IDENTIFICATION AND CLASSICATION OF ABNORMAL BEHAVIOR

1. CLINICAL ASSESSMENT OF ABNORMAL BEHAVIOR

A. 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), they 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.
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
reason to engage in clinical assessment will be to determine what treatment will work best. 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.
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 and that clinical assessment is an ongoing process.

B. Key Concepts in Assessment

The assessment process involves three critical concepts – reliability, validity, and
standardization. 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 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. 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.
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.
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.

C. 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.
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 sophisticated
equipment and videotape the session to examine it later. 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.
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 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. 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.
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.
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 like mental disorders. Ruling out such conditions can save costly
therapy or surgery.
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 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.
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?

2. DIAGNOSING AND CLASSIFYING ABNORMAL BEHAVIOR

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-TR
or ICD-11 (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, 2022). 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
and benefits of treatment, disability, and other factors (APA, 2022). Likewise, a patient may not
meet the full criteria for a diagnosis but demonstrate a clear need for treatment or care,
nonetheless. As stated in the DSM, “The fact that some individuals do not show all symptoms
indicative of a diagnosis should not be used to justify limiting their access to appropriate care”
(APA, 2022).
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.
People suffering from delusions, hallucinations, disorganized thinking (speech), grossly
disorganized or abnormal motor behavior, and/or negative symptoms are different from people
presenting with a primary clinical deficit in cognitive functioning that is not developmental but
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 neurocognitive disorder
(NCD). The latter can be further distinguished from neurodevelopmental disorders which
manifest early in development and involve developmental deficits that cause impairments in
social, personal, academic, or occupational functioning (APA, 2022). 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 (DSM) which is a “medical classification of disorders
and as such serves as a historically determined cognitive schema imposed on clinical and
scientific information to increase its comprehensibility and utility. The classification of disorders
(the way in which disorders are grouped) provides a high-level organization for the manual”
(APA, 2022, pg. 11). The DSM is currently in its 5th edition Text-Revision (DSM-5-TR) and is
produced by the American Psychiatric Association (APA, 2022). Alternatively, the World Health
Organization (WHO) publishes the International Statistical Classification of Diseases and
Related Health Problems (ICD) currently in its 11th edition. We will begin by discussing the
DSM and then move to the ICD.

2. The DSM Classification System

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). In March 2022, a Text-Revision
was published for the DSM-5, making it the DSM-5-TR.
The history of the DSM goes back to 1952 when the American Psychiatric Association
published the first edition of the DSM which was “…the first official manual of mental disorders
to contain a glossary of descriptions of the diagnostic categories” (APA, 2022, p. 5). The DSM
evolved through four major editions after World War II into a diagnostic classification system to
be used by 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, 2022, pg. 6).
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. An
intensive 6-year 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 findings at professional
meetings, performing field trials, and revisiting criteria and text” was undertaken (APA, 2022,
pg. 7). The process involved physicians, psychologists, social workers, epidemiologists,
neuroscientists, nurses, counselors, and statisticians, all who aided in the development and
testing of DSM-5 while individuals with mental disorders, families of those with a mental
disorder, consumer groups, lawyers, and advocacy groups provided feedback on the mental
disorders contained in the book. Additionally, disorders with low clinical utility and weak
validity were considered for deletion while “Conditions for Future Study” were placed in Section
3 and “contingent on the amount of empirical evidence generated on the proposed diagnosis,
diagnostic reliability or validity, presence of clear clinical need, and potential benefit in
advancing research” (APA, 2022, pg. 7).
2.2. The DSM-5 text revision process. In the spring 2019, APA started work on the Text-
Revision for the DSM-5. This involved more than 200 experts who were asked to conduct
literature reviews of the past 10 years and to review the text to identify any material that was out-
of-date. Experts were divided into 20 disorder review groups, each with its own section editor.
Four cross-cutting review groups to include Culture, Sex and Gender, Suicide, and Forensic,
reviewed each chapter and focused on material involving their specific expertise. The text was
also reviewed by an Ethnoracial Equity and Inclusion work group whose task was to “ensure
appropriate attention to risk factors such as racism and discrimination and the use of
nonstigmatizing language” (APA, 2022, pg. 11).
As such, the DSM-5-TR “is committed to the use of language that challenges the view that
races are discrete and natural entities” (APA, 2022, pg. 18). Some of changes include:

 Use of racialized instead of racial to indicate the socially constructed nature of race
 Ethnoracial is used to denote U.S. Census categories such as Hispanic, African
American, or White
 Latinx is used in place of Latino or Latina to promote gender-inclusive terminology
 The term Caucasian is omitted since it is “based on obsolete and erroneous views about
the geographic origin of a prototypical pan-European ethnicity” (pg. 18)
 To avoid perpetuating social hierarchies, the terms minority and non-White are avoided
since they describe social groups in relation to a racialized “majority”
 The terms cultural contexts and cultural backgrounds are preferred to culture which is
only used to refer to a “heterogeneity of cultural views and practices within societies”
(pg. 18)
  The inclusion of data on specific ethnoracial groups only when “existing research
documented reliable estimates based on representative samples.” This led to limited
inclusion of data on Native Americans since data from nonrepresentative samples may be
misleading.
 The use of gender differences or “women and men” or “boys and girls” since much of the
information on the expressions of mental disorders in women and men is based on self-
identified gender.
 Inclusion of a new section for each diagnosis providing information about suicidal
thoughts or behavior associated with that diagnosis.

3. Elements of a diagnosis. The DSM-5-TR states that the following make up the key
elements of a diagnosis (APA, 2022):

 Diagnostic Criteria and Descriptors – Diagnostic criteria are the guidelines for making a
diagnosis and should be informed by clinical judgment. 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, 2022, pg. 22). For example,
non-rapid eye movement (NREM) sleep arousal disorders can have either a sleepwalking
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. As the DSM-5-TR says, “Specifiers and subtypes provide
an opportunity to define a more homogeneous subgrouping of individuals with the
disorder who share certain features… and to convey information that is relevant to the
management of the individual’s disorder” (pg. 22).
 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 attention or 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.

4. DSM-5 disorder categories. The DSM-5 includes the following categories of disorders:

Table 1. DSM-5 Classification System of Mental Disorders

Disorder Category Short Description

Neurodevelopmental A group of conditions that arise in the developmental period and include intellectu
disorders disorders, autism spectrum disorder, specific learning disorder, motor disorders, an

Disorders characterized by one or more of the following: delusions, hallucinations

Schizophrenia Spectrum
speech, disorganized motor behavior, and negative symptoms

Characterized by mania or hypomania and possibly depressed mood; includes Bip

Bipolar and Related
disorder

Characterized by sad, empty, or irritable mood, as well as somatic and cognitive ch

Depressive functioning; includes major depressive, persistent depressive disorder, mood dysre
premenstrual dysphoric disorder

Characterized by excessive fear and anxiety and related behavioral disturbances; In

Anxiety
anxiety, panic disorder, generalized anxiety disorder, social anxiety disorder, agora

Characterized by obsessions and compulsions and includes OCD, hoarding, body d

Obsessive-Compulsive
trichotillomania, and excoriation

Trauma- and Stressor- Characterized by exposure to a traumatic or stressful event; PTSD, acute stress dis
Related and prolonged grief disorder

Dissociative Characterized by a disruption or discontinuity in memory, identity, emotion, perce

 consciousness, motor control, or behavior; dissociative identity disorder, dissociati
depersonalization/derealization disorder

Characterized by prominent somatic symptoms and/or illness anxiety associated w

Somatic Symptom
impairment; includes illness anxiety disorder, somatic symptom disorder, and conv

Characterized by a persistent disturbance of eating or eating-related behavior to in

Feeding and Eating Includes pica, rumination disorder, avoidant/restrictive food intake disorder, anore
eating disorder

Characterized by the inappropriate elimination of urine or feces; usually first diagn

Elimination
adolescence; Includes enuresis and encopresis

Characterized by sleep-wake complaints about the quality, timing, and amount of s

Sleep-Wake sleep terrors, narcolepsy, sleep apnea, hypersomnolence disorder, restless leg synd
sleep-wake disorders

Characterized by sexual difficulties and include premature or delayed ejaculation,

Sexual Dysfunctions
and erectile disorder (to name a few)

Characterized by distress associated with the incongruity between one’s experienc

Gender Dysphoria
the gender assigned at birth

Characterized by problems in the self-control of emotions and behavior and involv

Disruptive, Impulse-
of others and cause the individual to violate societal norms; includes oppositional
Control, Conduct
personality disorder, kleptomania, intermittent explosive disorder, conduct disorde
Substance-Related and
Characterized by the continued use of a substance despite significant problems rela
Addictive

Characterized by a decline in cognitive functioning over time and the NCD has no
Neurocognitive
early in life; Includes delirium, major and mild neurocognitive disorder, and Alzhe

Characterized by a pattern of stable traits which are inflexible, pervasive, and lead
Personality Includes paranoid, schizoid, borderline, obsessive-compulsive, narcissistic, histrio
antisocial, and avoidant personality disorder

Characterized by recurrent and intense sexual fantasies that can cause harm to the
Paraphilic
includes exhibitionism, voyeurism, sexual sadism, sexual masochism, pedophilic,

ST RE SS
When we are in trouble-particularly with emotional or personal problems-there is a simple model that can
help us understand our circumstances. This model is called the vulnerability, stress and coping model
and it can give us a clear and quick insight into what’s happening. It can also help us know what can we
do about it, even when our troubles make it hard to think straight.
Vulnerability
The first element of this model that can be best thought of as personal soft spots. They are a tendency
towards unwelcome emotional states such as feeling depressed.
Overwhelmed or anxious. The thing to understand is that all of us are vulnerable to nearby everything, but
the degree to which we wre vulnerable varies. It might also be useful to rethink your ideas about what
negative emotions are-it’s not so straightforward.
The reasons for these variations in vulnerability include genetic factors and the way we have been
affected by the things we have experienced in our past. Your level of vulnerability can also change over
time, even though it might be high now, it may reduce later if your circumstances change.

Stress- is anything that can disrupt your day-to-day life and cause you to try and cope. Many of
these stressors are external – unemployment, financial problems, relationships, family etc. but
many of them are internal; illness, substance abuse or changes due to age.

Many of these stressors are things we can't do anything about, but we can change some.

Copi ng

The third element here is coping, and this is where we do something about the stressors. Our
normal experience is to try and cope either by changing our environment or trying to fight back,
and most of the time our coping mechanisms are quite automatic. Some of these ways of coping
work well but others don't work well at all, depending on our response and the circumstances.
One big trap is believing the myth that self-criticism leads to self-improvement.

A third way of coping which we are reluctant to use – and sometimes only use as a last ditched
effort – is changing ourselves to increase our resilience. Often we only turn to this when our
other coping mechanisms fail us and we are in real trouble.

B ri ngi ng it together

This comes together when we consider how our vulnerabilities make us susceptible to stressors,
but this is modified by our coping strategies. If we use the right coping strategies, then this can
decrease our vulnerability to stressors. Further, if we become good at using the right coping
strategies, it could also decrease our vulnerability to other stressors.

Here's a quick example; we might have a vulnerability of a tendency towards low self-esteem.
When we are subject to a stressor (like the criticisms of our boss) then our coping mechanism
might be to get angry at our family.
How do you apply the Vulnerability, Stress and Coping model?

So how do we apply the Vulnerability, Stress and Coping model to our lives? Firstly have a look
at what your most pressing current stressors are. There might be more than just one emotion that
you are feeling here. Secondly, have a look at what your key vulnerabilities are, and how they
are affected by your stressors. Lastly have a look at what you're really doing as coping
mechanisms. Do your coping mechanisms really help with the stressors, or just avoid them? Do
these coping mechanisms really reduce your vulnerabilities, or just hide them?

If you can see your circumstances clearly, you might be able to choose a coping mechanism that
better fits the vulnerabilities that you have on their current stressors. To take the example above,
getting angry the family doesn't change your vulnerability and it doesn't change your boss'
criticism. One of the strengths of the Vulnerability, Stress and Coping model is it can be applied
to many problems.

Ge t t i ng help to cope better

If you decide you'd like to cope better, than psychotherapy can help you decide what you'd like
to change and help you as you go through the process of changing it. This will help you meet
your stressors head-on, and protect (and even reduce) your vulnerabilities.

Post Traumatic Stress Disorder or PTSD - is a trauma- and stressor-related disorder that can
occur after being exposed to severe trauma.

PTSD can be caused by a number of different traumatic events. According to the National Center
for PTSD, between 7 and 8 percent of the population experiences PTSD at some point in their
lives.

PTSD is a treatable condition, and many people with PTSD are able to successfully manage their
symptoms after receiving effective treatment.
Causes of PTSD

PTSD is caused by being exposed to trauma, including experiencing, witnessing, or even

learning about a severely traumatic experience.

EVENTS THAT MAY CAUSE PTSD

 military combat

 sexual or physical assault

 abuse or neglect

 natural disasters

 auto accidents (motorcycle, etc.)

 severe injury

 traumatic birth (postpartum PTSD)

 terrorism

 diagnosis of life-threatening illness

 witnessing violence and death

According to the NHS, 1 in 3 people who experience severe trauma will develop PTSD. There
are a few factors that make it more likely that someone will develop PTSD after a traumatic
event.

RISK FACTORS FOR PTSD

 having a history of mental health disorders such as panic disorder, depression, or OCD

 having little support from loved ones after the event

 experiencing further trauma or stress around the event

In addition to the above, brain structure and stress hormones may also play a role in the
development of PTSD.

In people with PTSD, the hippocampus — a part of the brain — appears to be smallerTrusted
Source. However, it’s unclear if the hippocampus was smaller before the trauma, or if the size is
reduced as a result of the trauma.

Researchers believe a malfunctioning hippocampus could stop the brain from processing trauma
properly, and this could lead to PTSD.

Similarly, people with PTSD have abnormally high levels of stress hormones, which are released
during traumatic events. These high amounts of hormones could be the cause of some PTSD
symptoms, such as numbness and hyperarousal.

There are a number of “resilience factors” too, which are factors that make it less likely that
someone will develop PTSD after a traumatic event.

FACTORS THAT MAKE PTSD LESS LIKELY

 having a strong support network

 learning to use positive coping strategies to address negative emotions

 feeling good about the actions you took when you experienced the traumatic event

This is not to say that people who develop PTSD aren’t resilient or strong. If you have PTSD, it’s
not your fault. PTSD is a natural, common, and understandable reaction to trauma.

SYMPTOMS OF PTSD

 intrusive thoughts such as if you can’t stop thinking about the traumatic event
  mood changes such as feeling hopeless, numb, or anxious

 being easily startled

 feeling overwhelming guilt or shame

 feeling disinterested in your relationships, career, or hobbies

 flashbacks, which may make you feel like you’re reliving the traumatic event

 nightmares

 feeling emotionally distressed when something reminds you of the event

 struggling to concentrate, sleep, or eat

 engaging in self-destructive behavior, including substance use

 self-harm

 suicidal thoughts

 panic attacks

 negative beliefs or expectations about oneself, others, or the world

Certain reminders of the event, or triggers, can incite or worsen the symptoms of PTSD.

According to the National Institute of Mental Health, these symptoms usually show up
within three monthsTrusted Source of experiencing the traumatic event. However, it’s possible
for the symptoms to develop later.

What’s the treatment for PTSD?

There are a number of different treatments for PTSD. These include talk therapy, medication,
and personal lifestyle changes.

Seeing a trained therapist is generally the first step when it comes to treating PTSD.
Talk therapy, or psychotherapy, involves talking to a professional about your experiences and
symptoms. There are a few different kinds of therapy that are effective for treating PTSD. These
include:

 Cognitive-behavioral therapy (CBT). CBT involves discussing the trauma and your
symptoms and helping you implement better thought and behavioral patterns.

 Exposure therapy. This therapy involves talking about the trauma and working through
it in a safe environment to help you process the experience.

 Eye movement desensitization and reprocessing (EMDR) therapy. This interactive

therapy involves moving your eyes from side-to-side while recalling the trauma so that
you can process the event outside of the strong emotions attached to the memories.

The type of therapy you receive will depend on your own needs and your healthcare provider’s
experience.

Medication for PTSD

Some prescription medications, such as sertraline (Zoloft) and paroxetine (Paxil), can help treat
the symptoms of PTSD.

Lifestyle changes

A number of lifestyle changes and self-care practices can help you manage your symptoms.

Some of the recommended coping strategies include:

WAYS TO MANAGE SYMPTOMS

 learning about PTSD to better understand your symptoms

 meditating

 exercising
  journaling

 attending a support group

 having a strong network of loved ones

 reducing negative coping mechanisms such as misusing drugs and alcohol

Emergency treatments

If you feel suicidal, or if you think you have a PTSD-related emergency, seek help immediately.

It might be wise to reach out to your healthcare provider or a trusted loved one or to go to an
emergency room at your local hospitalization.

Outlook for people with PTSD

If you have PTSD or suspect you have PTSD, seeking help from a professional can help.

If left untreated, PTSD can affect your relationships and impact daily life. It can make it difficult
to work, study, eat, or sleep. It may also lead to suicidal thoughts.

Fortunately, it’s possible to find effective treatments that reduce or even stop many of the
symptoms of PTSD.

Every person has different needs and needs a unique treatment plan. What works for one person
might not work for another. Ideally, your healthcare provider will help you find effective coping
tools and therapies to manage your PTSD symptoms

PSYCHOPHYSIOLOGICAL DISORDERS

Psychophysiological disorders- are physical diseases that are either brought about or worsened
by stress and other emotional factors. One of the mechanisms through which stress and
emotional factors can influence the development of these diseases is by adversely affect the
body’s immune system.

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).

1. Headaches. Among the most common types of headaches are migraines and tension
headaches (Williamson, 1981). Migraine headaches are often more severe and are 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 U.S. 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.

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, 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).

3. Insomnia. Insomnia, the difficulty falling or staying asleep, occurs in more than one-third of
the U.S. 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 psychological distress
and insomnia, intervention for both sleep issues as well as psychological issues is vital to
managing symptoms.

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).

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).

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.
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).

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).

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.

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).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.
 SOMATOFORM DISORDERS

Somatoform Disorder, also known as somatic symptom disorder (SSD) or psychosomatic

disorder, is a mental health condition that causes an individual to experience physical bodily
symptoms in response to psychological distress.

Young people particularly find it difficult to express their feelings and because of this, it is likely
that psychological distress is expressed as physical (somatic) symptoms. In light of this, it is
thought that up to 10% of children in the UK that complain of aches and pains (stomach aches,
joint pains, headaches, etc.) are given a diagnosis of 'medically unexplained symptoms (MUS)'.
It also impacts a large proportion of adults who attend the GP.

The mind and the body are very much connected and there are many ways in which physical and
psychological symptoms interact. For patients who repeatedly present with somatoform disorder
symptoms that are medically unexplained, it is vital to consider underlying psychological issues.
This could include the presence of co-existing disorders such as:
 Anxiety disorders
 Separation anxiety
 School phobia
 Eating disorders
 Depression
 Selective mutism

There are different types of somatoform disorder, including chronic fatigue syndrome (CFS) and
dissociative (conversion) disorder, which you can read more about in this article. There are
different ways of managing psychosomatic disorders, including:
 Individual psychological work
 Family therapy
 Sleep hygiene management and dietary advice
 Medication


Types of somatoform disorder

It is important to remember this mental health disorder can present itself in different ways. This
includes:

Persistent somatoform pain disorder

 The predominant complaint is of persistent, severe and distressing pain
 It cannot be explained fully by a physiological process or a physical disorder
 It occurs in association with emotional conflict or psychosocial problems
 The result is usually a marked increase in support and attention, either personal or medical
 Dissociative/conversion disorder

 A partial or complete loss of the normal integration between memories of the past, awareness of
identity, immediate sensations and control of bodily movements
 Medical examination does not reveal the presence of any known physical or neurological
disorder
 There is evidence of clear association in time with a stressful life event and problems
 The possibility of the later appearance of serious physical or psychiatric disorders should always
be kept in mind

Chronic fatigue syndrome (neurasthenia)

 Persistent and distressing complaints of increased fatigue after mental effort
 Persistent and distressing complaints of bodily weakness and exhaustion after minimal effort
 At least two of: muscular aches/pains, dizziness, tension headaches, sleep disturbance, inability
to relax, irritability, dyspepsia
 Autonomic or depressive symptoms present are not sufficiently persistent and severe enough to
fulfil the criteria for any of the more specific disorders
 Considerable cultural variations occur in the presentation of this disorder

There are many different reasons why someone could develop somatoform disorder. These fall
into three main categories:

Individual

Experience of physical illness, traits of vulnerable and sensitive personality, concerns about peer
relationships, high achievement orientation.

Family

Includes physical and mental health problems, parental somatisation, emotional over-
involvement, limited emotional 'vocabulary'.

Environment

Includes academic pressures, teasing and bullying.

Recognizing a patient with somatoform disorder

Main clinical features of this condition include:

 Persistent abdominal pain, headaches, joins pains, etc.
 Poor concentration, dizziness and moodiness
 Continual worry over decreasing physical health
 Onset of an acute flu-like illness or glandular fever
 Complete loss of bodily sensation or movements
 Loss or disturbance of motor function and pseudo-seizures (seizures that do not have the typical
features of an epileptic fit and are not accompanied by an abnormal EEG)
 Symptoms usually occur after a traumatic event and last for a few weeks or months
 Generally occurs more commonly in females than males
 Symptoms usually start in childhood or early adolescence

Abdominal pains are more common in younger children whilst headaches would affect older
children and adolescents, and conversion symptoms tend to occur around the age of 16.

Surveys from various countries have found that approximately 1 in 4 children complain of at
least one set of somatic symptoms weekly or fortnightly.

Assessment

Consider that a child has somatoform disorder if:

 There is a time relationship between psychosocial stressors and physical symptoms
 The nature and severity of the symptom or its resulting handicap is out of keeping with the
pathophysiology
 There is a concurrent psychiatric disorder

Family GPs or pediatricians are likely to be the first port of call for most children. Reassurance
that there is no treatable medical disorder will often relieve concerns enough for the child to
improve without the need for further intervention. However, sometimes symptoms persist.

Referral to a mental health service needs to be done in a sensitive manner with acknowledgement
of the symptoms, as many children and families in these circumstances might fear that they are
not being taken seriously and that referral to mental health services means their physical
symptoms are not believed.

Psychiatric assessment would include:

 Developmental and psychiatric history being taken
 Detailed school history investigated
 Mental health examination takes place

It is important to consider sending a patient for a psychiatric assessment if:

 Physical symptoms suggest a medical condition however, no medical disease, substance misuse
or another mental disorder can be found to account for the symptoms
 The symptoms cause significant distress or impairment in social, occupational or other areas of
functioning
 Physical symptoms are not intentionally produced
 The patient often resists attempts to discuss the possibility of psychological causation

General management strategies for GPs

 Make an effort to understand the family’s beliefs about the illness, how convinced they
are and how they feel about referral to mental health services.
 Do not question the reality of the symptoms
 Acknowledge that the illness is disrupting the patient’s life and affecting the family’s functioning
 Discuss physical concerns, results of physical investigations and physiological mechanisms
contributing to the symptoms e.g. contractures caused by immobilization
 Inform family about the high prevalence of MUS (up to 10%) as this might be reassuring about
the absence of an organic cause
 Be reassuring and non- judgmental when informing parents about the diagnosis of somatoform
disorder or other psychiatric disorder
 Emphasize that it may take time to recover but the majority of young people do very well if they
receive the correct treatment

Assessment and initial treatment is usually initiated by the GP or padiatrician. It is recommended

to use the bio-psycho-social framework and when the symptoms do not improve, a psychiatric
referral should be made.

Specific management strategies

Individual psychological work

 Motivational techniques
 Encouraging self-monitoring
 Developing techniques to deal with specific symptoms and impairments as well as developing
active, problem-focused coping strategies and attitudes

Family therapy
 Encouraging self-monitoring of pain
 Reinforcing well behavior
 Developing healthy coping skills such as relaxation, positive self-talk
 Problem solving skills
 Shifting parents' focus from physical symptoms to pleasant joint activities and symptom free
periods
 Liaison with school and social services
 Sleep hygiene and dietary advise
 Medication - there is no medication specifically licensed for somatoform disorder, but some
could be used for co-morbid disorders e.g. selective serotonin reuptake inhibitors (SSRIs) for
associated depression or anxiety

The aim of the treatment is to develop a partnership with the child, family and all professionals
involved. Hospitalization could be considered only in severe cases and when outpatient treatment
has not been successful.

Priory’s national network of hospitals and outpatient well-being centers are extremely well
placed to treat mental health conditions such as this, and we have experts who specialize in
somatoform disorder.
DISSOCIATIVE DISORDERS
Dissociative disorders-are a group of disorders characterized by symptoms of disruption and/or
discontinuity in consciousness, memory, identity, emotion, body representation, perception,
motor control and behavior. These symptoms are likely to appear following a significant stressor
or years of ongoing stress.

Different Types of Dissociative Disorders and the Necessity of Treatment

We may take for granted our grasp of reality and identity. But when we lose touch with those
foundational elements of life through trauma and dissociation, our everyday existence becomes
unsettling and distressful. We can trace different types of dissociative disorders back to
past experiences of trauma that caused protective dissociation. In order to effectively
reintegrate disconnected parts of the self and of life, it’s important to seek long-term
psychotherapy treatment and rehabilitation.

Our sense of self and identity is a complex bundle of all our life experiences, our relationship to
the world around us, and our working relationship with the inner landscape of our minds and
emotions. This layered sense of identity acts as a lens and a buffer through which we experience
life every day. Most of us have experienced what it’s like when this lens occasionally contracts
in times of mindlessness or stress and we “zone out.” But for some of us, this state of
dissociation persists or recurs, unsettling our sense of identity and getting in the way of our
everyday functioning.
We may take for granted that cumulative collection of experiences, familiar responses, and ways
of understanding ourselves. But when this foundational buffer is confused or inaccessible, we
can become disconnected from reality and from ourselves. We may end up feeling numb or like
our bodies and perceptions are not our own. The experience of dissociation can result in different
types of dissociative disorders, including dissociative identity disorder, depersonalization,
derealization, and dissociative amnesia. However the dissociation manifests, the road to
reconnection and recovery is a personal one for each of us.

Causes Dissociation and Dissociative Disorders

The reason people develop dissociative disorders in adulthood is generally traced back to earlier
trauma. Often related to physical, sexual, or emotional abuse or neglect in childhood, individuals
adapted to cope with this trauma by detaching or dissociating from the experience as it was
happening and as the memories or reminiscent triggers arise in the future. Whereas this
adaptation can help affected individuals to handle the overwhelming fear and emotions at the
time of the trauma, the dissociation may continue to kick in years later, even when there isn’t any
real danger or significant trauma. This reactive coping mechanism muddles their sense of
identity or their ability to experience their reality, and it can leave them feeling disconnected and
spaced out.
If you have someone in your life who experiences dissociation, you may find it very difficult to
relate to their struggles. In most cases, the source of their dissociative adaptation is buried deep
in their past, so you may not be able to draw a line directly to stressors around them at the
present. Even though the root cause of the disorder may be far away, it’s still critical that they
receive the help they need to live and thrive the best they possibly can now.

Different Types of Dissociative Disorders

Originally, a person’s dissociation serves to protect them from the intense trauma they encounter,
often through repeated early experiences of abuse, neglect, or dissociative behaviors in a parent,
caregiver, or someone else close to them. When dissociative patterns arise again, typically by
early adulthood, even when original traumas are no longer present, this coping response can
significantly affect the way they experience and participate with life. Here are some of the
various ways that dissociative disorders manifest.

Dissociative Identity Disorder

Formerly known as multiple personality disorder, dissociative identity disorder (DID) develops
as the experience of more than one distinct identity, and the person’s memories, personality,
thoughts, and behaviors shift when their identity experience shifts. People may face lapses in
their recent memory due to these shifts, as well as lapses in traumatic memories from their past
due to protective dissociation. The unpredictability and disorientation make everyday
functioning, independence, and a productive work life difficult. Because the experience is so
confusing for the individual and those around them, socialization and relationships suffer.
Someone with DID may also experience shifts in their perception of time and place, believing
that they are living an earlier traumatic incident.

Depersonalization Disorder
When someone develops depersonalization disorder, they tend to feel out of place in their own
body, mind, and sense of self. They may feel that their body parts or their reflection in the mirror
are unfamiliar, which can be unsettling and bring up feelings of anxiety and fear. With this
confusing disconnection between the person and their everyday experiences, they can also feel
numb to their thoughts and emotions as if they are running on autopilot.

Derealization Disorder
Derealization disorder is similar to depersonalization, but the individual experiences the
dissociation with the environment around them, including people and things. They may feel
detached from their experience as if they’re witnessing everything from far away or through a
window or movie screen. Things around them may seem two-dimensional, unreal, or hazy.
Depersonalization and derealization can occur separately or they can show up together with an
individual feeling disconnected both from themselves and from their external world. These
experiences are stressful, even if the individual is detached from and unable to express their
emotions.
Dissociative Amnesia Disorder

Dissociative amnesia is characterized by memory challenges and lapses, which most likely
developed to protect the individual from the trauma they experienced. A memory gap may be
specific to a past traumatic event or a broader length of time. The gap may be more narrowly
focused on certain details from an event or timeframe. Or it may be broad, and the individual
loses memory of their own life history and the understanding of what makes up their identity.

Treatment for Dissociative Disorders

With dissociative disorders, living a normal life can be challenging and may feel like a goal that
is completely out of reach, which is why our loved ones need help to process the sources of
trauma where their dissociation originates and to become aware of the ways that they are
disconnected from life in the present. Successful programs integrate personalized psychotherapy
and rehabilitation to help them readapt to everyday life in grounded and productive ways.
The experiences and severity of dissociative disorders vary among individuals, and even for an
individual the experience and severity of dissociation may change with time. Stress and trauma
in the present can trigger symptoms or make them worse. Because the primary effect is
disconnection, it is important to be able to bring awareness and empowered perspective to the
experience as much as possible with the help of a knowledgeable therapist. When we are
functioning and feeling our best, the elements of memory, emotion, thinking, sensing,
perceiving, and acting are integrated. With treatment for dissociative disorders, the goal is to
gradually reintegrate these elements of self and experience.
Because treatment for dissociation involves reconnecting threads that were separated around past
trauma, the treatment itself can be stressful when revisiting those areas. Treatment can also be
challenging for individuals who have developed a distrust of others through their experience of
dissociation. For these reasons, along with the overwhelming challenges to everyday functioning,
people with dissociative disorders benefit from long-term residential treatment programs.
Here, they are able to build a familiarity with the setting, the community, and their own place in
the program.
From that safe foundation, they can approach the difficult but important work of
compassionately reintegrating the unique parts of themselves, all with the support and guidance
of expert therapists and caregivers. Family and friends can also offer powerful support during
this time and especially for the long-term recovery of a loved one. Family involvement is
strongly encouraged through therapy sessions and educational groups from week to week. Peer
support groups for people with dissociative disorders also give them a continued opportunity to
maintain perspective as they practice empowering social interaction. In some cases, transitional
residential programs are a great way for clients to continue living in a community of recovery
before living more independently.
While there isn’t medication to treat dissociative disorders directly, people may be treated for co-
occurring disorders such as depression and anxiety. Beyond the critical phase of reintegrating
the self, clients will also have dedicated opportunities to learn strategies to cope with stress and
anxiety; to manage diverse independent responsibilities, such as finances, interpersonal skills,
and time management; and to socialize and relate to others. This treatment approach is designed
to reintegrate life as a whole and to empower clients so they can move on from the program
feeling ready to live a life of greater connection.

SEXUAL BEHAVIOR
Sexual Dysfunction
Sexual dysfunction is a problem that can happen during any phase of the sexual response cycle.
It prevents you from experiencing satisfaction from sexual activity.
The sexual response cycle traditionally includes excitement, plateau, orgasm and resolution.
Desire and arousal are both part of the excitement phase of the sexual response. It’s important to
know women don’t always go through these phases in order.
While research suggests that sexual dysfunction is common, many people don’t like talking
about it. Because treatment options are available, though, you should share your concerns with
your partner and healthcare provider.
Types of sexual dysfunction
 Sexual dysfunction generally is classified into four categories:
 Desire disorders: lack of sexual desire or interest in sex.
 Arousal disorders: inability to become physically aroused or excited during sexual
activity.
 Orgasm disorders: delay or absence of orgasm (climax).
 Pain disorders: pain during intercourse.
Who is affected by sexual dysfunction?
Sexual dysfunction can affect any age, although it is more common in those over 40 because it’s
often related to a decline in health associated with aging.
Symptoms and Causes
What are the symptoms of sexual dysfunction?
In people assigned male at birth:
 Inability to achieve or maintain an erection (hard penis) suitable for intercourse (erectile
dysfunction).
 Absent or delayed ejaculation despite enough sexual stimulation (retarded ejaculation).
 Inability to control the timing of ejaculation (early, or premature, ejaculation).
In people assigned female at birth:
 Inability to achieve orgasm.
 Inadequate vaginal lubrication before and during intercourse.
 Inability to relax the vaginal muscles enough to allow intercourse.

In everyone:
 Lack of interest in or desire for sex.
 Inability to become aroused.
 Pain with intercourse.

Causes sexual dysfunction

Physical causes: Many physical and/or medical conditions can cause problems with sexual
function. These conditions include diabetes, heart and vascular (blood vessel) disease,
neurological disorders, hormonal imbalances, chronic diseases such as kidney or liver failure,
and alcohol use disorder and substance use disorder. In addition, the side effects of some
medications, including some antidepressant drugs, can affect sexual function.
Psychological causes: These include work-related stress and anxiety, concern about sexual
performance, marital or relationship problems, depression, feelings of guilt, concerns about body
image and the effects of a past sexual trauma.
Medications can cause sexual dysfunction?
Some prescription medications and even over-the-counter drugs can have an impact on sexual
functioning. Some medicines can affect libido (desire) and others can affect the ability to become
aroused or achieve orgasm. The risk of sexual side effects is increased when an individual is
taking several medications.
Sexual side effects have been reported with the following medications:
Non-prescription medicines
Some over-the-counter antihistamines and decongestants can cause erectile dysfunction or
problems with ejaculation.
Antidepressants
 Tricyclic antidepressants, including amitriptyline (Elavil), doxepin (Sinequan),
imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor)
 Monoamine oxidase inhibitors (MAOIs), including phenelzine (Nardil) and
tranylcypromine (Parnate)
  Antipsychotic medications, including thioridazine (Mellaril), thiothixene (Navane), and
haloperidol (Haldol)
 Anti-mania medications such as lithium carbonate (Eskalith, Lithobid)
 Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline
(Zoloft), and paroxetine (Paxil).

The following medications may cause erectile dysfunction:

 Anti-hypertensive medications (used to treat high blood pressure)
 Diuretics, including spironolactone (Aldactone) and the thiazides (Diuril, Naturetin, and
others)
 Centrally acting agents, including methyldopa (Aldomet) and reserpine (Serpasil,
Raudixin)
 a-Adrenergic blockers, including prazosin (Minipress) and terazosin (Hytrin)
 b-adrenergic (beta) blockers, including propranolol (Inderal) and metoprolol (Lopressor)
The following medications may decrease sexual desire:
Hormones
 Leuprolide (Lupron)
 Goserelin (Zoladex)
Diagnosis and Tests
How is sexual dysfunction diagnosed?
In most cases, you recognize something’s interfering with your enjoyment (or a partner's
enjoyment) of a sexual relationship. Your provider usually begins with a complete history of
symptoms and a physical. They may order diagnostic tests to rule out medical problems that may
be contributing to the dysfunction. Typically lab testing plays a very limited role in the diagnosis
of sexual dysfunction.
An evaluation of attitudes about sex, as well as other possible contributing factors —
fear, anxiety, past sexual trauma/abuse, relationship concerns, medications, alcohol or drug
abuse, etc. — helps a clinician understand the underlying cause of the problem and recommend
the right treatment.

Treatment for sexual dysfunction

Most types of sexual dysfunction can be addressed by treating the underlying physical or
psychological problems. Other treatment strategies include:
Medication: When a medication is the cause of the dysfunction, a change in the medication may
help. Men and women with hormone deficiencies may benefit from hormone shots, pills or
creams. For men, drugs, including sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®,
Staxyn®) and avanafil (Stendra®) may help improve sexual function by increasing blood flow to
the penis. For women, hormonal options such as estrogen and testosterone can be used (although
these medications are not approved for this purpose). In premenopausal women, there are two
medications that are approved by the FDA to treat low desire, including flibanserin (Addyi®)
and bremelanotide (Vyleesi®).
Mechanical aids: Aids such as vacuum devices and penile implants may help men with erectile
dysfunction (the inability to achieve or maintain an erection). A vacuum device (EROS-CTD™)
is also approved for use in women, but can be expensive. Dilators may help women who
experience narrowing of the vagina. Devices like vibrators can be helpful to help improve sexual
enjoyment and climax.
Sex therapy: Sex therapists can people experiencing sexual problems that can’t be addressed by
their primary clinician. Therapists are often good marital counselors, as well. For the couple who
wants to begin enjoying their sexual relationship, it’s well worth the time and effort to work with
a trained professional.
Behavioral treatments: These involve various techniques, including insights into harmful
behaviors in the relationship, or techniques such as self-stimulation for treatment of problems
with arousal and/or orgasm.
Psychotherapy: Therapy with a trained counselor can help you address sexual trauma from the
past, feelings of anxiety, fear, guilt and poor body image. All of these factors may affect sexual
function.
Education and communication: Education about sex and sexual behaviors and responses may
help you overcome anxieties about sexual function. Open dialogue with your partner about your
needs and concerns also helps overcome many barriers to a healthy sex life.
Outlook / Prognosis
Can sexual dysfunction be cured?
The success of treatment for sexual dysfunction depends on the underlying cause of the problem.
The outlook is good for dysfunction that is related to a condition that can be treated or reversed.

SEXUAL VARIATIONS

“Sexual Variations” refer to sexual desires and behaviors outside what is considered to be the
normal range, although what is unusual or atypical varies between cultures and from one period
to another. Defining normality is extremely difficult (and arbitrary), because the definition
involves making a value judgment and therefore labelling how we view other people.

Sexual variations are also referred to as paraphilias, a neutral term for behaviors formerly called
deviant. They can be defined as conditions in which a person’s sexual gratification is dependent
on an unusual sexual experience revolving round particular sex objects. They are much more
common in men than women.

History and culture

Sexual variations have existed and been recorded for millennia in different parts of the world. For
example, early Buddhist texts contain numerous references to sexually variant behaviours among
monastic communities over 2000 years ago. These behaviours included sexual activity with animals and
sexual interest in corpses.
A case example of fetishism from Krafft-Ebing (1887)
Z began to masturbate at the age of 12. From that time he could not see a woman’s handkerchief without
having orgasm and ejaculation. He was irresistibly compelled to possess himself of it. At that time he was
a choir boy and used the handkerchiefs to masturbate within the bell tower close to the choir. But he
chose only such handkerchiefs as had black and white borders or violet stripes running through them. At
age 15, he had coitus. Later on he married. As a rule, he was potent only when he wound such a
handkerchief around his penis. Often he preferred coitus between the thighs of a woman where he had
placed a handkerchief. Whenever he espied a handkerchief, he did not rest until he was in possession of it.
He always had a number of them in his pockets and around his penis

In the clinical literature sexual variations had begun to be extensively discussed by the second
half of the 19th century. The classic example is Richard von Krafft-Ebing’s Psychopathia
Sexualized, first published in 1887. In this book the author, a neuropsychiatrist, details, among
others, fetishism, flagellation, sadism, necrophilia, sadistic acts with animals, masochism,
exhibitionism, bondage, paedophilia, bestiality, and incest.

Major sexual variations

Exhibitionism is among the most common of the sexual variations. The usual image is of a
middle aged man in a dirty raincoat “flashing.” Typically, however, exhibitionists are
postpubescent males up to the age of 40 who obtain high levels of sexual pleasure and
excitement from exposing their genitals to females, usually strangers, and who may masturbate
at the same time.

Paedophilia involves intense sexual urges and sexual activity with prepubescent children. Two
thirds of molested children are girls, usually between the ages of 8 and 11. To meet the
diagnostic criteria, a paedophile must be at least 16 years old and at least five years older than
the victim. Most paedophiles are men, but there are cases of women having repeated sexual
contact with children. In 90% of cases the molester is known to the child, and 15% (possibly
more) are relatives. Most paedophiles are heterosexual and are often married with their own
children, although they commonly have marital or sexual difficulties or problems with alcohol
misuse. Eighty per cent have a history of childhood sexual abuse.

Fetishism involves recurrent sexual urges or behaviours concerning the use of inanimate objects
such as leather and rubber garments, women’s underwear, stockings, and shoes and boots.

Transvestism refers to recurrent, intense sexually arousing fantasies, urges, and behaviors
involving cross dressing. A transvestite is a heterosexual male who derives sexual satisfaction by
wearing female clothing. Many are married and seem very masculine. They should not be
mistaken for female impersonators on the stage (such as “Dame Edna Everage”) or male
homosexuals who cross dress (“go in drag”), who are not sexually aroused or dependent on their
cross dressing for sexual excitement.

Transsexualism is not, strictly speaking, a paraphilia but rather an issue of gender role.
Transsexuals have an intense desire to become a member of the opposite sex, feeling that they
are trapped in the “wrong body.” Many therefore ask for surgical intervention for a sex change.
Transsexualism is found equally in males and females, and they should not be confused with
transvestites, who cross dress for sexual arousal but who do not want anatomical change.

Hypoxyphilia is an increasingly commonly reported variation that involves attempts to enhance

the pleasure of orgasm by a reduction of oxygen intake—for example, by placing a tight noose
around one’s neck. Such behavior has lead to fatalities.

Other sexual variations include gaining sexual pleasure from inflicting pain (sadism) or from
suffering pain or humiliation (masochism), sexual desire for corpses (necrophilia) or for animals
(zoophilia or bestiality), arousal from contact with urine (urophilia) and faeces (coprophilia), and
excitement from rubbing the genitals against a clothed person in a confined space such as the
Underground (frotteurism).

Combinations—It is not unusual for an individual to have more than one sexual variation. The
commonest combination is fetishism, transvestism, sadism, and masochism.

Clinical presentations

Sexual variations seen in clinical settings are only a proportion of the cases where such problems
exist. There are, broadly speaking, four classes of clinical referral.

• Those sent for clinical intervention by the law enforcing authorities. These are sex offenders
who are asked to have treatment to help them overcome their problem behavior.
 Those who seek help for their sexual variations because they are distressed by them. These
include people who worry that they might commit illegal or embarrassing acts. Many are
distressed by acts they see as “unnatural” or are afraid that they may endanger their life or their
career.

Those who seek help because their partners are distressed by the sexual variation. They are
themselves distressed because of their partner’s distress. These are people with stable or long
term relationships.

Those who present with frank sexual dysfunction. They report erectile difficulties or other
dysfunctions, which are usually secondary to strong variant desires and reliance on these for
arousal. For example, a man may find that he is unable to sustain an erection for sexual
intercourse with his partner unless he has contact with, say, a leather garment.

Assessment of sexual variations—aspects to be explored

 Variant arousal
 Sexual fantasies
 If there is a problem in arousal in relation to conventional stimuli, for example, consenting adult
partners
 Anxiety about conventional sexual activity
 Anxiety about social interactions with adults, especially those of the same age group and who are
potential sexual partners
 Difficulties with social interactions
 Problems with conventional adult sexual activity
 Whether the person has a problem with his or her gender role

Assessment

Clinical assessment in these cases needs to be comprehensive, with information elicited about a
number of aspects. Such a detailed assessment gives the clinician a full picture of the problem,
and enables him or her to plan a suitable intervention.

Treatment of sexual variations is difficult. After careful assessment, treatment goals must
be established, and, to achieve these, a comprehensive therapeutic package is usually
needed. Focusing on the variant arousal is only one aspect of treatment, and therapy that
takes this as the sole focus is rarely successful

Treatment
The aims of the treatment must be carefully considered, the therapist and the client need to arrive at an
agreed goal.
 Until about 20 years ago, most patients were treated with one aim only—to eliminate their
variant sexual arousal. The main technique used was electrical aversion therapy. This often
suppressed the problem behavior but did not eliminate it.

If the goal of treatment is to eliminate the sexual variation, it must be recognized that success
may be limited. Control may be achieved, but this needs to be supplemented with gains in other,
more acceptable, sexual behaviors. In practice, this means that any treatment program that
includes an attempt to get rid of the variation must also include enhancement of other outlets.
Other sexual anxieties or skills deficits need to be addressed.

Incorporation

An alternative to elimination is to incorporate the variation in a controlled way into the person’s
sexual repertoire. This is especially so in the case of people whose partners are distressed by the
dominant role of the variation in their sexual behavior. Obviously, this is not possible if the
variation is unacceptable, such as paedophilia. It is also important that the variation is something
the partner can tolerate in a limited way.

In practice, the therapist will use a multifaceted therapy program. One aspect of such a program
is conventional sex therapy, aimed at enhancing the sexual relationship. In further joint work, the
couple are helped to systematically reduce the role of the variation in their sexual relationship.
For example, a man with a rubber or leather fetish may be asked to wear only a leather arm band
during sex. Similarly, temporal control may be introduced, using a timetable approach. The
couple agree, for example, to use the fetish object in their sexual relations on certain days of the
week only.

Group therapy

Some clinics operate group therapy programs. These are most commonly used for sex offenders.
The programs involve group processes and group learning.

Chemical treatment

For those with serious difficulties, chemical treatment is sometimes considered. Reduction of the
sex drive through drugs will, of course, reduce the problem behavior, but its effectiveness is not
selective: that is, the drive is dampened down in toto, not just the desire for the variant behavior.
The drugs commonly used are medroxyprogesterone acetate and cyproterone acetate.
Orgasmic reconditioning

This approach has been used since the 1970s, and its main feature is the reinforcement of
conventional arousal and desires. Typically, the patient is asked to masturbate with his variant
fantasy and then, when orgasm is imminent (the point of no return), to switch to a fantasy of a
conventional sexual stimulus or behavior. The ensuing orgasm then powerfully reinforces the
conventional desire. In succeeding sessions (which the client carries out in privacy) the point
when the switching is made is brought forward so that, eventually, the entire sequence takes
place to conventional fantasies.

Aversion therapy

Electrical aversion involves the repeated pairing of the variant stimulus (such as pictures
projected on a screen) with an unpleasant stimulus (electric shock). The use of this procedure is
now uncommon. A related procedure is covert sensitization. Here, the aversion is covert and
imagined. The person is asked to fantasize a sequence of events involving his or her variant
behavior and, at a crucial point of the sequence, to imagine a powerful aversive scene. For
example, a paedophilias might be asked to imagine the appearance of a police officer at the point
of his approaching a child in his sequence of images. The aversive scenes are agreed in advance,
and typically more than one aversive consequence is used.

Legal AND ETHICAL ISSUES IN ABNORMAL PSYCHOLOGY

●Competency
○Know what you can and cannot do
○Make sure others know what you can and cannot do
○Psychologists have the competence to:
■Assess, conceptualize, provide interventions for clients
○Expert testimony
○Evaluations in child protection
○Guardian ad litem
○Guidelines
●Informed consent and confidentiality
○Clinicians should provide clients with a written statement
○Privileged communication
 ○Exceptions to confidentiality
○Limits in cases involving abuse
○Purpose of mandated reporting
○Duty to warn (or otherwise protect)
●Civil commitment
○Individuals who have been committed involuntarily to a mental hospital because the state
decided that they were disturbed enough to require hospitalization
○Often times found to be a danger to self, to others, or the community
○Procedures:
■The right to a jury trial
■The right to the assistance of counsel
■The right against self-incrimination
■The standard of proof
●The “beyond a reasonable doubt” standard
○False positive:
■An unjustified commitment
○False negative:
■A failure to commit a person when commitment is justified and necessary
○Standards for commitment:
■The definition of dangerousness
■The determination of dangerousness
●Variability in the legal definition
●Complexity of the literature
●Judgement biases
●Differential consequences to the predictor
●Psychological Disturbance and Criminal Law
○The Insanity Defense:
■Defendant admits to having committed the crime
 ■Pleads not guilty due to mental disturbance
■Claims he or she was not morally responsible at the time of the crime
○M’Naghten Rule
○Durham Rule
○American Law Institute’s (ALI) guidelines
○Insanity Defense Reform Act
●Psychological Disturbance and Criminal Law
○Competency to Stand Trial (CST):
■Questions the Defendant’s mental state at the time of the trial
■Ability to assist legal counsel at the time of the trial
●Patient’s Rights
○The Right to Receive Treatment:
■Must provide an individualized treatment program for each patient, skilled staff
in sufficient numbers to administer such treatment, and a human psychological and
physical environment
○The Right to Refuse Treatment:
■Issues surrounding competency, informed consent or other
○The Right to a Humane Environment:
■Right to privacy and dignity
■Opportunity for religious worship
■Nutritionally adequate diets
■Within multi-patient sleeping rooms, adequate privacy and furnishings
■Adequate and private bathing and toilet areas
■Right to wear own clothes and keep personal possessions
■Similar visitation and telephone rights as patients at other public hospitals
■Unrestricted right to send and receive mail
■Right to regular physical exercise
■Opportunity must exist for interaction with members of the opposite sex
●Ethics and the Mental Health Profession
○Mental health professionals decide which among countless variations are abnormal
○The power to commit someone involuntarily (a loss of freedom)
○Confidentiality and its limits (Tarasoff)