interview, all with their own strengths and limitations.
1. What does it mean that clinical assessment is an ongoing process?

2. Define and exemplify reliability, validity, and standardization.
3. For each assessment method, define it and then state its strengths and
limitations.
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3.2. Diagnosing and Classifying Abnormal Behavior
• Explain what it means to make a clinical diagnosis.
• Define syndrome.
• Clarify and exemplify what a classification system does.
• Identify the two most used classification systems.
• Outline the history of the DSM.
• Identify and explain the elements of a diagnosis.
• Outline the major disorder categories of the DSM-5.
• Describe the ICD-10.
• Clarify why the DSM-5 and ICD-11 need to be harmonized.
3.2.1. Clinical Diagnosis and Classification Systems
Before starting any type of treatment, the client/patient must be clearly diagnosed with a
mental disorder. Clinical diagnosis is the process of using assessment data to determine if the
pattern of symptoms the person presents with is consistent with the diagnostic criteria for a
specific mental disorder outlined in an established classification system such as the DSM-5 or
ICD-10 (both will be described shortly). Any diagnosis should have clinical utility, meaning it
aids the mental health professional in determining prognosis, the treatment plan, and possible
outcomes of treatment (APA, 2013). Receiving a diagnosis does not necessarily mean the person
requires treatment. This decision is made based upon how severe the symptoms are, level of
distress caused by the symptoms, symptom salience such as expressing suicidal ideation, risks
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and benefits of treatment, disability, and other factors (APA, 2013). Likewise, a patient may not
meet the full criteria for a diagnosis but require treatment nonetheless.
Symptoms that cluster together regularly are called a syndrome. If they also follow the
same, predictable course, we say that they are characteristic of a specific disorder.
Classification systems provide mental health professionals with an agreed-upon list of disorders
falling into distinct categories for which there are clear descriptions and criteria for making a
diagnosis. Distinct is the keyword here. People suffering from delusions, hallucinations,
disorganized speech, catatonia, and/or negative symptoms are different from people presenting
with a primary clinical deficit in cognitive functioning that is not developmental but has been
acquired (i.e., they have shown a decline in cognitive functioning over time). The former suffers
from a schizophrenia spectrum disorder while the latter suffers from a NCD or neurocognitive
disorder. The latter can be further distinguished from neurodevelopmental disorders which
manifest early in development and involve developmental deficits that cause impairments in
social, academic, or occupational functioning (APA, 2013). These three disorder groups or
categories can be clearly distinguished from one another. Classification systems also permit the
gathering of statistics to determine incidence and prevalence rates and conform to the
requirements of insurance companies for the payment of claims.
The most widely used classification system in the United States is the Diagnostic and
Statistical Manual of Mental Disorders currently in its 5th edition and produced by the American
Psychiatric Association (APA, 2013). Alternatively, the World Health Organization (WHO)
publishes the International Statistical Classification of Diseases and Related Health Problems
(ICD) currently in its 10th edition, with an 11th edition expected to be published in 2018. We
will begin by discussing the DSM and then move to the ICD.
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3.2.2. The DSM Classification System
3.2.2.1. A brief history of the DSM. The DSM-5 was published in 2013 and took the
place of the DSM IV-TR (TR means Text Revision; published in 2000), but the history of the
DSM goes back to 1944 when the American Psychiatric Association published a predecessor of
the DSM which was a “statistical classification of institutionalized mental patients” and “…was
designed to improve communication about the types of patients cared for in these hospitals”
(APA, 2013, p. 6). The DSM evolved through four major editions after World War II into a
diagnostic classification system to be used psychiatrists and physicians, but also other mental
health professionals. The Herculean task of revising the DSM began in 1999 when the APA
embarked upon an evaluation of the strengths and weaknesses of the DSM in coordination with
the World Health Organization (WHO) Division of Mental Health, the World Psychiatric
Association, and the National Institute of Mental Health (NIMH). This collaboration resulted in
the publication of a monograph in 2002 called A Research Agenda for DSM-V. From 2003 to
2008, the APA, WHO, NIMH, the National Institute on Drug Abuse (NIDA), and the National
Institute on Alcoholism and Alcohol Abuse (NIAAA) convened 13 international DSM-5
research planning conferences “to review the world literature in specific diagnostic areas to
prepare for revisions in developing both DSM-5 and the International Classification of Disease,
11th Revision (ICD-11)” (APA, 2013).
After the naming of a DSM-5 Task Force Chair and Vice-Chair in 2006, task force
members were selected and approved by 2007, and workgroup members were approved in 2008.
This group undertook an intensive process of “conducting literature reviews and secondary
analyses, publishing research reports in scientific journals, developing draft diagnostic criteria,
posting preliminary drafts on the DSM-5 website for public comment, presenting preliminary
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findings at professional meetings, performing field trials, and revisiting criteria and text”(APA,
2013).
The result was a “common language for communication between clinicians about the
diagnosis of disorders” along with a realization that the criteria and disorders contained within
were based on current research and may undergo modification with new evidence gathered “both
within and across the domains of proposed disorders” (APA, 2013). Additionally, some disorders
were not included within the main body of the document because they did not have the scientific
evidence to support their widespread clinical use, but were included in Section III under
“Conditions for Further Study” to “highlight the evolution and direction of scientific advances in
these areas to stimulate further research” (APA, 2013).
3.2.2.2. Elements of a diagnosis. The DSM 5 states that the following make up the key
elements of a diagnosis (APA, 2013):
• Diagnostic Criteria and Descriptors – Diagnostic criteria are the guidelines for
making a diagnosis. When the full criteria are met, mental health professionals can
add severity and course specifiers to indicate the patient’s current presentation. If the
full criteria are not met, designators such as “other specified” or “unspecified” can be
used. If applicable, an indication of severity (mild, moderate, severe, or extreme),
descriptive features, and course (type of remission – partial or full – or recurrent) can
be provided with the diagnosis. The final diagnosis is based on the clinical interview,
text descriptions, criteria, and clinical judgment.
• Subtypes and Specifiers – Subtypes denote “mutually exclusive and jointly exhaustive
phenomenological subgroupings within a diagnosis” (APA, 2013). For example, non-
rapid eye movement (NREM) sleep arousal disorders can have either a sleepwalking
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or sleep terror type. Enuresis is nocturnal only, diurnal only, or both. Specifiers are
not mutually exclusive or jointly exhaustive and so more than one specifier can be
given. For instance, binge eating disorder has remission and severity specifiers.
Somatic symptom disorder has a specifier for severity, if with predominant pain,
and/or if persistent. Again, the fundamental distinction between subtypes and
specifiers is that there can be only one subtype but multiple specifiers.
• Principle Diagnosis – A principal diagnosis is used when more than one diagnosis is
given for an individual. It is the reason for the admission in an inpatient setting or the
basis for a visit resulting in ambulatory care medical services in outpatient settings.
The principal diagnosis is generally the focus of treatment.
• Provisional Diagnosis – If not enough information is available for a mental health
professional to make a definitive diagnosis, but there is a strong presumption that the
full criteria will be met with additional information or time, then the provisional
specifier can be used.
3.2.2.3. DSM-5 disorder categories. The DSM-5 includes the following categories of
disorders:
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Table 3.1. DSM-5 Classification System of Mental Disorders
Disorder Category Short Description Module
Neurodevelopmental A group of conditions that arise in the developmental period Not

disorders and include intellectual disability, communication disorders, covered
autism spectrum disorder, motor disorders, and ADHD
Schizophrenia Disorders characterized by one or more of the following: 12

Spectrum delusions, hallucinations, disorganized thinking and speech,
disorganized motor behavior, and negative symptoms
Bipolar and Related Characterized by mania or hypomania and possibly depressed 4

mood; includes Bipolar I and II, cyclothymic disorder
Depressive Characterized by sad, empty, or irritable mood, as well as 4

somatic and cognitive changes that affect functioning;
includes major depressive and persistent depressive disorders
Anxiety Characterized by excessive fear and anxiety and related 7

behavioral disturbances; Includes phobias, separation
anxiety, panic attack, generalized anxiety disorder
Obsessive- Characterized by obsessions and compulsions and includes 9

Compulsive OCD, hoarding, and body dysmorphic disorder
Trauma- and Characterized by exposure to a traumatic or stressful event; 5

Stressor- Related PTSD, acute stress disorder, and adjustment disorders
Dissociative Characterized by a disruption or disturbance in memory, 6

identity, emotion, perception, or behavior; dissociative
identity disorder, dissociative amnesia, and
depersonalization/derealization disorder
Somatic Symptom Characterized by prominent somatic symptoms to include 8

illness anxiety disorder somatic symptom disorder, and
conversion disorder
Feeding and Eating Characterized by a persistent disturbance of eating or eating- 10

related behavior to include bingeing and purging
Elimination Characterized by the inappropriate elimination of urine or Not

feces; usually first diagnosed in childhood or adolescence covered
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Sleep-Wake Characterized by sleep-wake complaints about the quality, Not

timing, and amount of sleep; includes insomnia, sleep terrors, covered
narcolepsy, and sleep apnea
Sexual Dysfunctions Characterized by sexual difficulties and include premature Not

ejaculation, female orgasmic disorder, and erectile disorder covered
Gender Dysphoria Characterized by distress associated with the incongruity Not

between one’s experienced or expressed gender and the covered
gender assigned at birth
Disruptive, Impulse- Characterized by problems in self-control of emotions and Not

Control, Conduct behavior and involve the violation of the rights of others and covered
cause the individual to violate societal norms; includes
oppositional defiant disorder, antisocial personality disorder,
kleptomania, etc.
Substance-Related Characterized by the continued use of a substance despite 11

and Addictive significant problems related to its use
Neurocognitive Characterized by a decline in cognitive functioning over time 14

and the NCD has not been present since birth or early in life
Personality Characterized by a pattern of stable traits which are 13

inflexible, pervasive, and leads to distress or impairment
Paraphilic Characterized by recurrent and intense sexual fantasies that Not

can cause harm to the individual or others; includes covered
exhibitionism, voyeurism, and sexual sadism
3.2.3. The ICD-10
In 1893, the International Statistical Institute adopted the International List of Causes of
Death which was the first international classification edition. The World Health Organization
was entrusted with the development of the ICD in 1948 and published the 6th version (ICD-6).
The ICD-10 was endorsed in May 1990 by the 43rd World Health Assembly. The WHO states:
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ICD is the foundation for the identification of health trends and statistics globally, and the
international standard for reporting diseases and health conditions. It is the diagnostic
classification standard for all clinical and research purposes. ICD defines the universe of
diseases, disorders, injuries and other related health conditions, listed in a comprehensive,
hierarchical fashion that allows for:
• easy storage, retrieval and analysis of health information for evidence-based decision-
making;
• sharing and comparing health information between hospitals, regions, settings and
countries;
• and data comparisons in the same location across different time periods.
Source: http://www.who.int/classifications/icd/en/
The ICD lists many types of diseases and disorders to include Chapter V: Mental and
Behavioral Disorders. The list of mental disorders is broken down as follows:
• Organic, including symptomatic, mental disorders
• Mental and behavioral disorders due to psychoactive substance use
• Schizophrenia, schizotypal and delusional disorders
• Mood (affective) disorders
• Neurotic, stress-related and somatoform disorders
• Behavioral syndromes associated with physiological disturbances and physical factors
• Disorders of adult personality and behavior
• Mental retardation
• Disorders of psychological development
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• Behavioral and emotional disorders with onset usually occurring in childhood and
adolescence
• Unspecified mental disorder
3.2.4. Harmonization of DSM-5 and ICD-11
As noted earlier, the ICD-11 is currently in development with an expected publication
date of 2018. According to the DSM-5, there is an effort to harmonize the two classification
systems for a more accurate collection of national health statistics and design of clinical trials,
increased ability to replicate scientific findings across national boundaries, and to rectify the
issue of DSM-IV and ICD-10 diagnoses not agreeing (APA, 2013).

• Clinical diagnosis is the process of using assessment data to determine if the
pattern of symptoms the person presents with is consistent with the diagnostic
criteria for a specific mental disorder outlined in an established classification
system such as the DSM-5 or ICD-10.
• Classification systems provide mental health professionals with an agreed-
upon list of disorders falling into distinct categories for which there are clear
descriptions and criteria for making a diagnosis.
• Elements of a diagnosis in the DSM include the diagnostic criteria and
descriptors, subtypes and specifiers, the principle diagnosis, and a provisional
diagnosis.
1. What is clinical diagnosis?

2. What is a classification system and what are the two main ones used today?
3. Outline the diagnostic categories used in the DSM-5.
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3.3. Treatment of Mental Disorders – An Overview
• Clarify reasons why an individual may need to seek treatment.
• Critique myths about psychotherapy.
3.3.1. Seeking Treatment
3.3.1.1. Who seeks treatment? Would you describe the people who seek treatment as
being on the brink, crazy, or desperate? Or can the ordinary Joe in need of advice seek out
mental health counseling? The answer is that anyone can. David Sack, M.D. (2013) writes in the
article 5 Signs Its Time to Seek Therapy, published in Psychology Today, that “most people can
benefit from therapy at least some point in their lives,” and though the signs you need to seek
help are obvious at times, we often try “to sustain [our] busy life until it sets in that life has
become unmanageable.” So, when should we seek help? First, if we feel sad, angry, or not like
ourselves. We might be withdrawing from friends and families or sleeping more or less than we
usually do. Second, if we are abusing drugs, alcohol, food, or sex to deal with life’s problems. In
this case, our coping skills may need some work. Third, in instances when we have lost a loved
one or something else important to us, whether due to death or divorce, the grief may be too
much to process. Fourth, a traumatic event may have occurred, such as abuse, a crime, an
accident, chronic illness, or rape. Finally, if you have stopped doing the things you enjoy the
most. Sack (2013) says, “If you decide that therapy is worth a try, it doesn’t mean you’re in for a
lifetime of head shrinking.” A 2001 study in the Journal of Counseling Psychology found that
most people feel better within seven to 10 visits. In another study, published in 2006 in the
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Journal of Consulting and Clinical Psychology, 88% of therapy-goers reported improvements
after just one session.”
For more on this article, please visit:
https://www.psychologytoday.com/blog/where-science-meets-the-steps/201303/5-signs-its-
time-seek-therapy
3.3.1.2. When friends, family, and self-healing are not enough. If you are experiencing
any of the aforementioned issues, you should seek help. Instead of facing the potential stigma of
talking to a mental health professional, many people think that talking through their problems
with friends or family is just as good. Though you will ultimately need these people to see you
through your recovery, they do not have the training and years of experience that a psychologist
or similar professional has. “Psychologists can recognize behavior or thought patterns
objectively, more so than those closest to you who may have stopped noticing — or maybe never
noticed. A psychologist might offer remarks or observations similar to those in your existing
relationships, but their help may be more effective due to their timing, focus, or your trust in
their neutral stance” (http://www.apa.org/helpcenter/psychotherapy-myths.aspx). You also
should not wait to recover on your own. It is not a failure to admit you need help, and there could
be a biological issue that makes it almost impossible to heal yourself.
3.3.1.3. What exactly is psychotherapy? According to the APA, in psychotherapy
“psychologists apply scientifically validated procedures to help people develop healthier, more
effective habits.” Several different approaches can be utilized to include behavior, cognitive and
cognitive-behavior, humanistic-experiential, psychodynamic, couples and family, and biological
treatments.
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3.3.1.4. The client-therapist relationship. What is the ideal client-therapist relationship?
APA says, “Psychotherapy is a collaborative treatment based on the relationship between an
individual and a psychologist. Grounded in dialogue, it provides a supportive environment that
allows you to talk openly with someone who’s objective, neutral and nonjudgmental. You and
your psychologist will work together to identify and change the thought and behavior patterns
that are keeping you from feeling your best.” It’s not just about solving the problem you saw the
therapist for, but also about learning new skills to help you cope better in the future when faced
with the same or similar environmental stressors.
So how do you find a psychotherapist? Several strategies may prove fruitful. You could
ask family and friends, your primary care physician (PCP), look online, consult an area
community mental health center, your local university’s psychology department, state
psychological association, or use APA’s Psychologist Locator Service
(https://locator.apa.org/?_ga=2.160567293.1305482682.1516057794-1001575750.1501611950).
Once you find a list of psychologists or other practitioners, choose the right one for you by
determining if you plan on attending alone or with family, what you wish to get out of your time
with a psychotherapist, how much your insurance company pays for and if you have to pay out
of pocket how much you can afford, when you can attend sessions, and how far you are willing
to travel to see the mental health professional. Once you have done this, make your first
appointment.
But what should you bring? APA suggests, “to make the most of your time, make a list of
the points you want to cover in your first session and what you want to work on in
psychotherapy. Be prepared to share information about what’s bringing you to the psychologist.
Even a vague idea of what you want to accomplish can help you and your psychologist proceed
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efficiently and effectively.” Additionally, they suggest taking report cards, a list of medications,
information on the reasons for a referral, a notebook, a calendar to schedule future visits if
needed, and a form of payment. What you take depends on the reason for the visit.
In terms of what you should expect, you and your therapist will work to develop a full history
which could take several visits. From this, a treatment plan will be developed. “This
collaborative goal-setting is important, because both of you need to be invested in achieving your
goals. Your psychologist may write down the goals and read them back to you, so you’re both
clear about what you’ll be working on. Some psychologists even create a treatment contract that
lays out the purpose of treatment, its expected duration and goals, with both the individual’s and
psychologist’s responsibilities outlined.”
After the initial visit, the mental health professional may conduct tests to further
understand your condition but will continue talking through the issue. He/she may even suggest
involving others, especially in cases of relationship issues. Resilience is a skill that will be taught
so that you can better handle future situations.
3.3.1.5. Does it work? APA writes, “Reviews of these studies show that about 75 percent
of people who enter psychotherapy show some benefit. Other reviews have found that the
average person who engages in psychotherapy is better off by the end of treatment than 80
percent of those who don’t receive treatment at all.” Treatment works due to finding evidence-
based treatment that is specific for the person’s problem; the expertise of the therapist; and the
characteristics, values, culture, preferences, and personality of the client.
3.3.1.6. How do you know you are finished? “How long psychotherapy takes depends
on several factors: the type of problem or disorder, the patient's characteristics and history, the
patient's goals, what's going on in the patient's life outside psychotherapy and how fast the
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patient is able to make progress.” It is important to note that psychotherapy is not a lifelong
commitment, and it is a joint decision of client and therapist as to when it ends. Once over,
expect to have a periodic check-up with your therapist. This might be weeks or even months
after your last session. If you need to see him/her sooner, schedule an appointment. APA calls
this a “mental health tune up” or a “booster session.”
For more on psychotherapy, please see the very interesting APA article on this matter:
http://www.apa.org/helpcenter/understanding-psychotherapy.aspx

• Anyone can seek treatment and we all can benefit from it at some point in our
lives.
• Psychotherapy is when psychologists apply scientifically validated procedures
to help a person feel better and develop healthy habits.
1. When should you seek help?

2. Why should you seek professional help over the advice dispensed by family
and friends?
3. How do you find a therapist and what should you bring to your appointment?
4. Does psychotherapy work?
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Module Recap
That’s it. With the conclusion of Module 3, you now have the necessary foundation to
understand each of the groups of disorders we discuss beginning in Module 4 and through
Module 14.
In Module 3 we reviewed clinical assessment, diagnosis, and treatment. In terms of
assessment, we covered key concepts such as reliability, validity, and standardization; and
discussed methods of assessment such as observation, the clinical interview, psychological tests,
personality inventories, neurological tests, the physical examination, behavioral assessment, and
intelligence tests. In terms of diagnosis, we discussed the classification systems of the DSM-5
and ICD-10. For treatment, we discussed the reasons why someone may seek treatment, self-
treatment, psychotherapy, the client-centered relationship, and how well psychotherapy works.
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Disorders Covered:
4. Mood Disorders
5. Trauma- and Stressor-Related Disorders
6. Dissociative Disorders
Module 4:
Mood Disorders
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Module 4: Mood Disorders
Module Overview
In Module 4, we will discuss matters related to mood disorders to include their clinical
presentation, epidemiology, comorbidity, etiology, and treatment options. Our discussion will
introduce Major Depressive Disorder, Persistent Depressive Disorder (formerly Dysthymia),
Bipolar I disorder, Bipolar II disorder, and Cyclothymic disorder. We will also cover major
depressive, manic, and hypomanic episodes. Be sure you refer Modules 1-3 for explanations of
key terms (Module 1), an overview of the various models to explain psychopathology (Module
2), and descriptions of several therapies (Module 3).
Module Outline
• 4.1. Clinical Presentation – Depressive Disorders
• 4.2. Clinical Presentation – Bipolar Disorders
• 4.3. Epidemiology
• 4.4. Comorbidity
• 4.5. Etiology
• 4.6. Treatment
• Describe how depressive disorders present.
• Describe how bipolar disorders present.
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• Describe the epidemiology of mood disorders.
• Describe comorbidity in relation to mood disorders.
• Describe the etiology of mood disorders.
• Describe treatment options for mood disorders.
4.1. Clinical Presentation – Depressive Disorders
• Identify and describe the two types of depressive disorders.
• Classify symptoms of depression.
Within mood disorders are two distinct groups—individuals with depressive disorders
and individuals with bipolar disorders. The key difference between the two mood disorder
groups is episodes of mania/hypomania. More specifically, for a diagnosis of a bipolar disorder,
the individual must experience an episode of mania or hypomania that can alternate with periods
of depression; for a diagnosis of a depressive disorder, the individual must not ever experience a
period of mania/hypomania.
The two most common types of depressive disorders are Major Depressive Disorder
and Persistent Depressive Disorder. Persistent Depressive Disorder, previously known as
Dysthymia, is a continuous and chronic form of depression. While the symptoms of Persistent
Depressive Disorder are very similar to Major Depressive Disorder, they are usually less acute,
as symptoms tend to ebb and flow over a long period of time (more than two years).
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When making a diagnosis of depression, there are a wide range of symptoms that may be
present. These symptoms can generally be categorized into four categories: mood, behavioral,
cognitive, and physical symptoms.
4.1.1. Mood
While clinical depression can vary in its presentation among individuals, most, if not all
individuals with depression will report significant mood disturbances such as a depressed mood
for most of the day and/or feelings of anhedonia, which is the loss of interest in previously
interesting activities.
4.1.2. Behavioral
Behavioral issues such as decreased physical activity and reduced productivity—both at
home and work—are often observed in individuals with depression. This is typically where a
disruption in daily functioning occurs as individuals with depressive disorders are unable to
maintain their social interactions and employment responsibilities.
4.1.3. Cognitive
It should not come as a surprise that there is a serious disruption in cognitions as
individuals with depressive disorders typically hold a negative view of themselves and the world
around them. They are quick to blame themselves when things go wrong, and rarely take credit
when they experience positive achievements. Individuals with depressive disorders often feel
worthless, which creates a negative feedback loop by reinforcing their overall depressed mood.
Individuals with depressive disorder also report difficulty concentrating on tasks, as they are
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easily distracted from outside stimuli. This assertion is supported by research that has found
individuals with depression perform worse than those without depression on tasks of memory,
attention, and reasoning (Chen et al., 2013). Finally, thoughts of suicide and self-harm do
occasionally occur in those with depressive disorders; this will be discussed in the epidemiology
section in more detail.
4.1.4. Physical
Changes in sleep patterns are common in those experiencing depression with reports of
both hypersomnia and insomnia. Hypersomnia, or excessive sleeping, often impacts an
individual’s daily functioning as they spend majority of their time sleeping as opposed to
participating in daily activities (i.e., meeting up with friends, getting to work on time). Reports of
insomnia are also frequent and can occur at various points throughout the night to include
difficulty falling asleep, staying asleep, or waking too early with the inability to fall back asleep
before having to wake for the day. Although it is unclear whether symptoms of fatigue or loss of
energy are related to insomnia issues, the fact that those experiencing hypersomnia also report
symptoms of fatigue suggests that these symptoms are a component of the disorder rather than a
secondary symptom of sleep disturbance.
Additional physical symptoms, such as a change in weight or eating behaviors, are also
observed. Some individuals who are experiencing depression report a lack of appetite, often
forcing themselves to eat something during the day. On the contrary, others overeat, often
seeking “comfort foods,” such as those high in carbohydrates. Due to these changes in eating
behaviors, there may be associated changes in weight.
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Finally, psychomotor agitation or retardation, which is the purposeless or slowed physical
movement of the body (i.e., pacing around a room, tapping toes, restlessness, etc.) is also
reported in individuals with depressive disorders.
4.1.5. Diagnostic Criteria
According to the DSM-5 (APA, 2013), in order to meet criteria for a diagnosis of major
depressive disorder, an individual must experience at least five symptoms across the four
categories discussed above, in addition to either a depressed mood or loss of interest or pleasure
in activities. These symptoms must be present for at least two weeks.
For a diagnosis of persistent depressive disorder, an individual must experience a
depressed mood for most of the day for at least two years (APA, 2013). This feeling of a
depressed mood is also accompanied by two or more of the previously discussed symptoms. The
individual may experience a temporary relief of symptoms; however, the individual will not be
without symptoms for more than two months during this two-year period.
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• Mood disorder fall into one of two groups – depressive or bipolar disorders –
with the key distinction between the two being episodes of mania/hypomania.
• Persistent Depressive Disorder shares symptoms with Major Depressive
Disorder though they are usually not as severe and ebb and flow over a period
of at least two years.
• Symptoms of depression fall into one of four categories – mood, behavioral,
cognitive, and physical.
1. What are the different categories of mood disorder symptoms? Identify the
symptoms within each category.
2. What are the key differences in a major depression and a persistent depressive
disorder diagnosis?
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4.2. Clinical Presentation – Bipolar Disorders
• Distinguish the forms bipolar disorder takes.
• Describe a manic episode.
• Define cyclothymic disorder.
According to the DSM-5 (APA, 2013), there are two types of Bipolar Disorder- Bipolar I
and Bipolar II. A diagnosis of Bipolar I Disorder is made when there is at least one manic
episode. This manic episode can be preceded by or followed by a hypomanic or major
depressive episode, however, diagnostic criteria for a manic episode is the only criteria that needs
to be met for a Bipolar I diagnosis. A diagnosis of Bipolar II Disorder is made when there is a
current or history of a hypomanic episode and a current or past major depressive episode. In
simpler words, if an individual has ever experienced a manic episode, they qualify for a Bipolar I
diagnosis; however, if the criteria has only been met for a hypomanic episode, the individual
qualifies for a Bipolar II diagnosis.
4.2.1. Manic Episode. So, what defines a manic episode? The key feature of a manic
episode is a specific period of time in which an individual reports abnormal, persistent, or
expansive irritable mood for nearly all day, every day, for at least one week (APA, 2013).
Additionally, the individual will display increased activity or energy during this same time. With
regards to mood, an individual in a manic episode will appear excessively happy, often engaging
haphazardly in sexual or personal interactions. They also display rapid shifts in mood, also
known as mood lability, ranging from happy, neutral, to irritable.

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Inflated self-esteem or grandiosity is also present during a manic episode. Occasionally
these inflated self-esteem levels can appear delusional. For example, individuals may believe
they are friends with a celebrity, do not need to abide by laws, or even perceive themselves as
God.
Despite the increased activity level, individuals experiencing a manic episode also require
a decreased need for sleep, sleeping as little as a few hours a night yet still feeling rested.
Reduced need for sleep may also be a precursor to a manic episode, suggesting that a manic
episode is to begin imminently. It is not uncommon for those in a manic episode to have rapid,
pressured speech. It can be difficult to follow their conversation due to the quick pace of their
talking, as well as tangential storytelling. Additionally, they can be difficult to interrupt in
conversation, often disregarding the reciprocal nature of communication. If the individual is
more irritable than expansive, speech can become hostile and they engage in tirades, particularly
if they are interrupted or not allowed to engage in an activity they are seeking out (APA, 2013).
Based on their speech pattern, it should not be a surprise that racing thoughts and flights of ideas
also present during manic episodes. Because of these rapid thoughts, speech may become
disorganized or incoherent.
4.2.2. Hypomanic Episode. As mentioned above, for a Bipolar II diagnosis, an
individual must report symptoms consistent with a major depressive episode and at least one
hypomanic episode. An individual with Bipolar II disorder must not have a history of a manic
episode—if there is a history of mania, the diagnosis will be diagnosed with Bipolar I. A
hypomanic episode is similar to a manic episode in that the individual will experience
abnormally and persistently elevated, expansive, or irritable mood and energy levels, however,
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the behaviors are not as extreme as in mania. Behaviors consistent with a hypomanic episode
must be present for at least four days, compared to the one week in a manic episode.
Notably, there is a subclass of individuals who experience periods of hypomanic
symptoms and mild depressive symptoms (i.e., do not fully meet criteria for a depressive
episode). These individuals are diagnosed with cyclothymic disorder (APA, 2013). Presentation
of these symptoms occur for two or more years and are typically interrupted by periods of
normal moods. While only a small percentage of the population develops cyclothymic disorder,
it can eventually progress into Bipolar I or bipolar II disorder (Zeschel et al., 2015).

• An individual is diagnosed with Bipolar I disorder if they have ever
experienced a manic episode and are diagnosed with Bipolar II disorder if the
criteria has only been met for a hypomanic episode.
• A manic episode is characterized by a specific period of time in which an
individual reports abnormal, persistent, or expansive irritable mood for nearly
all day, every day, for at least one week.
• A hypomanic episode is characterized by abnormally and persistently elevated,
expansive, or irritable mood and energy levels, though not as extreme as in
mania, and must be present for at least four days.
• Cyclothymic disorder experience periods of hypomanic and mild depressive
symptoms without meeting the criteria for a depressive episode which lasts
two or more years and is interrupted by periods of normal moods.
1. What is the difference between Bipolar I an II disorder?

2. What are the key diagnostic differences between a hypomanic and manic
episode?
3. What is cyclothymic disorder?
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4.3. Epidemiology
• Describe the epidemiology of depressive disorders.
• Describe the epidemiology of bipolar disorders.
• Describe the epidemiology of suicidality.
4.3.1. Depressive Disorders
According to the DSM-5 (APA, 2013), the prevalence rate for major depression is
approximately 7% within the United States. The prevalence rate for persistent depressive
disorder is much lower, with a 0.5% rate among adults in the United States. There is a difference
among demographics, with individuals in the 18- to 29- year-old age bracket reporting the
highest rates of depression than any other age group. Similarly, depression is approximately 1.5
to 3 times higher in females than males. The estimated lifetime prevalence for major depressive
disorder in women is 21.3% compared to 12.7% in men (Nolen-Hoeksema, 2001).
4.3.2. Bipolar Disorders
Compared to depression, the epidemiological studies on the rates of Bipolar Disorder
suggest a significantly lower prevalence rate for both bipolar I and bipolar II. Within the two
disorders, there is a very minimal difference in the prevalence rates with yearly rates reported as
0.6% and 0.8% in the United States for bipolar I and bipolar II, respectively (APA, 2013). As for
gender differences, there are no apparent differences in the frequency of men and women
diagnosed with bipolar I; however, bipolar II appears to be more common in women, with
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approximately 80-90% of individuals with rapid-cycling episodes being women (Bauer &
Pfenning, 2005). Women are also more likely to experience rapid cycling between
manic/hypomanic episodes and depressive episodes.
4.3.3. Suicidality
Suicidality in depressive disorders, particularly bipolar disorder, is much higher than the
general public. In depressive disorders, males and those with a history of suicide attempts/threats
are most at risk for attempting suicide. Individuals with bipolar disorder are approximately 15
times more likely than the general population to attempt suicide. The prevalence rate of suicide
attempts in bipolar patients is estimated to be 33%. Furthermore, bipolar disorder may account
for one-quarter of all completed suicides (APA, 2013).

• Depressive disorders are experienced by about 7% of the population in the United
States, afflicting young adults and women the most.
• Bipolar disorder afflicts less than 1% of the US population and Bipolar II is more
common in women.
• Rates of suicide are greater in individuals with depressive disorders, particularly
bipolar disorder.
1. What are the prevalence rates of the mood disorders?

2. What gender differences exist in the rate of occurrence of mood disorders?
3. How do depressive disorders affect rates of suicide?
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4.4. Comorbidity
• Describe the comorbidity of depressive disorders.
• Describe the comorbidity of bipolar disorders.
Studies exploring depression symptoms among the general population show a substantial
pattern of comorbidity between depression and other mental disorders, particularly substance use
disorders (Kessler, Berglund, et al., 2003). Nearly three-fourths of participants with lifetime
MDD in a large-scale research study also met the criteria for at least one other DSM disorder
(Kessler, Berglund, et al., 2003). Among those that are the most common are anxiety disorders,
ADHD, and substance abuse.
Given the extent of comorbidity among individuals with MDD, researchers have tried to
identify which disorder precipitated the other. The majority of studies have identified most
depression cases occur secondary to another mental health disorder, meaning that the onset of
depression is a direct result of the onset of another disorder (Gotlib & Hammen, 2009).
4.4.2. Bipolar Disorders
Bipolar disorder also has a high comorbidity rate with other mental disorders, particularly
anxiety disorders, and disruptive/impulse-control disorders such as ADHD and Conduct
Disorder. Substance abuse disorders are also commonly seen in individuals with Bipolar
Disorder. Over half of those with Bipolar Disorder also meet diagnostic criteria for Substance
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Abuse Disorder, particularly alcohol abuse. The combination of Bipolar Disorder and Substance
Abuse Disorder places individuals at a greater risk of suicide attempt (APA, 2013). While these
comorbidities are high across both Bipolar I and Bipolar II, type II appears to have more
comorbidities, with 60% of individuals meeting criteria for three or more co-occurring mental
disorders (APA, 2013).

• Depressive disorders have a high comorbidity with substance use disorders,
anxiety disorders, ADHD, and substance abuse with these other disorders often
causing the depression.
• Bipolar disorder has a high comorbidity with anxiety disorders,
disruptive/impulse-control disorders, and substance abuse disorders.
1. Identify common comorbidities for Major Depression.

2. Identify common comorbidities for Bipolar Disorders.
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4.5. Etiology
• Describe the biological causes of mood disorders.
• Describe the cognitive causes of mood disorders.
• Describe the behavioral causes of mood disorders.
• Describe the sociocultural causes of mood disorders.
4.5.1. Biological
Research throughout the years continues to provide evidence that depressive disorders
have some biological cause. While it does not explain every depressive case, it is safe to say that
some individuals may at least have a predisposition to developing a depressive disorder. Among
the biological factors are genetic factors, biochemical factors, and brain structure.
4.5.1.1. Genetics. Like with any disorder, researchers often explore the prevalence rate of
depressive disorders among family members to determine if there is some genetic component,
whether it be a direct link or a predisposition. If there is a genetic predisposition to developing
depressive disorders, one would expect a higher rate of depression within families than that of
the general population. Research supports this with regards to depressive disorders as there is
nearly a 30% increase in relatives diagnosed with depression compared to 10% of the general
population (Levinson & Nichols, 2014). Similarly, there is an elevated prevalence among first-
degree relatives for both Bipolar I and Bipolar II disorders as well.
Another way to study the genetic component of a disorder is via twin studies. One would
expect identical twins to have a higher rate of the disorder as opposed to fraternal twins, as
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identical twins share the same genetic make-up, whereas fraternal twins only share roughly 50%,
similar to that of siblings. A large-scale study found that if one identical twin was diagnosed with
depression, there was a 46% chance their identical twin was diagnosed with depression. In
contrast, the rate of a depression diagnosis in fraternal twins was only 20%. Despite the fraternal
twin rate still being higher than that of a first-degree relative, this study provided enough
evidence that there is a strong genetic link in the development of depression (McGuffin et al.,
1996).
More recently, scientists have been studying depression at a molecular level, exploring
possibilities of gene abnormalities as a cause for developing a depressive disorder. While much
of the research is speculation due to sampling issues and low power, there is some evidence that
depression may be tied to the 5-HTT gene on chromosome 17, as this is responsible for the
activity of serotonin (Jansen et al., 2016).
Bipolar disorders share a similar genetic predisposition to that of major depressive
disorder. Twin studies within bipolar disorder yielded concordance rates for identical twins at as
high as 72%, yet the range for fraternal twins, siblings, and other close relatives ranged from 5-
15%. It is important to note that both of these percentages are significantly higher than that of the
general population, suggesting a strong genetic component within bipolar disorder (Edvardsen et
al., 2008).
4.5.1.2. Biochemical. As you will read in the treatment section, there is strong evidence
of a biochemical deficit in depression and bipolar disorders. More specifically, low activity
levels of norepinephrine and serotonin, have long been documented as contributing factors to
developing depressive disorders. This relationship was discovered accidentally in the 1950s
when MAOIs were given to tuberculosis patients, and miraculously, their depressive moods were
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also improved. Soon thereafter, medical providers found that medications used to treat high
blood pressure by causing a reduction in norepinephrine also caused depression in their patients
(Ayd, 1956).
While these initial findings were premature in the identification of how neurotransmitters
affected the development of depressive features, they did provide insight as to what
neurotransmitters were involved in this system. Researchers are still trying to determine exact
pathways; however, it does appear that both norepinephrine and serotonin are involved in the
development of symptoms, whether it be between the interaction between them, or their
interaction on other neurotransmitters (Ding et al., 2014).
Due to the close nature of depression and bipolar disorder, researchers initially believed
that both norepinephrine and serotonin were implicated in the development of bipolar disorder;
however, the idea was that there was a drastic increase in serotonin during mania episodes.
Unfortunately, research supports the opposite. It is believed that low levels of serotonin and high
levels of norepinephrine may explain mania episodes (Soreff & McInnes, 2014). Despite these
findings, additional research with this area is needed to conclusively determine what is
responsible for the manic episodes within bipolar disorder.
4.5.1.3. Endocrine system. As you may know, the endocrine system is a collection of
glands responsible for regulating hormones, metabolism, growth and development, sleep, and
mood, among other things. Some research has implicated hormones, particularly cortisol, a
hormone released as a stress response, in the development of depression (Owens et al., 2014).
Additionally, melatonin, a hormone released when it is dark outside to assist with the transition
to sleep, may also be related to depressive symptoms, particularly during the winter months.
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4.5.1.4. Brain anatomy. Seeing as neurotransmitters have been implicated in the
development of depressive disorders, it should not be a surprise that various brain structures have
also been identified as contributors to mood disorders. While exact anatomy and pathways are
yet to be determined, research studies implicate the prefrontal cortex, the hippocampus, and
the amygdala. More specifically, drastic changes in blood flow throughout the prefrontal cortex
have been linked with depressive symptoms. Similarly, a smaller hippocampus, and
consequently, fewer neurons, has also been linked to depressive symptoms. Finally, heightened
activity and blood flow in the amygdala, the brain area responsible for our fight or flight
emotions, is also consistently found in individuals with depressive symptoms.
Abnormalities to several brain structures has also been identified in individuals with
bipolar disorder; however, what or why these structures are abnormal has yet to be determined.
Researchers continue to focus on areas of the basal ganglia and cerebellum, which appear to be
much smaller in individuals with bipolar disorder compared to the general public. Additionally,
there appears to be a decrease in brain activity in regions associated with regulating emotions, as
well as an increase in brain activity among structures related to emotional responsiveness
(Houenou et al., 2011). Additional research is still needed to determine precisely how each of
these brain structures may be implicated in the development of bipolar disorder.
4.5.2. Cognitive
The cognitive model, arguably the most conclusive model with regards to depressive
disorders, focuses on the negative thoughts and perceptions of an individual. One theory often
equated with the cognitive model of depression is learned helplessness. Coined by Martin
Seligman (1975), learned helplessness was developed based on his laboratory experiment
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involving dogs. In this study, Seligman restrained dogs in an apparatus and routinely shocked
them regardless of their behavior. The following day, the dogs were placed in a similar
apparatus; however, this time they were not restrained and there was a small barrier placed
between the “shock” floor and the “safe” floor. What Seligman observed was that despite the
opportunity to escape the shock, the dogs flurried for a bit, and then ultimately laid down and
whimpered while being shocked.
Based on this study, Seligman concluded that the animals essentially learned that they
were unable to avoid the shock the day prior, and therefore, learned that they were helpless in
preventing the shocks. When they were placed in a similar environment but had the opportunity
to escape the shock, their learned helplessness carried over, and they continued to believe they
were unable to escape the shock.
This study has been linked to humans through research on attributional style (Nolen-
Hoeksema, Girgus & Seligman, 1992). There are two types of attributional styles—positive and
negative. A negative attributional style focuses on the internal, stable, and global influence of
daily lives, whereas a positive attributional style focuses on the external, unstable, and specific
influence of the environment. Research has found that individuals with a negative attributional
style are more likely to experience depression. This is likely due to their negative interpretation
of daily events. For example, if something bad were to happen to them, they would conclude that
it is their fault (internal), bad things always happen to them (stable), and bad things happen all
day to them. Unfortunately, this maladaptive thinking style often takes over an individual’s daily
view, thus making them more vulnerable to depression.
In addition to attributional style, Aaron Beck also attributed negative thinking as a
precursor to depressive disorders (Beck, 2002, 1991, 1967). Often viewed as the grandfather of
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Cognitive-Behavioral Therapy, Beck went on to coin the terms—maladaptive attitudes, cognitive
triad, errors in thinking, and automatic thoughts—all of which combine to explain the cognitive
model of depressive disorders.
Maladaptive attitudes, or negative attitudes about oneself, others, and the world around
them are often present in those with depressive symptoms. These attitudes are inaccurate and
often global. For example, “If I fail my exam, the world will know I’m stupid.” Will the entire
world really know you failed your exam? Not likely. Because you fail the exam, are you stupid?
No. Individuals with depressive symptoms often develop these maladaptive attitudes regarding
everything in their life, indirectly isolating themselves from others. The cognitive triad also
plays into the maladaptive attitudes in that the individual interprets these negative thoughts about
their experiences, themselves, and their futures.
Cognitive distortions, also known as errors in thinking, are a key component in Beck’s
cognitive theory. Beck identified 15 errors in thinking that are most common in individuals with
depression (see the end of the module). Among the most common are catastrophizing, jumping
to conclusions, and overgeneralization. I always like to use my dad as an example for
overgeneralization. Whenever we go to the grocery store, he always comments about how
whatever line he chooses, at every store, it is always the slowest line. Does this happen every
time he is at the store? I’m doubtful, but his error in thinking leads to him believing this is true.
Finally, automatic thoughts, or the constant stream of negative thoughts, also leads to
symptoms of depression as individuals begin to feel as though they are inadequate or helpless in
a given situation. While some cognitions are manipulated and interpreted negatively, Beck stated
that there is another set of negative thoughts that occur automatically. Research studies have
continually supported Beck’s maladaptive thoughts, attitudes, and errors in thinking as
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fundamental issues in those with depressive disorders (Lai et al., 2014; Possel & Black, 2014).
Furthermore, as you will see in the treatment section, cognitive strategies are among the most
effective forms of treatment for depressive disorders.
4.5.3. Behavioral
The behavioral model explains depression as a result of a change in the number of
rewards and punishments one receives throughout their life. This change can come from work,
intimate relationships, family, or even the environment in general. Among the most influential in
the field of depression is Peter Lewinsohn. He stated depression occurred in most people due to
the reduced positive rewards in their life. Because they were not positively rewarded, their
constructive behaviors occurred more infrequently until they stop engaging in the behavior
completely (Lewinsohn et al., 1990; 1984). An example of this is a student who keeps receiving
bad grades on their exam despite studying for hours. Over time, the individual will reduce the
amount of time they are studying, thus continuing to earn poor grades.
4.5.4. Sociocultural
In the sociocultural theory, the role of family and one’s social environment play a
substantial role in the development of depressive disorders. There are two sociocultural views-
the family-social perspective and the multi-cultural perspective.
4.5.4.1. Family-social perspective. Similar to that of the behavioral theory, the family-
social perspective of depression suggests that depression is related to the unavailability of social
support. This is often supported by research studies that show separated and divorced individuals
are three times more likely to experience depressive symptoms than those that are married or
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even widowed (Schultz, 2007). While many factors lead a couple to separate or end their
marriage, some relationships end due to a spouse’s mental health issues, particularly depressive
symptoms. Depressive symptoms have been positively related to increased interpersonal
conflicts, reduced communication, and intimacy issues, all of which are often reported in causal
factors leading to a divorce (Najman et al., 2014).
The family-social perspective can also be viewed oppositely, with stress and marital
discord leading to increased rates of depression in one or both spouses (Nezlek et al., 2000).
While some research indicates that having children provides a positive influence in one’s life, it
can also lead to stress both within the individual, as well as between partners due to division of
work and discipline differences. Studies have shown that women who had three or more young
children, and also lacked a close confidante and outside employment, were more likely than
other mothers to become depressed (Brown, 2002).
4.5.4.2. Multi-cultural perspective. While depression is experienced across the entire
world, one’s cultural background may influence what symptoms of depression are presented.
Common depressive symptoms such as feeling sad, lack of energy, anhedonia, difficulty
concentrating, and thoughts of suicide are a hallmark in most societies; other symptoms may be
more specific to one’s nationality. More specifically, individuals from non-Western countries
(China and other Asian countries) often focus on the physical symptoms of depression—
tiredness, weakness, sleep issues—and less of an emphasis on the cognitive symptoms.
Individuals from Latino and Mediterranean cultures often experience problems with “nerves”
and headaches as primary symptoms of depression (APA, 2013).
Within the United States, many researchers have explored potential differences across
ethnic or racial groups in both rates of depression, as well as presenting symptoms of those
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diagnosed with depression. These studies continually fail to identify any significant differences
between ethnic and racial groups; however, one major study has identified a difference in the rate
of recurrence of depression in Hispanic and African Americans (Gonzalez et al., 2010). While
the exact reason for this is unclear, researchers propose a lack of treatment opportunities as a
possible explanation. According to Gonzalez and colleagues (2010), approximately 54% of
depressed white Americans seek out treatment, compared to the 34% and 40% Hispanic and
African Americans, respectively. The fact that there is a large discrepancy in the use of treatment
between white Americans and minority Americans suggests that these individuals are not
receiving the effective treatment necessary to resolve the disorder, thus leaving them more
vulnerable for repeated depressive episodes.
4.5.4.3. Gender differences. As previously discussed, there is a significant difference
between gender and rates of depression, with women twice as likely to experience an episode of
depression than men (Schuch et al., 2014). There are a few speculations as to why there is such
an imbalance in the rate of depression across genders.
The first theory, artifact theory, suggests that the difference between genders is due to
clinician or diagnostic systems being more sensitive to diagnosing women with depression than
men. While women are often thought to be more “emotional,” easily expressing their feelings
and more willing to discuss their symptoms with clinicians and physicians, men often withhold
their symptoms or will present with more traditionally “masculine” symptoms of anger or
aggression. While this theory is a possible explanation for the gender differences in the rate of
depression, research has failed to support this theory, suggesting that men and women are
equally likely to seek out treatment and discuss their depressive symptoms (McSweeney, 2004;
Rieker & Bird, 2005).
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The second theory, hormone theory, suggests that variations in hormone levels trigger
depression in women more than men (Graziottin & Serafini, 2009). While there is biological
evidence supporting the changes in hormone levels during various phases of the menstrual cycle
and their impact on women’s ability to integrate and process emotional information, research
fails to support this theory as the reason for higher rates of depression in women (Whiffen &
Demidenko, 2006).
The third theory, life stress theory, suggests that women are more likely to experience
chronic stressors than men, thus accounting for their higher rate of depression (Astbury, 2010).
Women face increased risk for poverty, lower employment opportunities, discrimination, and
poorer quality of housing than men, all of which are strong predictors of depressive symptoms
(Garcia-Toro et al., 2013).
The fourth theory, gender roles theory, suggests that social and or psychological factors
related to traditional gender roles also influence the rate of depression in women. For example,
men are often encouraged to develop personal autonomy, seek out activities that interest them,
and display achievement-oriented goals; women are encouraged to empathize and care for
others, often fostering an interdependent functioning, which may cause women to value the
opinion of others more highly than their male counterparts do.
The final theory, rumination theory, suggests that women are more likely than men to
ruminate, or intently focus, on their depressive symptoms, thus making them more vulnerable to
developing depression at a clinical level (Nolen-Hoeksema, 2012). Several studies have
supported this theory and shown that rumination of negative thoughts is positively related to an
increase in depression symptoms (Hankin, 2009).
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While many theories try to explain the gender discrepancy in depressive episodes, no
single theory has produced enough evidence to fully explain why women experience depression
more than men. Due to the lack of evidence, gender differences in depression remains one of the
most researched topics within the subject of depression, while simultaneously being the least
understood phenomena within clinical psychology.
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• In terms of biological explanations for depressive disorders, there is evidence
that rates of depression are higher among identical twins (the same is true for
bipolar disorders), that the 5-HTT gene on chromosome 17 may be involved in
depressive disorders, that norepinephrine and serotonin affect depressive (both
being low) and bipolar disorders (low serotonin and high norepinephrine), the
hormones cortisol and melatonin affect depression, and several brain
structures are implicated in depression (prefrontal cortex, hippocampus, and
amygdala) and bipolar disorder (basal ganglia and cerebellum).
• In terms of cognitive explanations, learned helplessness, attributional style,
and maladaptive attitudes to include the cognitive triad, errors in thinking, and
automatic thoughts, help to explain depressive disorders.
• Behavioral explanations center on changes in the rewards and punishments
received throughout life.
• Sociocultural explanations include the family-social perspective and multi-
cultural perspective.
• Women are twice as likely to experience depression and this could be due to
women being more likely to be diagnosed than men (called the artifact theory),
variations in hormone levels in women (hormone theory), women being more
likely to experience chronic stressors (life stress theory), the fostering of an
interdependent functioning in women (gender roles theory), and that women
are more likely to intently focus on their symptoms (rumination theory).
1. How do twin studies explain the biological causes of mood disorders?

2. What brain structures are implicated in the development of mood disorders?
Discuss their role.
3. What is learned helplessness? How has this concept been used to study the
development and maintenance of mood disorders?
4. What is the cognitive triad?
5. What are common cognitive distortions observed in individuals with mood
disorders?
6. What are the identified theories that are used to explain the gender differences
in mood disorder development?
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4.6. Treatment of Mood Disorders
• Describe treatment options for depressive disorders.
• Describe treatment options for bipolar disorders.
• Determine the efficacy of treatment options for depressive disorders.
• Determine the efficacy of treatment options for bipolar disorders.
Given that Major Depressive Disorder is among the most frequent and debilitating
psychiatric disorders, it should not be surprising that the research on this disorder is quite
extensive. Among its treatment options, the most efficacious treatments include antidepressant
medications, Cognitive-Behavioral Therapy (CBT; Beck et al., 1979), Behavioral Activation
(BA; Jacobson et al., 2001), and Interpersonal Therapy (IPT; Klerman et al., 1984). Although
CBT is the most widely known and used treatment for Major Depressive Disorder, there is
minimal evidence to support one treatment modality over the other; treatment is generally
dictated by therapist competence, availability, and patient preference (Craighhead & Dunlop,
2014).
4.6.1.1. Psychopharmacology - Antidepressant medications. Antidepressants are often
the most common first-line attempt at treatment for MDD for a few reasons. Oftentimes an
individual will present with symptoms to their primary caregiver (a medical doctor) who will
prescribe them some line of antidepressant medication. Medication is often seen as an “easier”
treatment for depression as the individual can take the medication at their home, rather than
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attending weekly therapy sessions; however, this also leaves room for adherence issues as a large
percentage of individuals fail to take prescription medication as indicated by their physician.
Given the biological functions of neurotransmitters and their involvement in maintaining
depressive symptoms, it makes sense that this is an effective type of treatment.
Within antidepressant medications, there are a few different classes, each categorized by their
structural or functional relationships. It should be noted that no specific antidepressant
medication class or medication have been proven to be more effective in treating MDD than
others (APA, 2010). In fact, many patients may try several different types of antidepressant
medications until they find one that is effective, with minimal side effects.
4.6.1.2. Psychopharmacology - Selective serotonin reuptake inhibitors (SSRIs).
SSRIs are among the most common medications used to treat depression due to their relatively
benign side effects. Additionally, the required dose to reach therapeutic levels is low compared
to the other medication options. Possible side effects from SSRIs include but are not limited to
nausea, insomnia, and reduced sex drive.
SSRIs improve depression symptoms by blocking the reuptake of norepinephrine and/or
serotonin in presynaptic neurons, thus allowing more of these neurotransmitters to be available
for postsynaptic neurons. While this is the general mechanism through which all SSRI’s work,
there are minor biological differences among different types of medications within the SSRI
family. These small differences are actually beneficial to patients in that there are a few
treatment options to maximize medication benefits and minimize side effects.
4.6.1.3. Psychopharmacology - Tricyclic antidepressants. Although originally
developed to treat schizophrenia, tricyclic antidepressants were adapted to treat depression after
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failing to manage symptoms of schizophrenia (Kuhn, 1958). The term tricyclic came from the
molecular shape of the structure: three rings.
Tricyclic antidepressants are similar to SSRIs in that they work by affecting brain
chemistry, altering the number of neurotransmitters available for neurons. More specifically,
they block the absorption or reuptake of serotonin and norepinephrine, thus increasing their
availability for postsynaptic neurons. While effective, tricyclic antidepressants have been
increasingly replaced by SSRIs due to their reduced side effects. However, tricyclic
antidepressants have been shown to be more effective in treating depressive symptoms in
individuals who have not been able to achieve symptom reduction via other pharmacological
approaches.
While the majority of the side effects are minimal- dry mouth, blurry vision, constipation,
others can be serious- sexual dysfunction, tachycardia, cognitive and/or memory impairment, to
name a few. Due to the potential impact on the heart, tricyclic antidepressants should not be used
in cardiac patients as they may exacerbate cardiac arrhythmias (Roose & Spatz, 1999).
4.6.1.4. Psychopharmacology - Monoamine oxidase inhibitors (MAOIs). The use of
MAOIs as a treatment for depression began serendipitously as patients in the early 1950s
reported reduced depression symptoms while on the medication to treat tuberculosis. Research
studies confirmed that MAOIs were effective in treating depression in adults outside the
treatment of tuberculosis. Although still prescribed, they are not typically first-line medications
due to their safety concerns with hypertensive crises. Because of this, individuals on MAOIs
have strict diet restrictions to reduce their risk of hypertensive crises (Shulman, Herrman &
Walker, 2013).
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How do MAOIs work? In basic terms, monoamine oxidase is released in the brain to
remove excess neurotransmitters norepinephrine, serotonin, and dopamine. MAOIs essentially
prevent the monoamine oxidase (hence the name monoamine oxidase inhibitors) from removing
these neurotransmitters, thus resulting in an increase in these brain chemicals (Shulman, Herman
& Walker, 2013). As previously discussed, norepinephrine, serotonin, and dopamine are all
involved in the biological mechanisms of maintaining depressive symptoms.
While these drugs are effective, they come with serious side effects. In addition to the
hypertensive episodes, they can also cause nausea, headaches, drowsiness, involuntary muscle
jerks, reduced sexual desire, weight gain, etc. (APA, 2010). Despite these side effects, studies
have shown that individuals prescribed MAOIs for depression have a treatment response rate of
50-70% (Krishnan, 2007). Overall, despite their effectiveness, MAOIs are likely the best
treatment for late-stage, treatment-resistant depression patients who have exhausted other
treatment options (Krishnan, 2007).
It should be noted that occasionally, antipsychotic medications are used for individuals
with MDD; however, these are limited to individuals presenting with psychotic features.
4.6.1.5. Psychotherapy - Cognitive behavioral therapy (CBT). CBT was founded by
Aaron Beck in the 1960s and is a widely practiced therapeutic tool used to treat depression (and
other disorders as well). The basics of CBT involve what Beck called the cognitive triad—
cognitions (thoughts), behaviors, and emotions. Beck believed that these three components are
interconnected, and therefore, affect one another. It is believed that CBT can improve emotions
in depressed patients by changing both cognitions (thoughts) and behaviors, which in return
enhances mood. Common cognitive interventions with CBT include thought monitoring and
recording, identifying cognitive errors, examining evidence supporting/negating cognitions, and
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creating rational alternatives to maladaptive thought patterns. Behavioral interventions of CBT
include activity planning, pleasant event scheduling, task assignments, and coping-skills training.
CBT generally follows four phases of treatment:
• Phase 1: Increasing pleasurable activities. Similar to behavioral activation (see
below), the clinician encourages the patient to identify and engage in activities that
are pleasurable to the individual. The clinician can help the patient to select the
activity, as well as help them plan when they will engage in that activity.
• Phase 2: Challenging automatic thoughts. During this stage, the clinician provides
psychoeducation about the negative automatic thoughts that can maintain depressive
symptoms. The patient will learn to identify these thoughts on their own during the
week and maintain a thought journal of these cognitions to review with the clinician
in session.
• Phase 3: Identifying negative thoughts. Once the individual is consistently able to
identify these negative thoughts on a daily basis, the clinician can help the patient
identify how these thoughts are maintaining their depressive symptoms. It is at this
point that the patient begins to have direct insight as to how their cognitions
contribute to their disorder.
• Phase 4: Changing thoughts. The final stage of treatment involves challenging the
negative thoughts the patient has been identifying in the last two phases of treatment
and replacing them with positive thoughts.
4.6.1.6. Psychotherapy - Behavioral activation (BA). BA is similar to the behavioral
component of CBT in that the goal of treatment is to alleviate depression and prevent future
relapse by changing an individual’s behavior. Founded by Ferster (1973), as well as Lewinsohn
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and colleagues (Lewinsohn, 1974; Lewinsohn, Biglan, & Zeiss, 1976), the goal of BA is to
increase the frequency of behaviors so that individuals have opportunities to experience greater
contact with sources of reward in their lives. To do this, the clinician assists the patient by
developing a list of pleasurable activities that they can engage in outside of treatment (i.e., going
for a walk, going shopping, having dinner with a friend). Additionally, the clinician assists the
patient in identifying their negative behaviors—crying, sleeping in, avoiding friends—and
monitoring them so that they do not impact the outcome of their pleasurable activities. Finally,
the clinician works with the patient on effective social skills. By minimizing negative behaviors
and maximizing pleasurable activities, the individual will receive more positive reward and
reinforcement from others and their environment, thus improving their overall mood.
4.6.1.7. Psychotherapy - Interpersonal therapy (IPT). IPT was developed by Klerman,
Weissman, and colleagues in the 1970s as a treatment arm for a pharmacotherapy study of
depression (Weissman, 1995). The treatment was created based on data from post-World War II
individuals who expressed a substantial impact on their psychosocial life events. Klerman and
colleagues noticed a significant relationship between the development of depression and
complicated bereavement, role disputes, role transitions, and interpersonal deficits in these
individuals (Weissman, 1995). The idea behind IPT is that depressive episodes compromise
interpersonal functioning, which makes it difficult to manage stressful life events. The basic
mechanism of IPT is to establish effective strategies to manage interpersonal issues, which in
return, will ameliorate depressive symptoms.
There are two main principles of IPT. First, depression is a common medical illness with
a complex and multi-determined etiology. Since depression is a medical illness, it is also
treatable and not the patient’s fault. Second, depression is connected to a current or recent life
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event. The goal of IPT is to identify the interpersonal problem that is related to the depressive
symptoms and solve this crisis so the patient can improve their life situation while relieving
depressive symptoms.
4.6.1.8. Multimodal treatment. While both pharmacological and psychological
treatment alone is very effective in treating depression, a combination of the two treatments may
offer additional benefits, particularly in the maintenance of wellness. Additionally, multimodal
treatment options may be helpful for individuals who have not achieved wellness in a single
modality.
Multimodal treatments can be offered in three different ways: concurrently, sequentially,
or within a stepped manner (McGorry et al., 2010). With a stepped manner treatment,
pharmacological therapy is often used initially to treat depressive symptoms. Once the patient
reports some relief in symptoms, the psychosocial treatment is added to address the remaining
symptoms. While all three methods are effective in managing depressive symptoms, matching
patients to their treatment preferences may produce better outcomes than clinician-driven
treatment decisions.
4.6.2. Bipolar Disorder
4.6.2.1. Psychopharmacology. Unlike treatment for MDD, there is some controversy
regarding effective treatment of Bipolar Disorder. One suggestion is to treat Bipolar Disorder
aggressively with mood stabilizers such as Lithium or Depakote as these medications do not
induce pharmacological mania/hypomania. These mood stabilizers are occasionally combined
with antidepressants later in treatment only if absolutely necessary (Ghaemi, Hsu, Soldani &
Goodwin, 2003). Research has shown that mood stabilizers are less potent in treating depressive
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symptoms, and therefore, the combination approach is believed to help manage both the manic
and depressive episodes (Nivoli et al., 2011).
The other treatment option is to forgo the mood stabilizer and treat symptoms with newer
antidepressants early in treatment. Unfortunately, large scale research studies have not shown
great support for this method (Gijsman, Geddes, Rendell, Nolen, & Goodwin, 2004; Moller,
Grunze & Broich, 2006). Antidepressants often trigger a manic or hypomanic episode in bipolar
patients. Because of this, the first-line treatment option for Bipolar Disorder is mood stabilizers,
particularly Lithium.
4.6.2.2. Psychological treatment. Although psychopharmacology is the first and most
widely used treatment for bipolar disorders, occasionally psychological interventions are also
paired with medication as psychotherapy alone is not a sufficient treatment option. Majority of
psychological interventions are aimed at medication adherence, as many bipolar patients stop
taking their mood stabilizers when they “feel better” (Advokat et al., 2014). Social skills training
and problem-solving skills are also helpful techniques to address in the therapeutic setting as
individuals with bipolar disorder often struggle in this area.
4.6.3. Outcome of Treatment
4.6.3.1. Depressive treatment. As we have discussed, major depressive disorder has a
variety of treatment options, all found to be efficacious. However, research suggests that while
psychopharmacological interventions are more effective in rapidly reducing symptoms,
psychotherapy, or even a combined treatment approach, are more effective in establishing long-
term relief of symptoms.
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Rates of relapse for major depressive disorder are often associated with individuals
whose onset was at a younger age (particularly adolescents), those who have already experienced
multiple major depressive episodes, and those with more severe symptomology, especially those
presenting with severe suicidal ideation and psychotic features (APA, 2013).
4.6.3.2. Bipolar treatment. Lithium and other mood stabilizers are very effective in
managing symptoms of patients with bipolar disorder. Unfortunately, it is the adherence to the
medication regimen that is often the issue with these patients. Bipolar patients often desire the
euphoric highs that are associated with manic and hypomanic episodes, leading them to forgo
their medication. A combination of psychopharmacology and psychotherapy aimed at increasing
the rate of adherence to medical treatment may be the most effective treatment option for bipolar
I and II disorder.
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• Treatment of depressive disorders include psychopharmacological options
such as anti-depressant mediations, SSRIs, tricyclic antidepressants, and
MAOIs AND/OR psychotherapy options to include CBT, behavioral
activation (BA), and interpersonal therapy (IPT). A combination of the two
main approaches often works best, especially in relation to maintenance of
wellness.
• Treatment of bipolar disorder involves mood stabilizers such as Lithium and
psychological interventions with the goal of medication adherence, as well as
social skills training and problem-solving skills.
• In regard to depression, psychopharmacological interventions are more
effective in rapidly reducing symptoms, while psychotherapy, or even a
combined treatment approach, is more effective in establishing long-term
relief of symptoms.
• A combination of psychopharmacology and psychotherapy aimed at
increasing the rate of adherence to medical treatment may be the most
effective treatment option for bipolar I and II disorder.
1. Discuss the effectiveness of the different pharmacological treatments for

mood disorders.
2. What are the four phases of CBT? How do they address symptoms of mood
disorder?
3. What is ITP and what are its main treatment strategies?
4. What are the effective treatment options for Bipolar Disorder?
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Module Recap
That concludes our discussion of mood disorders. You should now have a good
understanding of the two major types of mood disorders – depressive and bipolar disorders. Be
sure you are clear on what makes them different from one another in terms of their clinical
presentation, epidemiology, comorbidity, and etiology. This will help you with understanding
treatment options and their efficacy.
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Module 5:
Trauma- and Stressor-Related Disorders
5-1
Module 5: Trauma- and Stressor-Related Disorders
Module Overview
In Module 5, we will discuss matters related to trauma- and stressor-related disorders to
include their clinical presentation, epidemiology, comorbidity, etiology, and treatment options.
Our discussion will consist of PTSD, acute stress disorder, and adjustment disorder. Prior to
discussing these clinical disorders, we will explain what stressors are, as well as identify
common stressors that may lead to a stressor-related disorder. Be sure you refer Modules 1-3 for
explanations of key terms (Module 1), an overview of models to explain psychopathology
(Module 2), and descriptions of various therapies (Module 3).
Module Outline
• 5.1. Stressors
• 5.2. Clinical Presentation
• 5.5. Etiology
• 5.6. Treatment
• Define and identify common stressors.
• Describe how trauma- and stressor-related disorders present.
• Describe the epidemiology of trauma- and stressor-related disorders.
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• Describe comorbidity in relation to trauma- and stressor-related disorders.
• Describe the etiology of trauma- and stressor-related disorders.
• Describe treatment options for trauma- and stressor-related disorders.
5.1. Stressors
• Define stressor.
• Identify and describe common stressors.
Before we dive into clinical presentations for the three most common trauma and stress-
related disorders, let’s discuss common events that precipitate a stress-related diagnosis. A stress
disorder occurs when an individual has difficulty coping with or adjusting to a recent stressor.
Stressors can be any event—either witnessed firsthand, experienced personally, or experienced
by a close family member—that increases physical or psychological demands on an individual.
These events are significant enough that they pose a threat, whether real or imagined, to the
individual. While many people experience similar stressors throughout their lives, only a small
percentage of individuals experience significant maladjustment to the event that psychological
intervention is warranted.
Among the most commonly studied triggers for trauma-related disorders are combat and
physical/sexual assault. Symptoms of combat-related trauma date back to World War I when
soldiers would return home with “shell shock” (Figley, 1978). Unfortunately, it wasn’t until after
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the Vietnam War that significant progress was made in both identifying and treating war-related
psychological difficulties (Roy-Byrne et al., 2004). With the more recent wars in Iraq and
Afghanistan, attention was again brought to Posttraumatic Stress Disorder (PTSD) symptoms
due to the large number of service members returning from deployments and reporting
significant trauma symptoms.
Physical assault, and more specifically sexual assault, is another commonly studied
traumatic event. Rape, or forced sexual intercourse or other sexual act committed without an
individual’s consent, occurs in one out of every five women and one in every 71 men (Black et
al., 2011). Unfortunately, this statistic likely underestimates the actual number of cases that
occur due to the reluctance of many individuals to report their sexual assault. Of the reported
cases, it is estimated that nearly 81% of female and 35% of male rape victims report both acute
stress disorder and posttraumatic stress disorder symptoms (Black et al., 2011).
Now that we’ve discussed a little about some of the most commonly studied traumatic
events, let’s take a look at the presentation for posttraumatic stress disorder, acute stress disorder,
and adjustment disorder.
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• A stressor is any event that increases physical or psychological demands on
an individual.
• It does not have to be personally experienced but can be witnessed or occur to
a close family member and have the same effect.
• Only a small percentage of people experience significant maladjustment due
to these events.
• The most studied triggers for trauma-related disorders include physical/sexual
assault and combat.
1. Given an example of a stressor you have experienced in your own life.

2. Why are the triggers of physical/sexual assault and combat more likely to lead
to a trauma-related disorder?
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5.2. Clinical Presentation and DSM Criteria
• Describe how PTSD presents itself.
• Describe how acute stress disorder presents itself.
• Describe how adjustment disorder presents itself.
5.2.1. Posttraumatic Stress Disorder
Posttraumatic stress disorder, or more commonly known as PTSD, is identified by the
development of physiological, psychological, and emotional symptoms following exposure to a
traumatic event. Individuals must have been exposed to a situation where actual or threatened
death occurred. Examples of these situations include but are not limited to: witnessing a
traumatic event as it occurred to someone else; learning about a traumatic event that occurred to
a family member or close friend; or being exposed to repeated events where one experiences an
aversive event (e.g., victims of child abuse/neglect, ER physicians in trauma centers, etc.). It is
important to understand that while the presentation of these symptoms varies among individuals,
to meet the criteria for a diagnosis of PTSD, individuals need to report symptoms among the four
different categories of symptoms.
The first category involves recurrent experiences of the traumatic event, which can occur
via flashbacks, distinct memories (which may be voluntary or involuntary), or even distressing
dreams. These recurrent experiences must be specific to the traumatic event or the moments
immediately following to meet the criteria for PTSD. Regardless of the method, the recurrent
experiences can last several seconds or extend for several days. They are often initiated by
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physical sensations similar to those experienced during the traumatic events or environmental
triggers such as a specific location. Because of these triggers, individuals with PTSD are known
to avoid stimuli (i.e., activities, objects, people, etc.) associated with the traumatic event.
The second category involves avoidance of stimuli related to the traumatic event.
Individuals with PTSD may be observed trying to avoid the distressing thoughts and/or feelings
related to the memories of the traumatic event. One way individuals will avoid these memories is
by avoiding physical stimuli such as locations, individuals, activities, or even specific situations
that trigger the memory of the traumatic event.
The third category experienced by individuals with PTSD is negative alterations in
cognition or mood. This is often reported as difficulty remembering an important aspect of the
traumatic event. It should be noted that this amnesia is not due to a head injury, loss of
consciousness, or substances, but rather, due to the traumatic nature of the event. The impaired
memory may also lead individuals to have false beliefs about the causes of the traumatic event,
often blaming themselves or others. An overall persistent negative state, including a generalized
negative belief about oneself or others is also reported by those with PTSD. Similar to those with
depression, individuals with PTSD may report a reduced interest in participating in previously
enjoyable activities, as well as the desire to engage with others socially.
The fourth and final category is alterations in arousal and reactivity. Because of the
negative mood and increased irritability, individuals with PTSD may be quick-tempered and act
out aggressively, both verbally and physically. While these aggressive responses may be
provoked, they are also sometimes unprovoked. It is believed these behaviors occur due to the
heightened sensitivity to potential threats, especially if the threat is similar to their traumatic
event. More specifically, individuals with PTSD have a heightened startle response and easily
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jump or respond to unexpected noises just as a telephone ringing or a car backfiring. Given this
heightened arousal state, it should not be surprising that individuals with PTSD also experience
significant sleep disturbances, with difficulty falling asleep, as well as staying asleep due to
nightmares.
Although somewhat obvious, these symptoms likely cause significant distress in social,
occupational, and other (i.e., romantic, personal) areas of functioning. Duration of symptoms is
also important, as PTSD cannot be diagnosed unless symptoms have been present for at least
one month. If they have not been present for a month, the individual may meet criteria for Acute
Stress Disorder (see below).
5.2.2. Acute Stress Disorder
Acute stress disorder is very similar to PTSD except for the fact that symptoms must be
present from 3 days to 1 month following exposure to one or more traumatic events. If the
symptoms are present after one month, the individual would then meet the criteria for PTSD.
Additionally, if symptoms present immediately following the traumatic event but resolve by day
3, an individual would not meet the criteria for acute stress disorder.
Symptoms of acute stress disorder follow that of PTSD with a few exceptions. PTSD
requires symptoms within each of the four categories discussed above; however, acute stress
disorder requires that the individual experience nine symptoms across five different categories
(intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal
symptoms). For example, an individual may experience several arousal and reactivity symptoms
such as sleep issues, concentration issues, and hypervigilance, but does not experience issues
regarding negative mood. Regardless of the category of the symptoms, so long as nine symptoms
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are present and the symptoms cause significant distress or impairment in social, occupational,
and other functioning, an individual will meet the criteria for acute stress disorder.
5.2.3. Adjustment Disorder
Adjustment disorder is the least intense of the three stress-related disorders discussed in
this module. An adjustment disorder occurs following an identifiable stressor that happened
within the past 3 months. This stressor can be a single event (loss of job, death of a family
member) or a series of multiple stressors (cancer treatment, divorce/child custody issues).
Unlike PTSD and acute stress disorder, adjustment disorder does not have a set of specific
symptoms an individual must meet for diagnosis, rather, whatever symptoms the individual is
experiencing must be related to the stressor and must be significant enough to impair social,
occupational, or other important areas of functioning. Bereavement can be diagnosed as an
adjustment disorder in extreme cases where an individual's grief exceeds the intensity or
persistence that is expected.
It should be noted that there are modifiers associated with adjustment disorder. Due to the
variety of behavioral and emotional symptoms that can be present with an adjustment disorder,
clinicians are expected to classify a patient’s adjustment disorder as one of the following: with
depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of
conduct, with mixed disturbance of emotions and conduct, or unspecified if the behaviors do not
meet criteria for one of the aforementioned categories. Based on the individual’s presenting
symptoms, the clinician will determine which category best classifies the patient’s condition.
These modifiers are also important when choosing treatment options for patients.
5-9

• In terms of stress disorders, symptoms lasting over 3 days but not exceeding
one month, would be classified as acute stress disorder while those lasting over
a month are typical of PTSD.
• If symptoms begin after a traumatic event but resolve themselves within three
days, the individual does not meet the criteria for a stress disorder.
• Symptoms of PTSD fall into four different categories for which an individual
must have at least one symptom in each category to receive a diagnosis. These
categories include recurrent experiences, avoidance of stimuli, negative
alterations in cognition or mood, and alterations in arousal and reactivity.
• As for acute stress disorder, to receive a diagnosis an individual must
experience nine symptoms across five different categories (intrusion
symptoms, negative mood, dissociative symptoms, avoidance symptoms, and
arousal symptoms).
• Finally, adjustment disorder is the last intense of the three disorders and does
not have a specific set of symptoms of which an individual has to have some
number. Whatever symptoms the person presents with, they must cause
significant impairment in areas of functioning such as social or occupational,
and several modifiers are associated with the disorder.
1. What is the difference in diagnostic criteria for PTSD, Acute Stress Disorder,
and Adjustment Disorder?
2. What are the four categories of symptoms for PTSD? How do these symptoms
present in Acute Stress Disorder and Adjustment Disorder?
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5.3. Epidemiology
• Describe the epidemiology of PTSD.
• Describe the epidemiology of acute stress disorder.
• Describe the epidemiology of adjustment disorders.
5.3.1. PTSD
The prevalence rate for PTSD in the US is 8.7% (APA, 2013). It should not come as a
surprise that the rates of PTSD are higher among veterans and others who work in fields with
high traumatic experiences (i.e., firefighters, police, EMTs, emergency room providers). In fact,
PTSD rates for combat veterans are estimated to be as high as 30% (NcNally, 2012). Between
one-third and one-half of all PTSD cases consist of rape survivors, military combat and captivity,
and ethically or politically motivated genocide (APA, 2013).
Concerning gender, PTSD is more prevalent among females than males, likely due to
their higher occurrence of exposure to traumatic experiences such as rape, domestic abuse, and
other forms of interpersonal violence (APA, 2013). Gender differences are not found in
populations where both males and females are exposed to significant stressors suggesting that
both genders are equally predisposed to developing PTSD. Prevalence rates vary slightly across
cultural groups, which may reflect differences in exposure to traumatic events. (Hinton & Lewis-
Fernandez, 2011). More specifically, prevalence rates of PTSD are highest for African
Americans, followed by Latino/Hispanic Americans and European Americans, and lowest for
Asian Americans (Hinton & Lewis-Fernandez, 2011).

5-11
The prevalence rate for acute stress disorder varies across the country and by traumatic
event. Accurate prevalence rates for acute stress disorder are difficult to determine as patients
must seek treatment within 30 days of the traumatic event, but it is estimated that anywhere
between 7-30% of individuals experiencing a traumatic event will develop acute stress disorder
(National Center for PTSD). While acute stress disorder is not a good predictor of who will
develop PTSD, approximately 50% of those with acute stress disorder do eventually develop
PTSD (Bryant, 2010; Bryant, Friedman, Speigel, Ursano, & Strain, 2010).
Similar to PTSD, acute stress disorder is more common in females than males; however,
unlike PTSD, there may be some neurobiological differences in the stress response that
contribute to females developing acute stress disorder more often than males (APA, 2013). With
that said, the increased exposure to traumatic events among females may also be a strong reason
why women are more likely to develop acute stress disorder.
Adjustment disorders are relatively common as they describe individuals who are having
difficulty adjusting to life after a significant stressor. In psychiatric hospitals, adjustment
disorders account for roughly 50% of the admissions, ranking number one for the most common
diagnosis (APA, 2013). As for the general public, it is estimated that anywhere from 5-20% of
outpatient referrals are due to an adjustment disorder (APA, 2013).
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• Regarding PTSD, rates are highest among people who are likely to be exposed
to high traumatic events, women, and African Americans.
• As for acute stress disorder, prevalence rates are hard to determine since
patients must seek medical treatment within 30 days, but females are more
likely to develop the disorder.
• Adjustment disorders are relatively common since they occur in individuals
having trouble adjusting to a significant stressor.
1. Compare and contrast the prevalence rates among the three trauma and stress-
related disorders.
5.4. Comorbidity
• Describe the comorbidity of PTSD.
• Describe the comorbidity of acute stress disorder.
• Describe the comorbidity of adjustment disorder.
5.4.1. PTSD
Given the traumatic nature of the disorder, it should not be surprising that there is a high
comorbidity rate between PTSD and other psychological disorders. Individuals with PTSD are
80% more likely than those without PTSD to report clinically significant levels of depressive,
bipolar, anxiety, or substance abuse-related symptoms (APA, 2013).
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There is also a strong relationship between PTSD and major neurocognitive disorders,
which may be due to the overlapping symptoms between these disorders (Neurocognitive
Disorders will be covered in Module 14). There has also been an increase in PTSD and traumatic
brain injuries (TBI) due to the recent wars in Afghanistan and Iraq. US military personnel and
combat veterans report a comorbidity rate between PTSD and TBI at nearly 50% (APA, 2013).
Because 30 days after the traumatic event, ASD becomes PTSD (or the symptoms remit),
the comorbidity of ASD with other psychological disorders has not been studied. While ASD
and PTSD cannot be comorbid disorders, several studies have explored the relationship between
ASD and PTSD in efforts to identify individuals most at risk for developing PTSD. Research
studies indicate roughly 80% of motor vehicle accident survivors, as well as assault victims, who
met the criteria for ASD went on to develop PTSD (Brewin, Andrews, Rose, & Kirk, 1999;
Bryant & Harvey, 1998; Harvey & Bryant, 1998). While some researchers indicated ASD is a
good predictor of PTSD, others argue further research between the two and confounding
variables should be further explored to determine more consistent findings.
Unlike most of the disorders we have reviewed thus far, adjustment disorders have a high
comorbidity rate with various other medical conditions (APA, 2013). Often following a critical
or terminal medical diagnosis, an individual will meet the criteria for adjustment disorder as they
process the news about their health and the impact their new medical diagnosis will have on their
life. Other psychological disorders are also diagnosed with adjustment disorder; however,
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symptoms of adjustment disorder must be met independently of the other psychological
condition (APA, 2013). For example, an individual with adjustment disorder with depressive
features must not meet the criteria for a major depressive episode; otherwise, the diagnosis of
major depression should be made over the adjustment disorder.

• PTSD has a high comorbidity rate with psychological and neurocognitive
disorders while this rate is hard to establish with acute stress disorder since it
becomes PTSD after 30 days.
• Adjustment disorder has a high comorbidity rate with other medical conditions
as people process news about their health and what the impact of a new
medical diagnosis will be on their life.
1. How common are comorbidities among trauma and stress-related disorders?

What are the most common comorbid diagnoses?
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5.5. Etiology
• Describe the biological causes of trauma- and stressor-related disorders.
• Describe the cognitive causes of trauma- and stressor-related disorders.
• Describe the social causes of trauma- and stressor-related disorders.
• Describe the sociocultural causes of trauma- and stressor-related disorders.
5.5.1. Biological
HPA axis. One theory for the development of trauma and stress-related disorders is the
over-involvement of the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is
involved in the fear-producing response, and some speculate that dysfunction within this axis is
to blame for the development of trauma symptoms. Within the brain, the amygdala serves as the
integrative system that inherently elicits the physiological response to a traumatic/stressful
environmental situation. The amygdala sends this response to the HPA axis in an effort to
prepare the body to “fight or flight.” The HPA axis then releases hormones—epinephrine and
cortisol—to help the body to prepare to respond to a dangerous situation (Stahl & Wise, 2008).
While epinephrine is known to cause physiological symptoms such as increased blood pressure,
increased heart rate, increased alertness, and increased muscle tension, to name a few, cortisol is
responsible for returning the body to homeostasis once the dangerous situation is resolved.
Researchers have studied the amygdala and HPA axis in individuals with PTSD, and have
identified heightened amygdala reactivity in stressful situations, as well as excessive
responsiveness to stimuli that is related to one’s specific traumatic event (Sherin & Nemeroff,
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2011). Additionally, studies have indicated that individuals with PTSD also show a diminished
fear extinction, suggesting an overall higher level of stress during non-stressful times. These
findings may explain why individuals with PTSD experience an increased startle response and
exaggerated sensitivity to stimuli associated with their trauma (Schmidt, Kaltwasser, & Wotjak,
2013).
5.5.2. Cognitive
Preexisting conditions of depression or anxiety may predispose an individual to develop
PTSD or other stress disorders. One theory is that these individuals may ruminate or over-
analyze the traumatic event, thus bringing more attention to the traumatic event and leading to
the development of stress-related symptoms. Furthermore, negative cognitive styles or
maladjusted thoughts about themselves and the environment may also contribute to PTSD
symptoms. For example, individuals who identify life events as “out of their control” report more
severe stress symptoms than those who feel as though they have some control over their lives
(Catanesi et al., 2013).
5.5.3. Social
While this may hold for many psychological disorders, social and family support have
been identified as protective factors for individuals prone to develop PTSD. More specifically,
rape victims who are loved and cared for by their friends and family members as opposed to
being judged for their actions before the rape, report fewer trauma symptoms and faster
psychological improvement (Street et al., 2011).
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As was mentioned previously, different ethnicities report different prevalence rates of
PTSD. While this may be due to increased exposure to traumatic events, there is some evidence
to suggest that cultural groups also interpret traumatic events differently, and therefore, may be
more vulnerable to the disorder. Hispanic Americans have routinely been identified as a cultural
group that experiences a higher rate of PTSD. Studies ranging from combat-related PTSD to on-
duty police officer stress, as well as stress from a natural disaster, all identify Hispanic
Americans as the cultural group experiencing the most traumatic symptoms (Kaczkurkin et al.,
2016; Perilla et al., 2002; Pole et al., 2001).
Women also report a higher incidence of PTSD symptoms than men. Some possible
explanations for this discrepancy are stigmas related to seeking psychological treatment, as well
as a greater risk of exposure to traumatic events that are associated with PTSD (Kubiak, 2006).
Studies exploring rates of PTSD symptoms for military and police veterans have failed to report
a significant gender difference in the diagnosis rate of PTSD suggesting that there is not a
difference in the rate of occurrence of PTSD in males and females in these settings (Maguen,
Luxton, Skopp, & Madden, 2012).
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• In terms of causes for trauma- and stressor-related disorders, an over-
involvement of the hypothalamic-pituitary-adrenal (HPA) axis has been cited
as a biological cause, with rumination and negative coping styles or
maladjusted thoughts emerging as cognitive causes.
• Culture may lead to different interpretations of traumatic events thus causing
higher rates among Hispanic Americans.
• Social and family support have been found to be protective factors for
individuals most likely to develop PTSD.
1. Discuss the four etiological models of the trauma and stress-related disorders.
Which model best explains the maintenance of trauma/stress symptoms?
Which identifies protective factors for the individual?
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5.6. Treatment
• Describe the treatment approach of the psychological debriefing.
• Describe the treatment approach of exposure therapy.
• Describe the treatment approach of CBT.
• Describe the treatment approach of Eye Movement Desensitization and Reprocessing
(EMDR).
• Describe the use of psychopharmacological treatment.
5.6.1. Psychological Debriefing
One way to negate the potential development of PTSD symptoms is thorough
psychological debriefing. Psychological debriefing is considered a type of crisis intervention
that requires individuals who have recently experienced a traumatic event to discuss or process
their thoughts and feelings related to the traumatic event, typically within 72 hours of the event
(Kinchin, 2007). While there are a few different methods to a psychological debriefing, they all
follow the same general format:
1. Identifying the facts (what happened?)
2. Evaluating the individual’s thoughts and emotional reaction to the events leading up
to the event, during the event, and then immediately following
3. Normalizing the individual’s reaction to the event
4. Discussing how to cope with these thoughts and feelings, as well as creating a
designated social support system (Kinchin, 2007).

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Throughout the last few decades, there has been a debate on the effectiveness of
psychological debriefing. Those within the field argue that psychological debriefing is not a
means to cure or prevent PTSD, but rather, psychological debriefing is a means to assist
individuals with a faster recovery time posttraumatic event (Kinchin, 2007). Research across a
variety of traumatic events (natural disasters, burns, war) routinely suggests that psychological
debriefing is not helpful in either the reduction of posttraumatic symptoms nor the recovery time
of those with PTSD (Tuckey & Scott, 2014). One theory is these early interventions may
encourage patients to ruminate on their symptoms or the event itself, thus maintaining PTSD
symptoms (McNally, 2004). In efforts to combat these negative findings of psychological
debriefing, there has been a large movement to provide more structure and training for
professionals employing psychological debriefing, thus ensuring that those who are providing
treatment are properly trained to do so.
5.6.2. Exposure Therapy
While exposure therapy is predominately used in anxiety disorders, it has also shown
great success in treating PTSD-related symptoms as it helps individuals extinguish fears
associated with the traumatic event. There are several different types of exposure techniques—
imaginal, in vivo, and flooding are among the most common types (Cahill, Rothbaum, Resick,
& Follette, 2009).
In imaginal exposure, the individual mentally re-creates specific details of the traumatic
event. The patient is then asked to repeatedly discuss the event in increasing detail, providing
more information regarding their thoughts and feelings at each step of the event. During in vivo
exposure, the individual is reminded of the traumatic event through the use of videos, images, or
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other tangible objects related to the traumatic event that induces a heightened arousal response.
While the patient is re-experiencing cognitions, emotions, and physiological symptoms related to
the traumatic experience, they are encouraged to utilize positive coping strategies, such as
relaxation techniques, to reduce their overall level of anxiety.
Imaginal exposure and in vivo exposure are generally done in a gradual process, with
imaginal exposure beginning with fewer details of the event, and slowly gaining information
over time. In vivo starts with images or videos that elicit lower levels of anxiety, and then the
patient slowly works their way up a fear hierarchy, until they are able to be exposed to the most
distressing images. Another type of exposure therapy, flooding, involves disregard for the fear
hierarchy, presenting the most distressing memories or images at the beginning of treatment.
While some argue that this is a more effective method, it is also the most distressing and places
patients at risk for dropping out of treatment (Resick, Monson, & Rizvi, 2008).
5.6.3. Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy, as discussed in the mood disorders chapter, has been
proven to be an effective form of treatment for trauma/stress-related disorders. It is believed that
this type of treatment is effective in reducing trauma-related symptoms due to its ability to
identify and challenge the negative cognitions surrounding the traumatic event, and replace them
with positive, more adaptive cognitions (Foa et al., 2005).
Trauma-focused cognitive-behavioral therapy (TF-CBT) is an adaptation of CBT that
utilizes both CBT techniques and trauma-sensitive principles to address the trauma-related
symptoms. According to the Child Welfare Information Gateway (CWIG; 2012), TF-CBT can be
summarized via the acronym PRACTICE:
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• P: Psycho-education about the traumatic event. This includes discussion about the
event itself, as well as typical emotional and/or behavioral responses to the event.
• R: Relaxation Training. Teaching the patient how to engage in various types of
relaxation techniques such as deep breathing and progressive muscle relaxation.
• A: Affect. Discussing ways for the patient to effectively express their emotions/fears
related to the traumatic event.
• C: Correcting negative or maladaptive thoughts.
• T: Trauma Narrative. This involves having the patient relive the traumatic event
(verbally or written), including as many specific details as possible.
• I: In vivo exposure (see above).
• C: Co-joint family session. This provides the patient with strong social support and a
sense of security. It also allows family members to learn about the treatment so that
they are able to assist the patient if necessary.
• E: Enhancing Security. Patients are encouraged to practice the coping strategies they
learn in TF-CBT to prepare for when they experience these triggers out in the real
world, as well as any future challenges that may come their way.
5.6.4. Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is a controversial treatment for a few reasons; however, the fact that the treatment
emerged from a personal observation over a theory is among the most argued reasons. In the late
1980s, psychologist Francine Shapiro found that by focusing her eyes on the waving leaves
during her daily walk, her troubling thoughts resolved on their own. From this observation, she
concluded that lateral eye movements facilitate the cognitive processing of traumatic thoughts
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(Shapiro, 1989). While EMDR has evolved somewhat since Shapiro’s first claims, the basic
components of EMDR consist of lateral eye movement induced by the therapist moving their
index finger back and forth, approximately 35 cm from the client’s face, as well as components
of cognitive-behavioral therapy and exposure therapy. The following 8-step approach is the
standard treatment approach of EMDR (Shapiro & Maxfield, 2002):
1. Patient History and Treatment Planning - Identify trauma symptoms and potential
barriers to treatment.
2. Preparation - Psychoeducation of trauma and treatment.
3. Assessment- Careful and detailed evaluation of the traumatic event. Patient identifies
images, cognitions, and emotions related to the traumatic event, as well as trauma-
related physiological symptoms.
4. Desensitization and Reprocessing - Holding the trauma image, cognition, and
emotion in mind, while simultaneously assessing their physiological symptoms, the
patient must track the clinician’s finger movement for approximately 20 seconds. At
this time, the patient must “blank it out” and let go of the memory.
5. Installation of Positive Cognitions - Once the negative image, cognition, and
emotions are reduced, the patient must hold onto a positive image or thought while
again tracking the clinician’s finger movement for approximately 20 seconds.
6. Body Scan - Patient must identify any lingering bodily sensations while again
tracking the clinician’s fingers for a third time to discard any remaining trauma
symptoms.
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7. Closure - Patient is provided with positive coping strategies and relaxation techniques
to assist with any recurrent cognitions or emotions related to the traumatic
experience.
8. Reevaluation - Clinician assesses if treatment goals were met. If not, schedules
another treatment session and identifies remaining symptoms.
As you can see from above, only steps 4-6 are specific to EMDR; the remaining
treatment is essentially a combination of exposure therapy and cognitive-behavioral techniques.
Because of the high overlap between treatment techniques, there have been quite a few studies
comparing the treatment efficacy of EMDR to TF-CBT and exposure therapy. While research
initially failed to identify a superior treatment, often citing EMDR and TF-CBT as equally
efficacious in treating PTSD symptoms (Seidler & Wagner, 2006), more recent studies have
found that EMDR may be superior to that of TF-CBT, particularly in psycho-oncology patients
(Capezzani et al., 2013; Chen, Zang, Hu & Liang, 2015). While meta-analytic studies continue to
debate which treatment is the most effective in treating PTSD symptoms, the World Health
Organization’s (2013) publication on the Guidelines for the Management of Conditions
Specifically Related to Stress, identified TF-CBT and EMDR as the only recommended
treatment for individuals with PTSD.
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5.6.5. Psychopharmacological Treatment
While psychopharmacological interventions have been shown to provide some relief,
particularly to veterans with PTSD, most clinicians agree that resolution of symptoms cannot be
accomplished without implementing exposure and/or cognitive techniques that target the
physiological and maladjusted thoughts maintaining the trauma symptoms. With that said,
clinicians agree that psychopharmacology interventions are an effective second line of treatment,
particularly when psychotherapy alone does not produce relief from symptoms.
Among the most common types of medications used to treat PTSD symptoms are
selective serotonin reuptake inhibitors (SSRIs; Bernardy & Friedman, 2015). As previously
discussed in the depression chapter, SSRIs work by increasing the amount of serotonin available
to neurotransmitters. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors
(MAOIs) are also recommended as second-line treatments. Their effectiveness is most often
observed in individuals who report co-occurring major depressive disorder symptoms, as well as
those who do not respond to SSRIs (Forbes et al., 2010). Unfortunately, due to the effective CBT
and EMDR treatment options, research on psychopharmacological interventions has been
limited. Future studies exploring other medication options are needed to determine if there are
alternative medication options for stress/trauma disorder patients.
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• Several treatment approaches are available to clinicians to alleviate the
symptoms of trauma- and stress-related disorders.
• The first approach, psychological debriefing, has individuals who have
recently experienced a traumatic event discuss or process their thoughts
related to the event and within 72 hours.
• Another approach is to expose the individual to a fear hierarchy and then
have them use positive coping strategies such as relaxation techniques to
reduce their anxiety or to toss the fear hierarchy out and have the person
experience the most distressing memories or images at the beginning of
treatment.
• The third approach is Cognitive Behavioral Therapy (CBT) and attempts to
identify and challenge the negative cognitions surrounding the traumatic
event and replace them with positive, more adaptive cognitions.
• The fourth approach, called EMDR, involves an 8-step approach and the
tracking of a clinician’s fingers which induces lateral eye movements and
aids with the cognitive processing of traumatic thoughts.
• Finally, when psychotherapy does not produce relief from symptoms,
psychopharmacology interventions are an effective second line of treatment
and may include SSRIs, TCAs, and MAOIs.
1. Identify the different treatment options for trauma and stress-related

disorders. Which treatment options are most effective? Which are least
effective?
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Module Recap
In Module 5, we discussed trauma- and stressor-related disorders to include PTSD, acute
stress disorder, and adjustment disorder. We defined what stressors were and then explained how
these disorders present themselves. In addition, we clarified the epidemiology, comorbidity, and
etiology of each disorder. Finally, we discussed potential treatment options for trauma- and
stressor-related disorders. Our discussion in Module 6 moves to dissociative disorders.
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Module 6:
Dissociative Disorders
6-1
Module 6: Dissociative Disorders
Module Overview
In Module 6, we will discuss matters related to dissociative disorders to include their
clinical presentation, epidemiology, comorbidity, etiology, and treatment options. Our discussion
will consist of dissociative identity disorder, dissociative amnesia, and
depersonalization/derealization. Be sure you refer Modules 1-3 for explanations of key terms
(Module 1), an overview of models to explain psychopathology (Module 2), and descriptions of
the various therapies (Module 3).
Module Outline
• 6.4. Etiology
• 6.5. Treatment
• Describe how dissociative disorders present.
• Describe the epidemiology of dissociative disorders.
• Describe comorbidity in relation to dissociative disorders.
• Describe the etiology of dissociative disorders.
• Describe treatment options for dissociative disorders.
6-2
6.1. Clinical Presentation
• Describe dissociative disorders.
• Describe how Dissociative Identity Disorder presents.
• Describe how dissociative amnesia presents.
• Describe how depersonalization/derealization presents.
Dissociative disorders are a group of disorders characterized by symptoms of disruption
in consciousness, memory, identity, emotion, perception, motor control, or behavior (APA,
2013). These symptoms are likely to appear following a significant stressor or years of ongoing
stress (i.e., abuse; Maldonadao & Spiegel, 2014). Occasionally, one may experience temporary
dissociative symptoms due to lack of sleep or ingestion of a substance; however, these would not
qualify as a dissociative disorder due to the lack of impairment in functioning. Furthermore,
individuals who suffer from acute stress disorder and PTSD often experience dissociative
symptoms, such as amnesia, flashbacks, depersonalization and derealization; however, because
of the identifiable stressor (and lack of additional symptoms listed below), they meet diagnostic
criteria for a stress disorder as opposed to a dissociative disorder.
There are three main types of dissociative disorders: Dissociative Identity Disorder,
Dissociative Amnesia, and Depersonalization/Derealization Disorder.
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6.1.1. Dissociative Identity Disorder (DID)
Dissociative Identity Disorder (DID) is what people commonly refer to as multiple
personality disorder. The key diagnostic criteria for DID is the presence of two or more distinct
personality states or expressions. The identities are distinct in that they often have a unique tone
of voice, engage in different physical gestures (including gait), and have different personalities—
ranging anywhere from cooperative and sweet to defiant and aggressive. Additionally, the
identities can be of varying ages and gender, have different memories, and sensory-motor
functioning.
The second main diagnostic criteria for DID is that there must be a gap in the recall of
events, information, or trauma due to the switching of personalities. These gaps are more
excessive than typical forgetting one may experience due to lack of attention. These personalities
must not be a secondary effect of a substance or medical condition (i.e., gap of information due
to seizure).
While personalities can present at any time, there is generally a dominant or primary
personality that is present the majority of the time. From there, an individual may have several
subpersonalities. Although it is hard to identify how many subpersonalities an individual may
have at one time, it is believed that there are on average 15 subpersonalities for women and 8 for
men (APA, 2000).
The presentation of switching between personalities varies among individuals and can
range from merely appearing to fall asleep, to very dramatic, involving excessive bodily
movements. While often sudden and unexpected, switching is generally precipitated by a
significant stressor, as the subpersonality best equipped to handle the current stressor will
present. The relationship between subpersonalities varies between individuals, with some
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individuals reporting knowledge of other subpersonalities while others have a one-way amnesic
relationship with subpersonalities, meaning they are not aware of other personalities (Barlow &
Chu, 2014). These individuals will experience episodes of “amnesia” when the primary
personality is not present.
6.1.2. Dissociative Amnesia Disorder
Dissociative amnesia disorder is identified by the inability to recall important
autobiographical information. This type of amnesia is different from what one would consider
permanent amnesia in that the information was successfully stored in memory; however, the
individual cannot retrieve it. Additionally, individuals experiencing permanent amnesia often
have a neurobiological cause, whereas dissociative amnesia does not (APA, 2013).
There are a few types of amnesia within dissociative amnesia. Localized amnesia, the
most common type, is the inability to recall events during a specific period. The length of time
within a localized amnesia episode can vary—it can be as short as the time immediately
surrounding a traumatic event, to months or years, should the traumatic event occur that long (as
commonly seen in abuse and combat situations). Selective amnesia is, in a sense, a component
of localized amnesia in that the individual can recall some, but not all, of the details during a
specific period. For example, a soldier may experience dissociative amnesia during the time they
were deployed, yet still have some memories of positive experiences such as celebrating
Thanksgiving dinner or Christmas dinner with their unit.
Conversely, some individuals experience generalized amnesia where they have a
complete loss of memory of their entire life history, including their own identity. Individuals
who experience this amnesia experience deficits in both semantic and procedural knowledge.
6-5
This means that individuals have no common knowledge of (i.e. cannot identify letters, colors,
numbers) nor do they have the ability to engage in learned skills (i.e. typing shoes, driving car).
While generalized amnesia is extremely rare, it is also extremely frightening. The onset is
acute, and the individual is often found wandering in a state of disorientation. Many times, these
individuals are brought into emergency rooms by law enforcement following a dangerous
situation such as an individual wandering on a busy road.
Dissociative fugue is considered to be the most extreme type of dissociative amnesia.
Not only does an individual forget personal information, but they also flee to a different location
(APA, 2013). The degree of the fugue varies among individuals—with some experiencing
symptoms for a short time (only hours) to others lasting years, affording individuals to take on
new identities, careers, and even relationships. Similar to their sudden onset, dissociative fugues
also end abruptly. Post dissociative fugue, the individual generally regains most of their memory
and rarely relapses. Emotional adjustment after the fugue is dependent on the time the individual
spent in the fugue, with those having been in a fugue state longer experiencing more emotional
distress than those who experienced a shorter fugue (Kopelman, 2002).
6.1.3. Depersonalization/Derealization Disorder
Depersonalization/Derealization disorder is categorized by recurrent episodes of
depersonalization and/or derealization. Depersonalization can be defined as a feeling of
unreality or detachment from oneself. Individuals describe this feeling as an out-of-body
experience where you are an observer of your thoughts, feelings, and physical being.
Furthermore, some patients report feeling as though they lack speech or motor control, thus
feeling at times like a robot. Distortions of one’s physical body have also been reported, with
6-6
various body parts appearing enlarged or shrunken. Emotionally, one may feel detached from
their feelings, lacking the ability to feel emotions despite knowing they have them.
Symptoms of derealization include feelings of unreality or detachment from the world—
whether it be individuals, objects, or their surroundings. For example, an individual may feel as
though they are unfamiliar with their surroundings, even though they are in a place they have
been to many times before. Feeling emotionally disconnected from close friends or family
members whom they have strong feelings for is another common symptom experienced during
derealization episodes. Sensory changes have also been reported, such as feeling as though your
environment is distorted, blurry, or even artificial. Distortions of time, distance, and size/shape of
objects may also occur.
These episodes can last anywhere from a few hours to days, weeks, or even months
(APA, 2013). The onset is generally sudden, and like the other dissociative disorders, is often
triggered by intense stress or trauma. As one can imagine, depersonalization/derealization
disorder can cause significant emotional distress, as well as impairment in one’s daily
functioning (APA, 2013).
6-7

• Dissociative disorders are characterized by disruption in consciousness,
memory, identity, emotion, perception, motor control, or behavior. They
include Dissociative Identity Disorder (DID), dissociative amnesia, and
depersonalization/derealization disorder.
• First, DID is present when a person has two or more distinct personality
states or expressions with one becoming the dominant or primary
personality.
• Dissociative amnesia is characterized by the inability to recall important
autobiographical information, whether during a specific period (localized) or
one’s entire life (generalized) or forgetting personal information and fleeing
to a different location (fugue).
• Depersonalization/derealization disorder includes a feeling of unreality or
detachment from oneself (depersonalization) and feelings of unreality or
detachment from the world (derealization).
1. Identify the diagnostic criteria for each of the three dissociative disorders.
How are they similar? How are they different?
2. What is the difference between depersonalization and derealization?
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6.2. Epidemiology
• Describe the epidemiology of dissociative disorders.
Dissociative disorders were once believed to be extremely rare; however, more recent
research suggests that they may be more present in the general population than once thought.
Estimates for the prevalence rate of DID is 1.5%, with an equal distribution between men and
women (APA, 2013). Similarly, a large community sample suggested dissociative amnesia
occurs in approximately 1.8% of the population. Unlike DID, females are twice as more likely to
be diagnosed with dissociative amnesia than males (APA, 2013). Similar to trauma-related
disorders, it is believed that more women experience dissociative amnesia due to their increased
chances of encountering significant stress/trauma compared to that of men.
While many individuals experience brief episodes of depersonalization/derealization
throughout their life, the estimated number of individuals who experience clinically significant
symptoms is estimated to be 2%, with an equal ratio of men and women experiencing these
symptoms (APA, 2013).
The onset of dissociative disorders is generally late adolescence to early adulthood, with
the exception of DID. Due to the high comorbidity between childhood abuse and DID, it is
believed that symptoms begin in early childhood following the repeated exposure to abuse;
however, the full onset of the disorder is not observed (or noticed by others) until adolescence
(Sar et al., 2014).
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• In general, somewhere between 1.5 and 2% of individuals experience a dissociative
disorder with an equal number of males and females experiencing DID and
depersonalization/derealization disorder and more females experiencing dissociative
amnesia.
1. What are the prevalence rates for dissociative disorders? What are some identified
barriers in determining prevalence rates of these disorders?
6.3. Comorbidity
• Describe the comorbidity of dissociative disorders.
Given that a traumatic experience often precipitates dissociative disorders, it should not
be surprising that there is a high comorbidity between dissociative disorders and PTSD.
Similarly, depressive disorders are also commonly found in combination with dissociative
disorders, likely due to the impact the disorders have on social and emotional functioning. In
individuals with dissociative amnesia, a wide range of emotions related to their inability to recall
memories during the episode often present once the amnesia episode is in remission (APA,
2013). These emotions frequently contribute to the development of a depressive episode.
Due to the rarity of these disorders with respect to other mental health disorders, it is
often difficult to truly determine comorbid diagnoses. There has been some evidence of
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comorbid somatic symptom disorder and conversion disorder, particularly for those who
experience dissociative amnesia. Furthermore, dependent, avoidant, and borderline personality
disorders have been suspected as co-occurring disorders among the dissociative disorder family.

• Many dissociative disorders have been found to have a high comorbidity with
PTSD and depressive disorders.
• Somatic symptom and conversion disorders, as well as some personality
disorders, have also been found to be comorbid.
1. What are the common comorbid diagnoses for individuals with dissociative
disorders?
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6.4. Etiology
• Describe the biological causes of dissociative disorders.
• Describe the cognitive causes of dissociative disorders.
• Describe the sociocultural causes of dissociative disorders.
• Describe the psychodynamic causes of dissociative disorders.
6.4.1. Biological
While studies on the involvement of genetic underpinnings need additional research,
there is some suggestion that heritability rates for dissociation rage from 50-60% (Pieper, Out,
Bakermans-Kranenburg, Van Ijzendoorn, 2011). However, it is suggested that the combination
of genetic and environmental factors may play a larger role in the development of dissociative
disorders than genetics alone (Pieper, Out, Bakermans-Kranenburg, Van Ijzendoorn, 2011).
6.4.2. Cognitive
One proposed cognitive theory of dissociative disorders, particularly dissociative
amnesia, is a memory retrieval deficit. More specifically, Kopelman (2000) theorizes that the
combination of psychological stress and various other biopsychosocial predispositions affects the
frontal lobes executive system’s ability to retrieve autobiographical memories (Picard et al.,
2013). Neuroimaging studies have supported this theory by showing deficits to several prefrontal
regions, which is one area responsible for memory retrieval (Picard et al., 2013). Despite these
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findings, there is still some debate over which specific brain regions within the executive system
are responsible for the retrieval difficulties, as research studies have reported mixed findings.
Specific to DID, neuroimaging studies have shown differences in hippocampus activation
between subpersonalities (Tsai, Condie, Wu & Chang, 1999). As you may recall, the
hippocampus is responsible for storing information from short-term to long-term memory. It is
hypothesized that this brain region is responsible for the generation of dissociative states and
amnesia (Staniloiu & Markowitsch, 2010).
The sociocultural model of dissociative disorders has been primarily influenced by
Lilienfeld and colleagues (1999) who argue that the influence of mass media and its publications
of dissociative disorders, provide a model for individuals to not only learn about dissociative
disorders but also engage in similar dissociative behaviors. This theory has been supported by
the significant increase in DID cases after the publication of Sybil, a documentation of a
woman’s 16 subpersonalities (Goff & Simms, 1993).
These mass media productions are not just suggestive to patients. It has been suggested
that mass media also influences the way clinicians gather information regarding dissociative
symptoms of patients. For example, therapists may unconsciously use questions or techniques in
session that evoke dissociative types of problems in their patients following exposure to a media
source discussing dissociative disorders.
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6.4.4. Psychodynamic
The psychodynamic theory of dissociative disorders assumes that dissociative disorders
are caused by an individual’s repressed thoughts and feelings related to an unpleasant or
traumatic event (Richardson, 1998). In blocking these thoughts and feelings, the individual is
subconsciously protecting himself from painful memories.
While a single incidence of repression may explain dissociative amnesia, psychodynamic
theorists believe that DID results from repeated exposure to traumatic experiences, such as
childhood abuse, neglect, or abandonment (Dalenberg et al., 2012). According to the
psychodynamic perspective, children who experience repeated traumatic events such as physical
abuse or parental neglect lack the support and resources to cope with these experiences. In an
effort to escape from their current situation, children develop different personalities to essentially
flee the dangerous situation they are in. While there is limited scientific evidence to support this
theory, the nature of severe childhood psychological trauma is consistent with this theory, as
individuals with DID have the highest rate of childhood psychological trauma compared to all
other psychiatric disorders (Sar, 2011).
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• Though there is some evidence for a genetic component to dissociative
disorders, a combination of genes and environment are thought to play a
larger role.
• A cognitive explanation assumes a memory retrieval deficit, particularly
related to dissociative amnesia, and differential hippocampus activation
between subpersonalities in DID.
• Mass media is also purported to have caused a rise in dissociative disorders
due to the attention it gives these disorders in its publications and movies
such as Sybil.
• Finally, repressed thoughts and feelings are thought to be the cause of
dissociative disorders in the psychodynamic theory.
1. How do the biological, cognitive, sociocultural, and psychodynamic

perspectives differ in their explanation of the development of dissociative
disorders?
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6.5. Treatment
• Clarify why treatment for dissociative disorders is limited.
• Describe treatment options for dissociative identity disorder.
• Describe treatment options for dissociative amnesia.
• Describe treatment options for depersonalization/derealization.
Treatment for dissociative disorders is limited for a few reasons. First, with respect to
dissociative amnesia, many individuals recover on their own without any intervention.
Occasionally treatment is sought out after recovery due to the traumatic nature of memory loss.
Second, the rarity of these disorders has offered limited opportunities for research on both the
development and effectiveness of treatment methods. Due to the differences between dissociative
disorders, treatment options will be discussed specific to each disorder.
6.5.1. Dissociative Identity Disorder
The ultimate treatment goal for DID is the integration of subpersonalities to the point of
final fusion (Chu et al., 2011). Integration refers to the ongoing process of merging
subpersonalities into one personality. Psychoeducation is paramount for integration, as the
individual must have an understanding of their disorder, as well as acknowledge their
subpersonalities. As mentioned above, many individuals have a one-way amnesic relationship
with the subpersonalities, meaning they are not aware of one another. Therefore, the clinician
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must first make the individual aware of the various subpersonalities that present across different
situations.
Achieving integration requires several steps. First, the clinician needs to build a
relationship and strong rapport with the primary personality. From there, the clinician can begin
to encourage communication and coordination between the subpersonalities gradually. Making
the subpersonalities aware of one another, as well as addressing their conflicts, is an essential
component of the integration of subpersonalities, and the core of DID treatment (Chu et al.,
2011).
Once the individual is aware of their personalities, treatment can continue with the goal
of fusion. Fusion occurs when two or more alternate identities join together (Chu et al., 2011).
When this happens, there is a complete loss of separateness. Depending on the number of
subpersonalities, this process can take quite a while. Once all subpersonalities are fused and the
individual identifies themselves as one unified self, it is believed the patient has reached final
fusion.
It should be noted that final fusion is difficult to obtain. As you can imagine, some
patients do not find final fusion a desirable outcome, particularly those with harrowing histories;
chronic, severe stressors; advanced age; and comorbid medical and psychiatric disorders, to
name a few. For individuals where final fusion is not the treatment goal, the clinician may work
toward resolution or sufficient integration and coordination of subpersonalities that allows the
individual to function independently (Chu et al., 2011). Unfortunately, individuals that do not
achieve final fusion are at greater risk for relapse of symptoms, particularly those with whose
DID appears to stem from traumatic experiences.
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Once an individual reaches final fusion, ongoing treatment is essential to maintain this
status. In general, treatment focuses on social and positive coping skills. These skills are
particularly helpful for individuals with a history of traumatic events, as it can help them process
these events, as well as help prevent future relapses.
6.5.2. Dissociative Amnesia
As previously mentioned, many individuals regain memory without the need for
treatment; however, there is a small population that does require additional treatment. While
there is no evidenced-based treatment for dissociative amnesia, both hypnosis and phasic therapy
have been shown to produce some positive effects in patients with dissociative amnesia.
6.5.2.1. Hypnosis. One theory of dissociative amnesia is that it is a form of self-hypnosis
and that individuals hypnotize themselves to forget information or events that are unpleasant
(Dell, 2010). Because of this theory, one type of treatment that has routinely been implemented
for individuals with dissociative amnesia is hypnosis. Through hypnosis, the clinician can help
the individual contain, modulate, and reduce the intensity of the amnesia symptoms, thus
allowing them to process the traumatic or unpleasant events underlying the amnesia episode
(Maldonadao & Spiegel, 2014). To do this, the clinician will encourage the patient to think of
memories just before the amnesic episode as though it was the present time. The clinician will
then slowly walk them through the events during the amnesic period in an effort to reorient the
individual to experience these events. This technique is essentially a way to encourage a
controlled recall of dissociated memories, something that is particularly helpful when the
memories include traumatic experiences (Maldonadao & Spiegel, 2014).
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Another form of “hypnosis” is the use of barbiturates, also known as “truth serums,” to
help relax the individual and free their inhibitions. Although not always effective, the theory is
that these drugs reduce the anxiety surrounding the unpleasant events enough to allow the
individual to recall and process these memories in a safe environment (Ahern et al., 2000).
6.5.3. Depersonalization/Derealization Disorder
Depersonalization/derealization disorder symptoms generally occur for an extensive
period before the individual seeks out treatment. Because of this, there is some evidence to
support that the diagnosis alone is effective in reducing symptom intensity, as it also relieves the
individual’s anxiety surrounding the baffling nature of the symptoms (Medford, Sierra, Baker, &
David, 2005).
Due to the high comorbidity of depersonalization/derealization disorder with anxiety and
depression, the goal of treatment is often alleviating these secondary mental health symptoms
related to the depersonalization/derealization symptoms. While there has been some evidence to
suggest treatment with an SSRI is effective in improving mood, the evidence for a combined
treatment method of psychopharmacological and psychological treatment is even more
compelling (Medford, Sierra, Baker, & David, 2005). The psychological treatment of preference
is cognitive-behavioral therapy as it addresses the negative attributions and appraisals
contributing to the depersonalization/derealization symptoms (Medford, Sierra, Baker, & David,
2005). By challenging these catastrophic attributions in response to stressful situations, the
individual is able to reduce overall anxiety levels, which consequently reduces
depersonalization/derealization symptoms.
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• Treatment for DID involves the integration of subpersonalities to the point
of final fusion and takes several steps to achieve.
• For some patients, this is not possible as they do not find final fusion to be a
desirable outcome.
• Instead, the clinician will work to achieve resolution or sufficient
integration and coordination of the subpersonalities to allow the person to
function independently.
• For dissociative amnesia, hypnosis and phasic therapy are used, as well as
barbiturates known as “truth serums.”
• Finally, diagnosis alone is sometimes enough to reduce the intensity of
symptoms related to depersonalization/derealization disorder and due to the
high comorbidity with anxiety and depression, alleviation of these
secondary symptoms is often the goal of treatment.
1. What is the treatment goal for dissociative identity disorder? How is it

achieved?
2. What are the treatment options for dissociative amnesia and
depersonalization/depersonalization disorder?
Module Recap
In this module, we discussed the dissociative disorders of Dissociative Identity Disorder,
Dissociative Amnesia, and Depersonalization/Derealization Disorder in terms of their clinical
presentation, epidemiology, comorbidity, etiology, and treatment approaches.
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Disorders Covered:
7. Anxiety Disorders
8. Somatic Symptom and Related Disorders
9. Obsessive-Compulsive and Related Disorders

Module 7:
Anxiety Disorders
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Module 7: Anxiety Disorders
Module Overview
In Module 7, we will discuss matters related to anxiety disorders to include their clinical
include Generalized Anxiety Disorder, Specific Phobias, Agoraphobia, Social Anxiety Disorder,
and Panic Disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an
overview of the various models to explain psychopathology (Module 2), and descriptions of the
various therapies (Module 3).
Module Outline
• 7.4. Etiology
• 7.5. Treatment
• Describe how anxiety disorders present.
• Describe the epidemiology of anxiety disorders.
• Describe comorbidity in relation to anxiety disorders.
• Describe the etiology of anxiety disorders.
• Describe treatment options for anxiety disorders.

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• Describe how Generalized Anxiety Disorder presents.
• Describe how Specific Phobias present.
• Describe how Agoraphobia presents.
• Describe how Social Anxiety Disorder presents.
• Describe how Panic Disorder presents.
The hallmark symptoms of anxiety-related disorders are excessive fear or worry related
to behavioral disturbances. Fear is an adaptive response, as it often prepares your body for an
impending threat. Anxiety, however, is more difficult to identify as it is often the response to a
vague sense of threat. The two can be distinguished from one another as fear is related to either a
real or a perceived threat, while anxiety is the anticipation of a future threat (APA, 2013).
As you will see throughout the chapter, individuals may experience anxiety in many
different forms. Generalized anxiety disorder, the most common of the anxiety disorders, is
characterized by a global and persistent feeling of anxiety. A specific phobia is observed when
an individual experiences anxiety related to a specific object or subject. Similarly, an individual
may experience agoraphobia when they feel fear specific to leaving their home and traveling to
public places. Social anxiety disorder occurs when an individual experiences anxiety related to
social or performance situations, where there is the possibility of being evaluated negatively.
And finally, there is panic disorder, where an individual experiences recurrent panic attacks
consisting of physical and cognitive symptoms.

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7.1.1. Generalized Anxiety Disorder (GAD)
Generalized anxiety disorder, commonly referred to as GAD, is a disorder
characterized by an underlying excessive worry related to a wide range of events or activities.
While many individuals experience some levels of worry throughout the day, individuals with
GAD experience worry of greater intensity and for longer periods than the average person (APA,
2013). Additionally, they are often unable to control their worry through various coping
strategies, which directly interferes with their ability to engage in daily social and occupational
tasks. Individuals with GAD will also experience somatic symptoms during intensive periods of
anxiety. These somatic symptoms may include sweating, dizziness, shortness of breath,
insomnia, restlessness, or muscle aches (Gelenberg, 2000).
7.1.2. Specific Phobia
Specific phobia is distinguished by fear or anxiety specific to an object or a situation.
While the amount of fear or anxiety related to the specific object or situation varies among
individuals, it also varies related to the proximity of the object/situation. When individuals are
face-to-face with their specific phobia, immediate fear is present. It should also be noted that
these fears are excessive and irrational, often severely impacting one’s daily functioning (APA,
2013).
Individuals can experience multiple specific phobias at the same time. In fact, nearly 75%
of individuals with a specific phobia report fear of more than one object (APA, 2013). When
making a diagnosis of specific phobia, it is important to identify the stimulus. Among the most
commonly diagnosed specific phobias are animals, natural environments (height, storms, water),
blood-injection-injury (needles, invasive medical procedures), or situational (airplanes, elevators,
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enclosed places; APA, 2013). Given the high percentage of individuals who experience more
than one specific phobia, all specific phobias should be listed as a diagnosis to identify an
appropriate treatment plan.
7.1.3. Agoraphobia
Similar to GAD, agoraphobia is defined as an intense fear triggered by a wide range of
situations; however, unlike GAD, the fears are related to situations in which the individual is in
public situations where escape may be difficult. In order to receive a diagnosis of agoraphobia,
there must be a presence of fear in at least two of the following circumstances: using public
transportation such as planes, trains, ships, buses; being in large, open spaces such as parking
lots or on bridges; being in enclosed spaces like stores or movie theaters; being in a large crowd
similar to those at a concert; or being outside of the home in general (APA, 2013). When an
individual is in one (or more) of these situations, they experience significant fear, often reporting
panic-like symptoms (see Panic Disorder). It should be noted that fear and anxiety-related
symptoms are present every time the individual encounters these situations. If symptoms only
occur occasionally, a diagnosis of agoraphobia is not warranted.
Due to the intense fear and somatic symptoms, individuals will go to great lengths to
avoid these situations, often preferring to remain within their home where they feel safe, thus
causing significant impairment in one’s daily functioning. They may also engage in active
avoidance, where the individual will intentionally avoid agoraphobic situations. These avoidance
strategies may be behavioral, including having food delivery to avoid going to grocery store or
only taking a job that does not require the use of public transportation, or cognitive, by using
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distraction and various other cognitive techniques to get through the agoraphobic situation
successfully.
7.1.4. Social Anxiety Disorder
For social anxiety disorder, the anxiety or fear relates to social situations, particularly
those in which an individual can be evaluated by others. More specifically, the individual is
worried that they will be judged negatively and viewed as stupid, anxious, crazy, boring, or
unlikeable, to name a few. Some individuals report feeling concerned that their anxiety
symptoms will be obvious to others via blushing, stuttering, sweating, trembling, etc. These fears
severely limit an individual’s behavior in social settings.
To explain social anxiety in greater detail, let’s review the story of Mary. Mary reported
the onset of her social anxiety disorder in early elementary school when teachers would call on
students to read parts of their textbook aloud. Mary stated that she was fearful of making
mistakes while reading and to alleviate this anxiety, she would read several sections ahead of the
class to prepare for her turn to read aloud. Despite her preparedness, one day in 5th grade, Mary
was called to read and she stumbled on a few words. While none of her classmates realized her
mistake, Mary was extremely embarrassed and reported higher levels of anxiety during future
read aloud moments in school. In fact, when she was called upon, Mary stated she would
completely freeze up and not talk at all. After a few moments of not speaking, her teacher would
skip Mary and ask another student to read her section. It took several years and a very supportive
teacher for Mary to begin reading aloud in class again.
Similar to Mary, individuals with social anxiety disorder report that all or nearly all social
situations provoke this intense fear. Some individuals even report significant anticipatory fear
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days or weeks before a social event is to occur. This anticipatory fear often leads to avoidance of
social events in some individuals; others will attend social events with a marked fear of possible
threats. Because of these fears, there is a significant impact on one’s social and occupational
functioning.
It is important to note that the cognitive interpretation of these social events is often
excessive and out of proportion to the actual risk of being negatively evaluated. As we saw in
Mary’s case, when she stumbled upon her words while reading to the class, none of her peers
even noticed her mistake. Situations in which individuals experience anxiety toward a real threat,
such as bullying or ostracizing, would not be diagnosed with social anxiety disorder as the
negative evaluation and threat are real.
7.1.5. Panic Disorder
Panic disorder consists of a series of recurrent, unexpected panic attacks coupled with
the fear of future panic attacks. A panic attack is defined as a sudden or abrupt surge of fear or
impending doom along with at least four physical or cognitive symptoms. Physical symptoms
include heart palpitations, sweating, trembling or shaking, shortness of breath, feeling as though
they are being choked, chest pain, nausea, dizziness, chills or heat sensations, and
numbness/tingling. Cognitive symptoms may consist of feelings of derealization (feelings of
unreality) or depersonalization (feelings of being detached from oneself), the fear of losing
control or ‘going crazy,’ or the fear of dying (APA, 2013). While symptoms generally peak
within a few minutes, it seems much longer for the individual experiencing the panic attack.
There are two key components to panic disorder—the attacks are unexpected, meaning
there is nothing that triggers them, and they are recurrent, meaning they occur multiple times.
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Because these panic attacks occur frequently and are primarily “out of the blue,” they cause
significant worry or anxiety in the individual as they are unsure of when the next attack will
happen. In some individuals, significant behavioral changes such as fear of leaving their home or
attending large events occur as the individual is fearful an attack will happen in one of these
situations, causing embarrassment. Additionally, individuals report worry that others will think
they are “going crazy” or losing control if they were to observe an individual experiencing a
panic attack. Occasionally, an additional diagnosis of agoraphobia is given to an individual with
panic disorder if their behaviors meet diagnostic criteria for this disorder as well (see more
below).
The frequency and intensity of these panic attacks vary widely among individuals. Some
people report panic attacks occurring once a week for months on end, others report more
frequent attacks multiple times a day, but then experience weeks or months without any attacks.
The intensity of symptoms also varies among individuals, with some patients experiencing
nearly all symptoms and others reporting only 4, the minimum required for the diagnosis.
Furthermore, individuals report variability within their panic attack symptoms, with some panic
attacks presenting with more symptoms than others. At this time, there is no identifying
information (i.e., demographic information) to suggest why some individuals experience panic
attacks more frequently or more severe than others (APA, 2013).
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• All anxiety disorders share the hallmark symptoms of excessive
fear or worry related to behavioral disturbances.
• GAD is characterized by an underlying excessive worry related to
a wide range of events or activities and an inability to control their
worry through coping strategies.
• Specific phobia is characterized by fear or anxiety specific to an
object or a situation and individuals can experience fear of more
than one object.
• Agoraphobia is characterized by intense fear related to situations
in which the individual is in public situations where escape may
be difficult.
• Social anxiety disorder is characterized by fear or anxiety related
to social situations, especially when evaluation by others is
possible.
• Panic disorder is characterized by a series of recurrent, unexpected
panic attacks coupled with the fear of future panic attacks.
1. What is the difference between fear and anxiety?

2. What are the key differences between generalized anxiety disorder and
agoraphobia?
3. Individuals with social anxiety disorder will experience both physical and
cognitive symptoms, particularly when presented with social interactions.
What are these symptoms?
4. What are the common types of specific phobias?
5. What are the physical and cognitive symptoms observed during panic
disorder?
6. What are the key components of panic disorder?
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7.2. Epidemiology
• Describe the epidemiology of Generalized Anxiety Disorder.
• Describe the epidemiology of Specific Phobias.
• Describe the epidemiology of Agoraphobia.
• Describe the epidemiology of Social Anxiety Disorder.
• Describe the epidemiology of Panic Disorder.
7.2.1. Generalized anxiety disorder
The prevalence rate for generalized anxiety disorder is estimated to be 3% of the general
population, with nearly 6% of individuals experiencing GAD sometime during their lives. While
it can present at any age, it generally appears first in childhood or adolescence. Similar to most
anxiety-related disorders, females are twice as likely to be diagnosed with GAD as males (APA,
2013).
7.2.2. Specific phobia
The prevalence rate for specific phobias is 7-9% within the United States. While young
children have a prevalence rate of approximately 5%, teens have nearly a double prevalence rate
than that of the general public at 16%. There is a 2:1 ratio of females to males diagnosed with
specific phobia; however, this rate changes depending on the different phobic stimuli. More
specifically, animal, natural environment, and situational specific phobias are more commonly
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diagnosed in females, whereas blood-injection-injury phobia is reportedly diagnosed equally
between genders.
7.2.3. Agoraphobia
The yearly prevalence rate for agoraphobia across the lifespan is roughly 1.7%. Females
are twice as likely as males to be diagnosed with agoraphobia (notice the trend…). While it can
occur in childhood, agoraphobia typically does not develop until late adolescence/early
adulthood and usually tapers off in later adulthood.
7.2.4. Social anxiety disorder
The overall prevalence rate of social anxiety disorder is significantly higher in the United
States than in other countries, with an estimated 7% of the US population diagnosed with a social
anxiety disorder. Within the US, the prevalence rate remains the same among children through
adults; however, there appears to a significant decrease in the diagnosis of social anxiety disorder
among older individuals. Regarding gender, there is a higher diagnosis rate in females than
males. This gender discrepancy appears to be greater among children and adolescents than
adults.
7.2.5. Panic disorder
Prevalence rates for panic disorder are estimated at around 2-3% in adults and
adolescents. Higher rates of panic disorder are found in American Indians and non-Latino
whites. Females are more commonly diagnosed than males with a 2:1 diagnosis rate—this
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gender discrepancy is seen throughout the lifespan. Although panic disorder can occur in young
children, it is generally not observed in individuals younger than 14 years of age.

• Prevalence rates for anxiety disorders range from 1.7% for agoraphobia up to 9%
for specific phobias.
• For most anxiety disorders, females are twice as likely to be diagnosed.
1. Create a table of the prevalence rates across the various anxiety related disorders.
What are the differences between the disorders? Which prevalence rates are
higher in children? Adolescents? Women?
2. What are the gender differences observed in the phobia stimuli?
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7.3. Comorbidity
• Describe the comorbidity of Generalized Anxiety Disorder.
• Describe the comorbidity of Specific Phobias.
• Describe the comorbidity of Agoraphobia.
• Describe the comorbidity of Social Anxiety Disorder.
• Describe the comorbidity of Panic Disorder.
7.3.1. Generalized anxiety disorder
There is a high comorbidity between generalized anxiety disorder and the other anxiety-
related disorders, as well as major depressive disorder, suggesting they all share common
vulnerabilities, both biological and psychological.
7.3.2. Specific phobia
Seeing as the onset of specific phobias occurs at a younger age than most other anxiety
disorders, it is generally the primary diagnosis with the occasional generalized anxiety disorder
comorbid diagnosis. Children and teens diagnosed with a specific phobia are at an increased risk
for additional psychopathology later in life. More specifically, other anxiety disorders,
depressive disorders, substance-related disorders, and somatic symptom disorders.
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7.3.3. Agoraphobia
Similar to the other anxiety disorders, comorbid diagnoses include additional anxiety
disorders, depressive disorders, and substance use disorders, all of which typically occurs after
the onset of agoraphobia (APA, 2013). Also, there is high comorbidity between agoraphobia and
PTSD. While agoraphobia can be a symptom of PTSD, an additional diagnosis of agoraphobia is
made when all symptoms of agoraphobia are met in addition to the PTSD symptoms.
7.3.4. Social anxiety disorder
Among the most common comorbid diagnoses with a social anxiety disorder are other
anxiety-related disorders, major depressive disorder, and substance-related disorders. Generally
speaking, social anxiety disorders will precede that of other mental health disorders, except for
separation anxiety disorder and specific phobia, seeing as these two disorders are more
commonly diagnosed in childhood (APA, 2013). The high comorbidity rate among anxiety-
related disorders and substance-related disorders is likely connected to the efforts of self-
medicating. For example, an individual with social anxiety disorder may consume more alcohol
in social settings in efforts to alleviate the anxiety of the social situation.
7.3.5. Panic disorder
Panic disorder rarely occurs in isolation, as many individuals also report symptoms of
other anxiety disorders, major depression, and substance abuse. There is mixed evidence as to
whether panic disorder precedes other comorbid psychological disorders—estimates suggest that
1/3 of individuals with panic disorder will experience depressive symptoms prior to panic
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symptoms, whereas the remaining 2/3 will experience depressive symptoms concurrently or after
the onset of panic disorder (APA, 2013).
Unlike some of the other anxiety disorders, there is a high comorbid diagnosis with
general medical symptoms. More specifically, individuals with panic disorder are more likely to
report somatic symptoms such as dizziness, cardiac arrhythmias, asthma, irritable bowel
syndrome, and hyperthyroidism (APA, 2013). The relationship between panic symptoms and
somatic symptoms is unclear; however, there does not appear to be a direct medical cause
between the two.

• Many anxiety disorders are comorbid with one another.
• Other common comorbid disorders include depressive disorders and
substance-related disorders.
• Agoraphobia has a high comorbidity with PTSD and panic disorder with
general medical symptoms.
1. There is a high comorbidity rate within the anxiety-related disorders. What

other disorders commonly occur with specific anxiety related disorders?
2. What anxiety-related disorder has a high comorbidity with medical
symptoms?
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7.4. Etiology
• Describe the biological causes of anxiety disorders.
• Describe the psychological causes of anxiety disorders.
• Describe the sociocultural causes of anxiety disorders.
7.4.1. Biological
7.4.1.1. Biological - Genetic influences. While genetics have been known to contribute
to the presentation of anxiety symptoms, the interaction between genetics and stressful
environmental influences appears to account for more anxiety disorders than genetics alone
(Bienvenu, Davydow, & Kendler, 2011). The quest to identify specific genes that may
predispose individuals to develop anxiety disorders has led researchers to the serotonin
transporter gene (5-HTTLPR). Mutation of the 5-HTTLPR gene is related to a reduction in
serotonin activity and an increase in anxiety-related personality traits (Munafo, Brown, &
Hairiri, 2008).
7.4.1.2. Biological - Neurobiological structures. Researchers have identified several
brain structures and pathways that are likely responsible for anxiety responses. Among those
structures is the amygdala, the area of the brain that is responsible for storing memories related
to emotional events (Gorman, Kent, Sullivan, & Coplan, 2000). When presented with a fearful
situation, the amygdala initiates a reaction to ready the body for a response. First, the amygdala
triggers the hypothalamic-pituitary-adrenal (HPA) axis to prepare for immediate action— either
to fight or flight. The second pathway is activated by the feared stimulus itself, by sending a
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sensory signal to the hippocampus and prefrontal cortex, for determination if threat is real or
imagined. If it is determined that no threat is present, the amygdala sends a calming response to
the HPA axis, thus reducing the level of fear. If there is a threat present, the amygdala is
activated, producing a fear response.
Specific to panic disorder is the implication of the locus coeruleus, the brain structure
that serves as an “on-off” switch for norepinephrine neurotransmitters. It is believed that
increased activation of the locus coeruleus results in panic-like symptoms; therefore, individuals
with panic disorder may have a hyperactive locus coeruleus, leaving them more susceptible to
experience more intense and frequent physiological arousal than the general public (Gorman,
Kent, Sullivan, & Coplan, 2000). This theory is supported by studies in which individuals
experienced increased panic symptoms following the injection of norepinephrine (Bourin,
Malinge, & Guitton, 1995).
Unfortunately, norepinephrine and the locus coeruleus fail to fully explain the
development of panic disorder, as treatment would be much easier if only norepinephrine was
implicated. Therefore, researchers argue that a more complex neuropathway is likely responsible
for the development of panic disorder. More specifically, the corticostriatal-thalamocortical
(CSTC) circuit, also known as the fear-specific circuit, is theorized as a major contributor to
panic symptoms (Gutman, Gorman, & Hirsch, 2004). When an individual is presented with a
frightening object or situation, the amygdala is activated, sending a fear response to the anterior
cingulate cortex and the orbitofrontal cortex. Additional projection from the amygdala to the
hypothalamus activates endocrinologic responses to fear, releasing adrenaline and cortisol to
help prepare the body to fight or flight (Gutman, Gorman, & Hirsch, 2004). This complex
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pathway supports the theory that panic disorder is mediated by several neuroanatomical
structures and their associated neurotransmitters.
7.4.2. Psychological
7.4.2.1. Psychological - Cognitive. The cognitive perspective on the development of
anxiety related disorders centers around dysfunctional thought patterns. As seen in depression,
maladaptive assumptions are routinely observed in individuals with anxiety-related disorders,
as they often engage in interpreting events as dangerous or overreacting to potentially stressful
events, which contributes to an overall heightened anxiety level. These negative appraisals, in
combination with a biological predisposition to anxiety likely contribute to the development of
anxiety symptoms (Gallagher et al., 2013).
Sensitivity to physiological arousal not only contributes to anxiety disorders in general,
but also for panic disorder where individuals experience various physiological sensations and
misinterpret them as catastrophic. One explanation for this theory is that individuals with panic
disorder are more susceptible to more frequent and intensive physiological symptoms than the
general public (Nillni, Rohan, & Zvolensky, 2012). Others argue that these individuals have had
more trauma-related experiences in the past, and therefore, are quick to misevaluate their
symptoms as a potential threat. This misevaluation of symptoms as impending disaster likely
maintain symptoms as the cognitive misinterpretations to physiological arousal creates a
negative feedback loop, leading to more physiological changes.
Social anxiety is also primarily explained by cognitive theorists. Individuals with social
anxiety disorder tend to hold unattainable or extremely high social beliefs and expectations.
Furthermore, they often engage in preconceived maladaptive assumptions that they will behave
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incompetently in social situations and that their behaviors will lead to terrible consequences.
Because of these beliefs, they anticipate social disasters will occur and, therefore, avoid social
encounters (or limit them to close friends/family members) in efforts to prevent the disaster
(Moscovitch et al., 2013). Unfortunately, these cognitive appraisals are not only isolated to
before and during the event. Individuals with social anxiety disorder will also evaluate the social
event after it has taken place, often obsessively reviewing the details. This overestimation of
social performance negatively reinforces future avoidance of social situations.
7.4.2.2. Psychological – Behavioral. The behavioral explanation for the development of
anxiety disorders is mainly reserved for phobias—both specific and social phobia. More
precisely, behavioral theorists focus on classical conditioning - when two events that occur
close together become strongly associated with one another, despite their lack of causal
relationship. Watson and Rayner’s (1920) infamous Little Albert experiment is an example of
how classical conditioning can be used to induce fear through associations. In this study, Little
Albert developed a fear of white rats by pairing a white rate with a loud sound. This experiment,
although lacking ethical standards, was groundbreaking in the development of learned behaviors.
Over time, researchers have been able to replicate these findings (in more ethically sound ways)
to provide further evidence of the role of classical conditioning in the development of phobias.
7.4.2.3. Psychological – Modeling is another behavioral explanation of the development
of specific and social phobias. In modeling, an individual acquires a fear though observation and
imitation (Bandura & Rosenthal, 1966). For example, when a young child observes their parent
display irrational fears of an animal, the child may then begin to display similar behaviors.
Similarly, seeing another individual being ridiculed in a social setting may increase the chances
of developing social anxiety, as the individual may become fearful that they would experience a
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similar situation in the future. It is speculated that the maintenance of these phobias is due to the
avoidance of the feared item or social setting, thus preventing the individual from learning that
the object or situation is not something that should be feared.
While modeling and classical conditioning largely explain the development of phobias,
there is some speculation that the accumulation of a large number of these learned fears will
develop into GAD. Through stimulus generalization, or the tendency for the conditioned
stimulus to evoke similar responses to other conditions, a fear of one item (such as the dog) may
become generalized to other items (such as all animals). As these fears begin to grow, a more
generalized anxiety will present, as opposed to a specific phobia.
Seeing how prominent the biological and psychological constructs are in explaining the
development of anxiety-related disorders, we also need to review the social constructs that
contribute and maintain anxiety disorders. While characteristics such as living in poverty,
experiencing significant daily stressors, and increased exposure to traumatic events are all
identified as significant contributors to anxiety disorders, additional sociocultural influences such
as gender and discrimination have also received considerable attention, mainly due to the
epidemiological nature of the disorder.
Gender has largely been researched within anxiety disorders due to the consistent
discrepancy in the diagnosis rate between men and women. As previously discussed, women are
routinely diagnosed with anxiety disorders more often than men, a trend that is observed
throughout the entire lifespan. One potential explanation for this discrepancy is the influence of
social pressures on women. Women are more susceptible to experience traumatic experiences
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throughout their life, which may contribute to anxious appraisals of future events. Furthermore,
women are more likely to use emotion-focused coping, which is less effective in reducing
distress than problem-focused coping (McLean & Anderson, 2009). These factors may increase
levels of stress hormones within women that leave them susceptible to develop symptoms of
anxiety. Therefore, it appears a combination of genetic, environmental, and social factors may
explain why women tend to be diagnosed more often with anxiety-related disorders.
Exposure to discrimination and prejudice, particularly relevant to ethnic minorities and
other marginalized groups, can also impact an individual’s anxiety level. Discrimination and
prejudice contribute to negative interactions, which is directly related to negative affect and an
overall decline in mental health (Gibbons et al., 2014). The repeated exposure to discrimination
and prejudice over time can lead to fear responses in individuals, along with subsequent
avoidance of social situations in efforts to protect themselves emotionally.
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• Biological causes of anxiety disorders include the serotonin transporter gene
(5-HTTLPR); brain structures to include the amygdala, hippocampus, and
prefrontal cortex; and the locus coeruleus and corticostriatal-thalamocortical
(CSTC) circuit in relation to panic disorder.
• Psychological causes of anxiety disorders include maladaptive assumptions,
the linking of events through classical conditioning, modeling, and stimulus
generalization as it relates to GAD.
• Sociocultural causes of anxiety disorders include social pressures leading to
a higher rate of diagnosis for women and discrimination and prejudice
which affects ethnic minorities and other marginalized groups.
3. Discuss the biological etiology of panic disorders. What brain structures and
neurotransmitters are involved?
4. How does the cognitive model explain the development and maintenance of
anxiety related disorders?
5. What is the difference between emotion-focused and problem-focused
coping strategies? How do these two coping strategies explain differences in
anxiety related disorders?
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7.5. Treatment
• Describe treatment options for Generalized Anxiety Disorder.
• Describe treatment options for Specific Phobias.
• Describe treatment options for Agoraphobia.
• Describe treatment options for Social Anxiety Disorder.
• Describe treatment options for Panic Disorder.
7.5.1. Generalized Anxiety Disorder
7.5.1.1. Psychopharmacology. Benzodiazepines, a class of sedative-hypnotic drugs that
will be discussed in more detail in the Substance Abuse module, originally replaced barbiturates
as the leading anti-anxiety medication due to their less addictive nature, yet equally effective
ability to calm individuals at low dosages. Unfortunately, as more research was done on
benzodiazepines, serious side effects, as well as physical dependence of benzodiazepines at large
dosages, has routinely been documented (NIMH, 2013). Due to these negative effects, selective
serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)
are generally considered to be first-line medication options for those with GAD. Findings
indicate a 30-50% positive response rate to these psychopharmacological interventions (Reinhold
& Rickels, 2015). Unfortunately, none of these medications continue to provide any benefit once
they are stopped; therefore, other effective treatment options such as CBT, relaxation training,
and biofeedback are often encouraged before the use of pharmacological interventions.
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7.5.1.2. Rational-Emotive therapy. Albert Ellis developed rational emotive therapy in
the mid-1950s as one of the first forms of cognitive-behavioral therapy. Ellis proposed that
individuals were not aware of the effect their negative thoughts had on their behaviors and
various relationships, and thus, established a treatment to address these thoughts and provide
relief to those suffering from anxiety and depression. The goal of rational emotive therapy is to
identify irrational, self-defeating assumptions, challenge the rationality of those assumptions, and
to replace them with new, more productive thoughts and feelings. By identifying and replacing
these assumptions, one will experience relief of GAD symptoms (Ellis, 2014).
7.5.1.3. Cognitive Behavioral Therapy (CBT). CBT is discussed in great detail in the
Mood Disorder Module; however, it is also among the most effective treatment options for a
variety of anxiety disorders, including GAD. Findings suggest 60 percent of individuals report a
significant reduction/elimination in anxious thoughts one-year post treatment (Hanrahan, Field,
Jones, & Davy, 2013). The fundamental goal of CBT is a combination of cognitive and
behavioral strategies aimed to identify and restructure maladaptive thoughts while also providing
opportunities to utilize these more effective thought patterns through exposure-based
experiences. Through repetition, the individual will be able to identify and replace anxious
thoughts outside of therapy sessions, ultimately reducing their overall anxiety levels (Borkovec,
& Ruscio, 2001).
7.5.1.4. Biofeedback. Biofeedback provides a visual representation of a patient’s
physiological arousal. To achieve this feedback, a patient is connected to a computer that
provides continuous information on their physiological states. There are several ways a patient
can connect to the computer. Among the most common is electromyography (EMG). EMG
measures the amount of muscle activity currently experienced by the individual. An electrode is
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placed on a patient’s skin just above a major muscle group, usually the forearm or the forehead.
Other common areas of measurement are electroencephalography (EEG), which measures the
neurofeedback or brain activity; heart rate variability (HRV), which measures autonomic
activity such as heart rate or blood pressure; and galvanic skin response (GSR) which measures
sweat.
Once the patient is connected to the biofeedback machine, the clinician can walk the
patient through a series of relaxation scripts or techniques as the computer simultaneously
measures the changes in muscle tension. The theory behind biofeedback is that in providing a
patient with a visual representation of changes in their physiological state, they become more
skilled at voluntarily reducing their physiological arousal, and thus, their overall sense of anxiety
or stress. While research has identified only a modest effect of biofeedback on anxiety levels,
patients do report a positive experience with the treatment due to the visual feedback of their
physiological arousal (Brambrink, 2004).
7.5.2. Specific Phobias
7.5.2.1. Exposure treatments. While there are many treatment options for specific
phobias, research routinely supports the behavioral techniques as the most effective treatment
strategies. Seeing as the behavioral theory suggests phobias develop via classical conditioning,
the treatment approach revolves around breaking the maladaptive association between the object
and fear. This is generally accomplished through exposure treatments. As the name implies, the
individual is exposed to their feared stimuli. This can be done in several different approaches:
systematic desensitization, flooding, and modeling.
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Systematic desensitization is an exposure technique that utilizes relaxation strategies to
help calm the individual as they are presented with the fearful object. The notion behind this
technique is that both fear and relaxation cannot exist at the same time; therefore, the individual
learns how to replace their fearful reaction with a calm, relaxing reaction.
To begin, the patient, with assistance from the clinician, will identify a fear hierarchy, or
a list of feared objects/situations ordered from least fearful to most fearful. After teaching several
different types of relaxation techniques, the clinician will present items from the fear hierarchy,
starting from the least fearful object/subject, while the patient practices using the learned
relaxation techniques. The presentation of the feared object/situation can be in person—in vivo
exposure—or it can be imagined—imaginal exposure. Imaginal exposure tends to be less
intensive than in vivo exposure; however, it is less effective than in vivo exposure in eliminating
the phobia. Depending on the phobia, in vivo exposure may not be an option, such as with a fear
of a tornado. Once the patient can effectively employ relaxation techniques to reduce their
anxiety to a manageable level, the clinician will slowly move up the fear hierarchy until the
individual does not experience excessive fear of all objects on the list.
Flooding is another exposure technique in which the clinician does not utilize a fear
hierarchy, but rather repeatedly exposes the individual to their most feared object or situation.
Similar to systematic desensitization, flooding can be done in either in vivo or imaginal
exposure. Clearly, this technique is more intensive than systematic or gradual exposure to feared
objects. Because of this, patients are at a greater likelihood of dropping out of treatment, thus not
successfully overcoming their phobias.
Modeling is another common technique used to treat phobia disorders (Kelly, Barker,
Field, Wilson, & Reynolds, 2010). In this technique, the clinician approaches the feared
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object/subject while the patient observes. As the name implies, the clinician models appropriate
behaviors when exposed to the feared stimulus, showing that the phobia is irrational. After
modeling several times, the clinician encourages the patient to confront the feared stimulus with
the clinician, and then ultimately, without the clinician.
7.5.3. Agoraphobia
Similar to the treatment approaches for specific phobias, exposure-based techniques are
among the most effective treatment options for individuals with agoraphobia. However, unlike
the high success rate in specific phobias, exposure treatment for agoraphobia has been less
effective in providing complete relief of the disorder. The success rate may be impacted by the
high comorbidity rate of agoraphobia and panic disorder. Because of the additional presentation
of panic symptoms, exposure treatments alone are not the most effective in eliminating
symptoms as residual panic symptoms often remain (Craske & Barlow, 2014). Therefore, the
best treatment approach for those with agoraphobia and panic disorder is a combination of
exposure and CBT techniques (see Panic disorder treatment).
For individuals with agoraphobia without panic symptoms, the use of group therapy in
combination with individual exposure therapy has been identified as a successful treatment
option. The group therapy format allows the individual to engage in exposure-based field trips to
various community locations, while also maintaining a sense of support and security from a
group of individuals whom they know. Research indicates that this type of treatment provides
improvement form nearly 60 to 80 percent of patients with agoraphobia; however, there is a
relatively high rate of partial relapse, suggesting that long-term treatment or booster sessions
should continue for several years at minimum (Craske & Barlow, 2014).
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7.5.4. Social Anxiety Disorder
7.5.4.1. Exposure. A hallmark treatment approach for all anxiety disorders is exposure.
Specific to social anxiety disorder, the individual is encouraged to engage in social situations
where they are likely to experience increased anxiety. Initially, the clinician will role-play
various social situations with the patient so that the patient can practice social interactions in a
safe, controlled environment (Rodebaugh, Holaway, & Heimberg, 2004). As the patient becomes
habituated to the interaction with the clinician, the clinician and patient may venture outside of
the treatment room and engage in social settings with random strangers at various locations such
as fast-food restaurants, local stores, libraries, etc. The patient is encouraged to continue with
these exposures outside of treatment to help reduce anxiety related to social situations.
7.5.4.2. Social skills training. This treatment is specific to social anxiety disorder as it
focuses on the patient’s skill deficits or inadequate social interactions that contribute to their
negative social experiences and anxiety. During a session, the clinician may use a combination of
skills such as modeling, corrective feedback, and positive reinforcement to provide feedback and
encouragement to the patient regarding their behavioral interactions (Rodebaugh, Holaway, &
Heimberg, 2004). By incorporating the clinician’s feedback into their social repertoire, the
patient can engage in positive social behaviors outside of the treatment room and improve their
overall social interactions while reducing ongoing social anxiety.
7.5.4.3. Cognitive restructuring. While exposure and social skills training are suitable
treatment options, research routinely supports the need to incorporate cognitive restructuring as
an additive component in treatment to provide substantial symptom reduction. Similar to
cognitive restructuring previously discussed in the Mood Disorder module, the clinician will
work with the therapist to identify negative, automatic thoughts that contribute to the distress in
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social situations. The clinician can then help the patient establish new, positive thoughts to
replace these negative thoughts. Research indicates that implementing cognitive restructuring
techniques before, during, and after exposure sessions enhances the overall effects of treatment
of social anxiety disorder (Heimberg & Becker, 2002).
7.5.5. Panic Disorder
7.5.5.1. Cognitive Behavioral Therapy (CBT). CBT is the most effective treatment
option for individuals with panic disorder as the focus is on correcting misinterpretations of
bodily sensations (Craske & Barlow, 2014). Nearly 80 percent of people with panic disorder
report complete remission of symptoms after mastering the following five components of CBT
for panic disorder (Craske & Barlow, 2014).
7.5.5.2. Psychoeducation. Treatment begins by educating the patient on the nature of
panic disorder, the underlying causes of panic disorder, as well as the mechanisms that maintain
the disorder such as the physical, cognitive, and behavioral response systems (Craske & Barlow,
2014). This part of treatment is fundamental in correcting any myths or misconceptions about
panic symptoms, as they often contribute to the exacerbation of panic symptoms.
7.5.5.3. Self-monitoring. Self-monitoring, or the awareness of self-observation, is
essential to the CBT treatment process for panic disorder. In this part of treatment, the individual
is taught to identify the physiological cues immediately leading up to and during a panic attack.
Then, the patient is encouraged to recognize and document the thoughts and behaviors associated
with these physiological symptoms. By bringing awareness to the symptoms, as well as the
relationship between physical arousal and cognitive-behavioral responses, the patient learns the
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fundamental processes with which they can manage their panic symptoms (Craske & Barlow,
2014).
7.5.5.4. Relaxation training. Similar to that in exposure-based treatment for phobias,
prior to engaging in exposure training, the individual must learn relaxation techniques to apply
during onset of panic attacks. While breathing training was once included as the relaxation
training technique of choice for panic disorder due to the high report of hyperventilation during
panic attacks, more recent research has failed to support this technique as effective in the use of
panic disorder (Schmidt et al., 2000). Findings suggest that breathing retraining is more
commonly misused as a safety behavior or means for avoiding physical symptoms as opposed to
an effective physiological response to stress (Craske & Barlow, 2014).
7.5.5.5. Progressive muscle relaxation. To replace the breathing retraining, Craske &
Barlow (2014) suggest progressive muscle relaxation (PMR). In PMR, the patient learns to
tense and relax various large muscle groups throughout the body. Generally speaking, the patient
is encouraged to start at either the head or the feet, and gradually work their way through the
entire body, holding the tension for roughly 10 seconds before relaxing. The theory behind PMR
is that in tensing the muscles for a prolonged period, the individual exhausts those muscles,
forcing them (and eventually) the entire body to engage in relaxation (McCallie, Blum, & Hood,
2006).
7.5.5.6. Cognitive restructuring. Cognitive restructuring, or the ability to recognize
cognitive errors and replace them with alternate, more appropriate thoughts, is likely the most
powerful part of CBT treatment for panic disorder, aside from the exposure part. Similar to the
discussion in the Mood Disorder module, cognitive restructuring involves identifying the role of
thoughts in generating and maintaining emotions. The clinician encourages the patient to view
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these thoughts as “hypotheses” as opposed to fact, which allows the beliefs to be questioned and
challenged. This is where the detailed recordings in the self-monitoring section of treatment are
helpful. By discussing what the patient has recorded for the relationship between physiological
arousal and thoughts/behaviors, the clinician can help the patient restructure the maladaptive
thought processes to more positive thought processes, which in return, helps to reduce fear and
anxiety.
7.5.5.7. Exposure. As discussed in detail in the specific phobia section, the patient is next
encouraged to engage in a variety of exposure techniques such as in vivo exposure and
interoceptive exposure, while also incorporating the cognitive restructuring and relaxation
techniques previously learned to reduce and eliminate ongoing distress. Interoceptive exposure
involves inducing panic-specific symptoms to the individual repeatedly for a prolonged period,
so that maladaptive thoughts about the sensations can be disconfirmed and conditional anxiety
responses are extinguished (Craske & Barlow, 2014). Some examples of these exposure
techniques include spinning a patient repeatedly in a chair to induce dizziness and breathing in a
paper bag to cause hyperventilation. These treatment approaches can be presented gradually;
however, the patient must endure the physiological sensations for at least 30 seconds to 1 minute
to ensure adequate time for applying cognitive strategies to misappraisal of cognitive symptoms
(Craske & Barlow, 2014).
Interoceptive exposure is continued both in and outside of treatment until panic
symptoms remit. Over time, the habituation of fear within an exposure session ultimately leads to
habituation across treatment and long-term remission of panic symptoms (Foa & McNally,
1996). Occasionally, panic symptoms will return in individuals who report complete remission
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of panic disorder. Follow-up booster sessions reviewing the steps above are generally effective in
eliminating symptoms again.
7.5.5.8. Pharmacological interventions. According to Craske & Barlow (2014), nearly
half of patients with panic disorder present to psychotherapy already on medication, likely
prescribed by their primary care physician. Some researchers argue that anti-anxiety medications
impede the progress of CBT treatment as the individual is not able to fully experience the
physiological sensations during exposure sessions, thus limiting their ability to modify
maladaptive thoughts and maintaining the panic symptoms. Results from large clinical trials
suggest no advantage during or immediately after treatment of combining CBT and medication
(Craske & Barlow, 2014). Additionally, when the medication was discontinued post-treatment,
the CBT+ medication groups fared worse than the CBT treatment-only groups, thus supporting
the theory that immersion in interoceptive exposure is limited due to the use of medication.
Therefore, it is suggested that medications be reserved for those who do not respond to CBT
therapy alone (Kampman, Keijers, Hoogduin & Hendriks, 2002).
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• Treatment options for GAD include benzodiazepines, rational-emotive
therapy, CBT, and biofeedback.
• Treatment options for specific phobias include exposure treatments such as
systematic desensitization, flooding, and modeling.
• Treatment options for agoraphobia include exposure and CBT techniques.
• Treatment options for social anxiety disorder include exposure treatment,
social skills training, and cognitive restructuring.
• Treatment options for panic disorder include CBT, psychoeducation, self-
monitoring, relaxation training, cognitive restructuring, exposure, and
pharmacological interventions.
6. Discuss the types of exposure treatments for individuals with anxiety

disorders? Which are most effective? What have been some concerns with
exposure treatment?
7. What is biofeedback? How is biofeedback used to treat anxiety related
disorders?
8. What are the concerns with using pharmacological interventions in the
treatment of anxiety disorders? Is there a time when it is helpful to use this
treatment method?
Module Recap
Module 7, the first module of Unit 3, covered the topic of anxiety disorders. This
discussion included Generalized Anxiety Disorder, Specific Phobias, Agoraphobia, Social
Anxiety Disorder, and Panic Disorder. As with other modules in this book, we discussed the
clinical presentation, epidemiology, comorbidity, and etiology of the anxiety disorders.
Treatment options included biological, psychological, and sociocultural options. In Module 8, we
will discuss somatic symptom and related disorders.
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Module 8:
Somatic Symptom and Related Disorders
8-1
Module 8: Somatic Symptom and Related Disorders
Module Overview
In Module 8, we will discuss matters related to somatic symptom disorders to include the
clinical presentation, epidemiology, comorbidity, etiology, and treatment options for Somatic
Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, and Factitious Disorder. We
also will discuss psychological factors affecting other medication conditions in relation to their
clinical presentation, diagnostic criteria, common types of psychophysiological disorders, and
treatment. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview
of the various models to explain psychopathology (Module 2), and descriptions of therapies
(Module 3).
Module Outline
• 8.4. Etiology
• 8.5. Treatment
• 8.6. Psychological Factors Affecting Other Medical Conditions
• Describe how somatic symptom disorders present.
• Describe the epidemiology of somatic symptom disorders.
8-2
• Describe comorbidity in relation to somatic symptom disorders.
• Describe the etiology of somatic symptom disorders.
• Describe treatment options for somatic symptom disorders.
• Describe psychological factors affecting other medical conditions in terms of their
clinical presentation, diagnostic criteria, common types of psychophysiological
disorders, and treatment.
• Describe how Somatic Symptom Disorder presents.
• Describe how Illness Anxiety Disorder presents.
• Describe how Conversion Disorder presents.
• Describe how Factitious Disorder presents.
Psychological disorders that feature somatic symptoms are often challenging to diagnose
due to the internalizing nature of the disorder, meaning there is no real way for a clinician to
measure the somatic symptom. Furthermore, the somatic symptoms could take on many forms.
For example, the individual may be faking the physical symptoms, imagining the symptoms,
exaggerating the symptoms, or they could be real and triggered by external factors such as stress
or other psychological disorders. The symptoms also may be part of a real medical illness or
disorder, and therefore, the symptoms should be treated medicinally.
8-3
All of the disorders within this chapter share a common feature: there is a presence of
somatic symptoms associated with significant distress or impairment. Oftentimes, individuals
with a somatic disorder will present to their primary care physician with their physical
complaints. Occasionally, they will be referred to clinical psychologists after an extensive
medical evaluation concludes that a medical diagnosis cannot explain their current symptoms. As
you will read further, despite their similarities, there are key features among the various disorders
that distinguish them from one another.
8.1.1. Somatic Symptom Disorder
Individuals with somatic symptom disorder often present with multiple somatic
symptoms at one time. These symptoms are significant enough to impact their daily functioning,
such as preventing them from attending school, work, or family obligations. The symptoms can
be localized (i.e., in one spot) or diffused (i.e., entire body), and can be specific or nonspecific
(e.g., fatigue). Individuals with somatic symptom disorder often report excessive thoughts,
feelings, or behaviors surrounding their somatic symptoms (APA, 2013). For example,
individuals with somatic symptom disorder may spend an excessive amount of time or energy
evaluating their symptoms, as well as the potential seriousness of their symptoms. A lack of
medical explanation is not needed for a diagnosis of somatic symptom disorder, as it is assumed
that the individual’s suffering is authentic. Somatic symptom disorder is often diagnosed when
another medical condition is present, as these two diagnoses are not mutually exclusive.
Somatic symptom disorder patients generally present with significant worry about their
illness. Their interpretation of symptoms is often viewed as threatening, harmful, or troublesome
(APA, 2013). Because of their negative appraisals, they often fear that their medical status is
8-4
more serious than it typically is, and high levels of distress are often reported. Oftentimes these
patients will “shop” at different physician offices to confirm the seriousness of their symptoms.
8.1.2. Illness Anxiety Disorder
Illness anxiety disorder, previously known as hypochondriasis, involves an excessive
preoccupation with having or acquiring a serious medical illness. The key distinction between
illness anxiety disorder and somatic symptom disorder is that an individual with illness anxiety
disorder does not typically present with any somatic symptoms. Occasionally an individual will
present with a somatic symptom; however, the intensity of the symptom is mild and does not
drive the anxiety. Acquiring a serious illness drives concerns.
Individuals with illness anxiety disorder generally are cleared medically; however, some
individuals are diagnosed with a medical illness. In this case, their anxiety surrounding the
severity of their disorder is excessive or disproportionate to their actual medical diagnosis. While
an individual’s concern for an illness may be due to a physical sign or sensation, most
individual’s concerns are derived not from a physical complaint, but their actual anxiety related
to a suspected medical disorder. This excessive worry often expands to general anxiety regarding
one’s health and disease. Unfortunately, this anxiety does not appease even after reassurance
from a medical provider or negative test results, even when provided by multiple physicians and
diagnostic tests.
As one can imagine, the preoccupation and anxiety associated with attaining a medical
illness severely impacts daily functioning. The individual will often spend copious amounts of
time scanning and analyzing their body for “clues” of potential ailments. Additionally, an
excessive amount of time is often spent on internet searches related to symptoms and rare
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illnesses. Although extreme, some cases of invalidism have been reported due to illness anxiety
disorder (APA, 2013).
8.1.3. Conversion Disorder
Conversion disorder occurs when an individual presents with one or more symptoms of
voluntary motor or sensory function (APA, 2013). Common motor symptoms include weakness
or paralysis, abnormal movements (e.g., tremors), and gait abnormalities (i.e., limping).
Additionally, sensory symptoms such as altered, reduced, or absent skin sensations, and vision or
hearing impairment are also reported in many individuals. Less commonly seen are epileptic
seizures and episodes of unresponsiveness resembling fainting or coma (Marshall et al., 2013).
According to the DSM-5 (APA, 2013), symptoms of conversion disorder are described as
either functional or psychogenic. Functional symptoms would be those of abnormal central
nervous system functioning and are often assumed to be associated with a neurological disorder.
Psychogenic symptoms have no biological basis for the symptoms, and therefore, are
psychological in nature.
The most challenging aspect of conversion disorder is the complex relationship with a
medical evaluation. While a diagnosis of conversion disorder requires that the symptoms not be
explained by a neurological disease, just because a medical provider fails to provide evidence
that it is not a specific medical disorder is not sufficient. Therefore, there must be evidence of an
incompatibility of the medical disorder and the symptoms. For example, an individual
experiencing seizures would require a normal simultaneous electroencephalogram (EEG),
indicating that there is not epileptic activity during what was previously thought of as an
epileptic seizure.
8-6
8.1.4. Factitious Disorder
Factitious disorder, commonly referred to as Munchausen syndrome, differs from the
three previously discussed somatic disorders in that there is deliberate falsification of medical or
psychological symptoms of oneself or another, with the overall intention of deception. While a
medical condition may be present, the severity of impairment related to the medical condition is
more excessive due to the individual’s need to deceive those around them. Even more alarming
is that this disorder is not only observed in the individual leading the deception— it can also be
present in another individual, often a child or an individual with a compromised mental status
who is not aware of the deception behind their illness (also known as Munchausen by Proxy).
Some examples of factitious disorder behaviors include but are not limited to altering a
urine or blood test, falsifying medical records, ingesting a substance that would indicate
abnormal laboratory results, physically injuring oneself, and inducing illness by injecting or
ingesting a harmful substance (APA, 2013). While it is unclear why an individual would want to
fake their own (or someone else’s) physical illness, there is some evidence suggesting that
factors such as depression, lack of parental support during childhood, or an excessive need for
social support may contribute to this disorder (McDermott, Leamon, Feldman, & Scott, 2012;
Ozden & Canat, 1999; Feldman & Feldman, 1995).
8-7

• Somatic symptom disorder is characterized by the presence of multiple
somatic symptoms, whether localized or diffused and specific or
nonspecific, at one time which impact daily functioning.
• Illness anxiety disorder is characterized by concern over having or
acquiring a serious illness, and not the actual presence of somatic
symptoms. Individuals spend a great deal of time scanning and analyzing
their body for “clues” of potential ailments.
• Conversion disorder is characterized by one or more symptoms of
voluntary motor or sensory function, which are either functional or
psychogenic.
• Factitious disorder is characterized by deliberate falsification of medical or
psychological symptoms of oneself or another, with the overall intention
of deception.
1. What are some commonly shared features of somatic disorders?

2. Which somatic disorder usually accompanies a medical diagnosis?
3. What are the key distinctions between illness anxiety disorder and somatic
symptom disorder?
4. Define functional and psychogenic symptoms?
5. What are the key differences between factitious disorder and the other
somatic disorders?
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8.2. Epidemiology
• Describe the epidemiology of somatic disorders.
The prevalence rates for somatic disorders are often difficult to determine; however,
overall estimates of somatic symptom disorder are around 5-7% (APA, 2013). There is a trend
that females report more somatic symptoms than males; thus more females are diagnosed with
somatic symptom disorder than males (APA, 2013).
Seeing as illness anxiety disorder is a newer diagnosis (replacing hypochondriasis),
prevalence rates are largely based on the previous disorder. Previous findings suggest that illness
anxiety disorder occurs in 1-10% of the general population and is equal among males and
females.
Prevalence rates of factitious disorder could not be obtained; however, the illness is
incredibly rare. More recent research has indicated that nearly 8% of individuals admitted to a
psychiatric inpatient unit present with factitious symptoms (Catalina, Gomez, de Cos, 2008). It is
believed that these symptoms are likely related to physical symptoms felt in the past and are
therefore exaggerated, as opposed to deliberately feigning the symptoms.
8-9

• Though prevalence rates for somatic symptom disorders are hard to determine,
it is believed that between 1 and 10% of the population suffer from one of
these disorders.
• Females are more like to be diagnosed with somatic symptom disorder and are
as like as males to be diagnosed with illness anxiety disorder.
1. Create a table of the prevalence rates across the various somatic disorders.
What are the differences between the disorders? Which prevalence rates are
higher in children? Adolescents? Women?
8.3. Comorbidity
• Describe the comorbidity of somatic disorders.
Given that half of psychiatric patients also have an additional medical disorder, 35% have
an undiagnosed medical condition, and approximately 20% reported medical problems caused
their mental condition, it should not come as a surprise that somatic disorders, in general, have
high comorbidity with other psychological disorders (Felker, Yazel, & Short, 1996). More
specifically, anxiety and depression are among the most commonly co-diagnosed disorders for
somatic disorders. While there is not a lot of information regarding specific comorbidities among
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somatic related disorders, there is some evidence to suggest that those with illness anxiety
disorder are at risk of developing somatic symptom and personality disorders (APA, 2013).
Similarly, personality disorders are more common in individuals with conversion disorder than
the general public, with approximately two-thirds of individuals with illness anxiety disorder are
likely to have at least one other psychological disorder (APA, 2013).
There is also high comorbidity between somatic disorders and other physical disorders
classified as central sensitivity syndromes (CSSs), due to their common central sensitization
symptoms, yet medically unexplained symptoms (McGeary, Harzell, McGeary, & Gatchel,
2016). Disorders included in this group are fibromyalgia, irritable bowel syndrome, and chronic
fatigue syndrome. Comorbidity rates are estimated at 60% for these functional syndromes and
somatic pain disorder (Egloff et al., 2014).

• Anxiety and depression have a high comorbidity with somatic symptom
disorders.
• Conversion disorder frequently occurs with personality disorders.
• Central sensitivity syndrome also has high comorbidity with somatic disorders.
1. In general, what other disorders often occur with somatic disorders?
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8.4. Etiology
• Describe the psychodynamic causes of somatic disorders.
• Describe the cognitive causes of somatic disorders.
• Describe the behavioral causes of somatic disorders.
• Describe the sociocultural causes of somatic disorders.
8.4.1. Psychodynamic
Psychodynamic theory suggests that somatic symptoms present as a response against
unconscious emotional issues. Two factors initiate and maintain somatic symptoms: primary
gain and secondary gain. Primary gains produce internal motivators, whereas secondary gains
produce external motivators (Jones, Carmel & Ball, 2008). When you relate this to somatic
disorders, the primary gain, according to psychodynamic theorists, provides protection from the
anxiety or emotional symptoms and/or conflicts. This need for protection is expressed via a
physical symptom such as pain, headache, etc. The secondary gain, the external experiences
from the physical symptoms that maintain these physical symptoms, can range from attention
and sympathy to missed work, obtaining financial assistance, or psychiatric disability, to name a
few.
8.4.2. Cognitive
Cognitive theorists often believe that somatic disorders are a result of negative beliefs or
exaggerated fears of physiological sensations. Individuals with somatic related disorders may
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have a heightened sensitivity to bodily sensations. This sensitivity, combined with their
maladaptive thought patterns, may lead individuals to overanalyze and interpret their
physiological symptoms in a negative light.
For example, an individual with a headache may catastrophize the symptoms and believe
that their headache is the direct result of a brain tumor, as opposed to stress or other inoculate
reasons. When their medical provider does not confirm this diagnosis, the individual may then
catastrophize even further, believing they have an extremely rare disorder that requires an
evaluation from a specialist.
8.4.3. Behavioral
Keeping true with the behavioral approach to psychological disorders, behaviorists
propose that somatic disorders are developed and maintained by reinforcers. More specifically,
individuals experiencing significant somatic symptoms are often rewarded by gaining attention
from other people (Witthoft & Hiller, 2010). These rewards may also extend to more significant
factors, such as receiving disability.
While the behavioral theory of somatic disorders appears to be similar to the
psychodynamic theory of secondary gains, there is a clear distinction between the two—
behaviorists view these gains as the primary reason for the development and maintenance of the
disorder, whereas psychodynamic theorists view these gains as secondary, only after the
underlying conflicts create the disorder.
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There are a couple of different ways that sociocultural factors contribute to somatic
related disorders. First, there is the social factor of familial influence that likely plays a
significant role in the attention to somatic symptoms. Individuals with somatic symptom disorder
are more likely to have a family member or close friend who is overly attentive to their somatic
symptoms or report high anxiety related to their health (Watt, O’Connor, Stewart, Moon, &
Terry, 2008; Schulte, Petermann, & Noeker, 2010).
Culturally, Western countries express less of a focus on somatic complaints compared to
those in the Eastern part of the world. This may be explained by the different evaluations of the
relationship between mind and body. For example, Westerners tend to have a view that
psychological symptoms sometimes influence somatic symptoms, whereas Easterners focus more
heavily on the mind-body relationship and how psychological and somatic symptoms interact
with one another. These different cultural beliefs are routinely seen in research where Asian
populations are more likely to report the physical symptoms related to stress than the cognitive
or emotional problems that many in the United States report (Sue & Sue, 2016).
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• Psychodynamic causes of somatic disorders include primary and secondary
gain.
• Cognitive causes of somatic disorders include negative beliefs or
exaggerated fears of physiological sensations.
• Behavioral causes of somatic disorders include reinforcers such as attention
gained from others or receiving disability.
• Sociocultural causes of somatic disorders include familial influence and
culture.
1. How does catastrophizing contribute to the development and maintenance of

somatic disorders?
2. How do somatic disorders develop according to behavioral theorists? Does
this theory also explain how the symptoms are maintained? Explain.
3. What does the sociocultural model suggest regarding somatic disorders
across cultures?
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8.5. Treatment
• Describe treatment options for somatic disorders.
Treatment for these disorders is often difficult as individuals see their problems as
completely medical, and therefore, do not think psychological intervention is necessary
(Lahmann, Henningsen, & Noll-Hussong, 2010). Generally speaking, once an individual does
not find relief from their symptoms after meeting with several different physicians, they often do
willingly engage in psychotherapy, psychopharmacology, or both (Raj et al., 2014).
Among the most effective treatment approaches is the biopsychosocial model of
treatment. This approach takes into account the various biological, psychological, and social
factors that influence the illness and presenting symptoms (Gatchel et al., 2007). This treatment
is often achieved through a multidisciplinary approach where the symptoms are managed by
many providers, usually including a physician, psychiatrist, and psychologist. The
interdisciplinary approach involves a higher level of care as the multiple disciplines interact with
one another and identify a treatment goal (Gatchel et al., 2007). This approach, although more
difficult to find, particularly in more rural settings, is presumed to be more effective due to the
integration of health care providers and their ability to work together to treat the patient
uniformly.
8.5.1. Psychotherapy
8.5.1.1. Psychodynamic. Interpersonal psychotherapy, a type of psychodynamic therapy,
has been found to be efficacious in treating somatic disorders. Interpersonal psychotherapy

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focuses on the relationship between self-experience and the unconscious, and how these factors
contribute to body dysfunction. This type of treatment has been shown to reduce anxiety,
depression, and improve the overall quality of life immediately following treatment; however,
effects appear to diminish over time (Abass et al., 2014; Steinert et al., 2015).
8.5.1.2. CBT. Traditional cognitive-behavioral therapies (CBT) have been employed to
address the cognitive attributions and maladaptive coping strategies that are responsible for the
development and maintenance of the disorder. The most common misattribution for these
disorders is catastrophic thinking, or the rumination about worst-case scenario outcomes.
Additionally, goals of CBT treatment are the acceptance of the medical condition, addressing
avoidance behaviors, and mediating expectations of treatment (Gatchel et al., 2014).
8.5.1.3. Behavioral. Behavioral therapies have also been shown to effectively manage
complex chronic somatic symptoms, particularly pain. The behavioral approach involves
bringing attention to physiological symptoms, the individual’s attribution to those symptoms,
and the subsequent anxiety produced by the negative attributions (Looper & Kirmayer, 2002).
8.5.2. Psychopharmacology
Psychopharmacological interventions are rarely used due to possible side effects and
unknown efficacy. Given that these individuals already have a heightened reaction to their
physiological symptoms, there is a high likelihood that the side effects of medication would
produce more harm than help. With that said, psychopharmacological interventions may be
helpful for those individuals who have comorbid psychological disorders such as depression or
anxiety, which may negatively impact their ability to engage in psychotherapy (McGeary,
Harzell, McGeary, & Gatchel, 2016).
8-17

• The biopsychosocial model of treatment is one of the most effective for
somatic disorders as it takes into account the various biological,
psychological, and social factors that influence the illness and presenting
symptoms and includes a multidisciplinary approach.
• Psychotherapy options include interpersonal psychotherapy, CBT, and
behavioral.
• Psychopharmacological interventions are rarely used for somatic disorders
due to the side effects of the medication producing more harm than good.
When used, they deal with comorbid disorders such as depression or
anxiety.
1. Discuss the difference between multidisciplinary and interdisciplinary

approaches to treatment of somatic disorders.
2. What is the biopsychosocial model for treatment of somatic disorders? What
are the three main components of this treatment?
3. Are there any treatments that are not effective in treating somatic disorders?
If so, why?
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8.6. Psychological Factors Affecting Other Medical Conditions
• Describe how psychological factors affecting other medical conditions presents.
• List and describe the most common types of psychophysiological disorders.
• Describe treatment options for psychological factors affecting other medical
conditions.
Although previously known as psychosomatic disorders, the DSM-5 has identified
physical illnesses that are caused or exacerbated by biopsychosocial factors as psychological
factors affecting other medical conditions. This disorder is different than all the previously
mentioned somatic related disorders as the primary focus of the disorder is not the mental
disorder, but rather the physical disorder. It is believed that a lack of positive coping strategies,
psychological distress, or maladaptive health behaviors exacerbate these physical symptoms
(McGeary, Harzell, McGeary, & Gatchel, 2016).
8.6.1. Psychophysiological Disorders
The most common types of psychophysiological disorders are headaches (migraines and
tension), gastrointestinal (ulcer and irritable bowel), insomnia, and cardiovascular-related
disorders (coronary heart disease and hypertension). We will briefly review these disorders and
discuss the associated psychological features believed to exacerbate symptoms.
8.6.1.1. Headaches. Among the most common types of headaches are migraines and
tension headaches (Williamson, 1981). Migraine headaches are often more severe and are
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explained by a throbbing pain localized to one side of the head, frequently accompanied by
nausea, vomiting, sensitivity to light, and vertigo. It is believed that migraines are caused by the
blood vessels in the brain narrowing, thus reducing the blood flow to various parts of the brain,
followed by the same vessels later expanding, thus rapidly changing the blood flow. It is
estimated that 23 million people in the US alone suffer from migraines (Williamson, Barker,
Veron-Guidry, 1994).
Tension headaches are often described as a dull, constant ache localized to one part of the
head or neck; however, it can co-occur in multiple places at one time. Unlike migraines, nausea,
vomiting, and sensitivity to light do not often occur with tension headaches. Tension headaches,
as well as migraines, are believed to be primarily caused by stress as they are in response to
sustained muscle contraction that is often exhibited by those under extreme stress or emotion
(Williamson, Barker, Veron-Guidry, 1994). In efforts to reduce the frequency and intensity of
both migraines and tension headaches, individuals have found relief in relaxation techniques, as
well as the use of biofeedback training to help encourage the relaxation of muscles.
8.6.1.2. Gastrointestinal. Among the two most common types of gastrointestinal
psychophysiological disorders are ulcers and irritable bowel syndrome (IBS). Ulcers, or
painful sores in the stomach lining, occur when mucus from digestive juices are reduced,
allowing digestive acids to burn a hole into the stomach lining. Among the most common type of
ulcers are peptic ulcers, which are caused by the bacteria H. pylori (Sung, Kuipers, El-Serag,
2009). While there is evidence to support the involvement of stress in the development of
dyspeptic symptoms, the evidence linking stress and peptic ulcers is slowly growing. (Purdy,
2013). Researchers believe that while H. pylori must be present for a peptic ulcer to develop,
8-20
increased stress levels may impact the amount of digestive acid present in the stomach lining,
thus increasing the frequency and intensity of symptoms (Sung, Kuipers, El-Serag, 2009).
IBS is a chronic, functional disorder of the gastrointestinal tract. Common symptoms of
IBS include abdominal pain and extreme bowel habits (diarrhea or constipation). It affects up to
a quarter of the population and is responsible for nearly half of all referrals to gastroenterologists
(Sandler, 1990).
Because IBS is a functional disorder, there are no known structural, chemical, or
physiological abnormalities responsible for the symptoms. However, there is conclusive
evidence that IBS symptoms are related to psychological distress, particularly in those with
anxiety or depression. Although more research is needed to pinpoint the timing between the
onset of IBS and psychological disorders, preliminary evidence suggests that psychological
distress is present before IBS symptoms. Therefore, IBS may be best explained as a somatic
expression of associated psychological problems (Sykes, Blanchard, Lackner, Keefer, &
Krasner, 2003).
8.6.1.3. Insomnia. Insomnia, the difficulty falling or staying asleep, occurs in more than
one-third of the US population, with approximately 10% of patients reporting chronic insomnia
(Perlis & Gehrman, 2013). While exact pathways of chronic psychophysiological insomnia are
unclear, there is evidence of some biopsychosocial factors that may predispose an individual to
develop insomnia such as anxiety, depression, and overactive arousal systems (Trauer et al.,
2015). Part of the difficulty with insomnia is the fact that these psychological symptoms can
impact one’s ability to fall asleep; however, we also know that lack of adequate sleep also
predisposes individuals to increased psychological distress. Due to this cyclic nature of
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psychological distress and insomnia, intervention for both sleep issues as well as psychological
issues is vital to managing symptoms.
8.6.1.4. Cardiovascular. Heart disease has been the leading cause of death in the United
States for the past several decades. Costs related to disability, medical procedures, and societal
burdens are estimated to be $444 billion a year (Purdy, 2013). With this large financial burden,
there have been considerable efforts to identify risk and protective factors in predicting
cardiovascular mortality.
Researchers have identified that depression is a predictor of early-onset coronary heart
disease (Ketterer, Knysk, Khanal, & Hudson, 2006). More specifically, there is a five-fold
increase of depression in those with coronary heart disease than the general population (Ketterer,
Knysk, Khanal, & Hudson, 2006). Additionally, anxiety and anger have also been identified as
an early predictor of cardiac events, suggesting psychological interventions aimed at reducing
anxiety and establishing positive coping strategies for anger management may be effective in
reducing future cardiac events (Ketterer, Knysk, Khanal, & Hudson, 2006).
8.6.1.5. Hypertension. Also called or chronically elevated blood pressure, is also found
to be affected by psychological factors. More specifically, constant stress, anxiety, and
depression have all been found to impact the likelihood of a cardiac event due to their impact on
vasoconstriction (Purdy, 2013). Elevated inflammatory markers such as C-reactive protein,
which is indicative of plaque instability, has been found in chronically depressed individuals,
thus predisposing them to potential heart attacks (Ketterer, Knysk, Khanal, & Hudson, 2006).
8-22
8.6.2. Treatments for Psychological Factors Affecting Other Medical Conditions
As more information regarding contributing factors to psychophysiological disorders is
discovered, more psychological treatment approaches have been developed and applied to these
medical problems. The most common types of treatments include relaxation training,
biofeedback, hypnosis, traditional CBT treatments, group therapy, as well as a combination of
the previous treatments.
8.6.2.1. Relaxation training. Relaxation training essentially teaches individuals how to
relax their muscles on command. While relaxation is used in combination with other
psychological interventions to reduce anxiety (as seen in PTSD and various anxiety disorders), it
has also been shown to be effective in treating physical symptoms such as headaches, chronic
pain, as well as pain related to specific causes (e.g., injection sites, side effects of medications;
McKenna et al., 2015).
8.6.2.2. Biofeedback. Biofeedback is a unique psychological treatment in which an
individual is connected to a machine (usually a computer) that allows for continuous monitoring
of involuntary physiological reactions. Measurements that can be obtained are heart rate,
galvanic skin response, respiration, muscle tension, and body temperature, to name a few.
There are a few different ways in which biofeedback can be administered. The first is
clinician-led. The clinician will actively guide the patient through a relaxation monologue,
encouraging the patient to relax muscles associated near the pain region (or within the entire
body). While going through the monologue, the clinician is provided with real-time feedback
about the patient’s physiological response. Research studies have routinely supported the use of
biofeedback, particularly for those with pain and headaches that have not been responsive to
pharmacological interventions (McKenna et al., 2015).
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Another option of biofeedback is through computer programs developed by
psychologists. The most common, a program called Wild Devine (now Unyte) is an integrative
relaxation program that encourages the use of breathing techniques while simultaneously
measuring the patient’s physiological responses. This type of programming is especially helpful
for younger patients as there are various “games” the child can play that requires the awareness
and control of their thoughts, feelings, and emotions.
8.6.2.3. Hypnosis. Hypnosis, which some argue is just an extreme sense of relaxation,
has been effective in reducing pain and managing anxiety symptoms associated with medical
procedures (Lang et al., 2000). Through extensive training, an individual can learn to engage in
self-hypnosis or obtain recorded hypnosis monologues to assist with the management of
physiological symptoms outside of hypnosis sessions. While additional research is still needed
within the field of hypnosis, studies have indicated that hypnosis is effective in not only treating
chronic pain, but also assists with a reduction in anxiety, improved sleep, and improved overall
quality of life. (Jensen et al., 2006).
8.6.2.4. Group Therapy. Group therapy is another effective treatment option for
individuals with psychological distress related to physical disorders. These groups not only aim
to reduce the negative emotions associated with chronic illnesses, but they also provide support
from other group members that are experiencing the same physical and psychological symptoms.
These groups are typically CBT based, and utilize cognitive and behavioral strategies in a group
setting to encourage acceptance of disease while also addressing maladaptive coping strategies.
8-24

• Psychological factors affecting other medical conditions has as its primary
focus the physical disorder, and not the mental disorder.
• The most common types of psychophysiological disorders include
headaches to include migraines and tension, gastrointestinal to include ulcers
and IBS, insomnia, coronary heart disease, and hypertension.
• Common treatments for these other medical conditions include relaxation
training, biofeedback, hypnosis, traditional CBT treatments, and group
therapy.
1. What are the most common types of psychophysiological disorders?

2. Discuss the differences between the different types of headaches.
3. What is the difference between ulcers and irritable bowel syndrome?
4. What are the identified predictors to coronary heart disease and other cardiac
events?
5. What are the most effective treatment options for psychophysiological
disorders?
Module Recap
In Module 8, we discussed somatic disorders in terms of their clinical presentation,
epidemiology, comorbidity, etiology, and treatment options. Somatic disorders included Somatic
Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, and Factitious Disorder. We
also discussed psychological factors affecting other medication conditions in relation to their
clinical presentation, common types of psychophysiological disorders, and treatment.
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Module 9:
Obsessive-Compulsive and Related
Disorders
9-1
Module 9: Obsessive-Compulsive and Related Disorders
Module Overview
In Module 9, we will discuss matters related to obsessive-compulsive and related
disorders to include their clinical presentation, epidemiology, comorbidity, etiology, and
treatment options. Our discussion will include obsessive compulsive disorder (OCD), body
dysmorphic disorder (BDD), and hoarding. Be sure you refer Modules 1-3 for explanations of
key terms (Module 1), an overview of the various models to explain psychopathology (Module
2), and descriptions of the therapies (Module 3).
Module Outline
• 9.4. Etiology
• 9.5. Treatment
• Describe how obsessive-compulsive disorders present.
• Describe the epidemiology of obsessive-compulsive disorders.
• Describe comorbidity in relation to obsessive-compulsive disorders.
• Describe the etiology of obsessive-compulsive disorders.
• Describe treatment options for obsessive-compulsive disorders.
9-2
• Describe how OCD presents.
• Describe how BDD presents.
• Describe how hoarding presents.
9.1.1. Obsessive-Compulsive Disorder
Obsessive-compulsive disorder, more commonly known as OCD, requires the presence
of both obsessions and compulsions. Obsessions are defined as repetitive and persistent
thoughts, urges, or images. These obsessions are intrusive, time-consuming, and unwanted, often
causing significant distress in an individual’s daily functioning. Common obsessions are
contamination (dirt on self or objects), errors of uncertainty regarding daily behaviors (locking
the door, turning off appliances), thoughts of physical harm or violence, and orderliness, to name
a few (Cisler, Adams, et al., 2011; Yadin & Foa, 2009). Often the individual will try to ignore
these thoughts, urges, or images. When they are unable to ignore them, the individual will
engage in compulsatory behaviors to alleviate the anxiety.
Compulsions are repetitive behaviors or mental acts that an individual performs in
response to an obsession. Common examples of compulsions are checking (e.g., repeatedly
checking if the stove is turned off even though the first four-times they checked it was), counting
(e.g., flicking the lights off and on exactly five times), hand washing, symmetry, or repeating
specific words (APA, 2013). These compulsive behaviors essentially alleviate the anxiety
9-3
associated with the obsessive thoughts. For example, an individual may feel as though their
hands are dirty after using utensils at a restaurant. They may obsess over this thought for some
time, impacting their ability to interact with others or complete a specific task. This obsession
will ultimately lead to the individual performing a compulsion where they will wash their hands
with extremely hot water to rid all the germs, or even wash their hands a specified number of
times if they also have a counting compulsion. At this point, the individual’s anxiety should be
temporarily relieved.
These obsessions and compulsions are more excessive than the typical “cleanliness” as
they consume a large part of the individual’s day. Additionally, they cause significant
impairment in one’s daily functioning. Given the example above, an individual with a fear of
contamination may refuse to eat at restaurants, or they may bring their utensils from home.
9.1.2. Body Dysmorphic Disorder
Body Dysmorphic Disorder (BDD) is another obsessive disorder; however, the focus of
these obsessions is with perceived defects or flaws in their physical appearance. A key feature of
these obsessions is that they are not observable to others. An individual who has a congenital
facial defect or a burn victim who is concerned about their scars are not examples of an
individual with BDD. The obsessions related to one’s appearance can run the spectrum from
feeling “unattractive” to “looking hideous.” While any part of the body can be a concern for an
individual with BDD, the most commonly reported areas are skin (acne, wrinkles, skin color),
hair (particularly thinning or excessive body hair), and nose size (APA, 2013).
Due to the distressing nature of the obsessions regarding one’s body, individuals with
BDD also engage in compulsive behaviors that take up a considerable amount of time in one’s
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day. For example, one may repeatedly compare their body to other people’s bodies in the general
public; frequently look at themselves in the mirror; engage in excessive grooming, which
includes using make-up to modify their appearance. Some individuals with BDD will go as far as
having numerous plastic surgeries in attempts to obtain their “perfect” appearance. While most
of us are guilty of engaging in some of these behaviors, to meet criteria for BDD, one must spend
a considerable amount of time preoccupied with their appearance (i.e., on average 3-8 hours a
day), as well as display significant impairment in social, occupational, or other areas of
functioning (APA, 2013).
9.1.2.1. Muscle Dysmorphia. While muscle dysmorphia is not a formal diagnosis, it is a
common type of BDD, particularly within the male population. Muscle dysmorphia refers to the
belief that one’s body is too small or lacks the appropriate amount of muscle definition (Ahmed,
Cook, Genen & Schwartz, 2014). While the severity of BDD between individuals with and
without muscle dysmorphia appears to be the same, some studies have found higher use of
substance abuse (i.e., steroid use), poorer quality of life, and increased reports of suicide attempts
in those with muscle dysmorphia (Pope, Pope, Menard, Fay Olivardia, & Philips, 2005).
9.1.3. Hoarding
Thanks to popular television shows, most of us have had some exposure to hoarding
disorder, even if it has only been through commercials. In hoarding, the key feature is the
persistent over-accumulation of possessions (APA, 2013). While we all obtain items throughout
our life, individuals with hoarding disorder continue to accumulate items without discarding
possessions, regardless of their value or sentiment. This lack of discarding occurs over a long
period and is not explained by a recent significant stressor (e.g., lost house in fire, so now keeps
9-5
everything). For example, last week’s newspaper that had no relevance to me or any historical
value, but those with hoarding disorder would keep this newspaper despite the lack of value or
sentiment.
The most commonly hoarded items are newspapers, magazines, clothes, bags, books,
mail, and paperwork (APA, 2013). While these items may be stored in attics and garages,
individuals with a hoarding disorder also have these items cluttering their living space,
sometimes to the extent that they are unable to utilize their furniture because it is covered in
stuff. Cognitive factors contributing to the need to hold onto these non-sentimental items are fear
of losing valuable information and fear of being wasteful. When asked to “clean out” their house
or get rid of these items, individuals with hoarding disorder experience significant distress. One’s
hoarding behaviors also impacts their daily functioning and causes impairment in social and
occupational functioning.
9-6

• As part of OCD, obsessions are repetitive and persistent thoughts, urges, or
images while compulsions are repetitive behaviors or mental acts that an
individual performs in response to an obsession.
• BDD is characterized by obsessions over perceived defects or flaws in one’s
physical appearance.
• Muscle dysmorphia refers to the belief that one’s body is too small or lacks
the appropriate amount of muscle definition and is a type of BDD common
to men.
• Hoarding disorder is characterized by accumulating items without
discarding possessions, regardless of their value or sentiment.
1. Define obsessions and compulsions. Provide a list of examples of each

thought/behavior.
2. What is body dysmorphic disorder? Give examples of characteristics that
would not be consistent with a BDD diagnosis.
3. Many of us save items throughout our lifetime that remind us of specific
events. How is this different from hoarding?
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9.2. Epidemiology
• Describe the epidemiology of OCD.
• Describe the epidemiology of BDD.
• Describe the epidemiology of hoarding.
9.2.1. OCD
The prevalence rate for OCD is approximately 1.2% both in the US and worldwide
(APA, 2013). Similar to other anxiety-related disorders, women are diagnosed with OCD more
often than males; however, in childhood, boys are diagnosed more frequently than girls (APA,
2013). With respect to gender and symptoms, females are more likely to be diagnosed with
cleaning related obsessions and compulsions. In contrast, males are more likely to display
symptoms related to forbidden thoughts and symmetry (APA, 2013). Additionally, males have
an earlier age of onset (5-15 yrs.) compared to women (20-24 yrs.; Rasmussen & Eisen, 1990).
Approximately two-thirds of all individuals with OCD had some symptoms present before the
age of 15 (Rasmussen & Eisen, 1990).
9.2.2. BDD
The point prevalence rate for BDD among US adults is 2.4% (APA, 2013).
Internationally, this rate drops to 1.7%-1.8% (APA, 2013). Despite the difference between the
national and international prevalence rates, the symptoms across races and cultures appear
similar.
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Gender-based prevalence rates indicate that women are more likely to be diagnosed with
BDD than males (2.5% females, 2.2% males; APA, 2013). While the diagnosis rates may be
different, general symptoms of BDD appear to be the same across genders with one exception:
males tend to report genital preoccupations while females are more likely to present with a
comorbid eating disorder.
9.2.3. Hoarding
While national studies on the prevalence rate of hoarding within the US and
internationally are not available, surveys estimate clinically significant hoarding as occurring in
2-6% of the population (APA, 2013; Gilliam & Tolin, 2010). Epidemiological studies suggest
that males report a higher incidence of hoarding behaviors; however, clinical samples are more
highly represented by females. What does this mean? Either epidemiological studies are skewed,
or females seek out treatment for hoarding more often than males. Additionally, older individuals
(between ages 55-94) are three times more likely to be diagnosed with hoarding disorder than
younger adults.
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• The prevalence rate for OCD is about 1.2% while BDD is 2.4% and hoarding
is estimated at 2-6%.
• In terms of gender, more males are diagnosed with OCD and are thought to
have hoarding disorder though clinical samples are more highly represented
by females likely due to their greater likelihood to seek treatment. More
females are diagnosed with BDD.
1. What are the key gender differences in prevalence rates and presentation of
symptoms for individuals with OCD?
2. What are some of the explanations regarding the lack of information regarding
prevalence rates in hoarding disorder?
9.3. Comorbidity
• Describe the comorbidity of OCD.
• Describe the comorbidity of BDD.
• Describe the comorbidity of hoarding.
9.3.1. OCD
There is a high comorbidity rate between OCD and other anxiety disorders. Nearly 76%
of individuals with OCD will be diagnosed with another anxiety disorder, most commonly panic
disorder, social anxiety disorder, generalized anxiety disorder, or a specific phobia (APA, 2013).
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Additionally, due to the nature of OCD and its symptoms, nearly 41% of those with OCD will
also be diagnosed with a major depressive episode (APA, 2013).
There is a high comorbidity rate between OCD and tic disorder, particularly in males
with an onset of OCD in childhood. Children presenting with early-onset OCD typically have a
different presentation of symptoms than traditional OCD. Research has also indicated a strong
triad of OCD, Tic disorder, and attention-deficit/hyperactivity disorder in children. Due to this
psychological disorder triad, it is believed there is a neurobiological mechanism at fault for the
development and maintenance of the disorders.
It should be noted that there are several disorders—schizophrenia, bipolar disorder,
eating disorders, and Tourette’s—where there is a higher incidence of OCD than the general
public (APA, 2013). Therefore, clinicians who have a patient diagnosed with one of the disorders
above should also routinely assess patients for OCD.
9.3.2. BDD
While research on BDD is still in its infancy, initial studies suggest that major depressive
disorder is the most common comorbid psychological disorder (APA, 2013). MDD typically
occurs after the onset of BDD. Additionally, there are some reports of social anxiety, OCD, and
substance-related disorders (likely related to muscle enhancement; APA, 2013).
9.3.3. Hoarding
Hoarding has an extremely high comorbidity rate with other mood and anxiety disorders,
with approximately 75% of individuals meeting diagnostic criteria for either major depressive
disorder, social anxiety disorder, or generalized anxiety disorder (APA, 2013). Additionally,
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nearly 20% also meet the criteria for OCD, which is not surprising seeing the similarity in their
etiology.

• OCD is shown to have a high comorbidity with anxiety and depressive
disorders as well as Tic disorder and ADHD in children.
• BDD has a high comorbidity with major depressive disorder.
• Hoarding has a high comorbidity with mood and anxiety disorders.
1. What is the comorbidity rate between OCD and other anxiety disorders?
2. This section discussed the OCD triad in children. What two other disorders
complete this triad?
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9.4. Etiology
• Describe the biological causes of obsessive-compulsive disorders.
• Describe the cognitive causes of obsessive-compulsive disorders.
• Describe the behavioral causes of obsessive-compulsive disorders.
9.4.1. Biological
There are a few biological explanations for obsessive-compulsive related disorders,
including hereditary transmission, neurotransmitter deficits, and abnormal functioning in brain
structures.
9.4.1.1. Hereditary transmission. With regards to heritability studies, twin studies
routinely support the role of genetics in the development of obsessive-compulsive behaviors, as
monozygotic twins have a substantially greater concordance rate (80-87%) than dizygotic twins
(47-50%; Carey & Gottesman, 1981; van Grootheest, Cath, Beekman, & Boomsma, 2005).
Additionally, first degree relatives of patients diagnosed with OCD are at a 5-fold increase to
develop OCD at some point throughout their lifespan (Nestadt, et al., 2000).
Interestingly, a study conducted by Nestadt and colleagues (2000) exploring the familial
role in the development of obsessive-compulsive disorder found that family members of
individuals with OCD had higher rates of both obsessions and compulsions than control families;
however, the familial relationship with regards to obsessions were stronger than that of
compulsions suggesting that there is a stronger heritability association for obsessions than
compulsions.
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This study also found a relationship between age of onset of OCD symptoms and family
heritability. Individuals who experienced an earlier age of onset, particularly before age 17, were
found to have more first-degree relatives diagnosed with OCD. In fact, after the age of 17, there
was no relationship between family diagnoses, suggesting those who develop OCD at an older
age may have a different diagnostic origin (Nestadt, et al., 2000).
Initial studies exploring genetic factors for BDD and hoarding also indicate a hereditary
influence; however, environmental factors appear to play a more significant role in the
development of these disorders than that of OCD (Ahmed, et al., 2014; Lervolino et al., 2009).
9.4.1.2. Neurotransmitters. Neurotransmitters, particularly serotonin, have been
identified as a contributing factor to obsessive and compulsive behaviors. This discovery was
made accidentally, when individuals with depression and comorbid OCD were given
antidepressant medications clomipramine and fluoxetine—both of which increase levels of
serotonin—to mediate symptoms of depression. Not only did these patients report a significant
reduction in their depressive symptoms, but also a substantial improvement in their OCD
symptoms (Bokor & Anderson, 2014). Interestingly enough, antidepressant medications that do
not affect serotonin levels are not effective in managing obsessive and compulsive symptoms,
thus offering additional support for deficits of serotonin levels as an explanation of obsessive and
compulsive behaviors (Sinopoli, Burton, Kronenberg, & Arnold, 2017; Bokor & Anderson,
2014). More recently, there has been some research implicating the involvement of additional
neurotransmitters—glutamate, GABA, and dopamine—in the development and maintenance of
OCD, although future studies are still needed to draw definitive conclusions (Marinova, Chuang,
& Fineberg, 2017).
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9.4.1.3. Brain structures. Seeing as neurotransmitters have direct involvement in the
development of obsessive-compulsive behaviors, it’s only logical that brain structures that house
these neurotransmitters also likely play a role in symptom development. Neuroimaging studies
implicate the brain structures and circuits in the frontal lobe, more specifically, the orbitofrontal
cortex, which is located just above each eye (Marsh et al., 2014). This brain region is responsible
for mediating strong emotional responses and converts them into behavioral responses. Once the
orbitofrontal cortex receives sensory/emotional information via sensory inputs, it transmits this
information through impulses. These impulses are then passed on to the caudate nuclei, which
filters through the many impulses received, passing along only the strongest impulses to the
thalamus. Once the impulses reach the thalamus, the individual essentially reassesses the
emotional response and decides whether or not to act (Beucke et al., 2013). It is believed that
individuals with obsessive compulsive behaviors experience overactivity of the orbitofrontal
cortex and a lack of filtering in the caudate nuclei, thus causing too many impulses to transfer to
the thalamus (Endrass et al., 2011). Further support for this theory has been shown when
individuals with OCD experience brain damage to the orbitofrontal cortex or caudate nuclei and
experience remission of OCD symptoms (Hofer et al., 2013).
9.4.2. Cognitive
Cognitive theorists believe that OCD behaviors occur due to an individual’s distorted
thinking and negative cognitive biases. More specifically, individuals with OCD are more likely
to overestimate the probability of harm, loss of control, or uncertainty in their life, thus leading
them to over-interpret potential negative outcomes of events. Additionally, some research has
indicated that those with OCD also experience disconfirmation bias, which causes the individual
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to seek out evidence of their failure to perform the ritual or compensatory behavior correctly
(Sue, Sue, Sue, & Sue, 2017). Finally, individuals with OCD often report the inability to trust
themselves and their instincts, and therefore, feel the need to repeat the compulsive behavior
multiple times to ensure it is done correctly. These cognitive biases are supported throughout
research studies that repeatedly find individuals with OCD experience more intrusive thoughts
than those without OCD (Jacob, Larson, & Storch, 2014).
We have identified that individuals with OCD experience cognitive biases and that these
biases contribute to the obsessive and compulsive behaviors, but why do these cognitive biases
occur so often? Everyone has times when they have repetitive or intrusive thoughts such as: “Did
I shut the oven off after cooking dinner?” or “Did I remember to lock the door before I left
home?” Fortunately, most individuals are able to either concede to their thoughts once, or even
forgo acknowledging their thoughts after they confidently talk themselves through their actions,
ensuring that the behavior in question was or was not completed. Unfortunately, individuals with
OCD are unable to neutralize these thoughts without performing a ritual as a way to put
themselves at ease. As you will see in more detail in the behavioral section below, the behaviors
(compulsions) used to neutralize the thoughts (obsessions) provide temporary relief to the
individual. As the individual is continually exposed to the obsession and repeatedly engages in
the compulsive behaviors to neutralize their anxiety, the behavior is repeatedly reinforced, thus
becoming a compulsion. This theory is supported by studies where individuals with OCD report
using more neutralizing strategies and report significant reductions in anxiety after employing
these neutralizing techniques (Jacob, Larson, & Storch, 2014; Salkovskis et al., 2003).
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9.4.3. Behavioral
The behavioral explanation of obsessive compulsive-related disorders focuses on
compulsions rather than obsessions. Behaviorists believe that these compulsions begin with and
are maintained through classical conditioning. As you may remember, classical conditioning
occurs when an unconditioned stimulus is paired with a conditioned stimulus to produce a
conditioned response. How does this explain OCD? Well, an individual with OCD may
experience negative thoughts or anxieties related to an unpleasant event (obsession;
unconditioned stimulus). These thoughts/anxieties cause significant distress to the individual,
and therefore, they seek out some behavior (compulsion) to alleviate these threats (conditioned
stimulus). This provides temporary relief to the individual, thus reinforcing the compulsive
behaviors used to lessen the threat. Over time, the conditioned stimulus (compulsive behaviors)
are reinforced due to the repeated exposure of the obsession and the temporary relief that comes
with engaging in these compulsive behaviors.
Strong support for this theory is the fact that the behavioral treatment option for OCD-
exposure and response prevention, is among the most effective treatments for these disorders. As
you will read below, this treatment essentially breaks the patient’s classical conditioning
associated with the obsessions and compulsions by preventing the individual from engaging in
the conditioned stimulus until anxiety is reduced.
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• Biological causes of obsessive-compulsive disorders include hereditary
transmission, neurotransmitter deficits particularly in relation to serotonin,
and abnormal functioning in brain structures.
• Cognitive causes of obsessive-compulsive disorders include distorted
thinking such as overestimating the probability of harm, loss of control, or
uncertainty in their life, and negative cognitive biases such as
disconfirmation bias.
• Behavioral causes of obsessive-compulsive disorders include classical
conditioning.
1. What are the biological implications regarding the etiology of OCD and
related disorders? What brain structures have been linked to these
disorders?
2. Discuss identified cognitive biases that are related to the development and
maintenance of OCD and related disorders?
3. The behavioral model discusses how classical conditioning may explain the
development and maintenance of these disorders. What are some identified
unconditioned and conditioned stimulus?
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9.5. Treatment
• Describe treatment options for OCD.
• Describe treatment options for BDD.
• Describe treatment options for hoarding.
9.5.1. OCD
9.5.1.1. Exposure and Response Prevention (ERP). Treatment of OCD has come a
long way in recent years. Among the most effective treatment options is exposure and response
prevention (March, Frances, Kahn, & Carpenter, 1997). First developed by psychiatrist Victor
Meyer (1966), as you might infer from the name, individuals are repeatedly exposed to their
obsession, thus causing anxiety/fears, while simultaneously prevented from engaging in their
compulsive behaviors. Exposure sessions are often done in vivo (in real life), via videos, or even
imaginary, depending on the type of obsession. For example, a fear that one’s house would burn
down if their compulsion was not carried out would obviously be done via imaginary exposure,
as it would not be ethical to have a person burn their house down.
Prior to beginning the exposure and response prevention exercises, the clinician must
teach the patient relaxation techniques for them to engage in during the distress of being exposed
to the obsession. Once relaxation techniques are taught, the clinician and patient will develop a
hierarchy of obsessions. Treatment will start at those with the lowest amount of distress to ensure
the patient has success with treatment, as well as preventing withdrawal of treatment.
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Within the hierarchy of obsessions, the individual is also gradually exposed to their
obsession. For example, an individual obsessed with germs, may first watch a person sneeze on
the computer in session. Once anxiety is managed and compulsions refrain at this level of
exposure, the individual would move on to being present in the same room as a sick individual,
to eventually shaking hands with someone obviously sick, each time preventing them from
engaging in their compulsive behavior. Once this level of their hierarchy was managed, they
would move on to the next obsession and so forth until the entire list was complete.
Treatment outcome for exposure and response prevention is very effective in treating
individuals with OCD. In fact, some studies suggest up to an 86% response rate when treatment
is completed (Foa et al., 2005). Combination treatments such as ERP with family counseling
(utilizing CBT techniques) may actually increase this response rate even higher (Bolleau, 2011;
Krebs & Heyman, 2015). Like most OCD related treatments, the largest barrier to treatment is
getting patients to commit to treatment, as the repeated exposures and prevention of compulsive
behaviors can be extremely distressing to patients.
9.5.1.2. Psychopharmacology. There has been minimal support for the treatment of
OCD with medication alone. This is likely due to the temporary resolution of symptoms during
medication use. Among the most effective medications are those that inhibit the reuptake of
serotonin, clomipramine and SSRIs. Reportedly, up to 60% of patients show improvement in
symptoms while taking these medications; however, symptoms are quick to return when
medications are discontinued (Dougherty, Rauch, & Jenike, 2002). While there has been some
promise in a combined treatment option of exposure and response prevention and SSRIs, these
findings were not superior to exposure and response prevention alone, suggesting that the
inclusion of medication in treatment does not provide an added benefit (Foa et al., 2005).
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9.5.2. BDD
Seeing as though there are strong similarities between OCD and BDD, it should not come
as a surprise that the only two effective treatments for BDD are those that are effective in OCD.
Exposure and response prevention has been successful in treating symptoms of BDD, as patients
are repeatedly exposed to their body imperfections/obsessions and prevented from engaging in
compulsions used to reduce their anxiety. (Veale, Gournay, et al., 1996; Wilhelm, Otto, Lohr, &
Deckersbach, 1999). The other treatment option, psychopharmacology, has also been shown to
reduce symptoms in patients with BDD. Similar to OCD, medications such as clomipramine and
SSRIs are generally prescribed. While these are effective in reducing BDD symptoms, once
medication is discontinued, symptoms resume nearly immediately suggesting this is not an
effective long-term treatment option for those with BDD.
Treatment of BDD appears to be difficult, with one study finding that only 9% of
participants had full remission at a 1-year follow-up, and 21% reported partial remission
(Phillips, Pagano, Menard & Stout, 2006). A more recent finding reported more promising
findings, with 76% of participants reporting full remission over 8 years (Bjornsson, Dyck, et al.,
2011).
9.5.2.1. Plastic surgery and medical treatments. Many individuals with BDD seek out
plastic surgery to attempt to correct their deficits. Phillips and colleagues (2001) evaluated
treatments of patients with BDD and found that 76.4% of the patients reported some form of
plastic surgery or medical treatment, with dermatology treatment the most reported (45%)
followed by plastic surgery (23%). The problem with this type of treatment is that the individual
is rarely satisfied with the outcome of the procedure, thus leading them to seek out additional
surgeries on the same defect (Phillips et al., 2001). Therefore, it is important that medical
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professionals thoroughly screen patients for psychological distress before completing any
medical treatment.
9.5.3. Hoarding
Recent research has concluded that unlike OCD, many individuals with hoarding disorder
do not experience intrusive thoughts, nor do they experience urges to perform rituals. Because of
this difference, treatment for hoarding disorder has moved away from exposure and response
prevention, and more toward a traditional cognitive-behavioral approach.
Frost and Hartl (1996) believed that individuals with hoarding disorder engage in
complex decision-making processes, overanalyzing the value and worth of possessions, thus
leading to hoarding the object as opposed to discarding it. Therefore, in addition to having the
individual engage in exposure treatment, an added component of cognitive restructuring and
motivational interviewing are added to address the complex-decision making that is involved in
maintaining unnecessary possessions. By discussing motives for keeping items, as well as fears
that may be associated with discarding items, clinicians can assist patients in their cognitive
processes to ultimately determine the item’s actual worth (Williams & Viscusi, 2016).
Unfortunately, due to the distressing nature of having to discard their possessions, many
individuals in treatment for hoarding disorder prematurely end treatment, thus never reaching
remission of symptoms (Mancebo, Eisen, Sibrava, Dyck, & Rasmussen, 2011).
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• Treatment options for OCD include exposure and response prevention, as
well as SSRIs though the drug does not provide an added benefit in
treatment.
• Treatment options for BDD include exposure and response prevention and
drugs clomipramine and SSRIs.
• Treatment options for hoarding include exposure treatment, cognitive
restructuring, and motivational interviewing.
1. Discuss the various types of treatments for OCD. Which treatment option has
the best outcome?
2. What are the different components of Exposure and Response Prevention?
How do they work together to reduce OCD symptoms?
3. According to Frost and Hartl (1996) what are the main components that
contribute to the maintenance of hoarding disorder?
Module Recap
As in all modules past, we have discussed the clinical presentation, epidemiology,
comorbidity, etiology, and treatment options for a specific class of disorders–obsessive
compulsive and related disorders.
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Disorders Covered:
10. Eating Disorders
11. Substance-Related and Addictive Disorders

Module 10:
Eating Disorders
10-1
Module 10: Eating Disorders
Module Overview
In Module 10, we will discuss matters related to eating disorders to include their clinical
include anorexia nervosa, bulimia nervosa, and binge eating disorder. Be sure you refer Modules
1-3 for explanations of key terms (Module 1), an overview of the various models to explain
psychopathology (Module 2), and descriptions of the therapies (Module 3).
Module Outline
• 10.4. Etiology
• 10.5. Treatment
• Describe how eating disorders present.
• Describe the epidemiology of eating disorders.
• Describe comorbidity in relation to eating disorders.
• Describe the etiology of eating disorders.
• Describe treatment options for eating disorders.
10-2
• Describe how Anorexia Nervosa presents.
• Describe how Bulimia Nervosa presents.
• Describe how Binge-Eating Disorder (BED) presents.
Eating disorders are very serious, yet relatively common mental health disorders,
particularly in Western society, where there is a heavy emphasis on thinness and physical
appearance. In fact, 13% of adolescents will be diagnosed with at least one eating disorder by
their 20th birthday (Stice, Marti, & Rohde, 2013). Furthermore, a large number of adolescents
will engage in significant disordered eating behaviors just below the clinical threshold (Culbert,
Burt, McGue, Iacono & Klump, 2009).
While there is no exact cause for eating disorders, the combination of biological,
psychological, and sociocultural factors have been identified as major contributors in both the
development and maintenance of eating disorders. This chapter serves as an introduction to three
of the most common eating disorders, their etiology, and treatment.
Within the DSM-5 (APA, 2013), there are six disorders classified under the Feeding and
Eating Disorders section: Pica, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder,
Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder. For this book, we will cover
the latter three.
Diagnostic criteria for eating disorders are mutually exclusive, meaning that only one of
these diagnoses can be assigned at any given time, except for Pica, which can be given as a
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diagnosis along with any of the aforementioned eating disorders. Given how similar many eating
disorders may present, it is important to review diagnostic criteria routinely to ensure the most
appropriate diagnosis has been made.
10.1.1. Anorexia Nervosa
Anorexia nervosa involves the restriction of food, which leads to significantly low body
weight relative to the individual's age, sex, and development. This restriction is often secondary
to an intense fear of gaining weight or becoming fat, despite the individual's low body weight.
Altered perception of self and an over-evaluation of one's body weight and shape contribute to
this disturbance of body size (National Eating Disorder Association).
Typical warning signs and symptoms of an individual with anorexia nervosa are divided
into two different categories: Emotional/Behavioral and Physical. Some emotional and
behavioral symptoms include dramatic weight loss, preoccupation with food, weight, calories,
etc., frequent comments about feeling "fat," eating a restricted range of foods, makes excuses to
avoid mealtimes, and often does not eat in public. Physical changes may include dizziness,
difficulty concentrating, feeling cold, sleep problems, thinning hair/hair loss, and muscle
weakness, to name a few.
The onset of the disorder typically begins with mild dietary restrictions such as
eliminating carbs or specific fatty foods. As weight loss is achieved, the dietary restrictions
progress to more severe, e.g., under 500 calories/day. While symptoms typically present in mid-
teenage years, there is a noticeable trend of younger girls—as young as eight years old—who
exhibit extreme dietary restrictive behaviors. While males are not immune to this disorder, the
number of females diagnosed each year is overwhelmingly larger than that of males.
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10.1.2. Bulimia Nervosa
Unlike anorexia nervosa where there is solely restriction of food, bulimia nervosa
involves a pattern of recurrent binge eating behaviors. Binge eating can be defined as a discrete
period of time where the amount of food consumed is significantly more than most people would
eat during a similar time period. Individuals with bulimia nervosa often report a sense of lack of
control over-eating during these binge-eating episodes. While not always, these binge-eating
episodes are usually followed by a feeling of disgust with oneself, which leads to
a compensatory behavior in an attempt to rid the body of the excessive calories. These
compensatory behaviors include vomiting, use of laxatives, fasting (or severe restriction), or
excessive exercise. This cycle of binge eating and compensatory behaviors occurs on average, at
least once a week for three months (National Eating Disorder Association).
It is important to note that while there are periods of severe calorie restriction like
anorexia, the two disorders cannot be diagnosed simultaneously. Therefore, it is important to
determine if an individual engages in a binge-eating episode—if they do, they do not meet the
criteria for anorexia nervosa.
Signs and symptoms of bulimia nervosa are similar to anorexia nervosa. These symptoms
include but are not limited to hiding food wrappers or containers after a bingeing episode, feeling
uncomfortable eating in public, developing food rituals, limited diet, disappearing to the
bathroom after eating a meal, and drinking excessive amounts of water or non-caloric beverages.
Additional physical changes include weight fluctuations both up and down, difficulty
concentrating, dizziness, sleep disturbance, and possible dental problems due to purging post
binge eating episode.
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Symptoms of bulimia nervosa typically present later in development- late adolescence or
early adulthood. Similar to anorexia nervosa, bulimia nervosa initially presents with mild
restrictive dietary behaviors; however, episodes of binge eating interrupt the dietary restriction,
causing bodyweight to rise around normal levels. In response to weight gain, patients engage in
compensatory behaviors or purging episodes to reduce body weight. This cycle of restriction,
binge eating, and calorie reduction often occurs for years before seeking help.
10.1.3. Binge-Eating Disorder (BED)
Binge-Eating Disorder is similar to Bulimia Nervosa in that it involves recurrent binge
eating episodes along with feelings of lack of control during the binge-eating episode; however,
these episodes are not followed by a compensatory behavior to rid the body of calories. Despite
the feelings of shame and guilt post-binge, individuals with BED will not engage in vomiting,
excessive exercises, or other compensatory behaviors. These binge eating episodes occur on
average, at least once a week for 3 months.
Because these binge-eating episodes occur without compensatory behaviors, individuals
with BED are at risk for obesity and related health disorders. Individuals with BED report
feelings of embarrassment at the quantity of food consumed, and thus will often refuse to eat in
public. Due to the restriction of eating around others, individuals with BED often engage in
secret binge eating episodes in private, followed by discrete disposal of wrappers and containers.
While much is still being researched about binge-eating disorder, current research
indicates that the onset of BED is later than that of anorexia nervosa and bulimia nervosa. Most
patients are middle-aged, and approximately one third or more are male. Binge-eating disorder
also appears to be more phasic rather than persistent, with individuals experiencing significant
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time periods where their binge-eating episodes are in control. The gender discrepancy in BED is
much smaller than that of anorexia nervosa and bulimia nervosa.

• Anorexia nervosa involves the restriction of food, which leads to significantly
low body weight relative to the individual's age, sex, and development, and an
intense fear of gaining weight or becoming fat.
• Bulimia nervosa is characterized by a pattern of recurrent binge eating
behaviors.
• Binge-eating disorder is characterized by recurrent binge eating episodes along
with a feeling of lack of control but no compensatory behavior to rid the body
of the calories.
1. What does mutually exclusive mean? What does that mean with respect to
eating disorders?
2. What are the key differences in diagnostic criteria for anorexia, bulimia, and
binge eating disorder?
3. Define compensatory behavior. What disorder is this found in?
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10.2. Epidemiology
• Describe the epidemiology of eating disorders.
According to the DSM-5 (APA, 2013), the prevalence rate for anorexia nervosa among
young women is 0.4%, whereas the prevalence rate for bulimia nervosa is 1%-1.5%. While BED
is still a relatively new diagnosis, the estimated prevalence rate in females is 1.6%. Prevalence
rates for males with anorexia or bulimia are unknown; however, research suggests the female-to-
male ratio is approximately 10:1 for both disorders (APA, 2015). The estimated prevalence rate
for BED in males is 0.8%. The ratio between females-to-males with BED is much less skewed
than that in anorexia and bulimia.

• BED has the highest prevalence rate of 1.6% followed by bulimia nervosa at 1-
1.5% and anorexia nervosa at 0.4%.
• Females are more likely to be diagnosed with anorexia or bulimia with an equal
number presenting with BED.
1. List the disorders in order from greatest to least prevalence rates.
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10.3. Comorbidity
• Describe the comorbidity of anorexia nervosa.
• Describe the comorbidity of bulimia nervosa.
• Describe the comorbidity of BED.
10.3.1. Anorexia
Anorexia is rarely a single diagnosis. High rates of bipolar disorder, depressive
symptoms, and anxiety disorders are also common among individuals with anorexia nervosa.
Obsessive-compulsive disorder is more often seen in those with the restrictive type of anorexia
nervosa, whereas alcohol use disorder and other substance use disorders are more commonly
seen in those with anorexia who engage in binge-eating/purging behaviors. Unfortunately, there
is also a high rate of suicidality, as many as 12 per 100,000 per year (APA, 2013).
10.3.2. Bulimia
The majority of individuals diagnosed with bulimia nervosa also present with at least one
other mental disorder. Similar to anorexia nervosa, there is also a high frequency of depressive
symptoms, as well as bipolar disorder. While some experience mood fluctuations as a result of
their eating pattern, a large number of individuals will identify mood symptoms prior to the onset
of bulimia nervosa (APA, 2013). Anxiety, particularly social anxiety, is often present in those
with bulimia nervosa. However, most mood and anxiety symptoms resolve once an effective
treatment of bulimia is established. Alcohol use, as well as substance abuse, is also prevalent in
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those with bulimia. The substance abuse tends to begin as a compensatory behavior (e.g.
stimulant use is used to control appetite and weight) and over time, as the eating disorder
progresses, so does the substance abuse. Finally, there is also a percentage of individuals with
bulimia nervosa who also display personality characteristics consistent with a range of
personality disorders.
10.3.3. BED
Since BED is a new diagnosis, research regarding comorbidity with other mental
disorders is still developing. Preliminary evidence suggests that BED shares similar
comorbidities with anorexia nervosa and bulimia nervosa. Common comorbidities include but
are not limited to bipolar disorder, depressive disorders, and anxiety disorders. Although there is
some evidence of comorbid substance abuse disorder, it is not as prevalent as that in bulimia
nervosa and anorexia nervosa.

• Anorexia and BED have a high comorbidity with bipolar disorder, depressive
symptoms, and anxiety disorders.
• Bulimia has a high comorbidity with bipolar disorder, depressive symptoms, social
anxiety, and alcohol and substance abuse.
1. Discuss the comorbidity rates among the three main eating disorders.
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10.4. Etiology
• Describe the biological causes of eating disorders.
• Describe the cognitive causes of eating disorders.
• Describe the sociocultural causes of eating disorders.
• Describe how personality traits are the cause of eating disorders.
What causes eating disorders? While researchers have yet to identify a specific cause of
eating disorders, the most compelling argument to date is that eating disorders are
multidimensional disorders. This means many contributing factors lead to the development of
an eating disorder. While there is likely a genetic predisposition, there are also environmental, or
external factors, such as family dynamics and cultural influences that impact their presentation.
Research supporting these influences is well documented for anorexia nervosa and bulimia
nervosa; however, seeing as BED has only just recently been established as a formal diagnosis,
research on the evolvement of BED is ongoing.
10.4.1. Biological
There is some evidence of a genetic predisposition for eating disorders, with relatives of
those diagnosed with an eating disorder being up to six times more likely than other individuals
to be diagnosed also (APA, 2013). Twin concordance studies also support the gene theory. If an
identical twin is diagnosed with anorexia, there is a 70% percent chance the other twin will
develop anorexia in their lifetime (APA, 2013). The concordance rate for fraternal twins (who
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share less genes) is 20 percent. While not as strong for bulimia, identical twins still display a 23
percent concordance rate, compared to the 9 percent fraternal twins rate (APA, 2013).
In addition to hereditary causes, disruption in the neuroendocrine system is common in
those with eating disorders (Culbert, Racine, & Klump, 2015). Unfortunately, it’s difficult for
researchers to determine if these disruptions caused the disorder or have been caused by the
disorder, as manipulation of eating patterns is known to trigger changes in hormone production.
With that said, researchers have explored the hypothalamus as a potential contributing factor.
The hypothalamus is responsible for regulating body functions, particularly hunger and thirst
(Fetissov & Mequid, 2010). Within the hypothalamus, the lateral hypothalamus is responsible for
initiating hunger cues that cause the organism to eat, whereas the ventromedial hypothalamus is
responsible for sending signals of satiation, telling the organism to stop eating. Clearly, a
disruption in either of these structures could explain why an individual may not take in enough
calories or experience periods of overeating.
10.4.2. Cognitive
Some argue that eating disorders are, in fact, a variant of Obsessive-Compulsive Disorder
(OCD). The obsession with body shape and weight—the hallmark of an eating disorder—is
likely a driving factor in anorexia nervosa. Distorted thought patterns and an over-evaluation of
body size likely contribute to this obsession and one’s desire for thinness. Research has
identified high levels of impulsivity, particularly in those with binge eating episodes, suggesting
a temporary lack of control is responsible for these episodes. Post binge-eating episode, many
individuals report feelings of disgust or even thoughts of failure. These strong cognitive factors
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are indicative as to why cognitive-behavioral therapy is the preferred treatment for eating
disorders.
Eating disorders are overwhelmingly found in Western countries where there is a heavy
emphasis on thinness—a core feature of eating disorders. It is also found in countries where food
is in abundance, as in places of deprivation, round figures are viewed as more desirable (Polivy
& Herman, 2002). While eating disorders were once thought of as disorders of higher SES,
recent research suggests that as our country becomes more homogenized, the more universal
eating disorders become.
10.4.3.1. Media. One commonly discussed contributor to eating disorders is the media.
The idealization of thin models and actresses sends the message to young women (and
adolescents) that to be popular and attractive, you must be thin. These images are not isolated to
magazines, but are also seen in television shows, movies, commercials, and large advertisements
on billboards and hanging in store windows. With the emergence of social media (e.g.,
Facebook, Snapchat, Instagram), exposure to media images and celebrities is even easier.
Couple this with the ability to alter images to make individuals even thinner, it is no wonder
many young people become dissatisfied with their body (Polivy & Herman, 2004).
10.4.3.2. Ethnicity. While eating disorders are not solely a “white woman” disorder,
there are significant discrepancies when it comes to race, especially for anorexia nervosa. Why is
this? Research indicates that black men prefer heavier women than do white men (Greenberg &
Laporte, 1996). Given this preference, it should not be surprising that black women and children
have larger ideal physiques than their white peers (Polivy & Herman, 2000). Since black women
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are less driven to thinness, black women would appear to be likely to develop anorexia; however,
findings suggest this is not the case. Caldwell and colleagues (1997) found that high-income
black women were equally as dissatisfied as high-income white women with their physique,
suggesting body image issues may be more closely related to SES than that of race. The race
discrepancies are also less significant in BED, where the prominent feature of the eating disorder
is not thinness (Polivy & Herman, 2002).
10.4.3.3. Gender. Males account for only a small percentage of eating disorders—
roughly 5-10% (APA, 2013). While it is unclear as to why there is such a discrepancy, it is likely
somewhat related to cultural desires of women being “thin” and men being “muscular” or
“strong.”
Of men diagnosed with an eating disorder, the overwhelming percentage of them
identified a job or sport as the primary reason for their eating behaviors (Strother, Lemberg,
Stanford, & Turberville, 2012). Jockeys, distance runners, wrestlers, and bodybuilders are some
of the professions identified as most restrictive regarding body weight.
There is some speculation that males are not diagnosed as frequently as women due to the
stigma attached to eating disorders. Eating disorders have routinely been characterized as a
“white, adolescent female” problem. Due to this bias, young men may not seek help for their
eating disorder in efforts to prevent labeling (Raevuoni, Keski-Rahkonen & Hoek, 2014).
10.4.3.4. Family. Family influences are one of the strongest external contributors to
maintaining eating disorders. Often family members are praised for their slenderness. Think
about the last time you saw a family member or close friend- how often have you said, “You
look great!” or commented on their appearance in some way? The odds are pretty high. While
the intent of the family member is not to maintain maladaptive eating behaviors by praising the
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physical appearance of someone struggling with an eating disorder, they are indirectly
perpetuating the disorder.
While family involvement can help maintain the disorder, it can also contribute to the
development of an eating disorder. Families that emphasize thinness or place a large emphasis on
physical appearance are more likely to have a child diagnosed with an eating disorder (Zerbe,
2008). In fact, mothers with eating disorders are more likely to have children who develop a
feeding/eating disorder than mothers without eating disorders (Whelan & Cooper, 2000).
Additional family characteristics that are common among patients receiving treatment for eating
disorders are enmeshed, intrusive, critical, hostile, or overly concerned with parenting (Polivy &
Herman, 2002). While there has been some correlation between these family dynamics and
eating disorders, they are not evident in all families of people with eating disorders.
10.4.4. Personality
There are many personality characteristics that are common in individuals with eating
disorders. While it is unknown if these characteristics are inherent in the individual’s personality
or a product of personal experiences, the thought is eating disorders develop due to the
combination of the two.
10.4.4.1. Perfectionism. It should come as no surprise that perfectionism, or the belief
that one must be perfect, is a contributing factor to disorders related to eating, weight, and body
shape (particularly anorexia nervosa). While an exact mechanism is unknown, it is believed that
perfectionism magnifies normal body imperfections, leading an individual to go to extreme (i.e.,
restrictive) behaviors to remedy the flaw (Hewitt, Flett & Ediger, 1995).
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10.4.4.2. Self-Esteem. Self-esteem, or one’s belief in their worth or ability, has routinely
been identified as a moderator of many psychological disorders, and eating disorders are no
exception. Low self-esteem not only contributes to the development of an eating disorder but is
also likely involved in the maintenance of the disorder. One theory, the transdiagnostic model
of eating disorders, suggests that overall low self-esteem increases the risk for over-evaluation of
body, which in turn, leads to negative eating behaviors that could lead to an eating disorder
(Fairburn, Cooper & Shafran, 2003).

• Biological causes of eating disorders include a genetic predisposition and
disruption in the neuroendocrine system.
• Cognitive causes of eating disorders include distorted thought patterns and an
over-evaluation of body size.
• Sociocultural causes of eating disorders include the idealization of thin models
and actresses by the media, SES, gender, and family involvement.
• The personality trait of perfectionism and low self-esteem are contributing
factors to disorders related to eating, weight, and body shape.
1. Define multidimensional disorders?

2. What evidence is there to suggest eating disorders are biologically driven?
3. According to the cognitive theory, eating disorders may be a variant of what
other disorder?
4. Discuss the four sociocultural subgroups that explains development of eating
disorders.
5. What are the two personality traits most commonly used to describe behaviors
associated with eating disorders?
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10.5. Treatment
• Describe treatment options for anorexia nervosa.
• Describe treatment options for bulimia nervosa.
• Describe treatment options for binge eating disorder.
• Discuss the outcome of treatment for eating disorders.
10.5.1. Anorexia
The immediate goal for the treatment of anorexia nervosa is weight gain and recovery
from malnourishment. This is often established via an intensive outpatient program, or if needed,
through an inpatient hospitalization program where caloric intake can be managed and
controlled. Both the inpatient and outpatient programs use a combination of therapies and
support to help restore proper eating habits. Of the most common (and successful) treatments are
Cognitive-Behavioral Therapy (CBT) and Family-Based Therapy (FBT).
10.5.1.1. CBT. Because anorexia nervosa requires changes to both eating behaviors as
well as thought patterns, CBT strategies have been very effective in producing lasting changes to
those suffering from anorexia nervosa. Some of the behavioral strategies include recording
eating behaviors—hunger pains, quality and quantity of food—and emotional behaviors—
feelings related to the food. In addition to these behavioral strategies, it is also important to
address the maladaptive thought patterns associated with their negative body image and desire to
control their physical characteristics. Changing the fear related to gaining weight is essential in
recovery.
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10.5.1.2. FBT. FBT is also an effective treatment approach, often used as a component of
individual CBT, especially for children and adolescents with the disorder. FBT has been shown
to elicit 50-60% of weight restoration in one year, as well as weight maintenance 2-4 years post-
treatment (Campbell & Peebles, 2014; LeGrange, Lock, Accurso, Agras, Darcy, Forsberg, et al,
2014). Additionally, FBT has been shown to improve rapid weight gain, produce fewer
hospitalizations, and is more cost-effective than other types of therapies with family involvement
(Agras, Lock, Brandt, Bryson, Dodge, Halmi, et al., 2014).
FBT typically involves 16-18 sessions which are divided into 3 phases: (1) Parents take
charge of weight restoration, (2) client’s gradual control overeating, and (3) address
developmental issues including fostering autonomy from parents (Chen, et al., 2016). While FBT
has shown to be effective in treating adolescents with anorexia nervosa, the application for older
eating patients (i.e., college-aged students and above) is still undetermined. As with adolescents,
the goal for a family-based treatment program should center around helping the patient separate
their feelings and needs from that of their family.
10.5.2. Bulimia
Just as anorexia nervosa treatment initially focuses on weight gain, the first goal of
bulimia nervosa treatment is to eliminate binge eating episodes and compensatory behaviors. The
aim is to replace both of these negative behaviors with positive eating habits. One of the most
effective ways to establish this is through Cognitive Behavioral Therapy (CBT).
10.5.2.1. CBT. Similar to anorexia nervosa, individuals with bulimia nervosa are
expected to keep a journal of their eating habits; however, with bulimia nervosa, it is also
important that the journal include changes in sensations of hunger and fullness, as well as other
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feelings surrounding their eating patterns in efforts to identify triggers to their binging episodes
(Agras, Fitzsimmons-Craft & Wilfley, 2017). Once these triggers are identified, psychologists
will utilize specific behavioral or cognitive techniques to prevent the individual from engaging in
binge episodes or compensatory behaviors.
One method for modifying behaviors is through Exposure and Response Prevention. As
previously discussed in the OCD chapter, this treatment is very effective in helping individuals
stop performing their compulsive behaviors by literally preventing them from engaging in the
action, while simultaneously using relaxation strategies to reduce anxiety associated with not
engaging in the negative behavior. Therefore, to prevent an individual from purging post-binge
episodes, the individual would be encouraged to partake in an activity that directly competes
with their ability to purge, e.g., write their thoughts and feelings in a journal at the kitchen table.
Research has indicated that this treatment is particularly helpful for individuals suffering from
comorbid anxiety disorders (particularly OCD; Agras, Fitzsimmons-Craft & Wilfley, 2017).
In addition to changing behaviors, it is also important to change the maladaptive thoughts
toward food, eating, weight, and shape. Negative thoughts such as “I am fat” and “I can’t stop
eating when I start” can be modified into more appropriate thoughts such as “My body is
healthy” or “I can control my eating habits.” By replacing these negative thoughts with more
appropriate, positive thought patterns, individuals begin to control their feelings, which in return,
can help them manage their behaviors.
10.5.2.2. Interpersonal Psychotherapy (IPT). IPT has also been established as an
effective treatment for those with bulimia nervosa, particularly if an individual has not been
successful with CBT treatment. The goal of IPT is to improve interpersonal functioning in those
with eating disorders. Originally a treatment for depression, IPT-E was adapted to address the
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social isolation and self-esteem problems that contribute to the maintenance of negative eating
behaviors.
IPT-E has 3 phases typically covered in weekly sessions over 4-5 months. Phase One
consists of engaging the patient in treatment and providing psychoeducation about their disease
and the treatment program. This phase also includes identifying interpersonal problems that are
maintaining the disease.
Phase Two is the main treatment component. In this phase, the primary focus is on
problem-solving interpersonal issues. The most common types of interpersonal issues are lack of
intimacy and interpersonal deficits, interpersonal role disputes, role transitions, grief, and life
goals. Once the main interpersonal problem is identified, the clinician supports the patient in
their pursuit to identify ways to change. A key component of IPT-E is the supportive role of the
clinician, as opposed to the teaching role in other treatments. The idea is that by having the
patient make changes, they can better understand their problems, and as a result, make more
profound changes (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012).
Phase Three is the final stage. The goals of this phase are to ensure that the changes made
in phase two are maintained. To achieve this, treatment sessions are spaced out, allowing patients
more time to engage in their changed behavior. Additionally, relapse prevention (i.e., problem-
solving ways not to relapse) is also discussed to ensure long term results. In doing this, the
patient reviews the progress they have made throughout treatment, as well as identifying
potential interpersonal issues that may arise, and how their treatment can be adapted to address
those issues.
Support for IPT-E is limited; however, two extensive studies suggest that IPT-E is
effective in treating bulimia nervosa, and possibly BED. While treatment is initially slower than
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CBT, it is equally effective in long-term follow-up and maintenance of disorder (Fairburn,
Marcus, & Wilson, 1993).
10.5.3. Binge Eating Disorder
Given the similar presentations of BED and bulimia nervosa, it should not be surprising
that the most effective treatments for BED are similar to that of bulimia nervosa. CBT, along
with antidepressant medications, are among the most effective in treating BED. Interpersonal
therapy, as well as dialectical behavioral therapy, have also been effective in reducing binge-
eating episodes; however, they have not been effective in weight loss (Guerdjikova, Mori,
Casuto, & McElroy, 2017). Goals of treatment are, of course, to eliminate binge eating episodes,
as well as reduce body weight as most individuals with BED are overweight. Seeing as BED has
only recently been established as a separate eating disorder, treatment research specific to this
disorder is expected to grow.
10.5.3.1. Antidepressant medications. Given the high comorbidity between eating
disorders and depressive symptoms, antidepressants have been a primary method of treatment for
years. While they have been shown to improve depressive symptoms, which may help
individuals make gains in their eating disorder treatment, research has not supported
antidepressants as an effective treatment strategy for treating the eating disorder itself.
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10.5.4. Outcome of Treatment
Now that we have discussed treatments for eating disorders, how effective are they?
Research has indicated favorable prognostic features for anorexia nervosa are early age of onset
and a short history of the disorder. Conversely, unfavorable features are a long history of
symptoms prior to treatment, severe weight loss, and binge eating and vomiting. The mortality
rate over the first 10 years from presentation is about 10% (APA, 2013). The majority of these
deaths are from medical complications due to the disorder or suicide.
Unfortunately, research has not identified any consistent predictors of positive outcomes
for bulimia nervosa. However, there is some speculation that individuals with childhood obesity,
low self-esteem, and those with a personality disorder have worse treatment outcomes (APA,
2013).
While treatment outcome for BED is still in its infancy, initial findings suggest that
remission rates of BED are much higher than that for anorexia nervosa and bulimia nervosa.
10-22

• Treatment options for anorexia nervosa include CBT and FBT.
• Treatment options for bulimia nervosa include CBT, exposure and response
prevention, and the three phases of interpersonal psychotherapy.
• Treatment options for BED include the taking of antidepressants to manage
depressive symptoms, CBT, and interpersonal therapy.
1. What is the initial (main) goal of treatment for anorexia?

2. What are the three phases of family-based treatment?
3. What is the goal for interpersonal psychotherapy? Discuss the three phases of
IPT.
4. What is the overall treatment effectiveness of eating disorders?
Module Recap
Module 10 covered eating disorders in terms of their clinical presentation, epidemiology,
comorbidity, etiology, and treatment options. In Module 11, we will discuss substance-related
and addictive disorders, which will conclude this part.
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Module 11:
Substance-Related and
Addictive Disorders
11-1
Module 11: Substance-Related and Addictive Disorders

Module Overview
Module 11 will cover matters related to substance-related and addictive disorders to
Our discussion will include substance intoxication, substance use disorder, and substance
withdrawal. We also list substances people can become addicted to. Be sure you refer to
Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to
explain psychopathology (Module 2), and descriptions of the therapies (Module 3).
Module Outline
• 11.4. Etiology
• 11.5. Treatment
• Describe how substance-related and addictive disorders present.
• Describe the epidemiology of substance-related and addictive disorders.
• Describe comorbidity in relation to substance-related and addictive disorders.
• Describe the etiology of substance-related and addictive disorders.
• Describe treatment options for substance-related and addictive disorders.
11-2
• Define substances and substance abuse.
• Describe properties of substance abuse.
11.1.1. Substance Abuse
Substance-related disorders are among the most prevalent psychological disorders, with
roughly 100 million people in the United States reporting the use of an illegal substance
sometime throughout their life (SAMHSA, 2014). While this disorder was previously classified
as “drug abuse,” the classification was expanded to acknowledge the abuse of other substances
such as alcohol, tobacco, and caffeine.
What are substances? Substances are any ingested materials that cause temporary
cognitive, behavioral, or physiological symptoms within the individual. The changes that are
observed directly after or within a few hours of ingestion of the substance are classified as
substance intoxication (APA, 2013). Substance intoxication symptoms vary greatly and are
dependent on the type of substance ingested. Specific substances and their effects will be
discussed later in the module.
Repeated use of these substances or frequent substance intoxication can develop into a
long-term problem known as substance abuse. Abuse occurs when an individual consumes the
substance for an extended period or has to ingest large amounts of the substance to get the same
effect a substance provided previously. The need to continually increase the amount of ingested
substance is also known as tolerance. As tolerance builds, additional physical and psychological
11-3
symptoms present, often causing significant disturbances in an individual’s personal and
professional life. Individuals with substance abuse are often spending a significant amount of
time engaging in activities that revolve around their substance use, thus spending less time in
recreational activities that once consumed their time. Sometimes, there is a desire to reduce or
abstain from substance use; however, cravings and withdrawal symptoms often prohibit this
from occurring on one’s own attempts. Common withdrawal symptoms include but are not
limited to cramps, anxiety attacks, sweating, nausea, tremors, and hallucinations. Depending on
the substance and the tolerance level, most withdrawal symptoms last anywhere from a few days
to a week. For those with extensive substance abuse or abuse of multiple substances, withdrawal
should be closely monitored in a hospital setting to avoid severe consequences such as seizures,
stroke, or even death.
According to the DSM-5 (APA, 2013), an individual is diagnosed with Substance
Intoxication, Use, and/or Withdrawal specific to the substance(s) the individual is ingesting.
While there are some subtle differences in symptoms, particularly psychological, physical, and
behavioral symptoms, the general diagnostic criteria for Substance Intoxication, Use, and
Withdrawal remains the same across substances. Therefore, the general diagnostic criteria for
Substance Intoxication, Use, and Withdrawal are reviewed below, with more specific details of
psychological, physical, and/or behavioral symptoms in the Types of Substances Abused section.
For a diagnosis of Substance Intoxication, the individual must have recently ingested a
substance (APA, 2013). Immediately following the ingestion of this substance, significant
behavioral and/or psychological change is observed. In addition, physical and physiological
symptoms present as a direct result of the substance ingested. As stated above, these behavioral,
physical, and physiological symptoms are dependent on the type of substance that is ingested
11-4
and, therefore, discussed in more detail within each substance category (i.e., depressants,
stimulants, hallucinogens/cannabis/combination).
To meet the criteria for Substance Use Disorder, an individual must experience
significant impairment or distress for 12 months due to their use of a substance (APA, 2013).
Distress or impairment can be described as any of the following: inability to complete or lack of
participation in work, school or home activities; increased time spent on activities obtaining,
using, or recovering from substance use; impairment in social or interpersonal relationships; use
of a substance in a potentially hazardous situation; psychological problems due to recurrent
substance abuse; craving the substance; an increase in the amount of substance used over time
(i.e., tolerance); difficulty reducing the amount of substance used despite a desire to reduce/stop
using; and/or withdrawal symptoms (APA, 2013). While the number of these symptoms may
vary among individuals, only two symptoms are required for a diagnosis of Substance Use
Disorder.
Finally, Substance Withdrawal is diagnosed when there is cessation or reduction of a
substance that has been used for a long period of time. Individuals undergoing substance
withdrawal will experience physiological and psychological symptoms within a few hours after
cessation/reduction (APA, 2013). These symptoms cause significant distress or impairment in
daily functioning. Similar to Substance Intoxication, physiological and psychological symptoms
during substance withdrawal are often specific to the substance abused and are discussed in more
detail within each substance category later in the module.
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11.1.2. Types of Substances Abused
The most commonly abused substances can be divided into three categories based on
how they impact one’s physiological state: depressants, stimulants, and
hallucinogens/cannabis/combination.
11.1.2.1. Depressants. Depressant substances such as alcohol, sedative-hypnotic drugs,
and opioids are known to have an inhibiting effect on one’s central nervous system; therefore,
they are often used to alleviate tension and stress. Unfortunately, when used in large amounts,
they can also impair an individual’s judgment and motor activity.
While alcohol is one of the only legal (over-the-counter) substances we will discuss, it is
also the most commonly consumed substance. According to the 2015 National Survey on Drug
Use and Health, approximately 70% of individuals drank an alcoholic beverage in the last year,
and nearly 56% of individuals drank an alcoholic beverage in the past month (SAMHSA, 2015).
While the legal age of consumption in the United States is 21, approximately 78% of teens report
that they drank alcohol at some point in their life (SAMHSA, 2013).
Despite the legal age of consumption, many college-aged students engage in binge or
heavy drinking. In fact, 45% of college-aged students report engaging in binge drinking, with
14% binge drinking at least 5 days per month (SAMHSA, 2013). In addition to these high levels
of alcohol consumption, students also engage in other behaviors such as skipping meals, which
can impact the rate of alcohol intoxication and place them at risk for dehydration, blacking out,
and developing alcohol-induced seizures (Piazza-Gardner & Barry, 2013).
The “active” substance of alcohol, ethyl alcohol, is a chemical that is absorbed quickly
into the blood via the lining of the stomach and intestine. Once in the bloodstream, ethyl alcohol
travels to the central nervous system (i.e., brain and spinal cord) and produces depressive
11-6
symptoms such as impaired reaction time, disorientation, and slurred speech. These symptoms
are produced due to the ethyl alcohol binding to GABA receptors, thus preventing GABA from
providing inhibitory messages and allowing the individual to relax (Filip et al., 2015).
The effect of ethyl alcohol in moderation allows for an individual to relax, engage more
readily in conversation, and in general, produce a confident and happy personality. However,
when consumption is increased or excessive, the central nervous system is unable to metabolize
the ethyl alcohol adequately, and adverse effects begin to present. Symptoms such as blurred
vision, difficulty walking, slurred speech, slowed reaction time, and sometimes, aggressive
behaviors are observed.
The extent to which these symptoms present are directly related to the concentration of
ethyl alcohol within the body, as well as the individual’s ability to metabolize the ethyl alcohol.
There are a lot of factors that contribute to how quickly one’s body can metabolize ethyl alcohol.
Food, gender, body weight, and medications are among the most common factors that affect
alcohol absorption (NIAAA,1997). More specifically, recent consumption of food, particularly
that high in fat and carbohydrates, slows the absorption rate of ethyl alcohol, thus reducing its
effects. With regard to gender, women absorb and metabolize alcohol differently than men,
likely due to the smaller amount of body water and the lower activity of an alcohol metabolizing
enzyme in the stomach. Another factor related to gender is weight—with individuals with more
body mass metabolizing the alcohol at a slower rate than those who weigh less. Finally, various
medications, both over the counter and prescription, can impact the liver’s ability to metabolize
alcohol, thus affecting the severity of symptoms that present (NIAAA, 1997).
Sedative-Hypnotic drugs, more commonly known as anxiolytic drugs, have a calming
and relaxing effect on individuals. When used at a clinically appropriate dosage, they can have a
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sedative effect, thus making them a suitable drug for treating anxiety-related disorders. In the
early 1900s, barbiturates were introduced as the main sedative and hypnotic drug; however, due
to their addictive nature, as well as respiratory distress when consumed in large amounts, they
have been largely replaced by benzodiazepines which are considered a safer alternative as they
have less addictive qualities (Filip et al., 2014).
Commonly prescribed benzodiazepines— Xanax, Ativan, and Valium—have a similar
effect to alcohol as they too bind to the GABA receptors and increase GABA activity (Filip et
al., 2014). This increase in GABA produces a sedative and calming effect. Benzodiazepines can
be prescribed for both temporary relief (pre-flight or before surgery) or long-term use
(generalized anxiety disorder). While they do not produce respiratory distress in large dosages
like benzodiazepines, they can cause intoxication and addictive behaviors due to their effects on
tolerance.
Opioids are naturally occurring, derived from the sap of the opium poppy. In the early
1800s, morphine was isolated from opium by German chemist Friedrich Wilhelm Adam
Serturner. Due to its analgesic effect, it was named after the Greek god of dreams, Morpheus
(Brownstein, 1993). Its popularity grew during the American Civil War as it was the primary
medication given to soldiers with battle injuries. Unfortunately, this is also when the addictive
nature of the medication was discovered, as many soldiers developed “Soldier’s Disease” as a
response to tolerance of the drug (Casey, 1978).
In an effort to alleviate the addictive nature of morphine, heroin was synthesized by the
German chemical company Bayer in 1898 and was offered in a cough suppressant (Yes, Bayer
promoted heroin). For years, heroin remained in cough suppressants as well as other pain
reducers until it was discovered that heroin was actually more addictive than morphine. In 1917,
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Congress identified that all drugs derived from opium were addictive, thus banning the use of
opioids in over-the-counter medications.
Opioids are unique in that they provide both euphoria and drowsiness. Tolerance to these
drugs builds quickly, thus resulting in an increased need of the medication to produce desired
effects. This rapid tolerance is also likely responsible for opioids’ highly addictive nature. Opioid
withdrawal symptoms can range from restlessness, muscle pain, fatigue, anxiety, and insomnia.
Unfortunately, these withdrawal symptoms, as well as intense cravings for the drug, can persist
for several months, with some reports up to years. Because of the intensity and longevity of these
withdrawal symptoms, many individuals struggle to remain abstinent, and accidental overdoses
are common (CDC, 2013).
The rise of abuse and misuse of opioid products in the early-to-mid 2000s is a direct
result of the increased number of opioid prescription medications containing oxycodone and
hydrocodone (Jayawant & Balkrishnana, 2005). The 2015 report estimated 12.5 million
Americans were abusing prescription narcotic pain relievers in the past year (SAMHSA, 2016).
In efforts to reduce the abuse of these medications, the FDA developed programs to educate
prescribers about the risks of misuse and abuse of opioid medications.
11.1.2.2. Stimulants. The two most common types of stimulants abused are cocaine and
amphetamines. Unlike depressants that reduce the activity of the central nervous system,
stimulants have the opposite effect, increasing the activity in the central nervous system.
Physiological changes that occur with stimulants are increased blood pressure, heart rate,
pressured thinking/speaking, and rapid, often jerky behaviors. Because of these symptoms,
stimulants are commonly used for their feelings of euphoria, to reduce appetite, and prevent
sleep.
11-9
Similar to opioids, cocaine is extracted from a South American plant—the coca plant—
and produces feelings of energy and euphoria. It is the most potent natural stimulant known to
date (Acosta et al., 2011). As stated, low doses can produce feelings of excitement, talkativeness,
and euphoria; however, as the amount of ingested cocaine increases, physiological changes such
as rapid breathing, increased blood pressure, and excessive arousal can be observed. The
psychological and physiological effects of cocaine are due to an increase of dopamine,
norepinephrine, and serotonin in various brain structures (Haile, 2012; Hart & Ksir, 2014).
One key feature of cocaine use is the rapid high of cocaine intoxication, followed by the quick
depletion, or crashing, as the drug diminishes within the body. During the euphoric intoxication,
individuals will experience poor muscle coordination, grandiosity, compulsive behavior,
aggression, and possible hallucinations and delusions (Haile, 2012). Conversely, as the drug
leaves the system, the individual will experience adverse effects such as headaches, dizziness,
and fainting (Acosta et al., 2011). These negative feelings often produce a negative feedback
loop, encouraging individuals to ingest more cocaine to alleviate the negative symptoms. This
also increases the chance of accidental overdose.
Cocaine is unique in that it can be ingested in various ways. While cocaine was initially
snorted via the nasal cavity, individuals found that if the drug was smoked or injected, its effects
were more potent and longer-lasting (Haile, 2012). The most common way cocaine is currently
ingested is via freebasing, which involves heating cocaine with ammonia to extract the cocaine
base. This method produces a form of cocaine that is almost 100 percent pure. Due to its low
melting point, freebased cocaine is easy to smoke via a glass pipe. Inhaled cocaine is absorbed
into the bloodstream and brain within 10-15 seconds suggesting its effects are felt almost
immediately (Addiction Centers of America).
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Crack is a derivative of cocaine that is formed by combining cocaine with water and
another substance (commonly baking soda) to create a solid structure that is then broken into
smaller pieces. Because of this process, it requires very little cocaine to make crack, thus making
it a more affordable drug. Coined for the crackling sound that is produced when it is smoked, it is
also highly addictive, likely due to the fast-acting nature of the drug. While the effects of cocaine
peak in 20-30 minutes and last for about 1-2 hours, the effects of crack peak in 3-5 minutes and
last only for up to 60 minutes (Addiction Centers of America).
Amphetamines are manufactured in a laboratory setting. Currently, the most common
amphetamines are prescription medications such as Ritalin, Adderall, and Dexedrine (prescribed
for sleep disorders). These medications produce an increase in energy and alertness and reduce
appetite when taken at clinical levels. However, when consumed at larger dosages, they can
produce intoxication similar to psychosis, including violent behaviors. Due to the increased
energy levels and appetite suppressant qualities, these medications are often abused by students
studying for exams, athletes needing extra energy, and individuals seeking weight loss (Haile,
2012). Biologically, similar to cocaine, amphetamines affect the central nervous system by
increasing the amount of dopamine, norepinephrine, and serotonin in the brain (Haile, 2012).
Methamphetamine, a derivative of amphetamine, is often abused due to its low cost and
feelings of euphoria and confidence; however, it can have serious health consequences such as
heart and lung damage (Hauer, 2010). Most commonly used intravenously or nasally,
methamphetamine can also be eaten or heated to a temperature in which it can be smoked. The
most notable effects of methamphetamine use are the drastic physical changes to one’s
appearance, including significant teeth damage and facial lesions (Rusyniak, 2011).
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While I’m sure you all are well aware of how caffeine is consumed, you may be
surprised to learn that in addition to coffee, energy drinks, and soft drinks, caffeine can also be
found in chocolate and tea. Because of the vast use of caffeine, it is the most widely consumed
substance in the world, with approximately 90% of Americans consuming some form of caffeine
every day (Fulgoni, Keast, & Lieberman, 2015). While caffeine is often consumed in moderate
dosages, caffeine intoxication and withdrawal can occur. In fact, an increase in caffeine
intoxication and withdrawal have been observed with the simultaneous popularity of energy
drinks. Common energy drinks such as Monster and RedBull have nearly double the amount of
caffeine of tea and coke (Bigard, 2010). While adults commonly consume these drinks, a
startling 30% of middle and high schoolers also report regular consumption of energy drinks to
assist with academic and athletic responsibilities (Terry-McElrath, O’Malley, & Johnston, 2014).
The rapid increase in caffeinated beverages has led to a rise in ER visits due to the intoxication
effects (SAMHSA, 2013).
11.1.2.3. Hallucinogens/Cannabis/Combination. The final category includes both
hallucinogens and cannabis- both of which produce sensory changes after ingestion. While
hallucinogens are known for their ability to produce more severe delusions and hallucinations,
cannabis also has the capability of producing delusions or hallucinations; however, this typically
occurs only when large amounts of cannabis are ingested. More commonly, cannabis has been
known to have stimulant and depressive effects, thus classifying itself in a group of its own due
to the many different effects of the substance.
Hallucinogens come from natural sources and have been involved in cultural and
religious ceremonies for thousands of years. Synthetic forms of hallucinogens have also been
created—most common of which are PCP, Ketamine, LSD, and Ecstasy. In general,
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hallucinogens produce powerful changes in sensory perception. Depending on the type of drug
ingested, effects can range from hallucinations, changes in color perception, or distortion of
objects. Additionally, some individuals report enhanced auditory, as well as changes in physical
perception such as tingling or numbness of limbs and interchanging hot and cold sensations
(Weaver & Schnoll, 2008). Interestingly, the effect of hallucinogens can vary both between
individuals, as well as within the same individual. This means that the same amount of the same
drug may produce a positive experience one time, but a negative experience the next time.
Overall, hallucinogens do not have addictive qualities; however, individuals can build a
tolerance, thus needing larger quantities to produce similar effects (Wu, Ringwalt, Weiss, &
Blazer, 2009). Furthermore, there is some evidence that long-term use of these drugs results in
psychosis, mood, or anxiety disorders due to the neurobiological changes after using
hallucinogens (Weaver & Schnoll, 2008).
Similar to hallucinogens and a few other substances, cannabis is also derived from a
natural plant—the hemp plant. While the most powerful of hemp plants is hashish, the most
commonly known type of cannabis, marijuana, is a mixture of hemp leaves, buds, and tops of
plants (SAMHSA, 2014). Many external factors impact the potency of cannabis, such as the
climate it was grown in, the method of preparation, and the duration of storage. Of the active
chemicals within cannabis, tetrahydrocannabinol (THC) appears to be the single component
that determines the potent nature of the drug. Various strains of marijuana have varying amounts
of THC; hashish contains a high concentration of THC, while marijuana has a small
concentration.
THC binds to cannabinoid receptors in the brain, which produces psychoactive effects.
These effects vary depending on both an individual’s body chemistry, as well as various strains
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and concentrations of THC. Most commonly, people report feelings of calm and peace,
relaxation, increased hunger, and pain relief. Occasionally, negative symptoms such as increased
anxiety or paranoia, dizziness, and increased heart rate also occur. In rare cases, individuals
develop psychotic symptoms or schizophrenia following cannabis use (Donoghue et al., 2014).
While nearly 20 million Americans report regular use of marijuana, only ten percent of these
individuals will develop a dependence on the drug (SAMHSA, 2013). Of particular concern is
the number of adolescents engaging in cannabis use. One in eight 8th graders, one in four 10th
graders, and one in three 12th graders reported use of marijuana in the past year (American
Academy of Child and Adolescent Psychiatry, 2013). Individuals who begin cannabis abuse
during adolescence are at an increased risk of developing cognitive effects from the drug due to
the critical period of brain development during adolescence (Gruber, Sagar, Dahlgren, Racine, &
Lukas, 2012). Increased discussion about the effects of marijuana use, as well as
psychoeducation about substance abuse in general, is important in preventing marijuana use
during adolescence.
It is not uncommon for substance abusers to consume more than one type of substance at
a time. This combination of substance use can have dangerous results depending on the
interactions between substances. For example, if multiple depressant drugs (i.e., alcohol,
benzodiazepines, and/or opiates) are consumed at one time, an individual is at risk for severe
respiratory distress or even death due to the compounding depressive effects on the central
nervous system. Additionally, when an individual is under the influence of one substance,
judgement may be impaired, and ingestion of a larger amount of another drug may lead to an
accidental overdose. Finally, the use of one drug to counteract the effects of another drug—
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taking a depressant to combat the effects of a stimulant—is equally as dangerous as the body is
unable to regulate homeostasis.

• An individual is diagnosed with Substance Intoxication, Use, and/or
Withdrawal specific to the substance or substances being ingested though the
symptoms remain the same across substances.
• Substance Intoxication occurs when a person has recently ingested a substance
leading to significant behavioral and/or psychological changes.
• Substance Use Disorder occurs when a person experiences significant
impairment or distress for 12 months due to the use of a substance.
• Substance Withdrawal occurs when there is a cessation or reduction of a
substance that has been used for a long period of time.
• Depressants include alcohol, sedative-hypnotic drugs, and opioids.
• Stimulants include cocaine and amphetamines, but caffeine as well.
• Hallucinogens come from natural sources and produce powerful changes in
sensory perception.
• Cannabis is also derived from a natural plant and produces psychoactive
effects.
• Many drugs are taken by users in combination which can have dangerous
results depending on the interactions between the substances.
1. What is a substance?
2. What is the difference between substance intoxication and substance abuse?
3. What is the difference between tolerance and withdrawal?
4. Create a table listing the three types of substances abused, as well as the
specific substances within each category.
5. What are the common factors that affect alcohol absorption?
6. What are the effects of sedative-hypnotic drugs?
7. What receptors are responsible for increasing activity in alcohol and
benzodiazepines?
8. What is responsible for the addictive nature of opioids?
9. What neurotransmitters are implicated in cocaine use?
10. What are the different ways cocaine can be ingested?
11. List the common types of amphetamines.
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11.2. Epidemiology
• Describe the epidemiology of depressants.
• Describe the epidemiology of stimulants.
• Describe the epidemiology of hallucinogens.
It has been estimated that nearly 9 percent of teens and adults in the United States have a
substance abuse disorder (SAMHSA, 2014). Asian/Pacific Islanders, Hispanics, and African
Americans are less likely to develop a lifetime substance abuse disorder compared to non-
Hispanic white individuals (Grant et al., 2016). Native Americans have the highest rate of
substance abuse at nearly 22 percent (NSDUH, 2013). Additional demographic variables also
suggest that overall substance abuse is greater in men than women, younger versus older
individuals, unmarried/divorced individuals than married, and in those with an education level of
a high school degree or lower (Grant et al., 2016). With regards to specific types of substances,
the highest prevalence rates of substances abused are cannabis, opioids, and cocaine, respectively
(Grant et al., 2016).
11.2.1. Depressants
Concerning depressant substances, men outnumber women in alcohol abuse 2 to 1
(Johnston et al., 2014). Ethnically, Native Americans have highest rate of alcoholism, followed
by White, Hispanic, African, Asian, respectively. With regards to opioid use, roughly 1 percent
of the population have this disorder, with 80% of those being addicted to pain-reliever opioids
such as oxycodone or morphine; the remaining 20% are heroin (SAMHSA, 2014).
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11.2.2. Stimulants
Nearly 1.1 percent of all high school seniors have used cocaine within the past month
(Johnston et al., 2014). Due to the high cost of cocaine, it is more commonly found in suburban
neighborhoods where consumers have the financial means to purchase the drugs.
Methamphetamine is used by men and women equally. It is popular among biker gangs, rural
America, and urban gay communities, as well as in clubs and all-night dance parties (aka raves;
Hopfer, 2011).
A major discussion concerning stimulant substance abuse is the abuse of stimulant
medication among college students. This is a growing concern, with 17% of college students
reportedly abusing stimulant medications. Greek organization membership, academic
performance, and other substance use were the most highly correlated variables related to
stimulant medication abuse.
11.2.3. Hallucinogens
Up to 14% of the general population have used LSD or another hallucinogen. Nearly 20
million adults and adolescents report current use of marijuana. Men report more than women.
Sixty-five percent of individuals report their first drug of use was marijuana—labeling it as a
gateway drug to other illicit substances (APA, 2013). Due to the increased research and positive
effects of medicinal marijuana, the movement to legalize recreational marijuana has gained
momentum, particularly in the Pacific Northwest of the United States.
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• More men and Native Americans are addicted to depressants.
• Cocaine is more prevalent in suburban neighborhoods due to its cost and
methamphetamine is used equally by men and women.
• Hallucinogens are used by up to 14% of the general population.
1. Identify the gender and ethnicity differences of substance abuse across the three
substance categories.
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11.3. Comorbidity
• Describe the comorbidity of substance-related and addictive disorders.
Substance abuse, in general, has a high comorbidity rate within itself (meaning abuse of
multiple different substances), as well as with other mental health disorders. Researchers believe
that substance abuse disorders are often secondary to another mental health disorder, as the
substance abuse develops as a means to “self-medicate” the underlying psychological disorder.
In fact, several large surveys identified alcohol and drug dependence to be twice as more likely
in individuals with anxiety, affective, and psychotic disorders than the general public (Hartz et
al., 2014). While it is difficult to identify exact estimates of the relationship between substance
abuse and serious mental health disorders, the consensus among researchers is that there is a
strong relationship between substance abuse and mood, anxiety, posttraumatic stress, and
personality disorders (Grant et al., 2016).

• Substance abuse has a high comorbidity within itself and with mental health
disorders.
1. With what other conditions is substance-related and addictive disorders highly

comorbid?
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11.4. Etiology
• Describe the biological causes of substance-related and addictive disorders.
• Describe the cognitive causes of substance-related and addictive disorders.
• Describe the behavioral causes of substance-related and addictive disorders.
• Describe the sociocultural causes of substance-related and addictive disorders.
11.4.1. Biological
11.4.1.1. Genetics. Similar to other mental health disorders, substance abuse is
genetically influenced. With that said, it is different than other mental health disorders in that if
the individual is not exposed to the substance, they will not develop substance abuse.
Heritability of alcohol abuse is among the most well studied substances, likely because it is the
only legal substance (except cannabis in some states). Twin studies have indicated a range of 50-
60% heritability risk for alcohol disorder (Kendler et al., 1997). Studies exploring the heritability
of other substance abuse, particularly drug use, suggests there may be a stronger heritability link
than previously thought (Jang, Livesley, & Vernon, 1995). Twin studies indicate that the genetic
component of drug abuse is stronger than drug use in general, meaning that genetic factors are
more significant for abuse of a substance over nonproblematic use (Tsuang et al., 1996).
Merikangas and colleagues (1998) found an 8-fold increased risk for developing a substance
abuse disorder across a wide range of substances.
Unique to substance abuse is the fact that both genetic and familial influence are both at
play. What does this mean? Well, biologically, the individual may be genetically predisposed to
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substance abuse; additionally, the individual may also be at risk due to their familial environment
where their parents or siblings are also engaging in substance abuse. Individuals whose parents
abuse substances may have a greater opportunity to ingest substances, thus promoting drug-
seeking behaviors. Furthermore, families with a history of substance abuse may have a more
accepting attitude of drug use than families with no history of substance abuse (Leventhal &
Schmitz, 2006).
11.4.1.2. Neurobiological. A longstanding belief about how drug abuse begins and is
maintained is the brain reward system. A reward can be defined as any event that increases the
likelihood of a response and has a pleasurable effect. The majority of research on the brain
reward system has focused on the mesocorticolimbic dopamine system, as it appears this area is
the primary reward system of most substances that are abused. As research has evolved in the
field of substance abuse, five additional neurotransmitters have also been implicated in the
reinforcing effect of addiction: dopamine, opioid peptides, GABA, serotonin, and
endocannabinoids. More specifically, dopamine is less involved in opioid, alcohol, and cannabis.
Alcohol and benzodiazepines lower the production of GABA, while cocaine and amphetamines
decrease dopamine. Cannabis has been shown to reduce the production of endocannabinoids.
11.4.2. Cognitive
Cognitive theorists have focused on the beliefs regarding the anticipated effects of
substance use. Defined as the expectancy effect, drug-seeking behavior is presumably motivated
by the desire to attain a particular outcome by ingesting a substance. The expectancy effect can
be defined in both positive and negative forms. Positive expectations are thought to increase
drug-seeking behavior, while negative experiences would decrease substance use (Oei &
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Morawska, 2004). Several studies have examined the expectancy effect on the use of alcohol.
Those with alcohol abuse reported expectations of tension reduction, enhanced sexual
experiences, and improved social pleasure (Brown, 1985). Additionally, observing positive
experiences, both in person and through television or social media, also shapes our drug use
expectancies.
While some studies have explored the impact of negative expectancy as a way to
eliminate substance abuse, research has failed to continually support this theory, suggesting that
positive experiences and expectations are a more powerful motivator of substance abuse than the
negative experiences (Jones, Corbin, Fromme, 2001).
11.4.3. Behavioral
Operant conditioning has been implicated in the role of developing substance use
disorders. As you may remember, operant conditioning refers to the increase or decrease of a
behavior, due to reinforcement or punishment. Since we are talking about increasing substance
use, behavioral theorists suggest that substance abuse is positively and negatively reinforced due
to the effects of a substance.
Positive reinforcement occurs when substance use is increased due to the positive or
pleasurable experiences of the substance. More specifically, the rewarding effect or pleasurable
experiences while under the influence of various substances directly impacts the likelihood that
the individual will use the substance again. Studies of substance use on animals routinely support
this theory as animals will work to receive injections of various drugs (Wise & Koob, 2013).
Negative reinforcement, or the increase of a given behavior due to the removal of a
negative effect, also plays a role in substance abuse in two different ways. First, many people
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ingest a substance as an escape from their unpleasant life—whether it be physical pain, stress, or
anxiety, to name a few. Therefore, the substance temporarily provides relief from a negative
environment, thus reinforcing future substance abuse (Wise & Koob, 2013). Secondly, negative
reinforcement is involved in symptoms of withdrawal. As previously mentioned, withdrawal
from a substance often produces significant negative symptoms such as nausea, vomiting,
uncontrollable shaking, etc. To eliminate these symptoms, an individual will consume more of
the substance, thus again escaping the negative symptoms and enjoying the “highs” of the
substance.
Arguably, one of the strongest influences of substance abuse is the impact of one’s
friends and the immediate environment. Peer attitudes, perception of others’ drug use, pressure
from peers to use substances, and beliefs about substance use are among the strongest predictors
of drug use patterns (Leventhal & Schmitz, 2006). This is particularly concerning during
adolescence when patterns of substance use typically begin.
Additionally, research continually supports a strong relationship between second-
generation substance abusers (Wilens et al., 2014). The increased possibility of family members’
substance abuse is likely related to both a genetic predisposition, as well as the accepting attitude
of the familial environment (Chung et al., 2014). Not only does a child have early exposure to
these substances if their parent has a substance abuse problem, but they are also less likely to
have parental supervision, which may impact their decision related to substance use (Wagner et
al., 2010). One potential protective factor against substance use is religiosity. More specifically,
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families that promote religiosity may actually reduce substance use by promoting negative
experiences (Galen & Rogers, 2004).
Another sociocultural view on substance abuse is stressful life events, particularly those
related to financial stability. Prevalence rates of substance abuse are higher among poorer people
(SAMHSA, 2014). Furthermore, additional stressors such as childhood abuse and trauma,
negative work environments, as well as discrimination are also believed to contribute to the
development of a substance use disorder (Hurd, Varner, Caldwell, & Zimmerman, 2014;
McCabe, Wilsnack, West, & Boyd, 2010; Unger et al., 2014).

• Biological causes of substance-related and addictive disorders include a genetic
predisposition though if the individual is not exposed to the substance they will
not develop the substance abuse and the brain reward system.
• Cognitive causes of substance-related and addictive disorders include the
expectancy effect, though research provides stronger support for positive
expectancy over negative expectancy.
• Behavioral causes of substance-related and addictive disorders include positive
and negative reinforcement.
• Sociocultural causes of substance-related and addictive disorders include friends
and the immediate environment.
1. Discuss the brain reward system. What neurobiological regions are implicated
within this system?
2. Define the expectancy effect. How does this explain the development and
maintenance of substance abuse?
3. Discuss operant conditioning in the context of substance abuse. What are the
reinforcers?
4. How does the sociocultural model explain substance abuse?
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11.5. Treatment
• Describe biological treatment options for substance-related and addictive disorders.
• Describe behavioral treatment options for substance-related and addictive disorders.
• Describe cognitive-behavioral treatment options for substance-related and addictive
disorders.
• Describe sociocultural treatment options for substance-related and addictive
disorders.
Given the large number of the population affected by substance abuse, it is not surprising
that there are many different approaches to treat substance use disorder. Overall, treatments for
substance-related disorders are only mildly effective, likely due in large part to the addictive
qualities in many of these substances (Belendiuk & Riggs, 2014).
11.5.1. Biological
11.5.1.1. Detoxification. Detoxification refers to the medical supervision of withdrawal
from a specified drug. While most detoxification programs are inpatient for increased
monitoring, some programs allow for outpatient detoxification, particularly if the addiction is not
as severe. There are two main theories of detoxification—gradually decreasing the amount of the
substance until the individual is off the drug completely, or, eliminate the substance entirely
while providing additional medications to manage withdrawal symptoms (Bisaga et al., 2015).
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Unfortunately, relapse rates are high for those engaging in detoxification programs, particularly
if they lack any follow-up psychological treatment.
11.5.1.2. Agonist drugs. As researchers continue to learn more about both the
mechanisms of substances commonly abused, as well as the mechanisms in which the body
processes these substances, alternative medications are created to essentially replace the drug in
which the individual is dependent on. These agonist drugs provide the individual with a “safe”
drug that has a similar chemical make-up to the addicted drug. One common example of this is
methadone, an opiate agonist that is often used in the reduction of heroin use (Schwartz,
Brooner, Montoya, Currens, & Hayes, 2010). Unfortunately, because methadone reacts to the
same neurotransmitter receptors as heroin, the individual essentially replaces their addiction to
heroin with an addiction to methadone. While this is not ideal, methadone treatment is highly
regulated under safe medical supervision. Furthermore, it is taken by mouth, thus eliminating the
potential adverse effects of unsterilized needles in heroin use. While some argue that methadone
maintenance programs are not an effective treatment because it simply replaces one drug for
another, others claim that the combination of methadone with education and psychotherapy can
successfully help individuals off both illicit drugs and methadone medications (Jhanjee, 2014).
11.5.1.3. Antagonist drugs. Unlike agonist drugs, antagonist drugs block or change the
effects of the addictive drug. The most commonly prescribed antagonist drugs are Disulfiram and
Naloxone. Disulfiram is often given to individuals trying to abstain from alcohol as it produces
significant negative effects (i.e., nausea, vomiting, increased heart rate, and dizziness) when
coupled with alcohol consumption. While this can be an effective treatment to eliminate alcohol
use, the individual must be motivated to take the medication as prescribed (Diclemente et al.,
2008).
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Similar to Disulfiram, Naloxone is used for individuals with opioid abuse. Naloxone acts
by binding to endorphin receptors, thus preventing the opioids from having the intended euphoric
effect. In theory, this treatment appears promising, but it is extremely dangerous as it can send
the individual into immediate, severe withdrawal symptoms (Alter, 2014). This type of treatment
requires appropriate medical supervision to ensure the safety of the patient.
11.5.2. Behavioral
11.5.2.1. Aversion therapy. Based on classical conditioning principles, aversion
therapy is a form of treatment for substance abuse that pairs the stimulus with some type of
negative or aversive stimulus. For example, an individual may be given a shock every time they
think about or attempt to drink alcohol. By pairing this aversive stimulus to the abused
substance, the individual will begin to independently pair the substance with an aversive thought,
thus reducing their craving/desire for the substance. Some view the use of agonist and antagonist
drugs as a form of aversion therapy as these medications utilize the same treatment strategy as
traditional aversion therapy.
11.5.2.2. Contingency management. Contingency management is a treatment approach
that emphasizes operant conditioning—increasing sobriety and adherence to treatment programs
through rewards. Originally developed to increase adherence to medication and reinforce opiate
abstinence in methadone patients, contingency management has been adapted to increase
abstinence in many different substance abuse treatment programs. In general, patients are
“rewarded” with vouchers or prizes in exchange for abstinence from substance use (Hartzler,
Lash, & Roll, 2012). These vouchers allow individuals to gain incentives specific to their
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interests, thus increasing the chances of abstinence. Common vouchers include movie tickets,
sports equipment, or even cash (Mignon, 2014).
Contingency management has been proven to be effective in treating various types of
substance abuse, particularly alcohol and cocaine (Lewis & Petry, 2005). Not only has it been
effective in reducing substance use in addicts, but it has also been effective in increasing the
amount of time patients remain in treatment as well as compliance with the treatment program
(Mignon, 2014). Despite its success, dissemination of this type of treatment has been rare. In an
effort to rectify this, the federal government has provided financial resources through SAMHSA
for the development, implementation, and evaluation of contingency management as a treatment
to reduce alcohol and drug use (Mignon, 2014).
11.5.3. Cognitive-Behavioral
11.5.3.1. Relapse prevention training. Relapse prevention training is essentially what it
sounds like—identifying potentially high-risk situations for relapse and then learning behavioral
skills and cognitive interventions to prevent the occurrence of a relapse. Early in treatment, the
clinician guides the patient to identify any interpersonal, intrapersonal, environmental, and
physiological risks for relapse. Once these triggers are identified, the clinician works with the
patient on cognitive and behavioral strategies such as learning effective coping strategies,
enhancing self-efficacy, and encouraging mastery of outcomes. Additionally, psychoeducation
about how substance abuse is maintained, as well as identifying maladaptive thoughts and
learning cognitive restructuring techniques, helps the patient make informed choices during high-
risk situations. Finally, role-playing these high-risk situations in session allows patients to
become comfortable engaging in these effective coping strategies that enhance their self-efficacy
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and ultimately reducing the chances of a relapse. Research for relapse prevention training
appears to be somewhat effective for individuals with substance-related disorders (Marlatt &
Donovan, 2005).
11.5.4.1. Self-help. In 1935, two men suffering from alcohol abuse met and discussed
their treatment options. Slowly, the group grew, and by 1946, this group was known as
Alcoholics Anonymous (AA). The two founders, along with other early members, developed the
Twelve Step Traditions as a way to help guide members in spiritual and character development.
Due to the popularity of the treatment program, other programs such as Narcotics Anonymous
and Cocaine Anonymous adopted and adapted the Twelve Steps for their respective substance
abuse. Similarly, Al-Anon and Alateen are two support groups that offer support for families and
teenagers of individuals struggling with alcohol abuse.
The overarching goal of AA is abstinence from alcohol. In order to achieve this, the
participants are encouraged to “take one day at a time.” In using the 12 steps, participants are
emboldened to admit that they have a disease, that they are powerless over this disease, and that
their disease is more powerful than any person. Therefore, participants turn their addiction over
to God and ask Him to help right their wrongs and remove their negative character defects and
shortcomings. The final steps include identifying and making amends to those who they have
wronged during their alcohol abuse.
While studies examining the effectiveness of AA programs are inconclusive, AA’s
membership indicates that 27% of its members have been sober less than one year, 24% have
been sober 1-5 years, 13% have been sober 5-10 years, 14% have been sober 10-20 years, and
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more than 22% have been sober over 20 years (Alcoholics Anonymous, 2014). Some argue that
this type of treatment is most effective for those who are willing and able to abstain from alcohol
as opposed to those who can control their drinking to moderate levels.
11.5.4.2. Residential treatment centers. Another type of treatment similar to self-help is
residential treatment programs. In this placement, individuals are completely removed from
their environment and live, work, and socialize within a drug-free community while also
attending regular individual, group, and family therapy. The types of treatment used within a
residential program varies from program to program, with most focusing on cognitive-behavioral
and behavioral techniques. Several also incorporate 12-step programs into treatment, as many
patients transition from a residential treatment center to a 12-step program post discharge. As
one would expect, the residential treatment goal is abstinence, and any evidence of substance
abuse during the program is grounds for immediate termination.
Studies examining the effectiveness of residential treatment centers suggest that these
programs are useful in treating a variety of substance abuse disorders; however, many of these
programs are very costly, thus limiting the availability of this treatment to the general public
(Bender, 2004; Galanter, 2014). Additionally, many individuals are not able to completely
remove themselves from their daily responsibilities for several weeks to months, particularly
those with families. Therefore, while this treatment option is very effective, it is also not an
option for most individuals struggling with substance abuse.
11.5.4.3. Community reinforcement. The goal for community reinforcement treatment
is for patients to abstain from substance use by replacing the positive reinforcements of the
substance with that of sobriety. This is done through several different techniques such as
motivational interviewing, learning adaptive coping strategies, and encouraging family support
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(Mignon, 2014). Essentially, the community around the patient reinforces the positive choices of
abstaining from substance use.
Community reinforcement has been found to be effective in both an inpatient and
outpatient setting (Meyers & Squires, 2001). It is believed that the intrinsic motivation and the
effective coping skills, in combination with the support of an individual’s immediate community
(friends and family) is responsible for the long-term positive treatment effects of community
reinforcement.

• Biological treatment options for substance-related and addictive disorders include
detoxification programs, agonist drugs, and antagonist drugs.
• Behavioral treatment options for substance-related and addictive disorders
include aversion therapy and contingency management.
• Cognitive-behavioral treatment options for substance-related and addictive
disorders include relapse prevention training.
• Sociocultural treatment options for substance-related and addictive disorders
include Alcoholics Anonymous, residential treatment centers, and community
reinforcement.
1. Discuss the differences between agonist and antagonist drugs. Give examples of
both.
2. What are the two behavioral treatments discussed in this module? Discuss their
effectiveness.
3. What are the main components of the 12-step programs? How effective are they
in substance abuse treatment?
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Module Recap
And that concludes Part IV of the book and Block 3 of mental disorders. In this module,
we discussed substance-related and addictive disorders to include substance intoxication,
substance use disorder, and substance withdrawal. Substances include depressants, sedative-
hypnotic drugs, opioids, stimulants, and hallucinogens. As in past modules, we discussed the
clinical presentation, epidemiology, comorbidity, and etiology of the disorders. We then also
discussed the biological, behavioral, cognitive-behavioral, and sociocultural treatment
approaches.
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Disorders Covered:
12. Schizophrenia Spectrum and Other Psychotic Disorders
13. Personality Disorders

Module 12:
Schizophrenia Spectrum and Other
Psychotic Disorders
12-1
Module 12: Schizophrenia Spectrum and Other Psychotic Disorders
Module Overview
In Module 12, we will discuss matters related to schizophrenia spectrum disorders to
Our discussion will consist of schizophrenia, schizophreniform disorder, schizoaffective
disorder, and delusional disorder. Be sure you refer Modules 1-3 for explanations of key terms
(Module 1), an overview of the various models to explain psychopathology (Module 2), and
descriptions of the therapies (Module 3).
Module Outline
• 12.4. Etiology
• 12.5. Treatment
• Describe how schizophrenia spectrum disorders present.
• Describe the epidemiology of schizophrenia spectrum disorders.
• Describe comorbidity in relation to schizophrenia spectrum disorders.
• Describe the etiology of schizophrenia spectrum disorders.
• Describe treatment options for schizophrenia spectrum disorders.

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• List and describe distinguishing features that make up the clinical presentation of
schizophrenia spectrum disorders.
• Describe how schizophrenia presents.
• Describe how schizophreniform disorder presents.
• Describe how schizoaffective disorder presents.
• Describe how delusional disorder presents.
12.1.1. The Clinical Presentation of Schizophrenia Spectrum Disorders
For the purpose of this book, the schizophrenia spectrum disorder module will cover,
Schizophrenia, Schizophreniform disorder, Schizoaffective disorder, and Delusional disorder.
These schizophrenia spectrum disorders are defined by one of the following main symptoms:
delusions, hallucinations, disorganized thinking (speech), disorganized or abnormal motor
behavior, and negative symptoms. Individuals diagnosed with a schizophrenia spectrum disorder
experience psychosis, which is defined as a loss of contact with reality. Psychosis episodes make
it difficult for individuals to perceive and respond to environmental stimuli, causing a significant
disturbance in everyday functioning. While there are a vast number of symptoms displayed in
schizophrenia spectrum disorders, presentation of symptoms varies greatly among individuals, as
there are rarely two cases similar in presentation, triggers, course, or responsiveness to treatment
(APA, 2013).
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12.1.1.1. Delusions. Delusions are “fixed beliefs that are not amenable to change in light
of conflicting evidence” (APA, 2013, pp. 87). This means that despite evidence contradicting
one’s thoughts, the individual is unable to distinguish their thoughts from reality. The inability to
identify thoughts as delusional is likely likely due to a lack of insight. There are a wide range of
delusions that are seen in the schizophrenia related disorders to include:
• Delusions of grandeur- belief they have exceptional abilities, wealth, or fame; belief
they are God or other religious saviors
• Delusions of control- belief that others control their thoughts/feelings/actions
• Delusions of thought broadcasting- belief that one’s thoughts are transparent and
everyone knows what they are thinking
• Delusions of persecution- belief they are going to be harmed, harassed, plotted or
discriminated against by either an individual or an institution; it is the most common
delusion (Arango & Carpenter, 2010)
• Delusions of reference- belief that specific gestures, comments, or even larger
environmental cues are directed directly to them
• Delusions of thought withdrawal- belief that one’s thoughts have been removed by
another source
It is believed that the presentation of the delusion is primarily related to the social,
emotional, educational, and cultural background of the individual (Arango & Carpenter, 2010).
For example, an individual with schizophrenia who comes from a highly religious family is more
likely to experience religious delusions (delusions of grandeur) than another type of delusion.
12.1.1.2. Hallucinations. Hallucinations can occur in any of the five senses: hearing
(auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations),
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touching (tactile hallucinations), and tasting (gustatory hallucinations). Additionally, they can
occur in a single modality or present across a combination of modalities (e.g., having auditory
and visual hallucinations). For the most part, individuals recognize that their hallucinations are
not real and attempt to engage in normal behavior while simultaneously combating ongoing
hallucinations.
According to various research studies, nearly half of all patients with schizophrenia
report auditory hallucinations, 15% report visual hallucinations, and 5% report tactile
hallucinations (DeLeon, Cuesta, & Peralta, 1993). Among the most common types of auditory
hallucinations are voices talking to the patient or various voices talking to one another.
Generally, these hallucinations are not attributable to any one person that the individual knows.
They are usually clear, objective, and definite (Arango & Carpenter, 2010). Additionally, the
auditory hallucinations can be pleasurable, providing comport to the patient; however, in other
individuals, the auditory hallucinations can be unsettling as they produce commands or malicious
intent.
12.1.1.3. Disorganized thinking. Among the most common cognitive impairments
displayed in patients with schizophrenia are disorganized thought, communication, and speech.
More specifically, thoughts and speech patterns may appear to be circumstantial or tangential.
For example, patients may give unnecessary details in response to a question before they finally
produce the desired response. While the question is eventually answered in circumstantial speech
patterns, in tangential speech patterns the patient never reaches the point. Another common
cognitive symptom is speech retardation, where the individual may take a long time before
answering a question. Derailment, or the illogical connection in a chain of thoughts, is another
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common type of disorganized thinking. Although not always, derailment is often seen in
illogicality, or the tendency to provide bizarre explanations for things.
These types of distorted thought patterns are often related to concrete thinking. That is,
the individual is focused on one aspect of a concept or thing and neglects all other aspects. This
type of thinking makes treatment difficult as individuals lack insight into their illness and
symptoms (APA, 2013).
12.1.1.4. Disorganized/Abnormal motor behavior. Psychomotor symptoms can also be
observed in individuals with schizophrenia. These behaviors may manifest as awkward
movements or even ritualistic/repetitive behaviors. They are often unpredictable and
overwhelming, severely impacting their ability to perform daily activities (APA, 2013).
12.1.1.5. Catatonic behavior. Catatonic behavior, the decreased or complete lack of
reactivity to the environment, is among the most commonly seen disorganized motor behavior in
schizophrenia. There runs a range of catatonic behaviors from negativism (resistance to
instruction); mutism or stupor (complete lack of verbal and motor responses); rigidity
(maintaining a rigid or upright posture while resisting efforts to be moved); or posturing (holding
odd, awkward postures for long periods; APA, 2013). There is one type of catatonic behavior,
catatonic excitement, where the individual experiences hyperactivity of motor behavior, in a
seemingly excited or delirious way.
12.1.1.6. Negative symptoms. Up until this point, all the schizophrenia symptoms can be
categorized as positive symptoms, or symptoms that are an over-exaggeration of normal brain
processes; these symptoms are also new to the individual. The final diagnostic criterion of
schizophrenia is negative symptoms, which are defined as the inability or decreased ability to
initiate actions, speech, express emotion, or feel pleasure (Barch, 2013). Negative symptoms
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often present before positive symptoms and remain once positive symptoms remit. Because of
their prevalence through the course of the disorder, they are also more indicative of prognosis,
with more negative symptoms suggesting a poorer prognosis. The poorer prognosis may be
explained by the lack of effectiveness antipsychotic medications have in addressing negative
symptoms (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). There are six main types of
negative symptoms seen in patients with schizophrenia. Such symptoms include:
• Affective flattening - Reduction in emotional expression; reduced display of
emotional expression
• Alogia - Poverty of speech or speech content
• Anhedonia - Inability to experience pleasure
• Apathy - General lack of interest
• Asociality - Lack of interest in social relationships
• Avolition - Lack of motivation for goal-directed behavior
12.1.2. Schizophrenia
As stated above, the hallmark symptoms of schizophrenia include the presentation of at
least two of the following for at least one month: delusions, hallucinations, disorganized speech,
disorganized/abnormal behavior, or negative symptoms. These symptoms create significant
impairment in an individual’s ability to engage in normal daily functioning such as work, school,
relationships with others, or self-care. It should be noted that the presentation of schizophrenia
varies significantly among individuals, as it is a heterogeneous clinical syndrome (APA, 2013).
While the presence of symptoms must persist for a minimum of 6 months to meet the
criteria for a schizophrenia diagnosis, it is not uncommon to have prodromal symptoms that
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precede the active phase of the disorder and residual symptoms that follow it. These prodromal
and residual symptoms are “subthreshold” forms of psychotic symptoms that do not cause
significant impairment in functioning, with the exception of negative symptoms (Lieberman et
al., 2001). Due to the severity of psychotic symptoms, mood disorder symptoms are also
common among individuals with schizophrenia; however, these mood symptoms are distinct
from a mood disorder diagnosis in that psychotic features will exist beyond the remission of
depressive symptoms.
12.1.3. Schizophreniform Disorder
Schizophreniform disorder is similar to schizophrenia, except for the length of
presentation of symptoms. Schizophreniform disorder is considered an “intermediate” disorder
between schizophrenia and brief psychotic disorder as the symptoms are present for at least one
month but not longer than six months. As you may recall, schizophrenia symptoms must be
present for at least six months; A brief psychotic disorder is diagnosed when symptoms are
present for less than one month. Approximately two-thirds of individuals who are initially
diagnosed with schizophreniform disorder will have symptoms that last longer than six months,
at which time their diagnosis is changed to schizophrenia (APA, 2013).
Another key distinguishing feature of schizophreniform disorder is the lack of criteria
related to impaired functioning. While many individuals with schizophreniform disorder do
display impaired functioning, it is not essential for diagnosis. Finally, any major mood
episodes—either depressive or manic— that are present concurrently with the psychotic features
must only be present for a short time, otherwise a diagnosis of schizoaffective disorder may be
more appropriate (APA, 2013).
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12.1.4. Schizoaffective Disorder
Schizoaffective disorder is characterized by the psychotic symptoms included in
schizophrenia and a concurrent uninterrupted period of a major mood episode—either a
depressive or manic episode. It should be noted that because the loss of interest in pleasurable
activities is a common symptom of schizophrenia, to meet the criteria for a depressive episode
within schizoaffective disorder, the individual must present with a pervasive depressed mood
(APA, 2013). While schizophrenia and schizophreniform disorder do not have a significant
mood component, schizoaffective disorder requires the presence of a depressive or manic
episode for the majority, if not the total duration of the disorder. While psychotic symptoms are
sometimes present in depressive episodes, they often remit once the depressive episode is
resolved. For individuals with schizoaffective disorder, psychotic symptoms should continue for
at least two weeks in the absence of a major mood disorder (APA, 2013). This is the key
distinguishing feature between schizoaffective disorder and major depressive disorder with
psychotic features.
12.1.5. Delusional Disorder
As suggestive of its title, delusional disorder requires the presence of at least one delusion
that lasts for at least one month in duration. It is important to note that if an individual
experiences hallucinations, disorganized speech, disorganized or catatonic behavior, or negative
symptoms—in addition to delusions—they should not be diagnosed with delusional disorder as
their symptoms are more aligned with a schizophrenia diagnosis. Unlike most other
schizophrenia-related disorders, daily functioning is not overly impacted due to the delusions.
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Additionally, if symptoms of depressive or manic episodes present during delusions, they are
typically brief compared to the duration of the delusions.
The DSM-V (APA, 2013) has identified five main subtypes of delusional disorder to
better categorize the symptoms of the individual's disorder. When making a diagnosis of
delusional disorder, one of the following modifiers (in addition to mixed presentation) is
included. Erotomanic delusion occurs when an individual reports a delusion of another person
being in love with them. Generally speaking, the individual whom the convictions are about is of
higher status, such as a celebrity. Grandiose delusion involves the conviction of having great
talent or insight. Occasionally, patients will report they have made an important discovery that
benefits the general public. Grandiose delusions may also take on religious affiliation, as people
believe they are prophets or even God. Jealous delusion revolves around the conviction that
one’s spouse or partner is/has been unfaithful. While many individuals may have this suspicion
at some point in their relationship, a jealous delusion is much more extensive and generally
based on incorrect inferences that lack evidence. Persecutory delusion involves the individual
believing that they are being conspired against, spied on, followed, poisoned or drugged,
maliciously maligned, harassed, or obstructed in pursuit of their long-term goals (APA, 2013).
Of all subtypes of delusional disorder, those experiencing persecutory delusions are the most at
risk of becoming aggressive or hostile, likely due to the persecutory nature of their distorted
beliefs. Finally, somatic delusion involves delusions regarding bodily functions or sensations.
While these delusions can vary significantly, the most common beliefs are that the individual
emits a foul odor despite attempts to rectify the smell; there is an infestation of insects on the
skin; or that they have an internal parasite (APA, 2013).
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• Schizophrenia spectrum disorders are characterized by delusions,
hallucinations, disorganized thinking (speech), disorganized or abnormal
motor behavior, and negative symptoms.
• Delusions are beliefs that do not change even when conflicting evidence is
presented and can be of grandeur, control, thought broadcasting,
persecution, reference, and thought withdrawal.
• Hallucinations occur in any sense modality and most individuals recognize
that they are not real.
• Disorganized thinking, abnormal motor behavior, catatonic behavior, and
negative symptoms such as affective flattening, alogia, anhedonia, apathy,
asociality, and avolition are also common to schizophrenia spectrum
disorders.
• Schizophrenia is characterized by delusions, hallucinations, disorganized
speech, disorganized/abnormal behavior, or negative symptoms.
• Schizophreniform disorder is considered an “intermediate” disorder
between schizophrenia and brief psychotic disorder as the symptoms are
present for at least one month but not longer than six months.
• Schizoaffective disorder is characterized by the psychotic symptoms
included in schizophrenia and a concurrent uninterrupted period of a major
mood episode—either a depressive or manic episode.
• Delusional disorder requires the presence of at least one delusion that lasts
for at least one month in duration to include erotomanic, grandiose,
jealous, persecutory, and somatic.
1. What are the five positive symptoms identified in a schizophrenia

diagnosis? Define and identify their difference.
2. What is meant by negative symptoms? What are the negative symptoms
observed in schizophrenia related disorders?
3. Identify diagnostic differences between Schizophrenia, Schizophreniform,
Schizoaffective, and Delusional disorder.
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12.2. Epidemiology
• Describe the epidemiology of schizophrenia spectrum disorders.
Schizophrenia occurs in approximately 0.3%-0.7% of the general population (APA,
2013). There is some discrepancy in rates of diagnosis between genders; these differences appear
to be related to the emphasis of various symptoms. For example, men typically present with
more negative symptoms, whereas women present with more mood-related symptoms. Despite
gender differences in the presentation of symptoms, there appears to be an equal risk for both
genders to develop the disorder.
Schizophrenia typically occurs between late teens and mid-30s, with the onset of the
disorder slightly earlier for males than females (APA, 2013). Earlier onset of the disorder is
generally predictive of a worse overall prognosis. Onset of symptoms is typically gradual, with
initial symptoms presenting similarly to depressive disorders; however, some individuals will
present with an abrupt presentation of the disorder. Negative symptoms appear to be more
predictive of prognosis than other symptoms. This may be due to negative symptoms being the
most persistent, and therefore, most difficult to treat. Overall, an estimated 20% of individuals
diagnosed with schizophrenia report complete recovery of symptoms (APA, 2013).
Schizoaffective disorder, schizophreniform disorder, and delusional disorder prevalence
rates are all significantly less than that of schizophrenia, occurring in less than 0.3% of the
general population. While schizoaffective disorder is diagnosed more in females than males
(similar to schizophrenia), schizophreniform and delusional disorder appear to be diagnosed

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equally between genders. The gender discrepancy in schizoaffective disorder is likely due to the
higher rate of depressive symptoms seen in females than males (APA, 2013).

• Less than 1% of the general population is diagnosed with schizophrenia and
20% of these people fully recovery from the disorder.
• Both genders have an equal risk of developing schizophrenia while men
typically display more negative symptoms while women present with more
mood-related symptoms.
• Schizoaffective disorder, schizophreniform disorder, and delusional disorder
have prevalence rates less than 0.3%.
1. Discuss the different prevalence rates across the schizophrenia related disorders.
Are there differences among the disorders? Between genders?
2. Are there differences in prevalence rates depending on symptom presentations?
If so, what?
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12.3. Comorbidity
• Describe the comorbidity of schizophrenia spectrum disorders.
There is a high comorbidity rate between schizophrenia-related disorders and substance
abuse disorders. Furthermore, there is some evidence to suggest that the use of various
substances (particularly marijuana) may place an individual at an increased risk of developing
schizophrenia if the genetic predisposition is also present (see diathesis-stress model below;
Corcoran et al., 2003). Additionally, there appears to be an increase in anxiety-related
disorders—specifically obsessive-compulsive disorder and panic disorder—among individuals
with schizophrenia than compared to the general public.
It should also be noted that individuals diagnosed with a schizophrenia-related disorder
are also at an increased risk for associated medical conditions such as weight gain, diabetes,
metabolic syndrome, and cardiovascular and pulmonary disease (APA, 2013). This
predisposition to various medical conditions is likely related to medications and poor lifestyle
choices, and also place individuals at risk for a reduced life expectancy.
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• Schizophrenia-related disorders have a high comorbidity with substance abuse
disorders, anxiety-related disorders, and some medical conditions.
1. What comorbidities exist between schizophrenia and other conditions?
12.4. Etiology
• Describe the biological causes of schizophrenia spectrum disorders.
• Describe the psychological causes of schizophrenia spectrum disorders.
• Describe the sociocultural causes of schizophrenia spectrum disorders.
12.4.1. Biological
12.4.1.1. Genetic/Family studies. Twin and family studies consistently support the
biological theory. More specifically, if one identical twin develops schizophrenia, there is a 48%
chance that the other will also develop the disorder within their lifetime (Coon & Mitter, 2007).
This percentage drops to 17% in fraternal twins. Similarly, family studies have also found
similarities in brain abnormalities among individuals with schizophrenia and their relatives; the
more similarities, the higher the likelihood that the family member also developed schizophrenia
(Scognamiglio & Houenou, 2014).

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12.4.1.2. Neurobiological. There is consistent and reliable evidence of a neurobiological
component in the transmission of schizophrenia. More specifically, neuroimaging studies have
found a significant reduction in overall and specific brain region volumes, as well as tissue
density of individuals with schizophrenia compared to healthy controls (Brugger, & Howes,
2017). Additionally, there has been evidence of ventricle enlargement as well as volume
reductions in the medial temporal lobe. As you may recall, structures such as the amygdala
(involved in emotion regulation), the hippocampus (involved in memory), as well as the
neocortical surface of the temporal lobes (processing of auditory information) are all structures
within the medial temporal lobe (Kurtz, 2015). Additional studies also indicate a reduction in the
orbitofrontal regions of the brain, a part of the frontal lobe that is responsible for response
inhibition (Kurtz, 2015).
12.4.1.3. Stress cascade. The stress-vulnerability model suggests that individuals have a
genetic or biological predisposition to develop the disorder; however, symptoms will not present
unless there is a stressful precipitating factor that elicits the onset of the disorder. Researchers
have identified the HPA axis and its consequential neurological effects as the likely responsible
neurobiological component responsible for this stress cascade.
The HPA axis is one of the main neurobiological structures that mediate stress. It
involves the regulation of three chemical messengers (corticotropin-releasing hormone [CRH],
adrenocorticotropic hormone [ACTH], and glucocorticoids) as they respond to a stressful
situation (Corcoran et al., 2003). Glucocorticoids, more commonly referred to as cortisol, is the
final neurotransmitter released which is responsible for the physiological change that
accompanies stress to prepare the body to “fight” or “flight.”
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It is hypothesized that in combination with abnormal brain structures, persistently
increased levels of glucocorticoids in brain structures may be the key to the onset of psychosis in
prodromal patients (Corcoran et al., 2003). More specifically, stress exposure (and increased
glucocorticoids) affects the neurotransmitter system and exacerbates psychotic symptoms due to
changes in dopamine activity (Walker & Diforio, 1997). While research continues to explore the
relationship between stress and onset of the disorder, evidence for the implication of stress and
symptom relapse is strong. More specifically, schizophrenia patients experience more stressful
life events leading up to a relapse of symptoms. Similarly, it is hypothesized that the worsening
or exacerbation of symptoms is also a source of stress as they interfere with daily functioning
(Walker & Diforio, 1997). This stress alone may be enough to initiate the onset of a relapse.
12.4.2.1. Cognitive. The cognitive model utilizes some of the aspects of the diathesis-
stress model in that it proposes that premorbid neurocognitive impairment places individuals at
risk for aversive work/academic/interpersonal experiences. These experiences, in turn, lead to
dysfunctional beliefs and cognitive appraisals, ultimately leading to maladaptive behaviors such
as delusions/hallucinations (Beck & Rector, 2005).
Beck proposed the following diathesis-stress model of development of schizophrenia:
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Adapted from Beck & Rector, 2005, pg. 580
Based on this theory, an underlying neurocognitive impairment (as discussed above)
makes an individual more vulnerable to experience aversive life events such as homelessness,
conflict within the family, etc. Individuals with schizophrenia are more likely to evaluate these
aversive life events with a dysfunctional attitude and maladaptive cognitive distortions. The
combination of the aversive events and negative interpretations produces a stress response in the
individual, thus igniting hyperactivation of the HPA axis. According to Beck and Rector (2005),
it is the culmination of these events leads to the development of schizophrenia.
12.4.3.1. Expressed emotion. Research regarding supportive family environments
suggests that families high in expressed emotion, meaning families that have high hostile,
critical, or overinvolved family members, are predictors of relapse (Bebbington & Kuipers,
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2011). In fact, individuals who return post-hospitalization to families with high criticism and
emotional involvement are twice as likely to relapse compared to those who return to families
with low expressed emotion (Corcoran et al., 2003). Several meta-analyses have concluded that
family atmosphere is causally related to relapse in patients with schizophrenia, and that these
outcomes can be improved when the family environment is improved (Bebbington & Kuipers,
2011). Therefore, one major treatment goal in families of patients with schizophrenia is to reduce
expressed emotion within family interactions.
12.4.3.2. Family dysfunction. Even for families with low levels of expressed emotion,
there is often an increase in family stress due to the secondary effects of schizophrenia. Having a
family member with schizophrenia increases the likelihood of a disruptive family environment
due to managing the patient’s symptoms and ensuring their safety while they are home (Friedrich
et al., 2015). Because of the severity of symptoms, families with a loved one diagnosed with
schizophrenia often report more conflict in the home as well as more difficulty communicating
with one another (Kurtz, 2015).
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• Biological causes of schizophrenia spectrum disorders include genetics,
several brain structures, and the HPA axis.
• Psychological causes of schizophrenia spectrum disorders include the
diathesis-stress model.
• Sociocultural causes of schizophrenia spectrum disorders include families
high in expressed emotion and family dysfunction.
1. What evidence is there to support a biological model with respect to

explaining the development and maintenance of the schizophrenia related
disorders?
2. Discuss the stress-vulnerability model with respect to schizophrenia related
disorders.
3. How does the sociocultural model explain the maintenance (and relapse) of
schizophrenia related symptoms?
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12.5. Treatment
• Describe psychopharmacological treatment options for schizophrenia spectrum
disorders.
• Describe psychological treatment options for schizophrenia spectrum disorders.
• Describe family interventions for schizophrenia spectrum disorders.
While a combination of psychopharmacological, psychological, and family interventions
is the most effective treatment in managing schizophrenia symptoms, rarely do these treatments
restore a patient to premorbid levels of functioning (Kurtz, 2015; Penn et al., 2004). Although
more recent advancements in treatment for schizophrenia appear promising, the disease itself is
still viewed as one that requires lifelong treatment and care.
12.5.1. Psychopharmacological
Among the first antipsychotic medications used for the treatment of schizophrenia was
Thorazine. Developed as a derivative of antihistamines, Thorazine was the first line of treatment
that produced a calming effect on even the most severely agitated patients and allowed for the
organization of thoughts. Despite their effectiveness in managing psychotic symptoms,
conventional antipsychotics (such as Thorazine and Chlorpromazine) also produced significant
side effects similar to that of neurological disorders. Therefore, psychotic symptoms were
replaced with muscle tremors, involuntary movements, and muscle rigidity. Additionally, these
conventional antipsychotics also produced tardive dyskinesia in patients, which included

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involuntary movements isolated to the tongue, mouth, and face (Tenback et al., 2006). While
only 10% of patients reported the development of tardive dyskinesia, this percentage increased
the longer patients were on the medication, as well as the higher the dose (Achalia, Chaturvedi,
Desai, Rao, & Prakash, 2014). In efforts to avoid these symptoms, clinicians have been
cognizant of not exceeding the clinically effective dose of conventional antipsychotic
medications. If the management of psychotic symptoms cannot be resolved at this level,
alternative medications are often added to produce a synergistic effect (Roh et al., 2014).
Due to the harsh side effects of conventional antipsychotic drugs, newer, arguably more
effective second-generation or atypical antipsychotic drugs have been developed. The atypical
antipsychotic drugs appear to act on both dopamine and serotonin receptors, as opposed to only
dopamine receptors in the conventional antipsychotics. Because of this, common medications
such as clozapine (Clozaril), risperidone (Risperdal), and aripiprazole (Abilify), appear to be
more effective in managing both positive and negative symptoms. While there continues to be a
risk of developing side effects such as tardive dyskinesia, recent studies suggest it is much lower
than that of the conventional antipsychotics (Leucht, Heres, Kissling, & Davis, 2011). Thus, due
to their effectiveness and minimal side effects, atypical antipsychotic medications are typically
the first line of treatment for schizophrenia (Barnes & Marder, 2011).
It should be noted that because of the harsh side effects of antipsychotic medications in
general, many individuals, nearly one half to three-quarters of patients, discontinue the use of
antipsychotic drugs (Leucht, Heres, Kissling, & Davis, 2011). Because of this, it is also
important to incorporate psychological treatment along with psychopharmacological treatment to
both address medication adherence, as well as provide additional support for symptom
management.
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12.5.2. Psychological Interventions
12.5.2.1. Cognitive Behavioral Therapy (CBT). As discussed in previous chapters, the
goal of treatment is to identify the negative biases and attributions that influence an individual’s
interpretations of events and the subsequent consequences of these thoughts and behaviors. For
schizophrenia, CBT focuses on the maladaptive emotional and behavioral responses to psychotic
experiences, which is directly related to distress and disability. Therefore, the goal of CBT is not
on symptom reduction, but rather to improve the interpretations and understandings of these
symptoms (and experiences) which will reduce associated distress (Kurtz, 2015). Common
features of CBT for schizophrenia patients include psychoeducation about their disease and the
course of their symptoms (i.e., ways to identify coming and going of delusions/hallucinations),
challenging and replacing the negative thoughts/behaviors associated with their
delusions/hallucinations to more positive thoughts/behaviors, and finally, learning positive
coping strategies to deal with their unpleasant symptoms (Veiga-Martinez, Perez-Alvarez, &
Garcia-Montes, 2008).
Findings from studies exploring CBT as a supportive treatment have been promising.
One study conducted by Aaron Beck (the founder of CBT) and colleagues (Grant, Huh,
Perivoliotis, Stolar, & Beck, 2011) found that recovery-oriented CBT produced a marked
improvement in overall functioning as well as symptom reduction in patients diagnosed with
schizophrenia. This study suggests that by focusing on targeted goals such as independent living,
securing employment, and improving social relationships, patients were able to slowly move
closer to these targeted goals. By also including a variety of CBT strategies such as role-playing,
scheduling community outings, and addressing negative cognitions, individuals were also able to
address cognitive and social skill deficits.
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12.5.3. Family Interventions
The diathesis-stress model of schizophrenia has primarily influenced family
interventions. As previously discussed, the emergence of the disorder and exacerbation of
symptoms is likely related to environmental stressors and psychological factors. While the
degree in which environmental stress stimulates an exacerbation of symptoms varies among
individuals, there is significant evidence to conclude that stress does impact illness presentation
(Haddock & Spaulding, 2011). Therefore, the overall goal of family interventions is to reduce
the stress on the individual that is likely to elicit the onset of symptoms.
Unlike many other psychological interventions, there is not a specific outline for family-
based interventions related to schizophrenia. However, the majority of programs include the
following components: psychoeducation, problem-solving skills, and cognitive-behavioral
therapy.
Psychoeducation is important for both the patient and family members as it is reported
that more than half of those recovering from a psychotic episode reside with their family
(Haddock & Spaulding, 2011). Therefore, educating families on the course of the illness, as well
as ways to recognize onset of psychotic symptoms, is important to ensure optimal recovery.
Problem-solving is a crucial component in the family intervention model. Seeing as family
conflict can increase stress within the home, which in return can lead to worsening of psychotic
symptoms, family members benefit from learning effective methods of problem-solving to
address family conflicts. Additionally, teaching positive coping strategies for dealing with the
symptoms of mental illness and its direct effect on the family environment may also alleviate
some friction within the home
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The third component, CBT, is similar to that described above. The goal of family-based
CBT is to reduce negativity among family member interactions, as well as help family members
adjust to living with someone with psychotic symptoms. These three components within the
family intervention program have been shown to reduce re-hospitalization rates, as well as slow
the worsening of schizophrenia-related symptoms (Pitschel-Walz, Leucht, Baumi, Kissling, &
Engel, 2001).
12.5.3.1. Social Skills Training. Given the poor interpersonal functioning among
individuals with schizophrenia, social skills training is another type of treatment commonly
suggested to improve psychosocial functioning. Research has indicated that poor interpersonal
skills not only predate the onset of the disorder but also remain significant even with the
management of symptoms via antipsychotic medications. Impaired ability to interact with
individuals in a social, occupational, or recreational setting is related to poorer psychological
adjustment (Bellack, Morrison, Wixted, & Mueser, 1990). This can lead to greater isolation and
reduced social support among individuals with schizophrenia. As previously discussed, social
support has been identified as a protective factor of symptom exacerbation, as it buffers
psychosocial stressors that are often responsible for the exacerbation of symptoms. Learning how
to interact with others appropriately (e.g., establish eye contact, engage in reciprocal
conversations, etc.) through role-play in a group therapy setting is one effective way to teach
positive social skills.
12.5.3.2. Inpatient Hospitalizations. More commonly viewed as community-based
treatments, inpatient hospitalization programs are essential in stabilizing patients in psychotic
episodes. Generally speaking, patients will be treated on an outpatient basis; however, there are
times when their symptoms exceed the needs of an outpatient service. Short-term
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hospitalizations are used to modify antipsychotic medications and implement additional
psychological treatments so that a patient can safely return to their home. These hospitalizations
generally last for a few weeks as opposed to a long-term treatment option that would last months
or years (Craig & Power, 2010).
In addition to short-term hospitalizations, there are also partial hospitalizations where an
individual enrolls in a full-day program but returns home for the evening. These programs
provide individuals with intensive therapy, organized activities, and group therapy programs that
enhance social skills training. Research supports the use of partial hospitalizations as individuals
enrolled in these programs tend to do better than those who enter outpatient care (Bales et al.,
2014).

• Psychopharmacological treatment options for schizophrenia spectrum disorders
include antipsychotic drugs such as Thorazine, Chlorpromazine, Clozaril,
Risperdal, and Abilify.
• Psychological treatment options for schizophrenia spectrum disorders include
CBT, the goal of which is to improve the interpretations and understandings of
symptoms (and experiences) which will reduce associated distress.
• Family interventions for schizophrenia spectrum disorders include
psychoeducation, problem-solving skills, cognitive-behavioral therapy (CBT),
social skills training, and inpatient/partial hospitalizations.
1. Define tardive dyskinesia.

2. What pharmacological interventions have been effective in managing
schizophrenia related disorder symptoms?
3. What is the main goal of family interventions? How is this achieved?
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Module Recap
In our first module of Part V – Block 4, we discussed the schizophrenia spectrum
disorders to include schizophrenia, schizophreniform disorder, schizoaffective disorder, and
delusional disorder. We started by describing their common features, such as delusions,
hallucinations, disorganized thinking, disorganized/abnormal motor behavior, catatonic behavior,
and negative symptoms. This led to a discussion of the epidemiology, comorbidity, etiology, and
treatment options of the disorders.
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Module 13:
Personality Disorders
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Module 13: Personality Disorders
Module Overview
In Module 13, we will cover matters related to personality disorders to include their
will include Cluster A disorders of paranoid, schizoid, and schizotypal; Cluster B disorders of
antisocial, borderline, histrionic, and narcissistic; and Cluster C personality disorders of
avoidant, dependent, and obsessive-compulsive. Be sure you refer Modules 1-3 for explanations
of key terms (Module 1), an overview of the various models to explain psychopathology
(Module 2), and descriptions of the therapies (Module 3).
Module Outline
• 13.4. Etiology
• 13.5. Treatment

• Describe how personality disorders present.
• Describe the epidemiology of personality disorders.
• Describe comorbidity in relation to personality disorders.
• Describe the etiology of personality disorders.
• Describe treatment options for personality disorders.
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• List the defining features of personality disorders.
• Describe the three clusters.
• Describe how paranoid personality disorder presents.
• Describe how schizoid personality disorder presents.
• Describe how schizotypal personality disorder presents.
• Describe how antisocial personality disorder presents.
• Describe how borderline personality disorder presents.
• Describe how histrionic personality disorder presents.
• Describe how narcissistic personality disorder presents.
• Describe how avoidant personality disorder presents.
• Describe how dependent personality disorder presents.
• Describe how obsessive-compulsive personality disorder presents.
13.1.1. Overview of Personality Disorders
Personality disorders have four defining features, which include distorted thinking
patterns, problematic emotional responses, over- or under-regulated impulse control, and
interpersonal difficulties. While these four core features are universal among all ten personality
disorders, the DSM-5 divides the personality disorders into three different clusters based on
symptom similarities.
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Cluster A is described as the odd/eccentric cluster and consists of Paranoid Personality
Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorder. The common
feature between these three disorders is social awkwardness and social withdrawal (APA, 2013).
Often these behaviors are similar to those seen in schizophrenia; however, they tend to be not as
extensive or impactful on daily functioning as seen in schizophrenia. In fact, there is a strong
relationship between cluster A personality disorders among individuals who have a relative
diagnosed with schizophrenia (Chemerinksi & Siever, 2011).
Cluster B is the dramatic, emotional, or erratic cluster and consists of Antisocial
Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, and
Narcissistic Personality Disorder. Individuals with these personality disorders often experience
problems with impulse control and emotional regulation (APA, 2013). Due to the dramatic,
emotional, and erratic nature of these disorders, it is nearly impossible for individuals to establish
healthy relationships with others.
And finally, Cluster C is the anxious/fearful cluster and consists of Avoidant Personality
Disorder, Dependent Personality Disorder, and Obsessive-Compulsive Personality Disorder. As
you read through the descriptions of the disorders, you will see an overlap with symptoms within
the anxiety and depressive disorders. Likely due to the similarity in symptoms with mental health
disorders that have effective treatment options, Cluster C disorders have the most treatment
options of all personality disorders.
To meet the criteria for any personality disorder, the individual must display the pattern
of behaviors in adulthood. Children cannot be diagnosed with a personality disorder. Some
children may present with similar symptoms, such as poor peer relationships, odd or eccentric
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behaviors, or peculiar thoughts and language; however, a formal personality disorder diagnosis
cannot be made until the age of 18.
13.1.2. Cluster A
13.1.2.1. Paranoid personality disorder. Paranoid personality disorder is characterized
by a marked distrust or suspicion of others. Individuals interpret and believe that other’s motives
and interactions are intended to harm them, and therefore, they are skeptical about establishing
close relationships outside of family members—although, at times, even family members’
actions are also believed to be malevolent (APA, 2013). Individuals with paranoid personality
disorder often feel as though they have been deeply and irreversibly hurt by others even though
they lack evidence to support that others intended to or did hurt them. Because of these persistent
suspicions, they will doubt relationships that show true loyalty or trustworthiness.
Individuals with paranoid personality disorder are also hesitant to share any personal
information or confide in others as they fear the information will be used against them (APA,
2013). Additionally, benign remarks or events are often viewed as demeaning or threatening. For
example, if an individual with paranoid personality disorder was accidentally bumped into at the
store, they would interpret this action as intentional, with the purpose of causing them injury.
Because of this, individuals with paranoid personality disorder are quick to hold grudges and
unwilling to forgive insults or injuries- whether intentional or not (APA, 2013). They are known
to quickly and angrily counterattack, either verbally or physically, in situations where they feel
they were insulted.
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13.1.2.2. Schizoid personality disorder. Individuals with schizoid personality disorder
display a persistent pattern of avoidance of social relationships, along with a limited range of
emotion among social relationships (APA, 2013). Similar to those with paranoid personality
disorder, individuals with schizoid personality disorder do not have many close relationships;
however, unlike paranoid personality disorder, this lack of connection is not due to suspicious
feelings, but rather, the lack of desire to engage with others and the preference to engage in
solitary behaviors. Individuals with schizoid personality disorder are often viewed as “loners”
and prefer activities where they do not have to engage with others (APA, 2013). Established
relationships rarely extend outside that of the family as they make no effort to start or maintain
friendships. This lack of establishing social relationships also extends to sexual behaviors, as
these individuals report a lack of interest in engaging in sexual experiences with others.
Regarding the limited range of emotion, individuals with schizoid personality disorder
are often indifferent to criticisms or praises of others and appear not to be affected by what
others think of them (APA, 2013). Individuals will rarely show any feelings or expressions of
emotion and are often described as having a “bland” exterior (APA, 2013). In fact, individuals
with schizoid personality disorder rarely reciprocate facial expressions or gestures typically
displayed in normal conversations such as smiles or nods. Because of this lack of emotion, there
is a limited need for attention or acceptance.
13.1.2.3. Schizotypal personality disorder. Schizotypal personality disorder is
characterized by a range of impairment in social and interpersonal relationships due to
discomfort in relationships, along with odd cognitive or perceptual distortions and eccentric
behaviors (APA, 2013). Similar to those with schizoid personality disorder, individuals also seek
isolation and have few, if any established relationships outside of family members.
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One of the most prominent features of schizotypal personality disorder is ideas of
reference, or the belief that unrelated events pertain to them in a particular and unusual way.
Ideas of reference also lead to superstitious behaviors or preoccupation with paranormal
activities that are not generally accepted in their culture (APA, 2013). The perception of special
or magical powers, such as the ability to mind-read or control other’s thoughts, has also been
documented in individuals with schizotypal personality disorder. Similar to schizophrenia,
unusual perceptual experiences such as auditory hallucinations, as well as unusual speech
patterns of derailment or incoherence, are also present.
Similar to the other personality disorders within cluster A, there is a component of
paranoia or suspiciousness of other’s motives. Additionally, individuals with schizotypal
personality disorder display inappropriate or restricted affect, thus impacting their ability to
appropriately interact with others in a social context. Significant social anxiety is often also
present in social situations, particularly in those involving unfamiliar people. The combination of
limited affect and social anxiety contributes to their inability to establish and maintain personal
relationships; most individuals with schizotypal personality disorder prefer to keep to themselves
in an effort to reduce this anxiety.
13.1.3. Cluster B
13.1.3.1. Antisocial personality disorder. The essential feature of antisocial personality
disorder is the persistent pattern of disregard for, and violation of, the rights of others. This
pattern of behavior begins in late childhood or early adolescence and continues throughout
adulthood. While this behavior presents before age 15, the individual cannot be diagnosed with
antisocial personality disorder until the age of 18. Prior to age 18, the individual would be
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diagnosed with Conduct Disorder. Although not discussed in this book as it is a disorder of
childhood, conduct disorder involves a repetitive and persistent pattern of behaviors that violate
the rights of others or major age-appropriate norms (APA, 2013). Common behaviors of
individuals with conduct disorder that go on to develop antisocial personality disorder are
aggression toward people or animals, destruction of property, deceitfulness or theft, or serious
violation of rules (APA, 2013).
While commonly referred to as “psychopaths” or “sociopaths,” individuals with
antisocial personality disorder fail to conform to social norms. This also includes legal rules as
individuals with antisocial personality disorder are often repeatedly arrested for property
destruction, harassing/assaulting others, or stealing (APA, 2013). Deceitfulness is another
hallmark symptom of antisocial personality disorder as individuals often lie repeatedly, generally
as a means to gain profit or pleasure. There is also a pattern of impulsivity—decisions made in
the moment without forethought of personal consequences or consideration for others (Lang et
al., 2015). This impulsivity also contributes to their inability to hold jobs as they are more likely
to impulsively quit their jobs (Hengartner et al., 2014). Employment instability, along with
impulsivity, also impacts their ability to manage finances; it is not uncommon to see individuals
with antisocial personality disorder with large debts that they are unable to pay (Derefinko &
Widiger, 2016).
While also likely related to impulsivity, individuals with antisocial personality disorder
tend to be extremely irritable and aggressive, repeatedly getting into fights. The marked
disregard for their safety, as well as the safety of others, is also observed in reckless behavior
such as speeding, driving under the influence, and engaging in sexual and substance abuse
behavior that may put themselves at risk (APA, 2013).
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Of course, the most known and devastating symptom of antisocial personality disorder is
the lack of remorse for the consequences of their actions, regardless of how severe they may be
(APA, 2013). Individuals often rationalize their actions as the fault of the victim, minimize the
harmfulness of the consequences of their behaviors, or display indifference (APA, 2013).
Overall, individuals with antisocial personality disorder have limited personal relationships due
to their selfish desire and lack of moral conscience.
13.1.3.2. Borderline personality disorder. Individuals with borderline personality
disorder display a pervasive pattern of instability in interpersonal relationships, self-image, and
affect (APA, 2013). The combination of these symptoms causes significant impairment in
establishing and maintaining personal relationships. They will often go to great lengths to avoid
real or imagined abandonment. Fears related to abandonment often lead to inappropriate anger as
they often interpret the abandonment as a reflection of their own behaviors. It is not uncommon
to experience intense fluctuations in mood, often observed as volatile interactions with family
and friends (Herpertz & Bertsch, 2014). Those with borderline personality disorder may be
friendly one day and hostile the next.
In an effort to prevent abandonment, individuals with borderline personality disorder will
often exhibit impulsive behaviors such as self-harm and suicidal behavior. In fact, individuals
with borderline personality disorder engage in more suicide attempts, and completion of suicide
is higher among these individuals than the general public (Linehan et al., 2015). Other impulsive
behaviors, such as non-suicidal self-injury (cutting) and sexual promiscuity, are frequently seen
within this population, typically occurring during high-stress periods (Sansone & Sansone,
2012).
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Another key characteristic of borderline personality disorder is unstable and intense
relationships. For example, individuals may idealize or experience intense feelings for another
person immediately after meeting them. Occasionally, hallucinations and delusions are present,
particularly of a paranoid nature; however, these symptoms are often transient and recognized as
unacceptable by the individual (Sieswerda & Arntz, 2007).
13.1.3.3. Histrionic personality disorder. Histrionic personality disorder is the first
personality disorder that addresses pervasive and excessive emotionality and attention-seeking.
These individuals are usually uncomfortable in social settings unless they are the center of
attention. To help gain attention, the individual is often vivacious and dramatic, using physical
gestures and mannerisms along with grandiose language. These behaviors are initially very
charming to their audience; however, they begin to wear due to the constant need for attention to
be on them. If the theatrical nature does not gain the attention they desire, they may go to great
lengths to draw attention, such as using a fictitious story or creating a dramatic scene (APA,
2013).
To ensure they gain the attention they desire, individuals with histrionic personality
disorder frequently dress and engage in sexually seductive or provocative ways. These sexually
charged behaviors are not only directed at those in which they have a sexual or romantic interest
but to the general public as well (APA, 2013). They often spend a significant amount of time on
their physical appearance to gain the attention they desire.
Individuals with histrionic personality disorder are easily suggestible. Their opinions and
feelings are influenced by not only their friends but also by current fads (APA, 2013). They also
tend to exaggerate relationships, considering casual acquaintanceships as more intimate than they
are.
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13.1.3.4. Narcissistic personality disorder. Similar to histrionic personality disorder,
narcissistic personality disorder also centers around the individual; however, with narcissistic
personality disorder, individuals display a pattern of grandiosity along with a lack of empathy for
others (APA, 2013). The grandiose sense of self leads to an overvaluation of their abilities and
accomplishments. They often come across as boastful and pretentious, repeatedly proclaiming
their superior achievements. These proclamations may also be fantasized as a means to enhance
their success or power. Oftentimes they identify themselves as “special” and will only interact
with others of high status.
Given the grandiose sense of self, it is not surprising that individuals with narcissistic
personality disorder need excessive admiration from others. While it appears that their self-
esteem is hugely inflated, it is very fragile and dependent on how others perceive them (APA,
2013). Because of this, they may constantly seek out compliments and expect favorable
treatment from others. When this sense of entitlement is not upheld, they can become irritated or
angry that their needs are not met.
A lack of empathy is also displayed in individuals with narcissistic personality disorder
as they often struggle to (or choose not to) recognize the desires or needs of others. This lack of
empathy also leads to exploitation of interpersonal relationships, as they are unable to understand
other’s feelings (Marcoux et al., 2014). They often become envious of others who achieve
greater success or possessions than them. Conversely, they believe everyone should be envious
of their achievements, regardless of how small they may actually be.
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13.1.4. Cluster C
13.1.4.1. Avoidant personality disorder. Individuals with avoidant personality disorder
display a pervasive pattern of social anxiety due to feelings of inadequacy and increased
sensitivity to negative evaluations (APA, 2013). The fear of being rejected drives their reluctance
to engage in social situations, so that they may prevent others from evaluating them negatively.
This fear extends so far that it prevents individuals from maintaining employment due to their
intense fear of negative evaluation or rejection.
Socially, they have very few if any friends, despite their desire to establish social
relationships. They actively avoid social situations in which they can develop new friendships
out of the fear of being disliked or ridiculed. Similarly, they are cautious of new activities or
relationships as they often exaggerate the potential negative consequences and embarrassment
that may occur; this is likely a result of their ongoing preoccupation with being criticized or
rejected by others.
Despite their view as socially inept, unappealing, or inferior, individuals with avoidant
personality disorder do not typically suffer from social skills deficits, but rather from
misattributions of their behaviors (APA, 2013).
13.1.4.2. Dependent personality disorder. Dependent personality disorder is
characterized by pervasive and excessive need to be taken care of by others (APA, 2013). This
intense need leads to submissive and clinging behaviors as they fear they will be abandoned or
separated from their parent, spouse, or another person with whom they are in a dependent
relationship. They are so dependent on this other individual that they cannot make even the
smallest decisions without first consulting with them and gaining their approval or reassurance.
They often allow others to assume complete responsibility for their life, making decisions in
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nearly all aspects of their lives. Rarely will they challenge these decisions as their fear of losing
this relationship greatly outweighs their desire to express their own opinion. Should the
relationship end, the individual experiences significant feelings of helplessness and quickly seeks
out another relationship to replace the old one (APA, 2013).
When they are on their own, individuals with dependent personality disorder express
difficulty initiating and engaging in tasks on their own. They lack self-confidence and feel
helpless when they are left to care for themselves or engage in tasks on their own. So that they do
not have to engage in tasks alone, individuals will go to great lengths to seek out support of
others, often volunteering for unpleasant tasks if it means they will get the reassurance they need
(APA, 2013).
13.1.4.3. Obsessive-Compulsive personality disorder. OCPD is defined by an
individual’s preoccupation with orderliness, perfectionism, and ability to control situations that
they lose flexibility, openness, and efficiency in everyday life (APA, 2013). One’s preoccupation
with details, rules, lists, order, organization, or schedules overshadows the larger picture of the
task or activity. In fact, the need to complete the task or activity is significantly impacted by the
individual’s self-imposed high standards and need to complete the task perfectly, that the task
often does not get completed. The desire to complete the task perfectly often causes the
individual to spend an excessive amount of time on the task, occasionally repeating it until it is to
their standard. Due to repetition and attention to fine detail, the individual often does not have
time to engage in leisure activities or engage in social relationships. Despite the excessive
amount of time spent on activities or tasks, individuals with OCPD will not seek help from
others, as they are convinced that the others are incompetent and will not complete the task up to
their standard.
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Personally, individuals with OCD are rigid and stubborn, particularly with their morals,
ethics, and values. Not only do they hold these standards for themselves, but they also expect
others to have similarly high standards, thus causing significant disruption to their social
interactions. The rigid and stubborn behaviors are also seen in their financial status, as they are
known to live significantly below their means to prepare financially for a potential catastrophe
(APA, 2013). Similarly, they may have difficulty discarding worn-out or worthless items, despite
their lack of sentimental value.
While some argue that OCPD and OCD are one and the same, others believe there is a
distinct difference as the personality disorder lacks definitive obsessions and compulsions (APA,
2013). Although many individuals are diagnosed with both OCD and OCPD, research indicates
that individuals with OCPD are more likely to be diagnosed with major depression, generalized
anxiety disorder, or substance abuse disorder than OCD (APA, 2013).
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• Personality disorders share the features of distorted thinking patterns,
problematic emotional responses, over- or under-regulated impulse control,
and interpersonal difficulties and divide into three clusters.
• Cluster A personality disorders are described as the odd/eccentric cluster and
share as the common feature social awkwardness and social withdrawal. It
consists of Paranoid, Schizoid , and Schizotypal personality disorders.
• Cluster B personality disorders are described as the dramatic, emotional, or
erratic cluster and consists of Antisocial, Borderline, Histrionic, and
Narcissistic personality disorders.
• Cluster C is the anxious/fearful cluster and consists of Avoidant, Dependent,
and Obsessive-Compulsive personality disorders.
• Paranoid personality disorder is characterized by a marked distrust or
suspicion of others.
• Schizoid personality disorder is characterized by a persistent pattern of
avoidance of social relationships, along with a limited range of emotion
among social relationships.
• Schizotypal personality disorder is characterized by a range of impairment in
social and interpersonal relationships due to discomfort in relationships,
along with odd cognitive or perceptual distortions and eccentric behaviors.
• The essential feature of antisocial personality disorder is the persistent
pattern of disregard for, and violation of, the rights of others. They show no
remorse for their behavior.
• Individuals with borderline personality disorder display a pervasive pattern
of instability in interpersonal relationships, self-image, and affect.
• Histrionic personality disorder addresses pervasive and excessive
emotionality and attention-seeking.
• Narcissistic personality disorder is characterized by a pattern of grandiosity
along with a lack of empathy for others.
• Individuals with avoidant personality disorder display a pervasive pattern of
social anxiety due to feelings of inadequacy and increased sensitivity to
negative evaluations.
• Dependent personality disorder is characterized by pervasive and excessive
need to be taken care of by others.
• OCPD is defined by an individual’s preoccupation with orderliness,
perfectionism, and ability to control situations that they lose flexibility,
openness, and efficiency in everyday life.
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1. What are the three clusters? How are disorders grouped into these three clusters?
Discuss the differences in symptom presentation between the three personality
clusters.
2. Create a chart identifying each of the disorders among the three clusters. Be sure to
include personality characteristics of each disorder. It is important to find
characteristics unique to each personality disorder to aid in their identification.
13.2. Epidemiology
• Describe the epidemiology of Cluster A personality disorders.
• Describe the epidemiology of Cluster B personality disorders.
• Describe the epidemiology of Cluster C personality disorders.
13.2.1. Cluster A
Disorders within Cluster A have a prevalence rate of around 3-4%. More specifically,
paranoid personality disorder is estimated to affect approximately 4.4% of the general
population, with no reported diagnosis discrepancy between genders (APA, 2013). Schizoid
personality disorder occurs in 3.1% of the general population, whereas prevalence rate for
schizotypal personality disorder is 3.9%. Both schizoid and schizotypal personality disorders are
more commonly diagnosed in males than females, with males also reportedly being more
impaired by the diagnosis than females (APA, 2013).
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13.2.2. Cluster B
Cluster B personality disorders have a wide range of occurrences in the general public.
Antisocial personality disorder has an estimated prevalence rate of up to 3.3% of the population
(APA, 2013). It is more common among men, particularly those with substance abuse disorders,
and in those from disadvantaged socioeconomic settings. While the majority of individuals with
antisocial personality disorder end up incarcerated at some point during their lifetime, criminal
activities appear to decline after the age of 40 (APA, 2013).
Borderline personality disorder, one of the more commonly diagnosed personality
disorders, is observed in 5.9% of the general population, with women making up 75% of the
diagnoses (APA, 2013). Among 10% of individuals with borderline personality disorder have
been seen in an outpatient mental health clinic, and nearly 20% have sought treatment in a
psychiatric inpatient unit (APA, 2013). This high percentage of inpatient treatment is likely
related to the high incidence of suicidal and self-harm behaviors.
Histrionic personality disorder is one of the most uncommon personality disorders,
occurring in only 1.84% of the general population (APA, 2013). While it was once believed to be
more commonly diagnosed in females than males, more recent findings suggest the diagnosis
rate is equal between genders.
Finally, narcissistic personality disorder is reportedly diagnosed in 6.2% of the general
public, with 75% of these individuals being men (APA, 2013).
13.2.3. Cluster C
Aside from OCPD, Cluster C personality disorders are rarely diagnosed in the general
public. For example, avoidant personality disorder occurs in 2.4% of the general population,
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whereas dependent personality disorder occurs in less than 1% of the population (APA, 2013).
While avoidant personality is diagnosed equally among men and women, women are more
frequently diagnosed with dependent personality disorder than men. (APA, 2013).
OCPD is the most commonly diagnosed personality disorder, occurring in 7.9% of
individuals. Some argue that OCPD and OCD should be combined into one disorder; however,
interestingly enough, more women are diagnosed with OCD than men, yet men are twice as
likely to be diagnosed with OCPD than women (APA, 2013). This may suggest that there is a
legitimate significant difference within the etiology of the two disorders.

• Disorders within Cluster A have a prevalence rate of around 3-4% with
males being diagnosed at higher rates for schizoid and schizotypal
• Antisocial personality disorder has an estimated prevalence rate of up to
3.3% of the population while borderline personality disorder is around 5.9%.
Histrionic only occurs in 1.84% of the general population and narcissistic in
6.2%. Antisocial and narcissistic are more common in men, borderline more
common in women, and males and females having an equal rate of diagnosis
in histrionic.
• As for Cluster C, these personality disorders are rarely diagnosed in the
general population with the exception being OCPD which is diagnosed in
almost 8% of individuals.
1. What is the difference in prevalence rates across the three clusters? Are there
any trends among gender?
2. Identify the most commonly occurring personality disorder. Which is the
least common?
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13.3. Comorbidity
• Describe the comorbidity of personality disorders.
Among the most common comorbid diagnoses with personality disorders are mood
disorders, anxiety disorders, and substance abuse disorders (Lenzenweger, Lane, Loranger, &
Kessler, 2007). A large meta-analysis exploring the data on the comorbidity of major depressive
disorder and personality disorders indicated a high diagnosis of major depressive disorder,
bipolar disorder, and dysthymia (Friborg, Martinsen, Martinussen, Kaiser, Overgard, &
Rosenvinge, 2014). Further exploration of major depressive disorder suggested the lowest rate of
diagnosis in cluster A disorders, higher rate in cluster B disorders, and the highest rate in cluster
C disorders. While the relationship between bipolar disorder and personality disorders has not
been consistently clear, the most recent findings report a high comorbidity rate between cluster B
personality disorders, with the exception of OCPD (which is in Cluster C), which had the highest
comorbidity rate than any other personality disorder. Overall analysis of dysthymia suggested
that it is the most commonly diagnosed major depressive disorder among all personality
disorders.
A more detailed analysis exploring the prevalence rates of the four main anxiety
disorders (generalized anxiety disorder (GAD), specific phobia, social phobia, and panic
disorder) among individuals with various personality disorders found a clear relationship specific
to personality disorders and anxiety disorders (Skodol, Geier, Grant, & Hasin, 2014). More
specifically, individuals diagnosed with borderline and schizotypal personality disorders were
found to have an additional diagnosis of one of the four main anxiety disorders. Individuals with
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narcissistic personality disorders were more likely to be diagnosed with GAD and panic disorder;
schizoid and avoidant personality disorders reported significant rates of GAD; avoidant
personality disorder had a higher diagnosis rate of social phobia. Substance abuse disorders
occur less frequently across the ten personality disorders but are most common in individuals
diagnosed with antisocial, borderline, and schizotypal personality disorders (Grant et al., 2015).

• Mood disorders, anxiety disorders, and substance abuse disorders have a high
comorbidity with personality disorders.
• Substance abuse disorders occur less frequently across the ten personality
disorders but when they do, are comorbid with antisocial, borderline, and
schizotypal personality disorders.
1. With what other disorders are personality disorders comorbid?
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13.4. Etiology
• Describe the biological causes of personality disorders.
• Describe the psychological causes of personality disorders.
• Describe the social causes of personality disorders.
Research regarding the development of personality disorders is limited compared to that
of other mental health disorders. The following is a general overview of contributing factors to
personality disorders as a whole. While there is some research lending itself to specific causes of
specific personality disorders, the overall contribution of biological, psychological, and social
factors will be reviewed.
13.4.1. Biological
Research across the personality disorders suggests some underlying biological or genetic
component; however, identification of specific mechanisms have not been identified in most
disorders, with the exception of those below. Because of this lack of concrete evidence,
researchers argue that it is difficult to determine what role genetics plays into the development of
these disorders compared to that of environmental influences. Therefore, while there is likely a
biological predisposition to personality disorders, exact causes cannot be determined at this time.
Research on the development of schizotypal personality disorder has identified similar biological
causes to that of schizophrenia—high activity of dopamine and enlarged brain ventricles (Lener
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et al., 2015). Similar differences in neuroanatomy may explain the high similarity of behaviors in
both schizophrenia and schizotypal personality disorder.
Surprisingly, antisocial personality disorder and borderline personality disorder also
have similar neurological changes. More specifically, individuals with both disorders reportedly
show deficits in serotonin activity (Thompson, Ramos, & Willett, 2014). These low levels of
serotonin activity in combination with deficient functioning of the frontal lobes—particularly the
prefrontal cortex which is used in planning, self-control, and decision making—as well as an
overly reactive amygdala, may explain the impulsive and aggressive nature of both antisocial and
borderline personality disorder (Stone, 2014).
Psychodynamic, cognitive, and behavioral theories are among the most common
psychological models used to explain the development of personality disorders. Although much
is still speculation, the following are general etiological views with regards to each specific
theory.
13.4.2.1. Psychodynamic. The psychodynamic theory places a large emphasis on
negative early childhood experiences and how these experiences impact an individual’s inability
to establish healthy relationships in adulthood. More specifically, individuals with personality
disorders report higher levels of childhood stress, such as living in impoverished environments,
exposure to domestic violence, and experiencing repeated maltreatment (Kumari et al., 2014).
Additionally, high levels of childhood neglect and parental rejection are also observed in
personality disorder patients, with early parental loss and rejection leading to fears of
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abandonment throughout an individual’s life (Caligor & Clarkin, 2010; Newnham & Janca,
2014; Roepke & Varter, 2014).
Psychodynamic theorists believe that maltreatment in early childhood has the potential to
negatively affect an individual’s sense of self and their perception of others, leading to the
development of a personality disorder. For example, an individual who was neglected as a young
child and deprived of love may report a lack of trust in others as an adult, a characteristic of
antisocial personality disorder (Meloy & Yakeley, 2010). Difficulty trusting others or beliefs that
they are unable to be loved may also impact one’s ability or desire to establish social
relationships, as seen in many personality disorders, particularly schizoid. Because of these early
childhood deficits, individuals may also overcompensate in their relationships in efforts to
convince themselves that they are worthy of love and affection (Celani, 2014). Conversely,
individuals may respond to their early childhood experiences by becoming emotionally distant,
using relationships as a sense of power and destructiveness.
13.4.2.2. Cognitive. While psychodynamic theory emphasizes early childhood
experiences, cognitive theorists focus on the maladaptive thought patterns and cognitive
distortions displayed by those with personality disorders. Overall deficiencies in thinking can
lead individuals with personality disorders to develop inaccurate perceptions of others (Beck,
2015). These dysfunctional beliefs likely originate from the interaction between a biological
predisposition and undesirable environmental experiences. Maladaptive thought patterns and
strategies are strengthened during aversive life events as a protective mechanism and ultimately
come together to form patterns of behavior displayed in personality disorders (Beck, 2015).
Cognitive distortions such as dichotomous thinking, also known as all-or-nothing
thinking, are observed in several personality disorders. More specifically, dichotomous thinking
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explains rigidity and perfectionism in OCPD, and the lack of self-sufficiency among individuals
with dependent and borderline personality disorders (Weishaar & Beck, 2006). Discounting the
positive also explains the underlying mechanisms for avoidant personality disorder (Weishaar &
Beck, 2006). For example, individuals who have been routinely criticized or rejected during
childhood may have difficulty accepting positive feedback from others, expecting only to receive
rejection and harsh criticism. In fact, they may employ these misattributions to positive feedback
to support their ongoing theory that they are constantly rejected and criticized by others.
13.4.2.3. Behavioral. Behavioral theorists apply three major theories to explain the
development of personality disorders: modeling, reinforcement, and lack of social skills. In
modeling, an individual learns maladaptive social patterns and behaviors by directly observing
family members engaging in similar behaviors (Gaynor & Baird, 2007). While we cannot
discredit the biological component of the familial influence, research does support an additive
modeling or imitating component to the development of personality disorders, especially
antisocial personality disorder (APA, 2013).
Reinforcement, or rewarding of maladaptive behaviors is also observed in the
development of many personality disorders. Parents may unintentionally reward aggressive
behaviors by giving in to a child’s desires in an effort to cease the situation or prevent escalation
of behaviors. When this is done repeatedly over time, children (and later as adults) continue with
these maladaptive behaviors as they are effective in gaining their needs and wants. On the other
side, there is some speculation that excessive reinforcement or praise during childhood may
contribute to the grandiose sense of self observed in individuals with narcissistic personality
disorder (Millon, 2011).
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Finally, failure to develop normal social skills may explain the development of some
personality disorders, such as avoidant personality disorder (Kantor, 2010). While there is some
discussion as to whether lack of social skills leads to avoidance of social settings, or if social
skills deficits develop as a result of avoiding social situations, most researchers agree that the
avoidance of social situations contributes to the development of personality disorders, whereas,
underlying deficits in social skills may contribute more to social anxiety disorder (APA, 2013).
13.4.3. Social
13.4.3.1. Family dysfunction. High levels of psychological and social dysfunction
within families have also been identified as contributing factors to the development of
personality disorders. High levels of poverty, unemployment, family separation, and witnessing
domestic violence are routinely observed in individuals diagnosed with personality disorders
(Paris, 1996). While formalized research has yet to explore the relationship between SES and
personality disorders fully, correlational studies suggest a link between poverty, unemployment,
and poor academic achievement with increased levels of personality disorder diagnoses (Alwin,
2006).
13.4.3.2. Childhood maltreatment. Childhood maltreatment is among the most
influential argument for the development of personality disorders in adulthood. Individuals with
personality disorders often struggle with a sense of self and the ability to relate to others—
something that is generally developed during the first four to six years of a child’s life, and it is
affected by the emotional environment in which that child was raised. This sense of self is the
mechanism in which individuals view themselves within their social context, while also
informing attitudes and expectations of others. A child who experiences significant
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maltreatment, whether it be through neglect or physical, emotional, or sexual abuse, is at-risk for
an underdeveloped or absent sense of self. Due to the lack of affection, discipline, or autonomy
during childhood, these individuals are unable to engage in appropriate relationships as adults as
seen across the spectrum of personality disorders.
Another way childhood maltreatment contributes to personality disorders is through the
emotional bonds or attachments developed with primary caregivers. John Bowlby thoroughly
researched the relationship between attachment and emotional development as he explored the
need for affection in Harlow monkeys (Bowlby, 1998). Based on Bowlby’s research, four
attachment styles have been identified: secure, anxious, ambivalent, and disorganized. While
securely attached children generally do not develop personality disorders, those with anxious,
ambivalent, and disorganized attachment are at an increased risk of developing various disorders.
More specifically, those with an anxious attachment are at-risk for developing internalizing
disorders, ambivalent are at-risk for developing externalizing disorders, and disorganized are at-
risk for dissociative symptoms and personality-related disorders (Alwin, 2006).
13-26

• Biological causes of personality disorders have not been identified in most
disorders, the exception being schizotypal which has similar biological
causes as schizophrenia and antisocial and borderline personality disorders
which have similar neurological changes.
• Psychological causes of personality disorders include negative early
childhood experiences; maladaptive thought patterns and cognitive
distortions; and modeling, reinforcement, and lack of social skills.
• Social causes of personality disorders include high levels of psychological
and social dysfunction within families and maltreatment.
1. What personality disorders are most explained by the biological model?

2. How does the psychodynamic model explain the development of
personality disorders?
3. What cognitive distortions are most commonly discussed with respect to
4. What are the three behavioral theories used to explain the development of
5. Discuss the roll of attachment and how theorists have used it to explain the
development of personality disorders.
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13.5. Treatment
• Describe treatment options for personality disorders.
13.5.1. Cluster A
Individuals with personality disorders within Cluster A often do not seek out treatment as
they do not identify themselves as someone who needs help (Millon, 2011). Of those that do seek
treatment, the majority do not enter it willingly. Furthermore, due to the nature of these
disorders, individuals in treatment often struggle to trust the clinician as they are suspicious of
the clinician’s intentions (paranoid and schizotypal personality disorder) or are emotionally
distant from the clinician as they do not have a desire to engage in treatment due to lack of
overall emotion (schizoid personality disorder; Kellett & Hardy, 2014, Colli, Tanzilli, Dimaggio,
& Lingiardi, 2014). Because of this, treatment is known to move very slowly, with many patients
dropping out before any resolution of symptoms.
When patients are enrolled in treatment, cognitive-behavioral strategies are most
commonly used with the primary intention of reducing anxiety-related symptoms. Additionally,
attempts at cognitive restructuring—both identifying and changing maladaptive thought
patterns—are also helpful in addressing the misinterpretations of other’s words and actions,
particularly for individuals with paranoid personality disorder (Kellett & Hardy, 2014). Schizoid
personality disorder patients may engage in CBT techniques to help experience more positive
emotions and more satisfying social experiences, whereas the goal of CBT for schizotypal
personality disorder is to evaluate unusual thoughts or perceptions objectively and to ignore the
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inappropriate thoughts (Beck & Weishaar, 2011). Finally, behavioral techniques such as social-
skills training may also be implemented to address ongoing interpersonal problems displayed in
the disorders.
13.5.2. Cluster B
13.5.2.1. Antisocial personality disorder. Treatment options for antisocial personality
disorder are limited and generally not effective (Black, 2015). Like Cluster A disorders, many
individuals are forced to participate in treatment, thus impacting their ability to engage in and
continue with treatment. Cognitive therapists have attempted to address the lack of morality and
encourage patients to think about the needs of others (Beck & Weishaar, 2011).
13.5.2.2. Borderline personality disorder. Borderline personality disorder is the one
personality disorder with an effective treatment option—Dialectical Behavioral Therapy (DBT).
DBT is a form of cognitive-behavioral therapy developed by Marsha Linehan (Linehan,
Armstrong, Suarez, Allmon, & Heard, 1991). There are four main goals of DBT: reduce suicidal
behavior, reduce therapy interfering behavior, improve quality of life, and reduce post-traumatic
stress symptoms.
Within DBT, five main treatment components collectively help to reduce harmful
behaviors (i.e., self-mutilation and suicidal behaviors) and replace them with practical, life-
enhancing behaviors (Gonidakis, 2014). The first component is skills training. Generally
performed in a group therapy setting, individuals engage in mindfulness, distress tolerance,
interpersonal effectiveness, and emotion regulation. Second, individuals focus on enhancing
motivation and applying skills learned in the previous component to specific challenges and
events in their everyday life. The third, and often the most distinctive aspect of DBT, is the use
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of telephone and in vivo coaching for DBT patients from the DBT clinical team. It is not
uncommon for patients to have the cell phone number of their clinician for 24/7 availability of
in-the-moment support. The fourth component, case management, consists of allowing the
patient to become their own “case manager” and effectively use the learned DBT techniques to
problem-solve ongoing issues. Within this component, the clinician will only intervene when
absolutely necessary. Finally, the consultation team, is a service for the clinicians providing the
DBT treatment. Due to the high demands of borderline personality disorder patients, the
consultation team offers support to the providers in their work to ensure they remain motivated
and competent in DBT principles to provide the best treatment possible.
Support for the effectiveness of DBT in borderline personality disorder patients has been
implicated in several randomized control trials (Harned, Korslund, & Linehan, 2014; Neacsiu,
Eberle, Kramer, Wisemeann, & Linehan, 2014). More specifically, DBT has shown to
significantly reduce suicidality and self-harm behaviors in those with borderline personality
disorders. Additionally, the drop-out rates for treatment are extremely low, suggesting that
patients value the treatment components and find them useful in managing symptoms.
13.5.2.3. Histrionic personality disorder. Individuals with histrionic personality
disorder are more likely to seek out treatment than other personality disorder patients.
Unfortunately, due to the nature of the disorder, they are very difficult patients to treat as they
are quick to employ their demands and seductiveness within the treatment setting. The overall
goal for the treatment of histrionic personality disorder is to help the patient identify their
dependency and become more self-reliant. Cognitive therapists utilize techniques to help patients
change their helpless beliefs and improve problem-solving skills (Beck & Weishaar, 2011).
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13.5.2.4. Narcissistic personality disorder. Of all the personality disorders, narcissistic
personality disorders are among the most difficult to treat (with maybe the exception of
antisocial personality disorder). Most individuals with narcissistic personality disorder only seek
out treatment for those disorders secondary to their personality disorder, such as depression
(APA, 2013). The focus of treatment is to address the grandiose, self-centered thinking, while
also trying to teach patients how to empathize with others (Beck & Weishaar, 2014).
13.5.3. Cluster C
While many individuals within avoidant and OCPD personality disorders seek out
treatment to address their anxiety or depressive symptoms, it is often difficult to keep them in
treatment due to distrust or fear of rejection from the clinician. Treatment goals for avoidant
personality disorder are similar to that of social anxiety disorder. CBT techniques, such as
identifying and challenging distressing thoughts, have been effective in reducing anxiety-related
symptoms (Weishaar & Beck, 2006). Specific to OCPD, cognitive techniques aimed at changing
dichotomous thinking, perfectionism, and chronic worrying help manage symptoms of OCPD.
Behavioral treatments such as gradual exposure to various social settings, along with a
combination of social skills training, have been shown to improve individuals’ confidence prior
to engaging in social outings when treating avoidant personality disorder (Herbert, 2007).
Antianxiety and antidepressant medications commonly used to treat anxiety disorders have also
been used with minimal efficacy; furthermore, symptoms resume as soon as the medication is
discontinued.
Unlike other personality disorders where individuals are skeptical of the clinician,
individuals with dependent personality disorder try to place obligations of their treatment on the
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clinician. Therefore, one of the main treatment goals for dependent personality disorder patients
is to teach them to accept responsibility for themselves, both in and outside of treatment (Colli,
Tanzilli, Dimaggio, & Lingiardi, 2014). Cognitive strategies such as challenging and changing
thoughts on helplessness and inability to care for oneself have been minimally effective in
establishing independence. Additionally, behavioral techniques such as assertiveness training
have also shown some promise in teaching individuals how to express themselves within a
relationship. Some argue that family or couples therapy would be particularly helpful for those
with dependent personality disorder due to the relationship between the patient and another
person being the primary issue; however, research on this treatment method has not yielded
consistently positive results (Nichols, 2013).

• Individuals with a Cluster A personality disorder do not often seek treatment
and when they do, struggle to trust the clinician (paranoid and schizotypal) or
are emotionally distant from the clinician (schizoid). When in treatment,
cognitive restructuring and cognitive behavioral strategies are used.
• In terms of Cluster B, treatment options for antisocial are limited and generally
not effective, borderline responds well to dialectical behavioral therapy (DBT),
histrionic patients seek out help but are difficult to work with, and finally
narcissistic are the most difficult to treat.
• For Cluster C, cognitive techniques aid with OCPD while gradual exposure to
various social settings and social skills training help with avoidant. Clinicians
use cognitive strategies to challenge thoughts on helplessness in patients with
dependent personality disorder.
1. What is the process in Dialectical Behavioral Therapy (DBT)? What does the
treatment entail? What disorders are treated with DBT?
2. Given the difference in personality characteristics between the three clusters,
how are the suggested treatment options different between cluster A, B, and C?
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Module Recap
Module 13 covered three clusters of personality disorders: Cluster A, which includes
paranoid, schizoid, and schizotypal; Cluster B, which includes antisocial, borderline, histrionic,
and narcissistic; and Cluster C which includes avoidant, dependent, and obsessive-compulsive.
We also covered the clinical description, epidemiology, comorbidity, etiology, and treatment of
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Disorders Covered:
14. Neurocognitive Disorders
and…..
15. Contemporary Issues in Psychopathology

Module 14:
Neurocognitive Disorders
14-1
Module 14: Neurocognitive Disorders
Module Overview
In Module 14, we will cover matters related to neurocognitive disorders to include their
will include Delirium, Major Neurocognitive Disorder, and Mild Neurocognitive Disorder. We
also discuss nine subtypes to include: Alzheimer’s disease, Traumatic Brain Injury (TBI),
Vascular Disorders, Substance Abuse, Dementia with Lewy Bodies, Frontotemporal Lobar
Degeneration (FTLD), Parkinson’s disease, Huntington’s disease, and HIV infection. Be sure
you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various
models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3).
Module Outline
• 14.3. Etiology
• 14.4. Treatment
• Describe how neurocognitive disorders present.
• Describe the epidemiology of neurocognitive disorders.
• Describe the etiology of neurocognitive disorders.
• Describe treatment options for neurocognitive disorders.
14-2
• Describe how Delirium presents itself.
• Describe how Major Neurocognitive Disorder presents itself.
• Describe how Mild Neurocognitive Disorder presents itself.
Unlike many of the disorders we have discussed thus far, neurocognitive disorders often
result from disease processes or medical conditions. Therefore, it is important that individuals
presenting with these symptoms complete a medical assessment to better determine the etiology
behind the disorder.
There are three main categories of neurocognitive disorders—Delirium, Major
Neurocognitive Disorder, and Mild Neurocognitive Disorder. Within major and minor
neurocognitive disorders are several subtypes due to the etiology of the disorder. For this book,
we will review diagnostic criteria for both major and minor neurocognitive disorders, followed
by a brief description of the various disease subtypes in the etiology section.
14.1.1. Delirium
Delirium is characterized by a notable disturbance in attention or awareness and cognitive
performance that is significantly altered from one’s usual behavior (APA, 2013). Disturbances in
attention are often manifested as difficulty sustaining, shifting, or focusing attention.
Additionally, an individual experiencing an episode of delirium will have a disruption in
cognition, including confusion of where they are. Disorganized thinking, incoherent speech, and
14-3
hallucinations and delusions may also be observed during periods of delirium. The onset of
delirium is abrupt, occurring for several hours. Symptoms can range from mild to severe and can
last from days to several months.
14.1.2. Major Neurocognitive Disorder
Individuals with major neurocognitive disorder show a significant decline in both overall
cognitive functioning as well as the ability to independently meet the demands of daily living
such as paying bills, taking medications, or caring for oneself (APA, 2013). While it is not
necessary, it is helpful to have documentation of the cognitive decline via neuropsychological
testing within a controlled, standardized testing environment. Information from close family
members or caregivers is also important in documenting the decline and impairment in areas of
functioning.
Within the umbrella of major neurocognitive disorder is dementia, a striking decline in
cognition and self-help skills due to a neurocognitive disorder. The DSM-5 (APA, 2013)
refrained from using this term in diagnostic categories as it is often used to describe the natural
decline in degenerative dementias that affect older adults; whereas neurocognitive disorder is the
preferred term used to describe conditions affecting younger individuals such as impairment due
to traumatic brain injuries or other medical conditions. Therefore, while dementia is accurate in
describing those experiencing major neurocognitive disorder due to age, it is not reflective of
those experiencing neurocognitive issues secondary to an injury or illness.
14-4
14.1.3. Mild Neurocognitive Disorder
Individuals with mild neurocognitive disorder demonstrate a modest decline in one of the
listed cognitive areas. The decline in functioning is not as extensive as that seen in major
neurocognitive disorder, and the individual does not experience difficulty independently
engaging in daily activities. However, they may require assistance or extra time to complete
these tasks, particularly if the cognitive decline continues to progress.
It should be noted that the primary difference between major and mild neurocognitive
disorder is the severity of the decline and independent functioning. Some argue that the two are
earlier and later stages of the same disease process (Blaze, 2013). Conversely, individuals can go
from major to mild neurocognitive disorder following recovery from a stroke or traumatic brain
injury (Petersen, 2011).

• Delirium is characterized by a notable disturbance in attention or awareness and
cognitive performance that is significantly altered from one’s usual behavior.
• Major neurocognitive disorder is characterized by a significant decline in both
overall cognitive functioning as well as the ability to independently meet the
demands of daily living.
• Mild neurocognitive disorder is characterized by a modest decline in one of the
listed cognitive areas.
1. Define delirium. How does this differ from mild and major neurocognitive
disorders?
2. What are the main differences between mild and major neurocognitive
disorders?
14-5
14.2. Epidemiology
• Describe the epidemiology of neurocognitive disorders.
Delirium often occurs among those hospitalized for other medical issues (up to 24%) and
in older individuals. While the rate of occurrence is quite rare among the general public (1-2%),
it significantly increases to 14% among individuals older than 85 years old (APA, 2013).
Major and mild neurocognitive disorder prevalence rates vary widely depending on the
etiological nature of the disorder. Dementia occurs in 1-2% of individuals at age 65, and up to
30% of individuals by age 85.
Alzheimer’s disease, the most commonly diagnosed neurocognitive disorder, is observed
in nearly 5.5 million Americans (Alzheimer’s Association, 2017a), with 7% of those between
ages 65 and 74; 53% between 75 and 84; and 40% older than 84 (APA, 2013). It should also be
noted that somewhere between 60-90% of dementias are attributable to Alzheimer’s disease
(APA, 2013).
Nearly 1.7 million traumatic brain injuries (TBI) happen each year within the United
States, with 59% of these injuries occurring in males (APA, 2013). The most common causes of
TBI are falls, automobile accidents, and accidental head strikes (APA, 2013). There has also
been an increase in TBI within the military due to the recent wars in Iraq and Afghanistan.
14-6

• As individuals age, the rate of occurrence of delirium and dementia increases
dramatically.
• As for Alzheimer’s disease, 53% of those afflicted with the disease are between
the ages of 75 and 84 with another 40% above 84.
1. What is the rate of occurrence of the neurocognitive disorders?
14.3. Etiology
• Define degenerative.
• Describe the symptoms and causes of Alzheimer’s disease.
• Describe the symptoms and causes of Traumatic Brain Injury (TBI).
• Describe the symptoms and causes of Vascular Disorders.
• Describe the symptoms and causes of Substance Abuse.
• Describe the symptoms and causes of Dementia with Lewy Bodies.
• Describe the symptoms and causes of Frontotemporal Lobar Degeneration (FTLD).
• Describe the symptoms and causes of Parkinson’s disease.
• Describe the symptoms and causes of Huntington’s disease.
• Describe the symptoms and causes of HIV infection.
14-7
Neurocognitive disorders occur due to a wide variety of medical conditions or injury to the
brain. Therefore, this section will focus on a brief description of the nine different etiologies of
neurocognitive disorders per the DSM-5. As you will see, the majority of these neurocognitive
disorders are both degenerative, meaning the symptoms and cognitive deficits become worse
over time, as well as related to a medical condition or disease.
Per the DSM-5 (APA, 2013), an individual will meet diagnostic criteria for either mild or
major neurocognitive disorder as listed above. In order to specify the type of neurocognitive
disorder, additional diagnostic criteria specific to one of the following subtypes must be met.
14.3.1. Alzheimer’s Disease
Alzheimer’s disease is the most prevalent neurodegenerative disorder. While the primary
symptom of Alzheimer’s disease is the gradual progression of impairment in cognition, it is also
important to identify concrete evidence of cognitive decline. This can be done in one of two
ways: via genetic testing of the individual or a documented family history of the disease, or,
through clear evidence of cognitive decline over time by repeated standardized
neuropsychological evaluations (APA, 2013). It is crucial to identify these markers in making the
diagnosis of Alzheimer’s disease as some individuals present with memory impairment but
eventually show a reversal of symptoms; this is not the case for individuals with Alzheimer’s
disease (APA, 2013).
14.3.1.1. Causes of Alzheimer’s disease. Autopsies of individuals diagnosed with
Alzheimer’s disease identify two abnormal brain structures— beta-amyloid plaques and
neurofibrillary tangles— both of which are responsible for neuron death, inflammation, and
loss of cellular connections (Lazarov, Mattson, Peterson, Pimplika, & van Praag, 2010). It is
14-8
believed that beta-amyloid plaques, large bundles of plaque that develop between neurons,
appear before the development of dementia symptoms. As these plaque bundles increase in size
and number, cognitive symptoms and impaired daily functioning become evident to close family
members. Neurofibrillary tangles are believed to appear after the onset of dementia symptoms
and are found inside of cells, affecting the protein that helps transport nutrients in healthy cells.
Both beta-amyloid plaques and neurofibrillary tangles impact the health of neurons within the
hippocampus, amygdala, and the cerebral cortex, areas associated with memory and cognition
(Spires-Jones & Hyman, 2014).
Researchers have identified additional genetic and environmental influences in the
development of Alzheimer’s disorder. Genetically, the apolipoprotein E (ApoE) that helps to
eliminate beta-amyloid by-products from the brain has been implicated in the development of
Alzheimer’s disorder. One of the three variants of this gene, the e4 allele, appears to reduce the
production of ApoE, thus increasing the number of beta-amyloid plaques within the brain.
However, not all individuals with the e4 allele develop Alzheimer’s disease; therefore, this
explanation may better explain a vulnerability to Alzheimer’s disease as opposed to the cause of
the disease.
Various brain regions have also been implicated in the development of Alzheimer’s
disease. More specifically, neurons shrinking or dying within the hypothalamus, thalamus, and
the locus ceruleus have been linked to declining cognition (Selkoe, 2011, 1992). Acetylcholine-
secreting neurons within the basal forebrain also appear to shrink or die, contributing to
Alzheimer’s disease symptoms (Hsu et al., 2015).
Environmental toxins such as high levels of zinc and lead may also contribute to the
development of Alzheimer’s disease. More precisely, zinc has been linked to the clumping of
14-9
beta-amyloid proteins throughout the brain. Although lead has largely been phased out of
environmental toxins due to negative health consequences, current elderly individuals were
exposed to these toxic levels of lead in gasoline and paint as young children. There is some
speculation that lead and other pollutants may impact cognitive functioning in older adults
(Richardson et al., 2014).
14.3.1.2. Onset of Alzheimer’s disease. Alzheimer’s disease is defined by the onset of
symptoms. Early-onset Alzheimer’s disease occurs before the age of 65. While only a small
percentage of individuals experience early onset of the disease, those that do experience early
disease progression appear to have a more genetically influenced condition and a higher rate of
family members with the disease.
Late-onset Alzheimer’s disease occurs after the age of 65 and has less of a familial
influence. This onset appears to occur due to a combination of biological, environmental, and
lifestyle factors (Chin-Chan, Navarro-Yepes, & Quintanilla-Vega, 2015). Nearly 30% of
individuals within this class of diagnosis have the ApoE gene that fails to eliminate the beta-
amyloid proteins from various brain structures. It is believed that the combination of the
presence of this gene along with environmental toxins and lifestyle choices (i.e., more stress)
impact the development of Alzheimer’s disease.
14.3.2. Traumatic Brain Injury (TBI)
TBIs occur when an individual experiences significant trauma or damage to the head.
Neurocognitive disorder due to TBI is diagnosed when persistent cognitive impairment is
observed immediately following the head injury, along with one or more of the following
14-10
symptoms: loss of consciousness, posttraumatic amnesia, disorientation, and confusion, or
neurological impairment (APA, 2013).
The presentation of symptoms varies among individuals and depends largely on the
location of the injury and the intensity of the trauma. Furthermore, the effects of a TBI can be
temporary or permeant. Symptoms generally range from headaches, disorientation, confusion,
irritability, fatigue, poor concentration, as well as emotional and behavioral changes. More
severe injuries can result in more significant neurological symptoms such as seizures, paralysis,
and visual disturbances (APA, 2013).
The most common type of TBI is a concussion. A concussion occurs when there is a
significant blow to the head, followed by changes in brain functioning. It often causes immediate
disorientation or loss of consciousness, along with headaches, dizziness, nausea, and sensitivity
to light (Alla, Sullivan, & McCrory, 2012). While symptoms of a concussion are usually
temporary, there can be more permanent damage due to repeated concussions, particularly if they
are close in time. The media has brought considerable attention to this with the recent
discussions of chronic traumatic encephalopathy (CTE) which is a progressive, degenerative
condition due to repeated head trauma. CTEs are most commonly seen in athletes (i.e., football
players) and military personnel (Baugh et al., 2012). In addition to the neurological symptoms,
psychological symptoms such as depression and poor impulse control have been observed in
individuals with CTE. These individuals also appear to be at greater risk for the development of
dementia (McKee et al., 2013).
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14.3.3. Vascular Disorders
Neurocognitive disorders due to vascular disorders can occur from a one-time event such
as a stroke or ongoing subtle disruptions of blood flow within the brain (APA, 2013). The
occurrence of these vascular disorders general begins with atherosclerosis, or the clogging of
arteries due to a build-up of plaque. The plaque builds up over time, eventually causing the
artery to narrow, thus reducing the amount of blood able to pass through to other parts of the
body. When these arteries within the brain become entirely obstructed, a stroke occurs. The lack
of blood flow during a stroke results in the death of neurons and loss of brain function (APA,
2013). There are two types of strokes—a hemorrhagic stroke that occurs when a blood vessel
bursts within the brain and an ischemic stroke, which is when a blood clot blocks the blood flow
in an artery within the brain (American Stroke Association, 2017).
While strokes can occur at any age, the majority of strokes occur after age 65 (Hall,
Levant, & DeFrances, 2012). A wide range of cognitive, behavioral, and emotional changes
occur following a stroke. Symptoms are generally dependent on the location of the stroke within
the brain as well as the extensiveness of damage to those brain regions (Poels et al., 2012). For
example, strokes that occur on the left side of the brain tend to cause problems with speech and
language, as well as physical movement on the right side of the body; whereas strokes that occur
on the right side of the brain tend to cause problems with impulsivity and impaired judgement,
short-term memory loss, and physical movement on the left side of the body (Hedna et al., 2013).
14.3.4. Substance Abuse
As discussed in the Substance Abuse chapter, significant cognitive changes occur due to
repetitive drug and alcohol abuse. Delirium can be observed in individuals with extreme
14-12
substance intoxication, withdrawal, or even when multiple substances have been used within a
close period (APA, 2013). While delirium symptoms are often transient during these states, mild
neurocognitive impairment due to heavy substance abuse may remain until a significant period
of abstinence is observed (Stavro, Pelletier, & Potvin, 2013).
14.3.5. Dementia with Lewy Bodies
Symptoms associated with neurocognitive disorder due to Lewy bodies include
significant fluctuations in attention and alertness; recurrent visual hallucinations; impaired
mobility; and sleep disturbance (APA, 2013). While the trajectory of the illness develops more
rapidly than Alzheimer’s disease, the survival period is similar in that most individuals do not
survive longer than eight years post-diagnosis (Lewy Body Dementia Association, 2017).
Lewy bodies are irregular brain cells that result from the buildup of abnormal proteins in
the nuclei of neurons. These brain cells deplete the cortex of acetylcholine, which causes the
behavioral and cognitive symptoms observed in both dementia with Lewy bodies and
Parkinson’s disease. The motor symptoms seen in both these disorders occur from the depletion
of dopamine by the Lewy body nerve cells that accumulate in the brain stem.
14.3.6. Frontotemporal Lobar Degeneration (FTLD)
FTLD causes progressive declines in language or behavior due to the degeneration in the
frontal and temporal lobes of the brain (APA, 2013). Symptoms of FTLD include significant
changes in behavior or language. Individuals may present with apathy or disinhibition.
Additionally, they may lose interest in socialization as they often lose empathy and sympathy for
others. Individuals may also engage in perseverative or compulsive behaviors. Cognitive decline
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is generally not as prominent as the behavioral and language changes, showing minimal deficits
in early stages of the disorder; however, they will present with a decline in executive functions
such as poor planning and organization, distractibility, and poor judgement to name a few (APA,
2013).
The language deficits commonly impact the fluency of speech and word meaning.
Individuals experience difficulties understanding words or naming objects (APA, 2013).
Occasionally, muscle weakness and other physical abnormalities are present, although not
necessary for diagnosis.
14.3.7. Parkinson’s Disease
The awareness of Parkinson’s disease has increased in recent years due in large part to
Michael J. Fox’s early diagnosis in 1991. It is the second-most common neurodegenerative
disorder in the United States, affecting approximately 630,000 individuals (Kowal, Dall,
Chakrabarti, Storm, & Jain, 2013). While many are aware of the tremors of hands, arms, legs, or
face, additional symptoms of rigidity of the limbs and trunk; slowness in initiating movement;
and drooping posture or impaired balance and coordination, are the other three main symptoms
of Parkinson’s disease (National Institute of Neurological Disorders and Stroke, 2017). These
motor symptoms are generally present at least one year prior to the beginning of cognitive
decline, although severity and progression of symptoms vary significantly from person to person.
14.3.8. Huntington’s Disease
Huntington’s disease is a rare genetic disorder that involves involuntary movement,
progressive dementia, and emotional instability. Due to the degenerative nature of the disorder,
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there is a shortened life-expectancy as death typically occurs 15-20 years post-onset of
symptoms (Clabough, 2013). Although symptoms can present at any time, the average age of
symptom presentation is during middle adulthood (APA, 2013). Symptoms generally begin with
neurocognitive decline along with changes in mood and personality. As symptoms progress,
more physical symptoms present, such as facial grimaces, difficulty speaking, and repetitive
movements. Because there is no treatment for Huntington’s disease, the severity of the cognitive
and physical impairments ultimately leads to complete dependency and the need for full-time
care.
14.3.9. HIV Infection
Not many people are aware that cognitive impairment is sometimes the first symptom of
untreated HIV. While symptoms vary among individuals, slower mental processing, difficulty
with complex tasks, and difficulty concentrating and learning new information are among the
most common early signs (APA, 2013). When HIV becomes active in the brain, significant
alterations of mental processes occur, thus leading to a diagnosis of neurocognitive disorder due
to HIV infection. Significant impairment can also occur due to HIV-infection related
inflammation throughout the central nervous system.
Fortunately, antiretroviral therapies used in treating HIV have been effective in reducing
and preventing the onset of severe cognitive impairments; however, HIV-related brain changes
still occur in nearly half of all patients on antiretroviral medication. There is hope that once
antiretroviral therapies are able to cross the blood-brain barrier in the central nervous system,
there will be a significant improvement in the prevalence of HIV-related neurocognitive disorder
(Vassallo et al., 2014).
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• Most neurocognitive disorders are degenerative meaning they become worse
over time.
• Alzheimer’s disease is characterized by the gradual progression of
impairment in cognition as well as the presence of beta-amyloid plaques and
neurofibrillary tangles.
• TBIs occur when an individual experiences significant trauma or damage to
the head with the most common type being a concussion.
• Vascular disorders generally begin with atherosclerosis which leads to a
stroke.
• Significant cognitive changes occur due to repetitive drug and alcohol abuse
such as delirium.
• Dementia with Lewy Bodies is characterized by significant fluctuations in
attention and alertness; recurrent visual hallucinations; impaired mobility;
and sleep disturbance.
• FTLD causes progressive declines in language or behavior due to the
degeneration in the frontal and temporal lobes of the brain.
• Parkinson’s disease is characterized by tremors of hands, arms, legs, or face;
rigidity of the limbs and trunk; slowness in initiating movement; and
drooping posture or impaired balance and coordination.
• Huntington’s disease involves involuntary movement, progressive dementia,
and emotional instability.
• HIV infection begins with slower mental processing, difficulty with complex
tasks, and difficulty concentrating and learning new information and
progresses to significant impairment and alterations of mental processes.
1. Define degenerative. What disorders discussed in this module are considered

degenerative?
2. Identify the biological causes of Alzheimer’s disease.
3. How do vascular disorders occur?
4. What are Lewy bodies? How does Dementia with Lewy Bodies differ from
Alzheimer’s disease?
5. What are the main symptoms of Parkinson’s Disease?
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14.4. Treatment
• Describe treatment options for neurocognitive disorders.
Treatment options for those with neurocognitive disorders are minimal at best, with most
attempting to treat secondary symptoms as opposed to the neurocognitive disorder itself.
Furthermore, the degenerative nature of these disorders also makes it difficult to treat, as many
diseases will progress regardless of the treatment options.
14.4.1. Pharmacological
Pharmacological interventions, and more specifically medications designed to target
acetylcholine and glutamate, the primary neurotransmitters affected by the disease, have been the
most effective treatment options in alleviating symptoms and reducing the speed of cognitive
decline within individuals diagnosed with Alzheimer’s disease. Specific medications such as
donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and memantine (Namenda)
are among the most commonly prescribed (Alzheimer’s Association, 2017a). Due to possible
negative side effects of the medications, these drugs are prescribed to individuals in the early or
middle stages of Alzheimer’s as opposed to those with advanced disease. Researchers have also
explored treatment options aimed at preventing the build-up of beta-amyloid and neurofibrillary
tangles; however, this research is still in its infancy (Alzheimer’s Association, 2017a)
Parkinson’s disease has also found success in pharmacological treatment options. The
medication levodopa increases dopamine availability, which provides relief of both physical and
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cognitive symptoms. Unfortunately, there are also significant side effects such as hallucinations
and psychotic symptoms; therefore, the medication is often only used when the benefits
outweigh the negatives of the potential risks (Poletti & Bonuccelli, 2013).
Among the most effective psychological treatment options for individuals with
neurocognitive disorders are the use of cognitive and behavioral strategies. More specifically,
engaging in various cognitive activities such as computer-based cognitive stimulation programs,
reading books, and following the news, have been identified as effective strategies in preventing
or delaying the onset of Alzheimer’s disease (Szalavits, 2013; Wilson, Segawa, Boyle, &
Bennett, 2012).
Engaging in social skills and self-care training are additional behavioral strategies used to
help improve functioning in individuals with neurocognitive deficits. For example, by breaking
down complex tasks into smaller, more attainable goals, as well as simplifying the environment
(i.e., labeling location of items, removing clutter), individuals can successfully engage in more
independent living activities.
14.4.3. Support for Caregivers
Supporting caregivers is an important treatment option to include as the emotional and
physical toll on caring for an individual with a neurocognitive disorder is often underestimated.
According to the Alzheimer’s Association (2017b), nearly 90% of all individuals with
Alzheimer’s disease are cared for by a relative. The emotional and physical demands on caring
for a family member who continues to cognitively and physically decline can lead to increased
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anger and depression in a caregiver (Kang et al. 2014). It is important that medical providers
routinely assess caregivers’ psychosocial functioning, and encourage caregivers to participate in
caregiver support groups, or individual psychotherapy to address their own emotional needs.

• Pharmacological interventions target the neurotransmitters acetylcholine and
glutamate and newer research is focused on the build-up of beta-amyloid and
neurofibrillary tangles.
• Psychological treatments include cognitive and behavioral strategies such as
playing board games, reading books, or social skills training.
• Caregivers need to join support groups to help them manage their own anger
and depression, especially since 90% of such caregivers are relatives of the
afflicted.
1. Review the listed treatment options for neurocognitive disorders. What are the
main goals of these treatments?
Module Recap
Our discussion in Module 14 turned to neurocognitive disorders to include the categories
of Delirium, Major Neurocognitive Disorder, and Mild Neurocognitive Disorder. We also
discussed the subtypes of Alzheimer’s disease, Traumatic Brain Injury (TBI), Vascular
Disorders, Substance Abuse, Dementia with Lewy Bodies, Frontotemporal Lobar Degeneration
(FTLD), Parkinson’s disease, Huntington’s disease, and HIV infection. The clinical description,
epidemiology, etiology, and treatment options for neurocognitive disorders were discussed.
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Module 15:
Contemporary Issues in Psychopathology
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Module 15: Contemporary Issues in Psychopathology
Module Overview
In our final module, we will tackle the issue of how clinical psychology interacts with
law. Our discussion will include topics related to civil and criminal commitment, patient’s rights,
and the patient-therapist relationship. We end on an interesting note and discuss whether gaming
can be addictive. Enjoy.
Module Outline
• 15.1. Legal Issues Related to Mental Illness
• 15.2. Patient’s Rights
• 15.3. The Therapist-Client Relationship
• 15.4. Future Directions
• Describe how clinical psychology interacts with law.
• Describe issues related to civil commitment.
• Describe issues related to criminal commitment.
• Outline patient’s rights.
• Clarify concerns related to the therapist-client relationship.
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15.1. Legal Issues Related to Mental Illness
• Define forensic psychology/psychiatry.
• Describe potential roles a forensic psychologist might have.
• Define civil commitment.
• Identify criteria for civil commitment.
• Describe dangerousness.
• Outline procedures in civil commitment.
• Define criminal commitment.
• Define NGRI.
• Describe pivotal rules/acts/etc. in relation to the concept of insanity.
• Define GBMI.
• Clarify what it means to be competent to stand trial.
15.1.1. Forensic Psychology/Psychiatry
According to the American Psychological Association, forensic psychology/psychiatry
is when clinical psychology is applied to the legal arena in terms of assessment, treatment, and
evaluation. Forensic psychology can also include the application of research from other subfields
in psychology to include cognitive and social psychology. Training includes law and forensic
psychology, and solid clinical skills are a must. According to APA, a forensic psychologist might
“perform such tasks as threat assessment for schools, child custody evaluations, competency
evaluations of criminal defendants and of the elderly, counseling services to victims of crime,
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death notification procedures, screening and selection of law enforcement applicants, the
assessment of post-traumatic stress disorder and the delivery and evaluation of intervention and
treatment programs for juvenile and adult offenders.” A key issue investigated by forensic
psychologists includes mens rea or the insanity plea. We will discuss this shortly.
To learn more about forensic psychology, or to investigate the article mentioned above,
please visit:
http://www.apa.org/ed/precollege/psn/2013/09/forensic-psychology.aspx
15.1.2. Civil Commitment
15.1.2.1. What is civil commitment? When individuals with mental illness behave in
erratic or potentially dangerous ways, to either themselves or others, then something must be
done. The responsibility to act falls on the government through what is called parens patriae or
“father of the country” or “country as parent.” Action, in this case, involves involuntary
commitment in a hospital or mental health facility and is done to protect the individual and
express concern over their well-being, much like a parent would do for their child. An individual
can voluntarily admit themselves to a mental health facility, and upon doing so, staff will
determine whether or not treatment and extended stay are needed.
15.1.2.2. Criteria for civil commitment. Though states vary in the criteria used to
establish the need for civil commitment, some requirements are common across states. First, the
individual must present a clear danger to either themselves or others. Second, the individual
demonstrates that he/she is unable to care for him or herself or make decisions about whether
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treatment or hospitalization is necessary. Finally, the individual believes he/she is about to lose
control, and so, needs treatment or care in a mental health facility.
15.1.2.3. Assessment of “dangerousness.” Dangerousness can best be defined as the
person’s capacity or likelihood of harming themselves or others. Most people believe that those
who are mentally ill are more dangerous than those free of mental illness, especially when
espousing self-reported conservatism and RWA (Right-Wing Authoritarianism; Gonzales, Chan,
and Yanos, 2017; DeLuca and Yanos, 2015) or after tragic events such as a mass shooting (Metzl
& MacLeish, 2015). The media plays a role in this, and as McGinty et al. (2014) found, 70% of
news coverage of serious mental illness (SMI) and gun violence over a 16-year period (1997 to
2012) focused on extreme events and described specific shootings by persons with SMI. The
authors wrote, “Even in thematic news coverage focused on describing the general problem of
SMI and gun violence, the majority of news stories did not mention that most people with SMI
are not violent or that we lack tools capable of accurately identifying persons with SMI who are
at heightened risk of committing future violence.” They concluded that media coverage of
persons with SMI as violent might contribute to negative public attitudes.
Rozel & Mulvey (2017) showed that mental illness is a weak risk factor for violence
though this is not to say that the mentally ill do not commit violent acts. The authors write, “…it
has been documented repeatedly that people who report diagnosable levels of psychiatric
symptoms also report more involvement in acts of violence toward others than the general
population reports.” Approximately 4% of criminal violence can be attributed to the mentally ill
(Metzl & MacLeish, 2015), while those with mental illness are three times more likely to be
targets and not perpetrators of violence (Choe et al., 2008).
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Regardless of this, we do attempt to identify the level of dangerousness a person may
exhibit or have the potential to exhibit. How easy is it to make this prediction? As you might
think, it can be very difficult. First, the definition of dangerousness is vague. It implies physical
harm, but what about psychological abuse or the destruction of property? Second, past criminal
activity is a good predictor of future dangerousness but is often not admissible in court. Third,
context is critical; in some situations, the person is perfectly fine, but in other circumstances, like
having to wait in line at the DMV, the person experiences considerable frustration and eventually
anger or rage.
15.1.2.4. Procedures in civil commitment. The process for civil commitment does vary
a bit from state to state, but some procedures are held in common. First, a family member,
mental health professional, or primary care practitioner, may request that the court order an
examination of an individual. If the judge agrees, two professionals, such as a mental health
professional or physician, are appointed to examine the person in terms of their ability for self-
care, need for treatment, psychological condition, and likelihood to inflict harm on self or others.
Next, a formal hearing gives the examiners a chance to testify as to what they found.
Testimonials may also be provided by family and friends, or by the individual him/herself. Once
testimonies conclude, the judge renders judgment about whether confinement is necessary and, if
so, for how long. Typical confinements last from 6 months to 1 year, but an indefinite period can
be specified too. In the latter case, the individual has periodic reviews and assessments. In
emergencies, the process stated above can be skipped and short-term commitment made,
especially if the person is an imminent threat to him/herself or others.
Before we move on, consider for a minute that a person who is accused of a crime is
innocent until proven guilty, has a trial, and if found guilty beyond a reasonable doubt (or almost
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complete certainty) is only then incarcerated. This is not true for the mentally ill, who may be
committed to a facility without ever having committed a crime or having a trial, but simply
because he or she was judged as having the potential to do so (or was seen as dangerous). This
potential means that there has to be “clear and convincing” proof, which the Supreme Court
defines as 75% certainty. The standard to commit is much different for those accused of criminal
acts and those who are mentally ill.
15.1.3. Criminal Commitment
When people are accused of crimes but found to be mentally unstable, they are usually
sent to a mental health institution for treatment. This is called criminal commitment.
Individuals may plead not guilty by reason of insanity (NGRI) or as it is also called, the
insanity plea. When a defendant pleads NGRI they are acknowledging their guilt for the crime
(actus rea) but wish to be seen as not guilty since they were mentally ill at the time (mens rea).
The origins of the modern definition of insanity go back to Daniel M’Naghten in 1843 England.
He murdered the secretary to British Prime Minister, Robert Peel, during an attempted
assassination of the Prime Minister. He was found to be not guilty due to delusions of
persecution, which outraged the public and led to calls for a more precise definition of insanity.
The M’Naghten rule states that having a mental disorder at the time of a crime does not mean
the person was insane. The individual also had to be unable to know right from wrong, or
comprehend the act as wrong. But how do you know what the person’s level of awareness was
when the crime was committed?
Dissatisfaction with the M’Haghten rule led some state and federal courts in the U.S. to
adopt instead the irresistible impulse test (1887), which focused on the inability of a person to
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control their behaviors. The issue with this rule is in distinguishing when a person is unable to
maintain control rather than choosing not to exert control over their behavior. This meant there
were two choices in the U.S. in terms of how insanity was defined – the M’Haghten rule and the
irresistible impulse test. A third test emerged in 1954 from the Durham v. United States case,
though it was short-lived. The Durham test, or products test, stated that a person was not
criminally responsible if their crime was a product of a mental illness or defect. It offered some
degree of flexibility for the courts but was viewed as too flexible. Since almost anything can
cause something else, the term product is too vague.
In 1962, the American Law Institute (ALI) offered a compromise to the three precepts in
use at the time. The American Law Institute standard stated that people are not criminally
responsible for their actions if, at the time of their crime, they had a mental disorder or defect
that did not allow them to distinguish right from wrong and to obey the law. Though this became
the standard, it also became controversial when defense attorneys used it as the basis to have
John Hinckley, accused of attempting to assassinate President Ronald Regan, found not guilty by
reason of insanity in 1982.
Public uproar led the American Psychiatric Association to reiterate the stance of the
M’Naghten test and assert people were only insane if they did not know right from wrong when
they committed their crime. The Federal Insanity Defense Reform ACT (IDRA) of 1984 “was
the first comprehensive federal legislation governing the insanity defense and the disposition of
individuals suffering from a mental disease or defect who are involved in the criminal justice
system.” The ACT included the following provisions:
• significantly modified the standard for insanity previously applied in the federal
courts
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• placed the burden of proof on the defendant to establish the defense by clear and
convincing evidence
• limited the scope of expert testimony on ultimate legal issues
• eliminated the defense of diminished capacity, created a special verdict of "not guilty
only by reason of insanity," which triggers a commitment proceeding
• provided for federal commitment of persons who become insane after having been
found guilty or while serving a federal prison sentence.
Source: https://www.justice.gov/usam/criminal-resource-manual-634-insanity-defense-reform-
act-1984
This is the current standard in all federal courts and about half of all state courts, with
Idaho, Kansas, Montana, and Utah choosing to get rid of the insanity plea altogether.
For more on the insanity plea, please visit:
https://www.npr.org/sections/health-shots/2016/08/05/487909967/with-no-insanity-
defense-seriously-ill-people-end-up-in-prison
Another possibility is for the jury to deliver a verdict of guilty but mentally ill (GBMI),
effectively acknowledging that the person did have a mental disorder when committing a crime,
but the illness was not responsible for the crime itself. The jurors can then convict the accused
and suggest he or she receive treatment. Though this looks like an excellent alternative, jurors
are often confused by it (Melville & Naimark, 2002), NGRI verdicts have not been reduced, and
all prisoners have access to mental health care anyway. Hence it differs from a guilty verdict in
name only (Slovenko, 2011; 2009).

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A final concept critical to this discussion is whether the defendant is competent to stand
trial and refers to the accused’s mental state at the time of psychiatric examination after arrest
and before going to trial. To be deemed competent, federal law dictates that the defendant must
have a rational and factual understanding of the proceedings and be able to rationally consult
with counsel when presenting his/her defense (Mossman et al., 2007; Fitch, 2007). This
condition guarantees criminal and civil rights and ensures the accused understands what is going
on during the trial and can aid in his or her defense. If they are not fit or competent, then they can
be hospitalized until their mental state improves.
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• Forensic psychology is when clinical psychology is applied to the legal arena
in terms of assessment, treatment, and evaluation, though it can include
research from other subfields to include cognitive and social psychology.
• Civil commitment occurs when a person acts in potentially dangerous ways
to themselves or others and can be initiated by the person or the government.
• Dangerousness is defined as the person’s capacity of harming themselves or
others and implies physical harm but not necessarily psychological abuse or
the destruction of property.
• Criminal commitment occurs when a person is accused of a crime but found
to be mentally unstable.
• Several rules or tests have been attempt to determine if a person is
responsible for their actions at the time a crime was committed. These
include the M’Naghten rule, irresistible impulse test, Durham test, and the
American Law Institute standard.
1. Describe the subfield of forensic psychology.

2. What is civil commitment and what criteria is used when establishing its
need?
3. What does the concept of dangerousness mean?
4. What is criminal commitment?
5. Outline the various rules/tests used to determine if someone is responsible
for the actions at the time of a crime.
6. Contrast the insanity plea with the concept of being competent to stand trial.
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15.2. Patient’s Rights
• Describe rights patients with mental illness have and identify key court cases.
The following are several rights that patients with mental illness have. They include:
• Right to Treatment – In the 1966 case of Rouse v. Cameron, the D.C. District court
said that the right to treatment is a constitutional right, and failure to provide
resources cannot be justified due to insufficient resources. In the 1972 case of Wyatt
v. Stickney, a federal court ruled that the state of Alabama was constitutionally
obligated to provide all people who were committed to institutions with adequate
treatment and had to offer more therapists, privacy, exercise, social interactions, and
better living conditions for patients. In the case of O’Connor v. Donaldson (1975), the
court ruled that patient’s cases had to be reviewed periodically to see if they could be
released. As well, if they are not a danger and are able to survive on their own or with
help from family or friends, that they be released.
• Right to Refuse Treatment – As patients have the right to request treatment, they
too have the right to refuse treatment such as biological treatment, psychotropic
medications (Riggins v. Nevada, 1992), and electroconvulsive therapy.
• Right to Less Restrictive Treatment – In Dixon v. Weinberger (1975), a U.S.
District Court ruled that individuals have a right to receive treatment in facilities less
restrictive than mental institutions. The only patients who can be committed to
hospitals are those unable to care for themselves.
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• Right to Live in a Community – The 1974 U.S. District Court case, Staff v. Miller,
ruled that state mental hospital patients had a right to live in adult homes in their
communities.

• Patients with a mental illness have a right to treatment, to refuse treatment, to
have less restrictive treatment, and to live in a community.
1. What rights do patients with mental illness have and what court cases were
pivotal to their establishment?
15.3. The Therapist-Client Relationship
• Describe three concerns related to the therapist-client relationship.
Three concerns are of paramount importance in terms of the therapist-client relationship. These
include the following:
• Confidentiality – As you might have learned in your introductory psychology course,
confidentiality guarantees that information about you is not disseminated without
your consent. This applies to students participating in research studies as well as
patients seeing a therapist.
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• Privileged communication – Confidentiality is an ethical principle while privileged
communication is a legal one, and states that confidential communications cannot be
disseminated without the patient’s permission. There are a few exceptions to this
which include the client being younger than 16, when they are a dependent elderly
person and a victim of a crime, or when the patient is a danger to him or herself or
others, to name a few.
• Duty to Warn – In the 1976 Tarasoff v. the Board of Regents of the University of
California ruling, the California Supreme Court said that a patient’s right to
confidentiality ends when there is a danger to the public, and that if a therapist
determines that such a danger exists, he/she is obligated to warn the potential victim.
Tatiana Tarasoff, a student at UC, was stabbed to death by graduate student, Prosenjit
Poddar in 1969, when she rejected his romantic overtures, and despite warnings by
Poddar’s therapist that he was an imminent threat. The case highlights the fact that
therapists have a legal and ethical obligation to their clients but, at the same time, a
legal obligation to society. How exactly should they balance these competing
obligations, especially when they are vague? The 1980 case of Thompson v. County
of Alameda ruled that a therapist does not have a duty to warn if the threat is
nonspecific.
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• There are three concerns which are important where the therapist-client
relationship is concerned – confidentiality, privileged communication, and the
duty to warn.
1. What are the three concerns related to the therapist-client relationship?

Describe each and state any relevant court rulings relevant to them.
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Check This Out
Can you play video games so much, that it becomes addictive? Does this
mean that it is a diagnosable mental illness to be listed in the DSM 5? Currently,
the disorder is only listed in the DSM 5 as a condition for further study and has
called it internet gaming disorder. Primarily affecting adolescent males aged
12 to 20, it is thought to include symptoms such as:
• Preoccupation or obsession with Internet games

• Withdrawal symptoms when not playing Internet games
• The person has tried to stop or curb playing Internet games, but has failed
to do so
• A person has had continued overuse of Internet games even with the
knowledge of how much they impact a person’s life
• The person uses Internet games to relieve anxiety or guilt or to escape
Psychology Today writes, “Again, while Internet Gaming Disorder is not an

"official" disorder in the DSM-5, the APA is encouraging further research on the
disorder for possible inclusion in future editions of the DSM.”
(See: https://www.psychologytoday.com/us/blog/here-there-and-
everywhere/201407/internet-gaming-disorder-in-dsm-5)
Did the World Health Organization (WHO) already make a decision for
themselves about this? In the draft of ICD 11 the WHO lists the disorder as a
mental health condition and defines it as “a "persistent or recurrent" behavior
pattern of "sufficient severity to result in significant impairment in personal,
family, social, educational, occupational or other important areas of
functioning." For more on this “disorder,” check out the following articles:
• The Cognitive Psychology of Internet Gaming Disorder (2014 article in
Clinical Psychology Review) –
https://www.sciencedirect.com/science/article/pii/S0272735814000658
• CNN – https://www.cnn.com/2017/12/27/health/video-game-disorder-
who/index.html
• Huffington Post - https://www.huffingtonpost.com/christopher-j-
ferguson/the-muddled-science-of-internet-gaming-
disorder_b_9405478.html
• WHO - http://www.who.int/features/qa/gaming-disorder/en/
What do you think?
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Module Recap
And that’s it. Our final module explored some concepts that transcend any one mental
disorder but affect people with mental illness in general. This included civil and criminal
commitment and issues such as NGRI or the insanity plea, what makes someone dangerous and
what we should do about it, and determining competency to stand trial. We then moved to patient
rights, such as the right to treatment and, conversely, the right to refuse treatment. Finally, we
ended by discussing the patient-therapist relationship and specifically, when the patient’s right to
confidentiality and privileged communication ends, and the therapist has a moral and legal
obligation to warn. We hope you find these topics interesting and explore the issues further
through the links that were provided and peer-reviewed articles that were cited.
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Glossary
Abnormal behavior – behavior that involves a combination of personal distress, psychological
dysfunction, deviance from social norms, dangerousness to self and others, and costliness to
society
Abnormal psychology – The scientific study of abnormal behavior, with the intent to be able to
reliably predict, explain, diagnose, identify the causes of, and treat maladaptive behavior
Absolute refractory period - After the neuron fires it will not fire again no matter how much
stimulation it receives
Acceptance techniques – A cognitive therapy used to reduce a client’s worry and anxiety
Action potential – When the neuron depolarizes and fires
Acute stress disorder - Though very similar to PTSD, symptoms must be present from 3 days to
1 month following exposure to one or more traumatic events
Adjustment disorder - Occurs following an identifiable stressor within the past 3 months;
stressor can be a single event (loss of job) or a series of multiple stressors (marital discord that
ends in a divorce); there is not a set of specific symptoms an individual must meet for diagnosis,
rather, the symptoms must be significant enough that they impair social, occupational, or other
important areas of functioning
Adrenal glands - Located on top of the kidneys, and which release cortisol to help the body deal
with stress
Glossary-1
Affective flattening - Reduction in emotional expression; reduced display of emotional
expression
Agoraphobia - When a person experiences fear specific to leaving their home and traveling to
public places
All-or-nothing principle – The neuron either hits -55mV and fires or it does not
Alogia - Poverty of speech or speech content
Amygdala – The part of the brain responsible for evaluating sensory information and quickly
determining its emotional importance
Anal Stage – Lasting from 2-3 years, the libido is focused on the anus as toilet training occurs
Anhedonia - Inability to experience pleasure
Anorexia Nervosa – An eating disorder characterized by the restriction of energy intake relative to
requirements, leading to a significantly low body weight in the context of age, sex, developmental
trajectory, and physical health; intense fear of gaining weight or of becoming fat, or persistent behavior
that interferes with weight gain, despite significantly low weight; and disturbance in the way in which
one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation,
or persistent lack of recognition of the seriousness of the current low body weight
Antecedents - The environmental events or stimuli that trigger a behavior
Antisocial personality disorder – Characterized by the persistent pattern of disregard for, and
violation of, the rights of others
Apathy - General lack of interest
Asociality - Lack of interest in social relationships
Asylums - Places of refuge for the mentally ill where they could receive care
Glossary-2
Attribution theory - The idea that people are motivated to explain their own and other people’s
behavior by attributing causes of that behavior to personal reasons or dispositional factors that
are in the person themselves or linked to some trait they have; or situational factors that are
linked to something outside the person
Automatic thoughts - The constant stream of negative thoughts, also leads to symptoms of
depression as individuals begin to feel as though they are inadequate or helpless in a given
situation
Autonomic nervous system - Regulates functioning of blood vessels, glands, and internal
organs such as the bladder, stomach, and heart; It consists of sympathetic and parasympathetic
nervous systems
Avoidant personality disorder - Display a pervasive pattern of social anxiety due to feelings of
inadequacy and increased sensitivity to negative evaluations
Avolition - Lack of motivation of goal-directed behavior
Axon - Sends signals/information to neighboring neurons
Axon terminals - The end of the axon where the electrical impulse becomes a chemical message
and is passed to an adjacent neuron
Behavior modification - The process of changing behavior
Behavioral assessment - The measurement of a target behavior
Behaviors - What the person does, says, thinks/feels
Binge-Eating Disorder (BED) – An eating disorder characterized by recurrent episodes of binge
eating associated with: significant distress regarding binge eating behaviors; binge eating occurring, on
Glossary-3
average, at least once a week for 3 months; and binge eating behaviors are not associated with
compensatory behaviors such as that in bulimia nervosa
Biological Model – Includes genetics, chemical imbalances in the brain, the functioning of the
nervous system, etc.
Bipolar Disorder I – A mood disorder characterized by a least one manic episode and the
symptoms are not explained by a personality disorder
Bipolar Disorder II – A mood disorder characterized by having at least one hypomanic episode and at
least one major depressive episode, never having had a manic episode, and the symptoms are not better
explained by a personality disorder; Symptoms cause clinically significant distress or impairment in daily
functioning
Body Dysmorphic Disorder (BDD) - is an obsessive disorder, the focus of the obsessions being
on perceived defects or flaws in the person’s physical appearance
Borderline personality disorder - Display a pervasive pattern of instability in interpersonal
relationships, self-image, affect, and instability
Bulimia Nervosa – An eating disorder characterized by recurrent episodes of binge eating, recurrent
compensatory behaviors to prevent weight gain, and the over-evaluation of shape and weight; the binge
eating and compensatory behaviors both occur, on average, at least once a week for 3 months and these
behaviors do not occur exclusively during an episode of anorexia nervosa
Catatonic behavior - The decrease or even lack of reactivity to the environment
Central nervous system (CNS) - The control center for the nervous system which receives,
processes, interprets, and stores incoming sensory information
Glossary-4
Cerebellum – The part of the brain involved in our sense of balance and for coordinating the body’s
muscles so that movement is smooth and precise; Involved in the learning of certain kinds of simple
responses and acquired reflexes
Chronic traumatic encephalopathy (CTE) - A progressive, degenerative condition due to
repeated head trauma
Civil commitment - When individuals with a mental illness behave in erratic or potentially
dangerous ways, it is responsibility of the government to place the individual in involuntary
commitment in a hospital or mental health facility to protect the individual
Classification - The way in which we organize or categorize things
Classification systems -Provide mental health professionals with an agreed upon list of
disorders falling in distinct categories for which there are clear descriptions and criteria for
making a diagnosis
Client-centered therapy - Stated that the humanistic therapist should be warm, understanding,
supportive, respectful, and accepting of his/her clients
Clinical assessment – The collecting of information and drawing conclusions through the use of
observation, psychological tests, neurological tests, and interviews to determine what the client’s
problem is and what symptoms he/she is presenting with
Clinical description - Includes information about the thoughts, feelings, and behaviors that
constitute that mental disorder
Clinical diagnosis - The process of using assessment data to determine if the pattern of
symptoms the person presents with is consistent with the diagnostic criteria for a specific mental
disorder set forth in an established classification system such as the DSM-5 or ICD-10
Glossary-5
Clinical interview - A face-to-face encounter between a mental health professional and a patient
in which the former observes the latter and gathers data about the person’s behavior, attitudes,
current situation, personality, and life history
Cognitive coping skills training - Teaches social skills, communication, and assertiveness
through direct instruction, role playing, and modeling
Cognitive restructuring - Also called rational restructuring, in which maladaptive cognitions
are replaced with more adaptive ones
Comorbidity - When two or more mental disorders are occurring at the same time and in the
same person
Compulsions - Repetitive behaviors or mental acts that an individual performs in response to an
obsession
Concussion - Occurs when there is a significant blow to the head, followed by changes in brain
functioning
Conditioning - A type of associative learning, occurs which two events are linked
Confounding variables - Variables not originally part of the research design but contribute to
the results in a meaningful way
Consciousness – According to Freud, the level of personality that is the seat of our awareness
Consequences - The outcome of a behavior that either encourages it to be made again in the
future or discourages its future occurrence
Contingencies - When one thing occurs due to another
Control group – The group in an experiment that does not receive the treatment or is not
manipulated
Glossary-6
Conversion Disorder – A somatic symptom and related disorders characterized by at least one
voluntary motor or sensory dysfunction, lack of medical compatibility between symptom and
neurological/medical condition, symptom(s) not better explained by another medical or mental disorder,
and causes clinically significant distress or impairment in daily functioning
Cortisol - A hormone released as a stress response
Counterconditioning - The reversal of previous learning
Courtesy stigma - When stigma affects people associated with the person with a mental disorder
Course – The particular pattern a disorder displays
Criminal commitment - When people are accused of crimes but found to be mentally unstable,
they are usually sent to a mental health institution for treatment
Critical thinking - Our ability to assess claims made by others and make objective judgments
that are independent of emotion and anecdote and based on hard evidence, and required to be a
scientist
Cross-sectional validity – When a behavior made in one environment happens in other
environments as well
Culture - The totality of socially transmitted behaviors, customs, values, technology, attitudes,
beliefs, art, and other products that are particular to a group, and determines what is normal
Culture-sensitive therapies – A sociocultural therapies that include increasing the therapist’s
awareness of cultural values, hardships, stressors, and/or prejudices faced by their client; the
identification of suppressed anger and pain; and raising the client’s self-worth
Cyclothymic disorder – A mood disorder characterized by hypomanic symptoms and mild
depressive symptoms (i.e. do not fully meet criteria for a depressive episode)
Glossary-7
Dangerousness - When behavior represents a threat to the safety of the person or others
Degenerative - Meaning the symptoms and cognitive deficits become worse overtime
Deinstitutionalization - The release of patients from mental health facilities
Delirium - Characterized by a significant disturbance in attention or awareness and cognitive
performance that is significantly altered from one’s usual behavior
Dementia - A major decline in cognition and self-help skills due to a neurocognitive disorder
Dendrites - Receives information from neighboring neurons and look like little trees
Denial – Sometimes life is so hard all we can do is deny how bad it is
Dependent personality disorder - Characterized by pervasive and excessive need to be taken
care of by others
Dependent variable (DV) – In an experiment, the variable that is measured
Depersonalization - Defined as a feeling of unreality or detachment from oneself
Depolarized – When ion gated channels open allowing positively charged Sodium ions to enter;
This shifts the polarity to positive on the inside and negative outside
Depressant substances - Such as alcohol, sedative-hypnotic drugs, and opioids, are known to
have a depressing, or inhibiting effect on one’s central nervous system; therefore, they are often
used to alleviate tension and stress
Derealization - Include feelings of unreality or detachment from the world—whether it be
individuals, objects, or their surroundings
Descriptive statistics – Statistics which provide a means of summarizing or describing data, and
presenting the data in a usable form

Glossary-8
Deviance - A move away from what is normal, or the mean, and so is behavior that occurs
infrequently
Displacement – When we satisfy an impulse with a different object because focusing on the
primary object may get us in trouble
Dissociative disorders - A group of disorders categorized by symptoms of disruption in
consciousness, memory, identify, emotion, perception, motor control, or behavior
Dissociative Amnesia Disorder - Dissociative disorder identified by the inability to recall
important autobiographical information
Dissociative fugue - Considered to be the most extreme type of dissociative amnesia where not
only does an individual forget personal information, but they also flee to a different location
Dissociative Identity Disorder – Dissociative disorder characterized by the presence of two or
more distinct personality states which causes discontinuity of self; difficulty recalling everyday events,
personal information, or traumatic events due to lapse of memory; and causes significant distress or
impairment in daily functioning
Distress – When a person experiences a disabling condition that can affect social, occupational,
or other domains of life and takes psychological and/or physical pain
Dopamine – Neurotransmitter which controls voluntary movements and is associated with the
reward mechanism in the brain
Dream analysis – In psychoanalytic theory, is an attempt to understand a person’s inner most
wishes as expressed in their dreams
Dysfunction – Includes “clinically significant disturbance in an individual’s cognition, emotion
regulation, or behavior that reflects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning” (APA, 2013)
Glossary-9
Ego – According to Freud, the part of personality that attempts to mediate the desires of the id
against the demands of reality, and eventually the moral limitations or guidelines of the superego
Ego-defense mechanisms – According to Freud, they protect us from the pain created by
balancing both the will of the id and the superego, but are considered maladaptive if they are
misused and become our primary way of dealing with stress
Emotional intelligence or EI – Is our ability to manage the emotions of others as well as
ourselves and includes skills such as empathy, emotional awareness, managing emotions, and
self-control
Enactive learning - Learning by doing
Endorphins – Neurotransmitters involved in reducing pain and making the person calm and
happy
Eros - Our life instincts which are manifested through the libido and are the creative forces that
sustain life
Erotomanic delusion - Occurs when an individual reports a delusion of another person being in
love with them
Enzymatic degradation - When enzymes are used to destroy excess neurotransmitters in the
synaptic space
Epidemiological study - A special from of correlational research in which the prevalence and
incidence of a disorder in a specific population are measured
Glossary-10
Epidemiology - The scientific study of the frequency and causes of diseases and other health-
related states in specific populations such as a school, neighborhood, a city, country, and the
world
Etiology - The cause of the disorder
Existential perspective - This approach stresses the need for people to continually re-create
themselves and be self-aware, acknowledges that anxiety is a normal part of life, focuses on free
will and self-determination, emphasizes that each person has a unique identity known only
through relationships and the search for meaning, and finally, that we develop to our maximum
potential
Exorcism – A procedure in which evil spirts were cast out through prayer, magic, flogging,
starvation, having the person ingest horrible tasting drinks, or noise-making
Experimental group – In an experiment, the group that receives the treatment or manipulation
Extinction - When something that we do, say, think/feel has not been reinforced for some time
Factitious disorder - Commonly referred to as Munchausen syndrome, is characterized by
intentional falsification of medical or psychological symptoms of oneself or another, with the
overall intention of deception
Fixed Interval schedule (FI) – With a FI schedule, you will reinforce after some set amount of
time
Fixed Ratio schedule (FR) – With this schedule, we reinforce some set number of responses
Flooding - Exposing the person to the maximum level of stimulus and as nothing aversive
occurs, the link between CS and UCS producing the CR of fear should break, leaving the person
unafraid
Glossary-11
Forensic psychology/psychiatry - When clinical psychology is applied to legal arena in terms
of assessment, treatment, and evaluation
Free association – In psychoanalytic theory, this technique involves the patient describing
whatever comes to mind during the session
Frontal lobe – Part of the cerebrum that contains the motor cortex which issues orders to the muscles of
the body that produce voluntary movement
Frontotemporal Lobar Degeneration (FTLD) - Causes progressive declines in language or
behavior due to the degeneration in the frontal and temporal lobes of the brain; symptoms
include significant changes in behavior and/or language
Fundamental attribution error - Occurs when we automatically assume a dispositional reason
for another person’s actions and ignore situational factor
GABA – Neurotransmitter responsible for blocking the signals of excitatory neurotransmitters
responsible for anxiety and panic
Gaps - Holes in the literature of a given area
Generalizability – Begin able to apply your findings for the sample to the population
Generalized amnesia – A type of dissociative amnesia in which the person has a complete loss
of memory of their entire life history, including their own identity
Generalized anxiety disorder - The most common anxiety disorder characterized by a global
and persistent feeling of anxiety
Genital Stage – Beginning at puberty, sexual impulses reawaken and unfulfilled desires from
infancy and childhood can be satisfied during lovemaking

Glossary-12
Glial cells - The support cells in the nervous system that serve five main functions: as a glue and
hold the neuron in place, form the myelin sheath, provide nourishment for the cell, remove waste
products, and protect the neuron from harmful substances
Glutamate – Neurotransmitter associated with learning and memory
Grandiose delusion - Involves the conviction of having a great talent or insight
Habituation - When we simply stop responding to repetitive and harmless stimuli in our
environment
Hippocampus - Our “gateway” to memory; Allows us to form spatial memories so that we can
accurately navigate through our environment and helps us to form new memories about facts and events
Histrionic personality disorder - Addresses the pervasive and excessive need for emotion and
attention from others; these individuals are often uncomfortable in social settings unless they are
the center of attention
Hoarding – Focused on the persistent over-accumulation of possessions
Hypertension - -Chronically elevated blood pressure
Hypomanic episode - Persistently elevated, expansive, or irritable mood; May present as persistent
increased activity or energy; Symptoms last at least 4 consecutive days and present most of the day,
nearly every day; Includes at least three of the following: inflated self-esteem or grandiosity, decreased
need for sleep, more talkative or pressured speech, flight of ideas, distractibility, increase in goal-directed
activity or psychomotor agitation, or excessive involvement in activities that have a high potential for
painful consequences
Glossary-13
Hypothalamic-pituitary-adrenal (HPA) axis - Involved in the fear producing response and
may be involved in the development of trauma symptoms
Hypothalamus – The part of the brain involved in drives associated with the survival of both the
individual and the species; It regulates temperature by triggering sweating or shivering, and
controls the complex operations of the autonomic nervous system
Hypothesis – A specific, testable prediction
Humanism - The worldview that emphasizes human welfare and the uniqueness of the
individual
Id – According to Freud, is the impulsive part of personality that expresses our sexual and
aggressive instincts
Ideas of reference - The belief that unrelated events pertain to them in a particular and unusual
way
Identification – This is when we find someone who has found a socially acceptable way to
satisfy their unconscious wishes and desires and we model that behavior
Illness anxiety disorder - Previously known as hypochondriasis, involves the excessive
preoccupation with having or acquiring a serious medical illness
Incidence - The number of new cases in a population over a specific period of time
Independent variable (IV) – In an experiment, the variable that is manipulated
Inferential statistics – Statistics which allow for the analysis of two or more sets of numerical
data
Insomnia - The difficult falling or staying asleep

Glossary-14
Intellectualization- When we avoid emotion by focusing on intellectual aspects of a situation
Intelligence tests - Used to determine the patient’s level of cognitive functioning and consists of
a series of tasks asking the patient to use both verbal and nonverbal skills
Ions - Charged particles found both inside and outside the neuron
Irritable bowel syndrome (IBS) - A chronic, functional disorder of the gastrointestinal tract
including symptoms such as abdominal pain and extreme bowel habits (diarrhea and/or
constipation)
Jealous delusion - Revolves around the conviction that one’s spouse or partner is/has been
unfaithful
Laboratory observation - A research method in which the scientist observes people or animals
in a laboratory setting
Latency Stage – From 6-12 years of age, children lose interest in sexual behavior and boys play
with boys and girls with girls
Latent content - The hidden or symbolic meaning of a dream
Glossary-15
Law of effect (Thorndike, 1905) - The idea that if our behavior produces a favorable
consequence, in the future when the same stimulus is present, we will be more likely to make the
response again, expecting the same favorable consequence
Learning - Any relatively permanent change in behavior due to experience
Libido - The psychic energy that drives a person to pleasurable thoughts and behaviors
Lifetime prevalence - Indicates the proportion of a population that has had the characteristic at
any time during their lives
Literature review - When we conduct a literature search through our university library or a
search engine such as Google Scholar to see what questions have been investigated already and
what answers have been found
Localized amnesia - The most common type of dissociative amnesia, is the inability to recall
events during a specific period of time
Major Depressive Disorder – A mood disorder characterized by depressed mood most of the
day or decreased interest or pleasure in all or most activities most of the day, along with
insomnia or hypersomnia, fatigue, feelings of worthlessness, or difficulty concentrating to name
a few symptoms; symptoms occur during a two week period
Major neurocognitive disorder – Individuals with the disorder show significant decline in both
overall cognitive functioning as well as the ability to independently meet the demands of daily
living such as paying bills, taking medications, or caring for oneself
Manic episode - Persistent elevated, expansive, or irritable mood. May present as persistent increased
goal-directed activity or energy; Symptoms last at least 1 week and present most of the day, nearly
Glossary-16
every day; includes three of the following: inflated self-esteem or grandiosity, decreased need for sleep,
more talkative or pressured speech, flight of ideas, distractibility, increase in goal-directed activity or
psychomotor agitation, or excessive involvement in activities that have a high potential for painful
consequences
Manifest content - The person’s actual retelling of the dream
Mass madness – or Group hysteria; When large numbers of people display similar symptoms
and false beliefs; a term used during the Middle Ages
Medulla – The part of the brain that regulates breathing, heart rate, and blood pressure
Melatonin - A hormone released when it is dark outside to assist with the transition to sleep
Mental disorders - Characterized by psychological dysfunction which causes physical and/or
psychological distress or impaired functioning and is not an expected behavior according to
societal or cultural standards
Mental health epidemiology - Refers to the occurrence of mental disorders in a population
Mental hygiene movement - An idea arising in the late 18th century to the early 19th century
with the fall of the moral treatment movement, it focused on the physical well-being of patients
Mental status examination - Used to organize the information collected during the clinical
interview and systematically evaluates the patient through a series of questions assessing
appearance and behavior to include grooming and body posture, thought processes and content to
include disorganized speech or thought and false beliefs, mood and affect such that whether the
person feels hopeless or elated, intellectual functioning to include speech and memory, and
awareness of surroundings to include where the person is and what the day and time are
Migraine headaches - Headaches explained by a throbbing pain localized to one side of the
head and often accompanied by nausea, vomiting, sensitivity to light, and vertigo
Glossary-17
Model - A representation or imitation of an object
Modeling - Techniques used to change behavior by having subjects observe a model in a
situation that usually causes them some anxiety
Moral treatment movement – An idea arising in Europe in the late 18th century and then in the
United States in the early 19th century, it stressed affording the mentally ill respect, moral
guidance, and humane treatment, all while considering their individual, social, and occupational
needs
Myelin sheath - The white, fatty covering which: 1) provides insulation so that signals from
adjacent neurons do not affect one another and, 2) increases the speed at which signals are
transmitted
Multicultural psychology – The area of psychology which attempts to understand how the
various groups, whether defined by race, culture, or gender, differ from one another
Multi-dimensional model – An explanation for mental illness that integrates multiple causes of
psychopathology and affirms that each cause comes to affect other causes over time
Narcissistic personality disorder - Individuals display a pattern of grandiosity along with a lack
of empathy for others
Naturalistic observation - A research method in which the scientist studies human or animal
behavior in its natural environment which could include the home, school, or a forest
Negative Punishment (NP) – This is when something good is taken away or subtracted making
a behavior less likely in the future
Glossary-18
Negative Reinforcement (NR) – This is when something bad or aversive is taken away or
subtracted due to your actions, making it that you will be more likely to make the same behavior
in the future when the same stimuli presents itself
Negative symptoms – The inability or decreased ability to initiate actions, speech, expressed
emotion, or to feel pleasure
Nerves - A group of axons bundled together like wires in an electrical cable
Neurological tests - Used to diagnose cognitive impairments caused by brain damage due to
tumors, infections, or head injury; or changes in brain activity
Neuron - The fundamental unit of the nervous system
Neurotransmitter – When the actual code passes from one neuron to another in a chemical form
Nomenclature – A naming system
Norepinephrine – Neurotransmitter which increases the heart rate and blood pressure and
regulates mood
Nucleus - The control center of the body
Observation – Observing others either naturalistically or in a controlled environment
Observational learning - When we learn by observing the world around us
Obsessions - Repetitive and persistent thoughts, urges, or images
Obsessive compulsive disorder - More commonly known as OCD, the disorder requires the
presence of both obsessions and compulsions
Glossary-19
Obsessive-Compulsive personality disorder - Defined by an individual’s preoccupation with
orderliness, perfectionism, and ability to control situations that they lose flexibility, openness,
and efficiency in everyday life
Operant conditioning - A type of associate learning which focuses on consequences that follow
a response or behavior that we make (anything we do, say, or think/feel) and whether it makes a
behavior more or less likely to occur
Oral Stage – Beginning at birth and lasting to 24 months, the libido is focused on the mouth and
sexual tension is relieved by sucking and swallowing at first, and then later by chewing and
biting as baby teeth come in
Panic disorder - When an individual experiences recurrent panic attacks consisting of physical
and cognitive symptoms
Paranoid personality disorder - Characterized by a marked distrust or suspicion of others
Parasympathetic nervous system – The part of the autonomic nervous system that calms the
body after sympathetic nervous system arousal
Parietal lobe – The part of the cerebrum that contains the somatosensory cortex and receives
information about pressure, pain, touch, and temperature from sense receptors in the skin,
muscles, joints, internal organs, and taste buds
Peripheral nervous system - Consists of everything outside the brain and spinal cord; It handles
the CNS’s input and output and divides into the somatic and autonomic nervous systems
Period prevalence - Indicates the proportion of a population that has the characteristic at any
point during a given period of time, typically the past year

Glossary-20
Persecutory delusion - Involves the individual believing that they are being conspired against,
spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in
pursuit of their long-term goals
Persistent Depressive Disorder – A mood disorder characterized by poor appetite or
overeating, insomnia or hypersomnia, low self-esteem, low energy, and feelings of hopelessness
lasting most of the day, for more days than not, for at least 2 years
Personality disorders - Have four defining features which include distorted thinking patterns,
problematic emotional responses, over- or under- regulated impulse control, and interpersonal
difficulties
Personality inventories - Ask clients to state whether each item in a long list of statements
applies to them, and could ask about feelings, behaviors, or beliefs
Phallic Stage – Occurring from about age 3 to 5-6 years, the libido is focused on the genitals and
children develop an attachment to the parent of the opposite sex and are jealous of the same sex
parent
Pineal gland - Helps regulate the sleep-wake cycle
Pituitary gland - The “master gland” which regulates other endocrine glands; It influences
blood pressure, thirst, contractions of the uterus during childbirth, milk production, sexual
behavior and interest, body growth, the amount of water in the body’s cells, and other functions
as well
Placebo - Or a sugar pill made to look exactly like the pill given to the experimental group
Point prevalence - Indicates the proportion of a population that has the characteristic at a
specific point in time
Polarized – When the neuron has a negative charge inside and a positive charge outside
Glossary-21
Pons – The part of the brain that acts as a bridge connecting the cerebellum and medulla and
helps to transfer messages between different parts of the brain and spinal cord
Posttraumatic stress disorder - More commonly known as PTSD, is identified by the
development of physiological, psychological, and emotional symptoms following exposure to a
traumatic even
Positive psychology – The position in psychology that holds a more positive conception of
human potential and nature
Positive Punishment (PP) – If something bad or aversive is given or added, then the behavior is
less likely to occur in the future
Positive Reinforcement (PR) – If something good is given or added, then the behavior is more
likely to occur in the future
Positive symptoms - Symptoms that are an over-exaggeration of normal brain processes
Preconscious – According to Freud, the level of personality that includes all of our sensations,
thoughts, memories, and feelings
Presenting problem – The issue the person displays
Prevalence - The percentage of people in a population that has a mental disorder or can be
viewed as the number of cases per some number of people
Prevention – When we identify the factors that cause specific mental health issues and
implement interventions to stop them from happening, or at least minimize their deleterious
effects
Prognosis - The anticipated course the mental disorder will take
Projection – When we attribute threatening desires or unacceptable motives to others
Glossary-22
Projective tests – A psychological test which consists of simple ambiguous stimuli that can
elicit an unlimited number of responses
Psychoanalysis - Psychoanalytic therapy used to understand the personality of a therapist’s
patient and to expose repressed material
Psychological debriefing - A type of crisis intervention that requires individuals who have
recently experienced a traumatic event to discuss or process their thoughts and feelings related to
the traumatic event, typically within 72 hours of the event
Psychological model – includes learning, personality, stress, cognition, self-efficacy, and early
life experiences and how they affect mental illness
Psychological or psychogenic perspective - States that emotional or psychological factors are
the cause of mental disorders and represented a challenge to the biological perspective
Psychological tests - Used to assess the client’s personality, social skills, cognitive abilities,
emotions, behavioral responses, or interests and can be administered either individually or to
groups in paper or oral fashion
Psychopathology - The scientific study of psychological disorders
Psychosis - A loss of contact with reality
Public stigma – When members of a society endorse negative stereotypes of people with a
mental disorder and discriminate against them
Punishment – Due to the consequence, a behavior/response is less likely to occur in the future
Random assignment – When participants have an equal chance of being placed in the control or
experimental group
Glossary-23
Rape - Forced sexual intercourse or other sexual act committed without an individual’s consent
Rationalization – When we offer well thought out reasons for why we did what we did but in
reality these are not the real reason
Reaction formation – When an impulse is repressed and then expressed by its opposite
Reactivity – When the observed changes behavior due to realizing they are being observed
Receptor sites – Locations where neurotransmitters bind to
Reinforcement – Due to the consequence, a behavior/response is more likely to occur in the
future
Reinforcement schedule - The rule for determining when and how often we will reinforce a
desired behavior
Relative refractory period - After a short period of time, the neuron can fire again, but needs
greater than normal levels of stimulation to do so
Regression – When we move from a mature behavior to one that is infantile in nature
Reliable – When our assessment is consistent
Replication - Repeating a study to confirm its results
Repolarization – When the Na channels close and Potassium channels open; K has a positive
charge and so the neuron becomes negative again on the inside and positive on the outside, or
polarizes
Repression – When unacceptable ideas, wishes, desires, or memories are blocked from
consciousness
Research design - Our plan of action of how we will go about testing the hypothesis
Resistance – According to psychoanalytic theory, is the point during free association that the
patient cannot or will not proceed any further
Glossary-24
Respondent conditioning (also called classical or Pavlovian conditioning) - Occurs when we
link a previously neutral stimulus with a stimulus that is unlearned or inborn
Respondent Discrimination – When the CR is elicited by a single CS or a narrow range of CSs
Respondent Extinction – When the CS is no longer paired with the UCS
Respondent Generalization – When a number of similar CSs or a broad range of CSs elicit the
same CR
Resting potential – When the neuron is waiting to fire
Reticular formation – The part of the brain responsible for alertness and attention
Reuptake reuptake - The process of the presynaptic neuron taking up excess neurotransmitters
in the synaptic space for future use
Reversal or ABAB design – A study in which the control is followed by the treatment, and then
a return to control and second administration of the treatment condition; builds replication in to
the design
Schema - A set of beliefs and expectations about a group of people, presumed to apply to all
members of the group, and based on experience
Self-stigma – When people with mental illnesses internalize the negative stereotypes and
prejudice, and in turn, discriminate against themselves
Schizoaffective disorder - Characterized by the psychotic symptoms included in criteria A of
schizophrenia and a concurrent uninterrupted period of a major mood episode—either a
depressive or manic episode
Glossary-25
Schizoid personality disorder - Displays a persistent pattern of avoidance from social
relationships along with a limited range of emotion among social relationships
Schizophrenia – A mental disorder that includes the presentation of at least two of the following
for at least one month: delusions, hallucinations, disorganized speech, disorganized/abnormal
behavior, or negative symptom
Schizophreniform Disorder – A mental disorder characterized by at least two of the following:
delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, and/or negative
symptoms
Schizotypal personality disorder - Characterized by a range of impairment in social and
interpersonal relationships due to discomfort in relationships, along with odd cognitive and/or
perceptual distortions and eccentric behaviors
Scientific method - A systematic method for gathering knowledge about the world around us
Sedative-Hypnotic drugs - More commonly known as anxiolytic drugs, these drugs have a
calming and relaxing effect on individuals
Selective amnesia - Is in a sense, a component of localized amnesia in that the individual can
recall some, but not all, of the details during a specific time period
Self-monitoring – When the person does their own measuring and recording of the ABCs
Self-serving bias - When we attribute our success to our own efforts (dispositional) and our
failures to outside causes (situational)
Sensitization - When our reactions are increased due to a strong stimulus
Serotonin – Neurotransmitter which controls pain, sleep cycle, and digestion; leads to a stable
mood and so low levels leads to depression
Single-subject experimental design – When we have to focus on one individual in a study
Glossary-26
Social anxiety disorder - Occurs when an individual experiences anxiety related to social or
performance situations, where there is the possibility that they will be evaluated negatively
Social cognition - The process of collecting and assessing information about others
Social desirability - When a participant answers questions dishonestly so that he/she is seen in a
more favorable light
Social norms - The stated and unstated rules of society
Sociocultural Model – includes factors such as one’s gender, religious orientation, race,
ethnicity, and culture that affect mental illness
Soma - The cell body
Somatic delusion - Involves delusions regarding bodily functions or sensations
Somatic nervous system - Allows for voluntary movement by controlling the skeletal muscles
and carries sensory information to the CNS
Somatic Symptom Disorder – A somatic symptom or related disorder characterized by
disproportionate and persistent thoughts of the seriousness of the symptom, high levels of anxiety about
the symptom, and/or excessive time/energy spent focused on the symptom
Specific phobia - Observed when an individual experiences anxiety related to a specific object
or subject
Spontaneous recovery – When the CS elicits the CR after extinction has occurred
Standardization – When we use clearly laid out rules, norms, and/or procedures in the process
of assessing client’s
Statistical significance - An indication of how confident we are that our results are due to our
manipulation or design and not chance
Stigma - When negative stereotyping, labeling, rejection, and loss of status occur
Glossary-27
Stressors - Any event- either witnessed firsthand, experienced personally or experienced by a
close family member- that increases physical or psychological demands on an individual
Sublimation – When we find a socially acceptable way to express a desire
Substance abuse - Occurs when an individual consumes the substance for an extended period of
time, or has to ingest large amounts of the substance to get the same effect a substance provided
previously
Substance Intoxication – A substance use disorder characterized by recent ingestion of substance,
significant behavioral or psychological changes immediately following the ingestion of substance,
physical and physiological symptoms develop after ingestion of substance, and changes in behavior not
attributable to a medical condition or other psychological disorder
Substance Use Disorder – A substance use disorder diagnosed when the individual presents
with at least two criteria to include: substance is consumed in larger amounts over time, desire or
inability to reduce quantity of substance use, cravings for substance use, use of the substance in
potentially hazardous situations, tolerance of substance use, and withdrawal, to name a few (11 total
criteria)
Substance Withdrawal - A substance use disorder characterized by cessation or reduction in
substance that has been previously used for a long or heavy period of time, physiological and/or
psychological symptoms within a few hours after cessation/reduction, physiological and/or psychological
symptoms cause significant distress or impairment in functioning, and symptoms not attributable to a
medical condition or other psychological disorder
Substances - Any ingested materials that cause temporary cognitive, behavioral, and/or
physiological symptoms within the individual
Superego - According to Freud, the part of personality which represents society’s expectations,
moral standards, rules, and represents our conscience

Glossary-28
Sympathetic nervous system - Involved when a person is intensely aroused; It provides the
strength to fight back or to flee (fight-or-flight instinct)
Synapse - The point where the code passes from one neuron to another; Consists of three parts –
the axon of the sending neuron; the space in between called the synaptic space, gap, or cleft; and
the dendrite of the receiving neuron
Syndrome - Symptoms occurred regularly in clusters
Target behavior - Whatever behavior we want to change and it can be in excess or needing to
be reduced, or in a deficit state and needing to be increased
Tension headaches - Often described as a dull, constant ache that is localized to one part of the
head/neck; however, it can co-occur in multiple places at one time
Thalamus – The major sensory relay center for all senses but smell
Thanatos - Our death instinct which is either directed inward as in the case of suicide and
masochism or outward via hatred and aggression
Thematic Apperception Test – A projective test which asks the individual to write a complete
story about each of 20 cards shown to them and give details about what led up to the scene
depicted, what the characters are thinking, what they are doing, and what the outcome will be
Theory – A systematic explanation of a phenomenon
Threshold of excitation - -55mV or the amount of depolarization that must occur for a neuron to
fire; It rises from -70mV to -55mV
Thyroid gland – The endocrine gland which regulates the body’s rate of metabolism and so how
energetic people are.

Glossary-29
Tolerance - The need to continually increase the amount of ingested substance
Transference – In psychoanalytic theory, this technique involves patients transfering to the
therapist attitudes he/she held during childhood
Trauma-focused cognitive-behavioral therapy (TF-CBT) - An adaptation of CBT, that
utilizes both CBT techniques, as well as trauma sensitive principles to address the trauma related
symptoms
Treatment - Any procedure intended to modify abnormal behavior into normal behavior
Trephination - In which a stone instrument known as a trephine was used to remove part of the
skull, creating an opening
Trial and error learning - Making a response repeatedly if it leads to success
Glossary-30
Ulcers - Or painful sores in the stomach lining, occur when mucus from digestive juices are
reduced, thus allowing digestive acids to burn a hole into the stomach lining
Unconscious – According to Freud, the level of personality not available to us
Uni-dimensional model – A single factor explanation for mental illness
Validity – When the test measures what it says it measures
Variable Interval schedule (VI) – Reinforcing at some changing amount of time
Variable Ratio schedule (VR) – Reinforcing some varying number of responses
Glossary-31
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Index
#
20th to 21st Centuries, and views of mental illness – Section 1.4.6
A
Abnormal behavior – Section 1.1.1
Abnormal psychology – Section 1.1.3
Absolute refractory period – Section 2.2.1.4
Acceptance techniques – Section 2.3.3.5
Action potential – Section 2.2.1.4
Acute Stress Disorder – Section 5.2.2
Epidemiology of – Section 5.3.2
Comorbidity of – Section 5.4.2
Adjustment Disorder – Section 5.2.3
Affect, types of – Section 2.1
Affective flattening – Section 12.1.1.6
Affective states – Section 2.1
Agoraphobia – Section 7.1.3
Comorbidity – Section 7.3.3
Treatment of – Section 7.5.3
Index-1
All-or-nothing principle Section 2.2.1.4
Alogia – Section 12.1.1.6
Alzheimer’s disease – Section 14.3.1
American Law Institute standard – Section 15.1.3
Amygdala – Section 2.2.1.6
Anal Stage – Section 2.3.1.2
Anhedonia – Section 12.1.1.6
Anorexia nervosa – Section 10.1.1
and EDNOS – Section 10.2.3
Antecedents – Section 3.1.3.6
Antisocial personality disorder – Section 13.1.3.1
Treatment of – Section 13.5.2.1
Apathy – Section 12.1.1.6
Asociality – Section 12.1.1.6
Attributions and cognitive errors – Section 2.3.3.3
Avoidant personality disorder – Section 13.1.4.1
Avolition – Section 12.1.1.6
Axon – Section 2.2.1.3
Axon terminals – Section 2.2.1.3
B
Bandura, A. – Section 2.3.2.4
Index-2
Behavioral assessment – Section 3.1.3.6
Behavioral model – Section 2.3.2
Evaluation of – Section 2.3.2.5
Related to mood disorders – Section 4.5.3
Related to anxiety disorders – Section 7.4.2.2
Related to somatic disorders – Section 8.4.3
Related to obsessive compulsive disorders – Section 9.4.3
Related to substance use and addictive disorders – Section 11.4.3; 11.5.2
Related to personality disorders – Section 13.4.2.3
Behavior modification – Section 2.3.2.5
Behaviors – Section 3.1.3.6
Binge eating disorder (BED) – Section 10.1.3
Biological model – Section 2.2
Related to trauma and stressor related disorders – Section 5.5.1
Related to dissociative disorders – Section 6.4.1
Related to anxiety disorders – Section 7.4.1
Related to eating disorders – Section 10.5.1
Related to schizophrenic disorders – Section 12.4.1
Index-3
Related to personality disorders – Section 13.4.1
Biological or somatogenic perspective – Section 1.4.6.1
Bipolar Disorder I and II – Section 4.2
Bobo Doll experiment – Section 2.3.2.4
Body Dysmorphic Disorder – Section 9.1.2
Borderline personality disorder – Section 13.1.3.2
Brain structure and chemistry – Section 2.2.1
Bulimia nervosa – Section 10.1.2
C
Cardiovascular – Section 8.6.1.4
Catatonic behavior – Section 12.1.1.5
Cathartic method – Section 1.4.6.2
Cerebellum – Section 2.2.1.6
Index-4
Cerebrum, lobes – Section 2.2.1.6
Chronic traumatic encephalopathy (CTE) – Section 14.3.2
Civil commitment – Section 15.1.2
Classification – Section 1.2
Classification systems – Section 3.2.1
Client-centered therapy – Section 2.3.4.1
Client-therapist relationship – Section 3.3.1.4; Section 15.3
Clinical assessment – Section 3.1.1
Clinical description – Section 1.2
Clinical diagnosis – Section 3.2.1
Clinical interview – Section 3.1.3.2
Cognitive behavioral therapy – Section 2.3.3.5; Section 5.6.3
In relation to schizophrenic disorders – Section 12.5.2.1
Cognitive coping skills training – Section 2.3.3.5
Cognitive model – Section 2.3.3
Related to anxiety disorders – Section 7.4.2.1
Index-5
Related to schizophrenic disorders – Section 12.4.2.1
Cognitive restructuring – Section 2.3.3.5
Cognitive therapies – Section 2.3.3.5
Comorbidity – Section 1.2
Of mood disorders – Section 4.4
Of trauma and stressor related disorders – Section 5.4
Of dissociative disorders – Section 6.3
Of somatic disorders – Section 8.3
Of obsessive compulsive disorders – Section 9.3
Of eating disorders – Section 10.4
Of substance-related and addictive disorders – Section 11.3
Of schizophrenic disorders – Section 12.3
Of personality disorders – Section 13.3
Competent to stand trial – Section 15.1.3
Computed tomography (CT scan) – Section 3.1.3.4
Concussion – Section 14.3.2
Conditioning – Section 2.3.2.1
Confidentiality – Section 15.3
Consequences – Section 3.1.3.6
Contingencies – Section 2.3.2.3
Conversion disorder – Section 8.1.3
Counterconditioning – Section 2.3.2.2
Course – Section 1.2
Index-6
Cost of mental illness – Section 1.1.2
Criminal commitment – Section 15.1.3
Cultural-sensitive therapies – Section 2.4.4
Culture – Section 1.1.2
Current views/trends, in mental illness – Section 1.4.7
D
Dangerousness – Section 1.1.2; 15.1.2.3
Deinstitutionalization – Section 1.4.7.2
Delirium – Section 14.1.1
Delusional disorder – Section 12.1.5
Delusions – Section 12.1.1.1
Dementia – Section 14.1.2
With Lewy bodies – Section 14.3.5
Dendrites – Section 2.2.1.3
Denial – Section 2.3.1.3
Dependent personality disorder – Section 13.1.4.2
Depersonalization/Derealization Disorder – Section 6.1.3
Depolarized – Section 2.2.1.4
Depressants – Section 11.1.2.1
Epidemiology of – 11.2.1
Depressive disorders
Index-7
Deviance – Section 1.1.2
Diagnosis, elements of – Section 3.2.2.2
Disorganized thinking – Section 12.1.1.3
Displacement – Section 2.3.1.3
Dissociative disorders – Section 6.1
Dissociative amnesia disorder – Section 6.1.2
Dissociative identity disorder – Section 6.1.1
Distress – Section 1.1.2
Dopamine – Section 2.2.1.5
Dream Analysis – Section 2.3.1.4
DSM – Section 3.2.2
Disorder categories – Section 3.2.2.3
Durham test (products test) – Section 15.1.3
Duty to Warn – Section 15.3
Dysfunction – Section 1.1.2
E
Eating Disorder Not Otherwise Specified (EDNOS) – Section 10.2
Ego defense mechanisms – Section 2.3.1.3
Electroconvulsive therapy – Section 2.2.3.2
Index-8
Emotion
Defined – Section 2.1
Characteristics of – Section 2.2
Enactive learning – Section 2.3.2.4
Environmental factors, and mental illness – Section 2.4.3
Endorphins – Section 2.2.1.5
Enzymatic degradation – Section 2.2.1.4
Epidemiological study – Section 1.5.2.4
Epidemiology – Section 1.2
Of mood disorders – Section 4.3
Of trauma and stressor related disorders – Section 5.3
Of anxiety disorders – Section 5.2
Of obsessive-compulsive disorders – Section 9.2
Of neurocognitive disorders – Section 14.2
Eros – Section 2.3.1.1
Erotomanic delusion – Section 12.1.5
Etiology – Section 1.2
of mood disorders – Section 4.5
Index-9
of trauma and stressor related disorders – Section 5.5
Of anxiety disorders – Section 7.4
Of obsessive compulsive disorders – Section 9.4
Of neurocognitive disorders – Section 14.3
Existential perspective – Section 2.3.4.2
Exorcism – Section 1.4.1
Experiments – Section 1.5.2.5
Exposure therapy – Section 5.6.2
Extinction, operant conditioning – Section 2.3.2.3
Eye Movement Desensitization and Reprocessing (EMDR) – Section 5.6.4
F
Factitious disorder – Section 8.1.4
Family interventions
In relation to schizophrenic disorders – Section 12.5.3
Federal Insanity Defense Reform ACT (IDRA) – Section 15.1.3
Fire – Section 2.2.1.4
Index-10
Fixated – Section 2.3.1.2
Flooding – Section 2.3.2.2
Forensic/legal psychology – Section 15.1.1
Free Association – Section 2.3.1.4
Frontotemporal Lobar Degeneration (FTLD) – Section 14.3.6
Fundamental attribution error – Section 2.3.3.3
G
GABA – Section 2.2.1.5
Gastrointestinal – Section 8.6.1.1
Gender factors, and mental illness – Section 2.4.2
Generalized Anxiety Disorder – Section 7.1.1
Genetic explanations for mental illness – Section 2.2.2.1
Genital Stage – Section 2.3.1.2
Glial Cells – Section 2.2.1.3
Glutamate – Section 2.2.1.5
Grandiose delusion – Section 12.1.5
Greco-Roman Thought – Section 1.4.2
Guilty but mentally ill (GBMI) – Section 15.1.3
Index-11
Habituation – Section 2.3.2.1
Hallucinations – Section 12.1.1.1
Hallucinogens/Cannabis/Combination – Section 11.1.2.5
Headaches – Section 8.6.1.1
Heuristics – Section 1.3
Hippocampus – Section 2.2.1.6
History, of mental illness – Section 1.4
Histrionic personality disorder – Section 13.1.3.3
HIV Infection – Section 14.3.9
Hoarding – Section 9.1.3
Hormonal imbalances – Section 2.2.2.2
Huntington’s disease – Section 14.3.8
Hypomanic Episode – Section 4.2
Humanistic perspective – Section 2.3.4.1
Hypertension – Section 8.6.1.1
Hypnosis – Section 8.6.2.3
Hypothalamus – Section 2.2.1.6
Index-12
I
ICD – Section 3.2.3
Ideas of reference – Section 13.1.2.3
Identification – Section 2.3.1.3
Illness anxiety disorder – Section 8.1.2
Incidence – Section 1.2
Insomnia – Section 8.6.1.3
Intellectualization – Section 2.3.1.3
Intelligence tests – Section 3.1.3.7
Intensity, and emotion – Section 2.2.3
Ions – Section 2.2.1.4
Irresistible impulse test – Section 15.1.3
J
Jealous delusion – Section 12.1.5
L
Latency Stage – Section 2.3.1.2
Latent content, of dreams – Section 2.3.1.4
Law of effect – Section 2.3.2.3
Learning – Section 2.3.2.1
Levels of personality (conscious, preconscious, unconscious) – Section 2.3.1.1
Index-13
Libido – Section 2.3.1.1
M
Magnetic Resonance Imaging (MRI) – Section 3.1.3.4
Major Depressive Disorder – Section 4.1
Major Depressive Episode – Section 4.1
Major Neurocognitive Disorder – Section 14.1.2
Maladaptive cognitions – Section 2.3.3.4
Managed health care – Section 1.4.7.3
Manic Episode – Section 4.2
Manifest content, of dreams – Section 2.3.1.4
Medulla – Section 2.2.1.6
Mental disorders – Section 1.1.3
Mental health, professionals – Section 1.6.1
Mental hygiene movement – Section 1.4.5
Mental status examination – Section 3.1.3.2
Mesmerism – Section 1.4.6.2
Middle Ages, and views of mental illness – Section 1.4.3
Mild Neurocognitive Disorder – Section 14.1.3
M’Naghten rule – Section 15.1.3
Model – Section 2.1.2
Modeling – Section 2.3.2.4
Mood – Section 2.1
Mood disorders – Module 4
Index-14
Symptoms of – Module 4.1
Types of – Module 4.1
Moral treatment movement – Section 1.4.5
Multicultural factors, and mental illness – Section 2.4.4
Multicultural psychology – Section 1.4.7.4
Multidimensional Models – Section 2.1.2
Multimethod study – Section 1.5.2.6
Myelin Sheath – Section 2.2.1.3
N
Narcissistic personality disorder – Section 13.1.3.4
Negative symptoms – Section 12.1.16
Nerves – Section 2.2.1.3
Nervous system, parts of – Section 2.2.1.2
Communication in – Section 2.2.1.1
Neural Transmission – Section 2.2.1.4
Neurological tests – Section 3.1.3.4
Neurotransimtters – Section 2.2.1.4
Neuron – Section 2.2.1.3
NGRI – Section 15.1.3
Nomenclature – Section 1.2
Norepinephrine – Section 2.2.1.5
Norms (social) – Section 1.1.2
Index-15
Nucleus – Section 2.2.1.3
O
Observational learning – Section 2.3.2.1; 2.3.2.4
OCD (Obsessive Compulsive Disorder) – Section 9.1.1
Obsessive-compulsive personality disorder (OCPD) – Section 13.1.4.2
Operant conditioning – Section 2.3.2.3
Opioids – Section 11.1.2.3
Oral Stage – Section 2.3.1.2
P
Panic disorder – Section 7.1.5
Paranoid personality disorder – Section 13.1.2.1
Parkinson’s disease – Section 14.3.7
Parts of personality (id, ego, superego) – Section 2.3.1.1
Patient’s rights – Section 15.2
Pavlov, Ivan Petrovich – Section 2.3.2.2
Perceptual set – Section 2.1
Index-16
Persecutory delusion – Section 12.1.5
Persistent Depressive Disorder – Section 4.1
Personality
Personality, development of – Section 2.3.1.2
Personality, structure of – Section 2.3.1.1
Personality disorders – Section 13.1.1
Personality inventories – Section 3.1.3.3
Psychological tests – Section 3.1.3.3
Phallic Stage – Section 2.3.1.2
Pharmacological – Section 14.4.1
Physical examination – Section 3.1.3.5
Polarized – Section 2.2.1.4
Pons – Section 2.2.1.6
Positive psychology – Section 1.1.1
Positive symptoms – Section 12.1.16
Positron Emission Tomography (PET) – Section 3.1.3.4
Prevention science – Section 1.4.7.6
Prescription rights for psychologists – Section 1.4.7.5
Presenting problem – Section 1.2
Prevalence – Section 1.2
Primary reinforcers/punishers – Section 2.3.2.3
Privileged communication – Section 15.3
Professional journals – Section 1.6.2.2
Index-17
Professional societies – Section 1.6.2.1
Prognosis – Section 1.2
Projection – Section 2.3.1.3
Projective tests – Section 3.1.3.3
Psychiatric drugs – Section 1.4.7.2
Psychoanalysis – Section 2.3.1.4
Psychodynamic theory – Section 2.3.1
Psychological or psychogenic perspective – Section 1.4.6.2
Psychological debriefing – Section 5.6.1
Psychomotor symptoms – Section 12.1.1.4
Psychopathology – Section 1.1.3
Psychopharmacology – Section 2.2.3.1
In relation to trauma and stressor related disorders – Section 5.6.5
In relation to somatic disorders – Section 8.5.2
In relation to schizophrenic disorders – Section 12.5.1
Psychophysiological Disorders – Section 8.6.1
Psychosis – Section 12.1.1
Psychosurgery – Section 2.2.3.3
Psychotherapy – Section 3.3.1.3
Index-18
Psychotropic drugs – Section 2.2.3.1
PTSD – Section 5.2.1
Punishment – Section 2.3.2.3
R
Rape – Section 5.1
Rationalization – Section 2.3.1.3
Reaction formation – Section 2.3.1.3
Reactivity – Section 3.1.3.1
Reappraisal – Section 2.1
Receptor sites – Section 2.2.1.4
Reform movement, and views of mental illness – Section 1.4.5
Regression – Section 2.3.1.3
Reinforcement – Section 2.3.2.3
Reinforcement schedules – Section 2.3.2.3
Relative refractory period – Section 2.2.1.4
Reliability – Section 3.1.2
Renaissance, and views of mental illness – Section 1.4.4
Repolarized – Section 2.2.1.4
Repression – Section 2.3.1.3
Index-19
Research Method – Section 1.5.2
Resistance – Section 2.3.1.4
Respondent conditioning – Section 2.3.2.2
Respondent discrimination – Section 2.3.2.2
Respondent extinction – Section 2.3.2.2
Respondent generalization – Section 2.3.2.2
Resting potential – Section 2.2.1.4
Reticular formation – Section 2.2.1.6
Reuptake – Section 2.2.1.4
Reversal design (ABAB design) – Section 1.5.2.5
Rogers, C. – Section 2.3.4.1
S
Schemas and cognitive errors – Section 2.3.3.2
Schizoaffective disorder – Section 12.1.4
Schizoid personality disorder – Section 13.1.2.2
Schizophrenia – Section 12.1.2
Schizophreniform disorder – Section 12.1.3
Schizotypal personality disorder – Section 13.1.2.3
Scientific method – Section 1.5.1
Secondary reinforcers/punishers – Section 2.3.2.3
Sedative-Hypnotic drugs – Section 11.1.2.2
Self-monitoring – Section 3.1.3.6
Self-serving bias – Section 2.3.3.3
Index-20
Sensitization – Section 2.3.2.1
Serotonin – Section 2.2.1.5
Social anxiety disorder – Section 7.1.4
Social cognition – Section 1.3; 2.3.3.2
Social identity theory – Section 1.3
Sociocultural Model – Section 2.4
Evaluation of – Section 2.4.5
Related to anxiety disorders – Section 7.4.3
Related to schizophrenic disorders – Section 12.4.3
Related to personality disorders – Section 13.4.3
Socioeconomic factors, and mental illness – Section 2.4.1
Soma – Section 2.2.1.3
Somatic delusion – Section 12.1.5
Somatic symptom and related disorders – Section 8.1
Somatic symptom disorder – Section 8.1.1
Index-21
Specific Phobia – Section 7.1.1
Spontaneous recovery – Section 2.3.2.2
Stages of personality development – Section 2.3.1.2
Standardization – Section 3.1.2
Stigma – Section 1.3
Stimulants – Section 11.1.2.4
Stressors – Section 5.1
Sublimation – Section 2.3.1.3
Substances – Section 11.1.1
Types of – Section 11.1.2
Substantia nigra – Section 2.2.1.6
Suicidality – Section 4.3.3
Synapse – Section 2.2.1.4
Synaptic gap/cleft/space – Section 2.2.1.4
Syndrome – Section 3.2.1
T
Target behavior – Section 3.1.3.6
Thalamus – Section 2.2.1.6
Thanatos – Section 2.3.1.1
Index-22
Thematic Apperception Test – Section 3.1.3.3
Thorndike – Section 2.3.2.3
Transference – Section 2.3.1.4
Trauma-focused Cognitive behavioral therapy – Section 5.6.3
Threshold of excitation – Section 2.2.1.4
Tolerance – Section 11.1.1
Traumatic Brain Injury (TBI) – Section 14.3.2
Treatment – Section 1.2; Section 3.3.1
Related to mood disorders – Section 4.6
Related to trauma and stressor related disorders – Section 5.6
Related to dissociative disorders – Section 6.5
Related to anxiety disorders – Section 7.5
Related to somatic disorders – Section 8.5
Related to Psychological Factors Affecting Other Medical Conditions – Section 8.6.2
Related to obsessive compulsive disorders – Section 9.5
Related to eating disorders – Section 10.6
Related to substance-related and addictive disorders – Section 11.5
Related to schizophrenic disorders – Section 12.5
Related to personality disorders – Section 13.5
Related to neurocognitive disorders – Section 14.4
Trial and error learning – Section 2.3.2.3
Trephination – Section 1.4.1
Index-23
Uni-Dimensional Model – Section 2.1.1
V
Validity – Section 3.1.2
Cross-sectional – Section 3.1.3.1
Vascular disorders – Section 14.3.3
Viral infections – Section 2.2.2.1
W
Watson, J.B. – Section 1.3.2.1; Section 2.1
Withdrawal – Section 1.1.1.1
Index-24

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What are the main topics covered in the textbook?

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What are some of the assessment and diagnostic methods discussed?

What are some of the assessment and diagnostic methods discussed?

Discovering Psychology Series

Alexis Bridley, Ph.D.

Contact Information about this OER:

1. Dr. Lee Daffin, Associate Professor of Psychology – [email protected]

2. Dr. Alexis Bridley - Adjunct Instructor – [email protected]

Part I. Setting the Stage

• Module 1: What is Abnormal Psychology? 1-1

• Module 2: Models of Abnormal Psychology 2-1

• Module 3: Clinical Assessment, Diagnosis, and Treatment 3-1

Part II. Mental Disorders – Block 1

• Module 4: Mood Disorders 4-1

• Module 5: Trauma- and Stressor-Related Disorders 5-1

• Module 6: Dissociative Disorders 6-1

Part III. Mental Disorders – Block 2

• Module 7: Anxiety Disorders 7-1

• Module 8: Somatic Symptom and Related Disorders 8-1

• Module 9: Obsessive-Compulsive and Related Disorders 9-1

Part IV. Mental Disorders – Block 3

• Module 10: Eating Disorders 10-1

• Module 11: Substance-Related and Addictive Disorders 11-1

• Module 12: Schizophrenia Spectrum and Other Psychotic Disorders 12-1

• Module 13: Personality Disorders 13-1

Part VI. Mental Disorders – Block 5

• Module 14: Neurocognitive Disorders 14-1

• Module 15: Contemporary Issues in Psychopathology 15-1

1.0 Fall 2017 Initial writing; feedback pending

1.01 Spring 2018 Addition of Modules 2, 3, and 15

1.03 Summer 2019 Proofreading edits

Enjoy the 2nd edition of Abnormal Psychology.

On behalf of, Alexis Bridley

Part I. Setting the Stage

1. What is Abnormal Psychology?

2. Models of Abnormal Psychology

3. Clinical Assessment, Diagnosis, and Treatment

Part I. Setting the Stage

Module 1: What is Abnormal Psychology?

• 1.1. Understanding Abnormal Behavior

• 1.2. Classifying Mental Disorders

• 1.3. The Stigma of Mental Illness

• 1.4. The History of Mental Illness

• 1.5. Research Methods in Psychopathology

• 1.6. Mental Health Professionals, Societies, and Journals

Module Learning Outcomes

• Explain what it means to display abnormal behavior.

• Clarify how mental health professionals classify mental disorders.

• Describe the effect of stigma on those who have a mental illness.

• Outline the history of mental illness.

they can publish their work in.

1.1. Understanding Abnormal Behavior

Section Learning Objectives

• Describe positive psychology.

• Define abnormal behavior.

• Explain the concept of dysfunction as it relates to mental illness.

• Explain the concept of distress as it relates to mental illness.

• Explain the concept of deviance as it relates to mental illness.

• Explain the concept of dangerousness as it relates to mental illness.