Abnormal Psychology Spring Semester  2013
Section 1: 3403-01
Section 2: 3403-02
SECTION 1:  Tuesday and Thursday 8:00 a.m. to 9:15 a.m. Room: Sabin 127

Teaching Assistant: Phoebe Fleur Walker:   E-mail: walkepab@uni.edu

Instructor: John Somervill: E-mail: john.somervill@uni.edu Office:  Baker 322   Phone: 273-3748
 WEB SITE: (http://www.uni.edu/somervil)
SECTION 2:Tuesday and Thursday 9:30 a.m. to 10:45 a.m Room: Sabin 127

Undergraduate Teaching Assistant:  Katie Ren Barkley: E-mail: barkleyk@uni.edu

Instructor: John Somervill  E-mail: john.somervill@uni.edu Office:  Baker 322   Phone: 273-3748
 WEB SITE: (http://www.uni.edu/somervil)







CHAPTER 1:  Historical Overview and the Concept of Abnormality






January 15 (No assignment) Explanation of Course/Policies




Thursday, January 17, 2013


Text Assignment: pp 1-27


Topic: Historical Overview of the Concept of Abnormality



I. What is abnormal behavior?

      1.  Statistical Infrequency

      2. Violation of Norms 

      3. Personal distress

      4. Disability or Behavioral Dysfunction (dysfunctional families_)

       5. Unexpectedness (unexpected responses to environmental stress).


II.  Gods, Demons, and Milieu Therapy (2000-450 B.C.)

1.      Early accounts of psychological problems often involved supernatural explanations

2.      Around 2000 B.C., the Babylonians attributed psychological problems to a demon named Idta, who served Ishtar, the goddess of witchcraft and darkness. Servants of Idta were sorcerers who relied on the powers of an evil eye and various concoctions – treatment involved incantations and other magical practices believed to be effective in combating demons

3.      The early Egyptians also relied on supernatural explanations. However, physical explanations were also recognized. The Ebers Papyrus, a medical document written in about 1550 B.C. contained the following remedy to be used against all kinds of witchcraft: select a large beetle, cut off its head and wings, boil it, dip it in oil, and apply it to the body part affected by witchcraft. Then warm the beetle’s head and wings in snake fat and have the affected individual drink the mixture

4.      In Memphis, Egypt, around 525 B.C., the temple of the healing god Imhotep became a hospital and medical school. Incubation or sleep therapy was practiced. Patients were encouraged to pursue artistic endeavors, travel the Nile, attend concerts – much like what we now call milieu therapy

5.      Early Hebrew conceptions varied.  Rabbi Ami suggested diversion, Rabbi Asi advocated talking freely about one’s worries, but the prevailing Mosaic position was simple and straightforward: God makes alive, kills, wounds, and heals. He could “smite thee with madness”. Demons were an alternate cause of insanity. Very peculiar behavior could lead to the accusation that one was a witch. If so, the command in Exodus was “Thou shalt not suffer a witch to live”. Having a familiar spirit or being a wizard led to death by stoning.

6.      During the Homeric period (about 1000 B.C.) a traveling healer named Aesculapius was later deified as the god of medicine. Hundreds of Aesculapian temples were constructed throughout the Greek countryside. Treatment may have involved incubation or sleep, possibly opium derivatives and hypnosis. Another aspect of treatment was having a harmless snake lick the patient’s eyelids and wounds – snakes were a powerful symbol of the underworld. The staff of Aesculapius, a rod with a snake wrapped around it, is still the emblem of medicine today


III. Somatogenesis and the Hippocratic School

1.      Somatogenesis in contrast to Psychogenesis (difference between disciplines of Psychology and Medicine)

2.      Hippocrates and Humoral Theory - four basic humors probably were first postulated by Empedocles (490-430 B.C.) For test purposes, however, we will assume that Hippocrates proposed the humoral theory:

(a)    Blood (heat): changeable temperament

(b)   Phlegm (cold):

(c)    Yellow Bile (Dryness):

(d)   Black Bile (moisture):

3.      Hippocrates (460 –370 B.C.): regarded as the father of modern medicine. Classified mental disorders into three categories:

(a)    Mania: involved large amounts of Blood (heat) and Black Bile (moisture)

(b)   Melancholia: caused by an abundance of Black Bile

(c)    Paranoia: The early Greek meaning of the term “paranoia” is unclear – it probably referred to some type of mental deterioration rather than behaviors currently associated with the term. Your text use4s the term Phrenitis (brain fever) – I am unsure if this has replaced “Paranoia

4.      Epilepsy or “falling sickness”: Hippocrates refuted the notion that it was a sacred

Disease. Assumed that cold phlegm secreted by the brain entered the veins and blocked the passage of air. The afflicted was thus rendered speechless and senseless

5.      Hippocrates recognized the brain as being of central importance – Pneuma, air that

      circulates and enters the brain, was considered critical for intellectual processes

6.      Hippocrates also adopted the concept that Hysteria (from the Greek “hysteron” meaning “uterus”) was caused by a wandering uterus – the suggested treatment was marriage or sexual intercourse

7.      The goal of Hippocrates was to rid medicine of supernatural beliefs that gods and   

         demons accounted for health and illness


IV.  Asclepiades (150 B.C.) practiced medicine in Rome. \

1.      Asclepaides’ treatment consisted of baths, messages, wine, and pleasant surroundings

2.      He was one of the first to reject the word insanity as a label for psychological problems – he preferred to describe such problems as “passions of sensation” – the word “passion” to the early Greeks and Romans connoted strong, often unacceptable emotionality

3.      Asclepiades emphasized humaneness – pleasant music and light airy surroundings were part of therapy.

4.      He strongly rejected harsh techniques such as bloodletting or housing people with emotional disturbance in dungeons


V. Cornelius Celsus (25 B.C. – 50 A.D.) favored harsh techniques

  1. Illness resulted from the wrath of the gods
  2. Treatment involved frightening patients to scare out undesirable spirits
  3. Patients were subjected to hunger chains, and sudden fright. He recommended confinement in total darkness, bloodletting, Hellebore and other agents to induce vomiting. The expression “scare the devil out of someone” had an historical, literal meaning


VI. Galen (130-200 A.D.)

1.      Revived and popularized the thinking of the Hippocratic School

2.      Galen composed nearly 500n treatises on a wide variety of topics

3.      Galen’s treatise “on the passions and errors of the soul” described a psychotherapeutic approach that vaguely resembled rational-emotive therapy (Albert Ellis).

4.      According to Galen, errors of passion were due to faulty judgment or mistakes due to irrational behavior such as anger, fear, or envy

5.      Galen advised selecting an individual recommended by others as a non-flatterer who was exceptionally honest to serve as a “therapist” who could point out irrational behavior. The “patient” had to be non defensive and willing to respond to criticism in a rational way


VII. The Decline of the Classical Era (200-475 A.D.)

  1. After the death of Galen, there appeared to be a rejection of both medical and philosophical conceptions of human nature
  2. Six plagues killed hundreds of thousands between the first and fourth centuries A.D.
  3. Barbaric tribes were marching on Rome and the Roman security system was degenerating
  4. Christianity, with Christ as the healer and comforter, was gaining immense popularity
  5. Christianity emerged as an institutionalized religion following the Edict of Milan in 313 – it established Christianity as an official religion of the Roman Empire


VIII. Aurelius Augustine  (354 – 430 A.D.) 

1.      Augustine engaged in extensive self-analysis which is evident in his major work, the Confessions

2.      He endorsed the belief that sexuality should be restricted to marriage and then only for the purpose of procreation

3.      Ideally, no man should marry which result in an earlier date for the perfection of the “city of God” and the subsequent ending of the world

4.      Augustine suggested that he might have more happily awaited the embraces of God if, for the sake of the kingdom, he had been made a eunuch (others had castrated themselves to rid themselves of sexual desire)

5.      Augustine’s attitudes toward sexuality were not original, but reflected those of both Hebrew and early Christian conceptions

6.      Before Augustine’s conversion, he attended orgies as a young man. After is conversion he was apparently bothered by dreams which he could not control regarding his sexual past

7.      It is like that the attitudes toward sexuality which Augustine helped codify, had a continuing influence for years to come


IX. Middle ages (476-1700

1.      King Robert II in 1022: trial at Orleans for heretics contained charges that would appear again and again in later witch trials

2.      The heretics were accused of chanting the names of demons at secret night meetings – when an evil spirit responded to the chant and appeared, torches were extinguished and males took the nearest female for a sex partner, whether it was his mother, sister, or a wayward nun.

3.      Children born to women impregnated at orgies were said to be ceremoniously burned to death eight days after birth and their ashes were made into a substance to be eaten at a mock communion. The accused heretics were later burned to death.

4.      The basic elements commonly attributed to European witch cults thereafter were: sexual orgies, child sacrifice, burning of the children’s bodies, and cannibalism

5.      The Inquisition, an ecclesiastical tribunal charged with the responsibility of investigating and punishing heretics, began in the 13th century under Pope Innocent III and remained active until the 19th century

6.      An obsession with the virtues of chastity by many inquisitors is depicted in examples from the Malleus Maleficarum (the “witch hammer”), a book written in either 1485 or 1486 by Heinrick Institoris (Henry Kramer) and Jakob Sprenger (James Sprenger). Example: Abbot S. Serenus, after praying for relief from his “genital instincts”, was rewarded with the vision of an angel who “seemed to open his belly and take out his entrails a burning tumor of flesh” The angel joyfully informed Abbot that he would “never again be pricked with that natural desire which is aroused even in babes and sucklings”

7.      In 1335, the trial of Catherine Delort was typical of many to follow: She admitted to having sex with a Shepard who convinced her to enter a pack with the devil. They robbed graves and burned the bodies. When Catherine cut her left arm and allowed blood to fall into the fire, a devil appeared in a purple flame and granted her evil powers. She admitted being transported to witch assemblies every Saturday night. She confessed to stealing children from their homes and eating them. She also admitted her love for a goat, with who she had sexual intercourse when not participating in orgies. When tortured, she gave names of others she met at witch assemblies. She was later burned to death.


X. The Significance of the witch Label (1400-1700)

  1. From 1400 to 1700, the activity of the Inquisitors was relentless. Thousands of witches were tried and burned. They were accused of night flights on wolves, cats, sticks, brooms and even manure of mules and hoses.\
  2. Children’s bodies were said to have been eaten raw, roasted, or fresh from the grave, though the inedible baptized head was often left behind
  3. The “obscene kiss” was a standard accusation – witches were accused of kissing the anus of the devil and masters of their assemblies as well as the anus and genitals of demon possessed cats.
  4. Before witch could be sentenced, a confession was required. Some believe that eat the flesh of a preverbal child would leave them speechless – a belief which could have led to some cannibalism to avoid being burned to death following a confession elicited by torture.
  5. There is reason to suspect that some persons accused of witchcraft, but certainly not all, had psychological problems. Economic reasons and political reasons undoubtedly played a role
  6. By the early eighteenth century, the execution and torture of witches had mostly ended, but belief in witches and witchcraft extended well into the 19th century.


XI. Social Change and the Development of Humane Treatment (1700-1885

  1. Franz Anton Mesmer (1733-1815): held a doctorate in Philosophy and a medical degree from Vienna Medical School. Believed you could cure patients by the use of magnets. Postulated a universal, invisible, gas like fluid in which all life forms were immersed fluid – later concluded that this was a magnetic fluid. Probably, Mesmer’s effectiveness was largely hypnotic suggestion. There was one case, Maria, an 18 year old pianist who had been blind since the age of 4. She appeared to be partially cured by Mesmer. However, the Committee to Sustain Morality acted against Mesmer following rumors of an affair with Maria. After that, Mesmer left Vienna for Paris and began a rather elaborate treatment regime for the wealthy – mostly women. Patients gathered around large tubs containing magnetized bottles of water. The floor was carpeted and curtains were drawn – mirrors reflected lights and astrological signs decorated the walls for mystic appeal. If the procedures failed to produce a “crisis” then Mesmer, dressed in a lilac robe and carrying a wand  would try to force magnetic fluid from her body. Failing that, he would gently run his fingers across her “hypochondia” (upper abdomen) to induce a tingle until she felt the fluid pass through her. Most of his clients were women and many rumors were circulated
  2. Philippe Pinel (1745-1826): he was very interested in the lot of the indigent and the insane. One of his close friends  “lost his reason” and was locked up in a madhouse. The friend escaped and his body was found half eaten by wolves or, more likely, wild dogs. This led Pinel to become intense interested in insanity. He was later appointed as a medical doctor in charge of the insane at La Bicetre, were he instituted many humane reforms
  3. York’s Retreat: established by William Tuke  (1732-1822) in England to provide human treatment. York’s Retreat was named after York Asylum, where abuses were common place.
  4. Benjamin Rush (1745-1813): called the first American Psychiatrist.  He was a signer of the Declaration of Independence Physician General of the Continental Army, Treasurer of the United States and a constant supporter of the poor and minority groups. . In 1784, he joined the medical staff at Pennsylvania Hospital and spent the next 30 years treating the insane. His treat procedures probably contributed to misery and death: his standard remedy for the insane was extensive bloodletting – often removing 20 ounces to 21/2 pints at a time. In one violent patient he removed a total of 29 pints in 47 different bloodletting sessions. Also use a large wheel like device called a Gyrator if he thought there was too little blood to the brain. Other techniques were frightening the patients, ducking in water, on rare occasions whipping.
  5. Dorothea Dix (1802-1887): a remarkable woman – daughter of a frequently drunk preacher who was a Harvard dropout. At the age of 12, she ran away to live with her grandmother. She left American for England after an extended illness. She returned to America after her health was restored. A Harvard divinity student asked her to recommend someone to teach Sunday school to imprisoned women (he was afraid to do so). Dix recommended herself. As a consequence, she leaned about insanity and imprisonment and the treatment of these women horrified her. This led to her eventual campaign to establish hospitals for the treatment of the insane in almost every State – a total of 32 large state hospitals

Early Biological Approaches

1. The origins of General Paresis and Syphilis: by the mid 1800 it was generally known in medicine that persons who had general paresis (paralysis) as had syphilis. In 1905, the specific microorganism that causes syphilis was disovered and these findings led to the establishment of a causal link between syphilis and damage to brain areas

2. Francis Galton (1822-1911) is crediteed with the origination of twin studies as a method in genetic research

3. Ugo Cerletti and Lucino Bini and Electroconvulsive Therapy (ECT). Cerletti observed that shocking pigs before slaughter would induce seizures. In 1938 he used electric shock to induce seizurts in a patient with schizophrenia. At the time it was believed that seizures were contraindicated in schizophrenia

4. Prefrontal lobotomy was introduced by Egas Moniz in 1935

5. Sigmund Freud (1856-1939): Psychoanalysis: important terms: Id, ego, and superego, five stages of psychosocial development(oral stage 1 -2 years, anal stage 2-3 years, phallic stage 3-6 years, Latency 6 to pubescense, and genital stage - onset of the adultyears).

Other significant psychoanalytic terms: the uunconscious, defense mechanisms, transference

6. John Watson (1878-1958) and the origins of Behavioral Psychology

Classical Conditioning

7. B. F. Skinner (1904-1990): Operant Conditioning






CHAPTER 2    Paradigms: Genetic, Neuroscience




LECTURE 2   Tuesday, January 22, 2013


Text Assignment: pp. 29-43


TOPIC: Genetic and Neuroscience Approaches





The Biological Paradigm (Somatogenic) (Medical model)


I. Genetics

1.      Genotype: Unobservable genetic constitution

2.      Phenotype: observable behavior such as behavioral manifestations of anxiety

3.      Neither are static – for example, genotypes switch on and off during development

4.      the various clinical syndromes are phenotypes (such as Schizophrenia). You don’t inherit clinical syndromes directly – we may inherit the genotypes for the syndrome

5.      First degree relatives – e.g. parents we share 50% of their genes

6.      Second-degree relatives – e.g. nieces and nephews. We share 25% of genetic make-up.


II. Twin Studies

1.      Starting point: probands or index cases (persons who have the diagnosis)

2.      Concordance: when twins are similar diagnostically, they are concordant

3.      Concordance: Monozygotic twins are higher than dizygotic

4.      The adoptee method – it is extremely rare for identical twins to be raised apart. For example, in Kallman’s studies of schizophrenia, the average age of separation for identical twins was something like 13.5 years


III. Linkage Analysis

1.      attempts to identify the specific genes involved by using blood samples to identify genetic markers – a pattern of inherited characteristics

2.      If the occurrence of a form of psychopathology among relatives goes along with the occurrence of another characteristic whose genetics are known (genetic marker), it is presumed that the gene predisposing to the psychopathology is on the same characteristic and in a similar location on the chromosome (that is, it is linked) as the gene controlling the other characteristic. This is what is meant by linkage analysis


IV. Biochemistry in the Nervous System

1.      Structure of the nerve cell

2.      Transmission of a neural impulse: a change in the electrical potential of a cell

3.      Receptor sites: configured so that specific neurotransmitters are fitted into them

4.      Excitatory messages – at the postsynaptic cell lead to creation of a neural impulse

5.      Inhibitory message – at the postsynaptic cell make it less likely to fire.

6.      Enzymes break some of what remains of a neurotransmitter down and some is pumped back into the presynaptic cell. This is called Reuptake.


V. Neurotransmitters

1.      Nor epinephrine – if high, then high arousal/anxiety disorders

2.      Serotonin – may be involved in depression

3.      Dopamine – may be involved in schizophrenia

4.      Gamma-amnobutyric acid (GABA)- may also be involved in anxiety disorders

5.      Also a possibility that there may be too many receptors that are too easily excited – produces an effect similar to having too many neurotransmitters released.


VI. Biological approaches to treatment

    1 .Prozac

    2. Thorazine – reduces activity of neurons that us dopamine by blocking their receptors


VII. Evaluation of Biological Paradigm

  1. Reductionism versus the whole is greater than the sum of its parts
  2. Could study the whole then reduce to the parts or you could study the parts and go to the whole












LECTURE 3   Thursday, January 24, 2013


Text Assignment: pp 43-60


Topic: Learning and Cognitive Therapies; Diathesis-Stress



I. Origins of Behaviorism

1.      John B. Watson (1878-1958): defined psychology as the study of observable behavior

2.      Little Albert and the rat (Watson and Rosalie Raynor)

3.      Pavlov (1849-1936) and Classical Conditioning: UCS, UCR, CS, CR

4.      Extinction


II. Operant Conditioning

1.      Operant Conditioning – so-called because it applies to behavior that operates on the environment

2.      Discriminative stimulus - external events which cue the organism that if it performs a certain behavior a certain consequence will follow

3.      Positive Reinforcement: strengthening a tendency to respond by presentation of a pleasant event

4.      Negative Reinforcement: strengthens a response by removal of an aversive event

5.      Punishment: punishing a response to suppress or prevent it’s reoccurrence

6.      Shaping: rewarding a series of responses, called Successive approximations, that more and more closely resemble the desired response


III. Modeling

1.      Alfred Bandura

2.      Modeling refers to the fact that witnessing certain behaviors such as those involved in fear or aggression can lead to an increase or decrease in certain behaviors

3.      Modeling may occur in absence of any obvious reinforcement


IV. Mediational Theory of Learning: holds that an environmental stimulus does not initiate a

an overt response directly, rather it does so through some intervening process,  or mediator, such as fear or thinking.


V. Behavior Therapy

1.      Behavior Modification: use primarily by therapist  who use operant conditioning to shape desired behaviors

2.      Counter conditioning: relearning achieved by eliciting a new response in the presence of a particular stimulus. For example, Mary Clover Jones fed a young boy when he was in the presence of a feared stimulus (rabbit)

3.      Systematic Desensitization: (Joseph Wolpe  1958) person is gradually exposed to the feared stimulus in fantasy (persons constructs a list of feared situations to be used) and is taught to relax during each step of exposure

4.      In Vivo Desensitization: gradual exposure to a real stimulus that is feared

5.      Virtual Reality: use of computer images to more closely resemble reality

6.      Aversive Conditioning: a stimulus, which is attractive to a patient, is paired with an unpleasant event. For example, the use of strong unpleasant odors whenever a person smokes. The early attempts to change sexual orientation by pairing shocks with arousal to same sex stimuli

7.      Operant Conditioning: 

(1)   Time out – place where all positive reinforcers are removed

(2)   Token Economy

8.      Modeling





I. Cognitive Behavior Therapy

1.      Aaron Beck’s Cognitive Therapy: developed cognitive therapy for depression based on the assumption that a depressed mood is caused by distortions in the way people perceive life experiences – e.g. Focus on negative happenings

2.      Albert Ellis; Rational Emotive Therapy (now renamed Rational Emotive Behavior Therapy – REBT):  sustained emotional reactions are caused by internal sentences that people repeat to themselves which are based on irrational beliefs such as I must be perfect or life isn’t fair


II. Diathesis-Stress Paradigm (an integrative paradigm) – basically assumes an interaction 

between biological and environmental factors (possessing a diathesis for a disorder increases the risk of developing it. Diathesis = a predisposition toward a disease.


III. Eclecticism: essentially using techniques from a variety of schools or paradigms –

      often using what seems to work best with a particular problem







CHAPTER 3:   Classification and Diagnosis/ Clinical Assessment Procedures




LECTURE 4  Tuesday, January 29, 2013


Text Assignment pp. 62-80


Topic: Classification and Diagnosis



I. Early efforts at a classification System

1.      World Health Organization (WHO): in 1939, added mental disorders to the International List of  Causes of Death

2.      The list was expanded in 1948


4.      The American Psychiatric Association published the first Diagnostic and Statistical Manual (DSM) in 1952

5.      The World Heath Organization (WHO) published a new, more widely accepted list in 1969

6.       The American Psychiatric Association published a second version of the DSM (DSM II) in 1968 which was similar to the WHO system published in 1969

7.      The American Psychiatric Association extensively revised the DSM again in 1980 (DSM III) and less extensively revised version in 1987 (DSM III-R)

8.      In 1988, the American Psychiatric Association appointed a Task force to begin work on the DSM IV. Unlike previous publications, many psychologists were included in the task force

9.      The DSM IV was published in 1994 with a text revision in 2000 (DSM-IV-TR). In the revised version, the diagnostic categories and criteria were essentially unchanged.


II. Five Dimensions of Classification

1.      Axis I: all diagnostic categories except personality disorders and mental retardation

2.      Axis II: Personality Disorders and Mental Retardation

3.      Axis III: General Medical Conditions

4.      Axis IV: Psychosocial and Environmental Problems

5.      Axis V: Current Level of Functioning: The Global Assessment of Functioning (GAF) A scale of 1 to 100


III. Diagnostic Categories

1.      Disorders usually diagnosed in infancy, childhood, or adolescence: separation anxiety disorder, conduct disorder, attention deficit/hyperactivity disorder, mental retardation, pervasive developmental disorders including autistic disorder, and learning disorders

2.      Substance-Related Disorders: alcohol, opiates, cocaine, amphetamine,

3.      Schizophrenia

4.      Mood Disorders: major depressive disorder, Mania, bipolar disorder

5.      Anxiety Disorders (phobias, panic, generalized, OCD, Posttraumatic, and acute stress disorder

6.      Somatoform Disorders: somatization disorder, conversion disorder, pain disorder, hypchondriasis; body dysmorphic disorder – preoccupation with an imagined defect in physical appearance

7.      Dissociative Disorders: dissociative amnesia; dissociative fugue; dissociative identity disorder (multiple personality); depersonalization disorder

8.      Sexual and Gender identity disorders: paraphilias; sexual dysfunctions; gender identity disorder

9.      Sleep Disorders: Dyssomnias – sleeps too much or too little; parasommnias – nightmares, sleepwalking

10.  Eating Disorders:: anorexia nervosa; bulimia nervosa

11.  Factitious Disorder: psychological need to assume role of sick person

12.  Adjustment disorders

13.  Impulse Control Disorders: intermittent explosive disorder; kleptomania; pyromania; pathological gambling; Trichotillomania (pulling out hair)

14.  Personality disorders: schizoid personality disorder; narcissistic personality disorder;  antisocial personality disorder

15.  Other conditions that may be a focus of clinical attention e.g. academic problem; bereavement; physical or sexual abuse, noncompliance with treatment

16.  Delirium, Dementia, Amnestic, and other cognitive disorders


IV. General Criticisms

1.      Categorical classification versus Dimensional classification

2.      Reliability; interrater reliability

3.      Construct validity: constructs in the DSM IV are inferred, not proven entities


V. Criticisms of Diagnosis

1.      Rules for making diagnostic decisions are unclear

2.      Reliability of axes I and II in everyday usage may not be as high as reliability in formal research studies

3.      Ethnic and cultural factors


VI. The DSM V (expected to be published in May, 2013)



LECTURE 5  Thursday, January 31, 2013


Text Assignment pp. 80-102


Topic: Clinical Assessment Procedures


I.  Reliability

1.      Interrater Reliability: the degree to which two independent raters or judges agree

2.      Test-retest reliability: measures the extent to which people are being observed or tested twice score in the same way

3.      Alternate Form Reliability: the extent to which scores on two different forms are consistent

4.      Internal Consistency Reliability: assesses whether the items on a test are related to one another


II. Validity

1.      Content Validity: whether a test adequately samples the domain of interest. For example, are enough relevant questions asked about the range of sexual behaviors that there is an adequate sample for a test on human sexuality (could be just a couple of questions that doesn’t adequately sample the topic)

2.      Criterion Validity:  determining whether a measure is associated in some expected way with the criterion (some other measure).

      Criterion validity would be Predictive Validity if you are using one measure to predict future performance on another measure. For example, using an IQ test at age five to predict academic performance at a later time in school. If you were using two criterion measures concurrently (at the same time) to see whether one predicts the other, then you would be concerned with Concurrent Validity. For example, using a standard IQ test as a criterion for a shorter IQ test you are attempting to develop

3.      Concurrent Validity: when both variables are measured at the same point in time, or concurrently, and they appear to measure the same thing

4.      Construct Validity: A construct is an inferred attribute such as anxiety or intelligence that a measure is trying to assess. Construct validity is looking at a wide variety of data from multiple sources to trey and infer whether the measure really measures what it purports to measure. One would expect thatr a measure of anxiety, for example, would correspond to multiple other sources of information which allow for the inference of anxiety.




I. Clinical Interviews:  The importance of establishing a rapport and trust so that the 

      client is comfortable in disclosing high personal information

1.      Unstructured Interview: advantages are that you may gain valuable info by not following preconceived topics or by restricting the areas you are trying to sample

2.      Structured Interview: the structured interview is particularly important if one is interviewing for research purposes. In research, you want the same kind of information from each subject and to be able to collect information in a standardized fashion. It also avoids ignoring areas that should be explored.


II. Psychological Tests


  1.  Minnesota Multiphasic Personality Inventory (MMPI):

          (a). developed in the early 1940s by Hathaway and McKinley and revised by Jim Butcher and his colleagues in 1989 (MMPI-2).

          (b) The 1940s test was restricted to white men and women from Minnesota.   The 1989 version included African American and Native American samples.

          (c) Validity scales on the MMPI (L Scale, F Scale, and K Scale)

          (d) Page 86, Table 4.1 list6s the scales and sample items

     2.  Projective Personality Tests

                  (a)   Rorschach Inkblot Test: Developed by Hermann Rorschach, MD (1884-1922). Began research in 1918 on inkblots following his discovery              that Szyman Hens in 1917 used inkblot cards to study the fantasies of his subjects. Rorschach published is findings on 300 mental patients and 100 normal subjects in 1921. He died the next year at about age 38

(b)   Thematic Apperception Test (TAT); Henry A. Murray, MD, PhD (1893 – 1988) 


  1. Intelligence Tests: Alfred Binet originally designed the test to identify Parisian children who needed special schooling. The role of Terman at Stanford University (hence the name Stanford-Binet Intelligence test
  2. Wechsler Intelligence Scale for Children (WISC) and the Wechsler Adult Intelligence Scale (WAIS): developed by David Wechsler
  3. In general, IQ tests are highly reliable. Construct validity depends partly on whether there is agreement on how psychologists define intrelligence




I. Behaviorally and Cognitively oriented psychologists tend to focus on the following

   Four factors:

1.      The environmental situation which precedes a problem

2.      Physiological and psychological factors which might influence behavior

3.      The overt responses a person makes or their observable behavior

4.      The consequences of behavior – reinforcers, negative reinforcers, punishment


II. Direct Observation of Behavior: can be very structured and involve identifying

sequences of behavior that make sense following the four factors listed above. One   could also chart specific behaviors and simply record their frequency during  a specified time interval



III. Self Observation: a therapist may request that a client record his or her own behavior.       

Interviews, self report inventories, self monitoring of behavior are all used by the cognitive behaviorists in some situations





I.   Brain Imaging: Computerized axial tomography (Ct or CAT scan)


II. Magnetic Resonance Imaging (MRI) – produces superior pictures to the CAT scan and 

     requires no radiation


III. Positron Emission Tomography (PET): allows assessment of both brain structure and

brain functioning short lived and harmless radioactive isotope is injected into the bloodstream. Computer analysis allows for the assessment of brain functioning


IV. Neuropsychological Assessment and neuropsychological tests such as the Reitan

Battery and the Halstead Battery have some validity in diagnosing and localizing brain disorders


V. Psychophysiological Assessment: for example, the electrocardiogram (EKG) and the

     Electroencephalogram (EEG)




I.  Supposedly, the WISC and the MMPI are relatively free of test bias for whites and

African Americans, but  Asians score higher on the MMPI. Research on the topic of cultural bias tends to focus on predictive validity. Unquestionably, minority children are over represented in special education classes. The question is why and what cultural factors make it difficult for many minority children to adapt to the quiet, relatively inactive, predominantly white educational system?








CHAPTER 4:  Research Methods in the Study of Abnormal Behavior




LECTURE 6: Tuesday, February 5, 2013


Text Assignment: pp. 104-129


Topic: Research Methods in the Study of Psychopathology



I. Introduction   

1.      Testability: to be useful, scientific claims must be testable

2.      Replicability: findings must be replicated by others


II. The Role of Theory

1.      Operationalism: defining constructs in terms of the measure. Criticism: the operationist tends to oversimplify a construct. A more meaningful, flexible approach involves a set of operations involving several different measures of a construct

2.      Skinner’s criticisms of the theoretical approach




I. The case Study

1.      Provides detailed study of one or more cases. Example: Thigpen and Cleckley’s book on Chris Sizemore (Evelyn White, Eve Black, and Jane)

2.      Generally case studies lack controls and cannot be generalized to groups

3.      Case studies are useful in generating hypotheses


II. Epidemiological Research

1.      Prevalence: the proportion of a population that has a disorder

2.      Lifetime prevalence rates: the prevalence over the course of a person’s life up until the time of the study

3.      3. Incidence: the number of new cases of a disorder that occur in some period

4.      Risk factors: conditions or variables that increase the likelihood of developing the disorder


III. The Correlational Method

  1. Designed to answer the question: is there a relationship between two or more variables?
  2. Correlation coefficients can range from +1.0 to 0 to –1.0
  3. Significance of a correlation: the same correlations as indicated by r may not or may not be significant depending on the number of observations. For example, a correlation of r= .5 may NOT be significant when observations are based on 20 persons but may be significant if based on 300 persons
  4. Significance level is indicating by little p. For example p< .05 means less than five times out of a hundred would you expect the results to be due to chance
  5. Classificatory variables: those variables, which are not manipulated by the experimenter but are inherent in the population. E.g. Schizophrenia, anxiety, gender – you don’t manipulate male and femaleness – you simply classify your groups according to maleness or femaleness
  6. What the text refers to as “classificatory variables” may be referred to as a    quasi-experimental design by others
  7. Problems of correlational research: the “Directionality Problem” just because two things are related, you don’t know which causes the other. Also, it is possible that neither causes the other and both are caused by a third variable (the “Third-Variable Problem)
  8. The High Risk Method: For example, rather than study 500 individual over 30 years to see who develops schizophrenia, you select people for study on the basis of be at risk for developing schizophrenia – for example, studying only those individuals who have a parent or grandparent who is diagnosed as schizophrenic


IV. The Experimental Approach

  1. Experimental Hypothesis:  also called the research hypothesis – basically your prediction regarding the outcome based on the research literature
  2. Null Hypothesis: statistical assumption that there are no significant differences between groups
  3. Independent variable: the variable manipulated by the experimenter
  4. Dependent Variable: the outcome variable – usually the main object of study that is predicted to vary as a result of the manipulation of the independent variable
  5. Random assignment: random assignment of subjects to the different experimental conditions or groups
  6. Experimental effect: the differences found between groups
  7. Internal validity: based on the inclusion of at least one control group necessary to attribute the effects to the manipulation the manipulation of the independent variable
  8. Confounds: uncontrolled variables that could potentially affect the outcome other than the experimental manipulations
  9. The Placebo Effect:  an improvement of physical or psychological functions that is a result of expectations by the client rather than a real effect of the drug or type of therapy
  10. Double-blind procedure: when neither the subject or the experimenter know which participants arte in the control group and which are in the experimental group
  11. Ethical; issues related to a no treatment control group
  12. Many current research projects compare a new treatment with one that has been previously investigated for which the expected outcomes are generally known
  13. External Validity: the extent to which the results can be generalized to other groups or situations
  14. Analogue Experiments: usually done on non-clinical populations with the intent of finding out possible implications for a clinical population  or a group which is of interest but not being studied. For example, studying aggressive behavior following a manipulation with college students to gain possible information about aggressive behavior in a different population (such as aggression committed by persons that might involve actual injury to others.


V. Single-Subject Experimental Designs: involves the following procedure:

1.      Establish a baseline (A)

2.      Introduce an experimental treatment (B)

3.      Reintroduce the baseline (A)

4.      Reintroduce the experimental treatment

5.      This procedure is known as the ABAB design


VI. Mixed Designs: Example

1.      Participants may be assigned as a Classificatory Variable (Schizophrenic and Bipolar groups)

2.      They may be further divided into two different levels of severity for Schizophrenia and Bipolar disorders

3.      Three different therapies may be used

4.      In a sense, each of the two classificatory variables is manipulated by defining two levels of severity – this results in a mixed design


VII. Meta-analysis and the effects of Psychotherapy: basically involves a technique to

study all available research studies in an area by standardizing the differences in studies using a statistical technique called “Effect-size”. The assumption is that all the methodological differences between what may several hundred studies may be minimized. It is an effort to make sense out of a vast amount of literature on a subject such as the effects of psychotherapy
















LECTURE 7       Tuesday, February 12, 2013


Text Assignment: pp. 131-173


Topic: Mood Disorders


I. Depression

1.      Signs of depression: sadness, feelings of worthlessness, withdrawal, loss of sleep, appetite, sexual desire, and interest in pleasurable activities

2.      Difficulties in concentration

3.      May neglect personal hygiene

4.      Often – numerous somatic complaints (more common  in children)

5.      Duration may be five months or longer or chronic


II. Mania

1.      Signs include: intense elation and/or irritability, hyperactivity, talkativeness, flight of ideas, distractibility, and grandiose plans

2.      Duration may be several days to several months

3.      Speech is difficult to interrupt and flight of ideas prevents understanding\

4.      Frustrating symptoms may result in anger or rage

5.      Sexual acting out is commo0n


III. Diagnosis of Major Depression

1.      DSM IV: At least two weeks of depression or loss of interest and pleasure; at least four of the symptoms listed above

2.      Lifetime prevalence ranges from 5.2% to 17.1%

3.      Two or three times more common in women than men

4.      More common than average in Jewish men and roughly equivalent to Jewish women

5.      Tends to be recurrent – 80% experience another episode. Average number of episodes is about four, each typically lasting from three to five months

6.      About 12% of Depression becomes chronic with a duration of more than two years


IV Diagnosis of Bipolar I Disorder

1.      Involves episodes of mania or mixed episodes pf both mania and depression

2.      Most with Bipolar I Disorder also experience episodes of depression

3.      Formal Diagnosis of a manic episode requires: presence of elevated or irritable mood plus at least three additional symptoms listed above – four if the mood is irritable

4.      Lifetime prevalence of Bipolar is approximately 1 %

5.      Average age of onset is in the twenties

6.      Bipolar disorder occurs about equally often in men and women

7.      Among women depressive episodes are more common and manic episodes are less common than among men

8.      Tends to recur – over 50% of the cases have four or more episodes


V. Considerable Variability among cases

1.      Some bipolar persons may experience a full range of symptoms for both depression and mania every day (mixed episode)

2.      Others have only mania or only depression during a clinical episode

3.      Others have major depression accompanied by hypomania (less extreme than mania) – DSM IV diagnosis would be Bipolar II

4.      Episodes of hypomania last only about four days and do not significantly impair social or occupational functioning

5.      Depression can occur with psychotic features (delusions or hallucinations) typically they are more severe and respond mote to antipsychotic meds than antidepressant meds

6.      Some have melancholic features: no pleasure in any activity; unable to even feel temporarily good, depressed mood worse in the morning they awaken about two hours early and lose appetite and weight

7.      Both manic and depressive episodes may have catatonic features

8.      If manic or depressive episodes occur within four weeks of childbirth, they are considered as having a postpartum onset

9.      Finally, the DSM IV recognizes some forms of bipolar and unipolar disorders as seasonal; reduced light during the winter may cause decreases in the activity of serotonin neurons; therapy may be involve exposing patients to a bright white light


VI. Chronic Mood Disorders

  1. Cyclothymic Disorder: frequent periods of depressed mood and hypomania – may be mixed with, alternate or be separated by periods of normal mood lasting as long as two months. Paired sets of symptoms: during depression – feel inadequate; during hypomania – inflated self-esteem. Or, too much or too little sleep. During hypomania, they may be sharp and creative
  2. Dysthymic Disorder: chronic depression. Dysthymic disorder differs from major depression in the duration, type, and number of symptoms. In the DSM IV, Dysthymic disorder as opposed to major depression, requires three or more symptoms (instead of five), and the duration of symptoms does not exceed two months
  3. Cyclothymic and Dysthmic disorders are not necessarily less severe forms of mood disorders as indicated by longitudinal studies indicating suicides and hospitalizations


VII. Mood Disorders and Creativity and Emotion

1.      Kay Jamison has noted that mood disorders, especially bipolar disorders, may be linked to artistic creativity

2.      Anxiety and depression often are comorbid, however depression is more likely to be associated with negative affect and anxiety and less likely to experience positive affect than anxious persons. Depressed persons also are less like to report somatic anxiety or anxious signs of autonomic arousal

3.      Some individuals with mixed anxiety- depression may show all of the above


Psychological Theories of Depression


I.  Psychoanalytic Theory

1.      Freud: depression may involve fixation at the Oral Stage leading to excessive dependency on others to maintain self-esteem. Over-dependent persons direct anger over the loss of a loved one (by death or separation) inwardly and develop self-blame, self-abuse, and depression.

II. Cognitive Theories of Depression: Aaron Beck

1.      Aaron Beck: thought processes are causative factors in depression. Depression is a result of the thinking process biased toward negative interpretations.  Individuals in childhood or adolescence acquire a negative schema – a tendency to see the world negatively – because of parental loss, tragedies, peer rejection, etc.

2.      The negative triad: negative views of the self, the world, and the future

3.      Four Cognitive Biases of depressed persons:

(a)    Arbitrary Inference: conclusions drawn with insufficient or no evidence

(b)   Selective Abstraction: conclusions drawn on the basis of one element from many

(c)    Overgeneralization: sweeping conclusion based on a single, perhaps trivial event

(d)   Magnification and Minimization: exaggeration in evaluation of performance or trivial events (either magnifying or minimizing significance of events)

4.      Beck’s primary assumption: our emotional reactions are primarily a function of how we construe our world – depressed people are victims of their own illogical self-judgements

5.      Evaluation: the primary issue is whether the correlation between depression and  

negative thoughts suggests that depression causes negative thoughts or negative thoughts causes depression (as Beck argues). The data would suggest both possibilities with perhaps, a leaning toward both negative thoughts and negative events causing depression


III. Cognitive Theories Continued: Learned Helplessness (Seligman. 1974)

  1. Learned helplessness: the individual’s perceived inability to control their own life situation
  2. Seligman’s experimental research with dogs: dogs who received inescapable shocks later, when the shocks became escapable, gave up
  3. The sense of helplessness and lack of control is a cardinal feature of depression
  4. Attribution and Learned Helplessness: people become depressed when they attribute negative life events to stable and global causes – if self-esteem collapses it may be a result of blaming the bad outcome on their own inadequacies


IV Cognitive Theories: Hopelessness theory

1.      Theory is that some forms of depression are caused a state of hopelessness – a component of helplessness


V. Evaluation

1.      Problems with college student analogue studies (frequently use the Beck Depression Inventory (DBI) which was really designed to assess severity of depression in an already diagnosed clinical group – not to select or diagnose persons for a study

2.      Attribution is assumed to be a factor when in fact attributions of depressed and non-depressed persons in one study did not differ

3.      Circular definitions “hopelessness depression is caused by hopelessness”


VI. Interpersonal Theory of Depression – the relationship between depressed persons and

      significant others

  1. Depressed persons elicit negative reactions from others
  2. Behavior of depressed persons elicits rejection
  3. Roommates reject fellow college roommates with depression
  4. Depressed persons tend to seek out negative feedback which validates their self-concept
  5. Negative self-concept causes them to doubt positive feedback and leads to constant efforts to be reassured by others (and irritates them in the process). It is conceivable that interpersonal difficulties and deficits may be a cause of depression as well as a consequence of it


VII. Biological Theories of Mood Disorders

1.      Genetic data. : the concordance rate for identical twins for bipolar disorder is about 70 % for identical twins and 25% for fraternal

2.      The data for unipolar depression is less decisive than for bipolar although genetic factors remain influential

3.      Neurochemistry:

(a)    Tricyclic drugs (e.g. imipramine – trade name Tofranil) – prevent some reuptake of both norepinephrine and serotonin by the presynaptic neuron after it is fired – thus leaving more of the neurotransmitter at the synapse so that transmission by the next nerve impulse is easier

(b)   Monoamine Oxidase Inhibitors (MAO) (e.g. Parnate): have their effect by presumably keeping the enzyme monoamine oxidase from deactivating neurotransmitters – results in increased levels of serotonin and norepinephrine in the synapse

(c)    Norepinephrine levels decrease in the urine of patients as they become


(d)   There is evidence that increasing norepinephrine levels can precipitate a manic episode in bipolar patients

(e)    Research on reduced serotonin levels and reduced norepinephrine levels indicate that the antidepressants increase levels when they are first taken, but after several days the neurotransmitters return to their earlier levels

(f)     It takes most antidepressant a couple of weeks before they are clinically effective

(g)    One possibility is that the meds alter the sensitivity of serotonin and norepinephrine postsynaptic receptors

(h)    Lithium – widely used to treat bipolar disorder may have its effect by regulating the G-proteins found in postsynaptic cell membranes and may modulate activity in the postsynaptic cell


VIII. The Neuroendricrine System

  1. Primarily involves the role of the hypothalamus in affecting the Pituitary gland and the hormones it produces
  2. The hypothalamic-pituitary-adrenocortical axis is thought to be overactive in depression , resulting in disturbances of appetite and sleep and other vegetative symptoms of depression
  3. Levels of cortisol (an adrenocortical hormone) are high in depressed patients
  4. Excesses of cortisol can damage the hippocampus and enlarge the adrenal glands – studies of depressed patients indicate that they exhibit hippocampal abnormalities
  5. High levels of cortisol may lower the density of serotonin receptors and impair the functi0on of adrenergic receptors

Treatment of Mood Disorders

I. Therapies for Mood Disorders

    1.  Psychoanalytic: One recent study indicates that a short form of psychodynamic therapy that focuses on present interactions and the social environment is as 

         effective as cognitive behavior therapy in the treatment of depression (e.g. Klerman and Weissman's Interpersonal Therapy).

     2. Cognitive and Behavior Therapies: Research has consistently supported the effectiveness of  Beck's cognitive theory of depression which focuses on modifying

          maladaptive thought patterns by persuaded the client to change their negative interpretation of events as well as encouraging them to become more active in  

          doing things

     3. NIMH Treatment of Depression Collaborative Research Program:  An extensive study comparing Cognitive therapy, Interpersonal therapy, Imipramine          

         and a placebo control, resulted in improvement of the first three over the placebo control group but no substantial differences in overall effectiveness

         of the three treatments, although there is considerable controversy regarding the relative effectiveness of imipramine - at least one renowned researcher,

         Donald Klein, concluded that the drug was more effective than the other two treatments

     4. Social Skills Training: shown to be effective by enhancing social behaviors by techniques such as assertion and social skills training

     5. Behavioral Activation Therapy: seeks to engage clients in behaviors or activities that are reinforcing to offset past patterns of avoidance which

         tend to maintain depression


II. Psychological Therapies for Bipolar Disorder: Medication continues to be the most effective treatment. Psychological supportive approaches involving    

     medication compliance and family education play an important role, particularly in reducing hospital stays


III. Biological Theories of Mood Disorders

    1.  Electroconvulsive Therapy (ECT): originated by Cerletti, an Italian seeking to experimentally induce seizures which were thought to be

         and effective treatment for schizophrenia. He watched animals in a slaughter house that were immobilized by electrically induced seizures.

         Cerletti first employed ECT with a schizophrenic patient in 1938. It later became a frequent treatment for depression. ECT is still used

         but only when depression does not respond to other treatment attempts - often ECT is viewed as a a last resort.

     2. Drug Therapy: although various antidepressants hasten a client's recovery from depression, relapse is still common when the medication is discontinued.

         Drug therapy is an effective treatment as is Cognitive Behavior Therapy and Interpersonal Therapy

    3. Drug Therapy and Bipolar Disorder: lithium carbonate results in improvement by roughly 80% of clients, but lithium must be closely

        monitored to avoid lithium toxicity which results in serious consequences and possibly death


IV. Depression in Childhood and Adolescence

    1.  Between the ages of 7 to 17, depression resembles adult depression. However, suicide attempts and guilt during this time are higher than

         those for adults. Adults tend to have more problems with awakening early in the morning, loss of appetite, and weight loss.

    2. Masked depression in children: sometimes inferred from aggressive behaviors and/or behavioral misconduct. In children, the estimated

        prevalence 1% of preschoolers, 2to3 % of school age children, and 7 to 13% in adolescents. Depression very often comorbid with anxiety.

    3. Etiology of Depression in Childhood and Adolescence: some evidence that home experiences - primarily the way in which parents interact                         

        with children may be a significant contributor to depression

    4. Treatment: may be best accomplished with a broad-spectrum approach that involves not only the child or adolescent, but also the parents and the school.


V. Suicide

    1. Suicide is not a type of disorder but is a behavioral act

    2. Every 20 minutes, there is a completed suicide in the US (31,000 suicides per year)

    3. Overall rate is 12 per 100,000, but during the age range of 75 to 84, the rate increases to 24 per 100,000

    4. It is estimated that attempts are as high as 200 to 1 (six million attempts per year)

    5. Most attempters never make another attempt, but about half of those who commit suicide, made art least one prior attempt

    6. Men are 4 to 5 times more likely to kill themselves than women, but 3 times as many women than men attempt suicide

    7. Risk increases 4 to 5 times higher in persons divorced or widowed

    8. Suicide rates are highest during spring and summer

    9. Especially high among psychiatrists, physicians, lawyers, and psychologists - even more so if they are women

   10. Guns are the most common method - particularly among men

   11. Rates of suicides in adolescents are far below those of adults but are increasing dramatically


VI. Perspectives on Suicide

    1.  Emile Durkheim distinguished three types of suicides:

        (a) Egoistic Suicide: committed by persons with few ties to the family, society, or community - strong feelings of social alienation

        (b) Altruistic Suicide: sacrificing one's self for the perceived good of society - e.g. Buddhist monks in Vietnam or possibly suicide bombers

        (c) Anomic Suicide: triggered by sudden changes such as a severe financial setback or possibly a stress response to natural disasters, or  tragedies such as 911


VII. Shneidman's Approach

      1. Proposed ten most frequent Communalities (see table 10.6 on page309)

      2. His basic view is that suicide is a conscious attempt to seek a solution to a problem that is causing intense suffering

      3. Most people who actually commit suicide are ambivalent - a very important fact related to prevention

      4. There is a narrowing of perceived options


VIII. Prediction and Prevention

    1. Key factor resulting from psychological testing is "hopelessness"

    2. Another key factor is perceived "life satisfaction"

    3. Suicide Prevention Centers: many are modeled after the Los Angeles Suicide Prevention Center founded in 1958 - now about 200 such centers in the US.  

        Most provide a 24 hour telephone service or hotline and are staffed largely by non professionals supervised by psychologists or psychiatrists

       Workers usually are guided by a list of risk factors which allow assessment of the lethality. Centers or hotlines may be the only contact that

       many isolated and alienated persons may have and they potentially provide a valuable prevention tool.


X. Clinical and Ethical Issues Regarding Suicide

    1. Protecting clients from harming themselves may require a breach of confidentiality by a therapist. Questions include w to

        what extent a person has a right to end his or her life? What steps should a professional take? Hospitalization? Sedation? What

        about the ethics of physician assisted suicide - for example, the work of Jack Kevorkian who was trued several times for murder and\

        Eventually was convicted and sent to prison in 1999.

    2. Oregon became the first state (1997) to have a law - the Death with Dignity Act - which made physician-assisted suicide legal. Contrary

        to predictions by critics, the law has not led to an increase in suicides












LECTURE 8,   Thursday, February 14, 2013


Text Assignment: pp 174-188


Topic: Phobias, Social Anxiety, Panic Disorder, Generalized Anxiety



I. Anxiety: Text Definition: an unpleasant feeling of fear and apprehension accompanied  

    By increased physiological arousal

1.  DSM II: anxiety and related disorders were classified under the general heading Neurosis

2.   DSM IV-R: uses Anxiety Disorders as the general classification that includes most of the disorders classified under Neuroses by the DSM II

3.   Comorbidity: when a person meets the criteria for more than one Anxiety Disorder. Comorbidity may result from disorders having similar symptoms and/or when etiological factors are similar or the same for two or more anxiety disorders


II. Phobias: Text Definition: a disrupting, fear-mediated avoidance that is out of

     Proportion to the actual danger posed by a particular object or situation and is  

     Recognized as groundless by the sufferer

     1. Phobos: the name of a Greek God who frightened his enemies

2.   Persons who have little contact with the feared object may not seek treatment

3.   Your theoretical paradigm influences how you view phobias: e.g. the symbol of an unconscious fear or as the fear per se


III. Specific Phobias

1.   Social Phobia: a persistent, irrational fear generally linked to the presence of other people

2.   Suicide rates are higher than for other disorders

3.   Avoidance of situations involving signs of embarrassment such as fear of blushing or perspiring

4.   Usually work in settings or occupations where they can avoid social contacts

5.   Social phobias can be either generalized or specific

6.   Lifetime prevalence for men is 11% and for women is 15%

7.   Onset usually begins in adolescence





CHAPTER 6 Continued




Tuesday, February 19, 2013


TEXT ASSIGNMENT: pp. 189-202


Anxiety: Etiology and Treatment



I. Etiology of Phobias

1.   Psychoanalytic Theory: phobias are a defense against the anxiety produced by repressed impulses – the anxiety is displaced from the feared id impulse and moved to a symbolic object or situation

2.   Behavioral Theory

(a)    Avoidance Conditioning: phobias are learned avoidance responses. According to two-factor theory proposed by Mowrer, 1. via classical conditioning we learn to fear a neutral stimulus, then 2. we learn to reduce this conditioned fear by escaping or avoiding the CS (operant or instrumental conditioning). There is some support for the Classical Conditioning explanation in that some people develop a phobia after a very painful experience with the feared object (however, some people don’t). Also there are persons with phobias who are unable to recall any specific learning experience that led to the fear

(b)   Modeling: vicarious learning – we learn a fear by observing others. We can learn a fear by seeing others experience pain or by hearing another person’s description of what did or might happen (e.g. horror movies such as jaws or snake stories)

(c)    Prepared Learning: certain neutral stimuli (prepared stimuli) may be easier to condition a fear response to than other neutral stimuli

(d)   Diathesis: a cognitive diathesis – believing that similar traumatic experiences will occur in the future – may be important in developing a phobia

3.   Social-skills Deficits in Social Phobias: socially anxious people are rated as being low in social skills

4.   Cognitive theories: Socially anxious people are more concerned about evaluation than are people who are not socially anxious and socially anxious persons view themselves more negatively even if they actually perform well in a social situation

5.   Predisposing biological factors – differences in the autonomic nervous system and possible genetic influences


II. Therapies for Phobias

1.  Importance of exposure to the feared stimulus

2.   Behavioral Approaches: flooding, learning social skills, modeling, desensitization

3.   Cognitive approaches: when combined with exposure techniques, cognitive approaches are more effective than any other approach (e.g. Albert Ellis and RET)

4.   Biological Approaches: drugs that reduce anxiety are referred to as sedatives, tranquilizers, or anxiolytics. MAO inhibitors (monoamine Oxidase Inhibitors seem to work well but have potentially serious side effects. The SSRI  (Selective Serotonin Reuptake Inhibitors) are safer but relapse is common when they are discontinued. The benzodiazepines are addictive (e.g. Valium)


III. Panic Disorder: sudden, often inexplicable attack of many severe symptoms – labored

breathing, heart palpitations, nausea, chest pain, feelings of choking and dizziness, sweating, trembling

1.   Depersonalization: feeling of being outside one’s body

2.   Derealization: a feeling that the world is not really real

3.   Situational triggers (cued attacks)

4.   Unknown triggers which may even occur in sleep (uncued attacks)

5.   Agoraphobia: avoiding situations which could be embarrassing or dangerous such as driving – the fear of having an attack in a public place

6.   80 percent of persons with other anxiety disorders also experience panic attacks, but not with sufficient frequency to warrant the diagnosis


IV. Etiology of Panic Disorder

1.  Biological theories: mitral valve prolapse syndrome causing heart palpitations that may serve as triggers; a possible genetic diathesis may be involved

2.  Noradrenergic activity: overactivity of the noradrenergic system. Overreativity may be due to a problem with gamma-aminobutryic (GABA) neurons that generally inhibit noradrenergic activity.

3.   Creating panic attacks experimentally: by hyperventilation hasn’t worked well.

4.   Psychological theories: Classical Conditioning theory – panic attacks become classically conditioned to internal bodily sensations of anxiety

5.   A second theory is that emphasizes catastrophic misinterpretation of internal bodily sensations of anxiety

6.   Perceived control may be a highly significant factor in triggering attacks – a psychological explanation


V. Therapies for panic attacks

1.   Biological: usually pharmaceutical approaches are the first kind of treatment if not the only kind

2.   Treatments include the SSRL’s, the benzodiazepines such as Alprazolam

3.   Self treatment involving alcohol abuse or other drugs


VI. Psychological Treatments for Panic Attacks

1.   Barlow’s treatment: for example, a person whose panic attacks begin with hyperventilation may be asked to breath rapidly while under safe conditions – they are also treated with relaxation techniques and taught to reinterpret the meaning of internal sensations. Panic Control Therapy (PCT) appears to be the most successful treatment thus far


VII. Generalized Anxiety Disorder (GAD): Chronic anxiety and worry

1.   lifetime prevalence of the disorder is about 5% of the general population

2.   Twice as common in women than men

3.   Has a high level of comorbidity

4.   Difficult to treat successfully


VIII. Etiology of Generalized Anxiety

1.   Psychoanalytic: unconscious conflict between ego and id impulses – the true source desires associated with previously punished id impulses that are striving for expression – is ever present – not displaced as in a phobia

2.   Cognitive-Behavioral Views: Borkovec argue that worry is actually negatively reinforcing in that it distracts patients from negative emotions (worry doesn’t produce much emotional arousal or physiological changes and actually blocks the processing of emotional stimuli

3.   Biological: most prevalent is the benzodiazepines  - may reduce anxiety by enhancing the release of gamma-aminobutyric acid  (GABA) which in turn, leads to an inhibition of noradrenergic activity


IX. Therapies for Generalized Anxiety Disorder

1.   Psychoanalytic: help patients confront the true sources of their conflicts

2.   Behavioral: one approach is to reformulate generalized anxiety into specific identifiable situations (which in effect makes it a phobia) then treat the phobia(s)

3.   Cognitive Approaches: Barlow uses exaggerated exposure – has the client imagine the worst possible outcome (similar to flooding) – because the person remains in the fearful situation during exposure, extinction presumably will eventually take place

4.   Biological: most frequently used drugs for GAD are probably the benzodiazepines – particularly Valium and Xanax












LECTURE 10   Thursday, February 21, 2013


Text Assignment: pp 203-225

Topic: , Obsessive Compulsive and Post Traumatic Stress Disorders


I. Obsessive-compulsive disorder (OCD):  Text Definition: “an anxiety disorder in

which the mind is flooded with persistent and uncontrollable thoughts and the individual is compelled to repeat certain acts again and again, causing significant distress and interference with everyday functioning”.

1.    OCD has a lifetime prevalence of 2.5%

2.     Early onset is more common among men

3.     With men, checking behavior is more common and with women, compulsive cleaning is more common

4.    Obsessions: intrusive and recurring thoughts, impulses, and images, often seeming irrational to the person experiencing them

5.    The most frequent obsessions are fears of contamination, expressing some sexual or aggressive impulse, and hypochondriacal concerns about bodily functions

6.    Compulsions: a repetitive behavior or mental act that a person feels compelled to perform to reduce distress caused by obsessive thoughts

7.    Terms like compulsive gambling or compulsive drinking are not accurate with respect to OCD as they imply pleasurable, abut excessive activities



II. Posttraumatic Stress Disorder (PTSD): an extreme response to a severe stressor

including increased anxiety, avoidance of stimuli associated with the trauma, and a numbing of emotional responses.

1.   First introduced as a diagnosis in DSM-III

2.   Prior to DSM III: terms such as “Shell-Shocked” (World War I) , “Combat Fatigue or Combat Exhaustion” (World War II) may have included some of the behaviors now classified under Posttraumatic Stress

3.   Acute Stress Disorder: If a trauma leads to a significant impairment in social or occupational functioning that lasts for less than one month, then the classification would be Acute Stress Disorder. Approximately 90% of rape victims experience an Acute Stress Disorder as compared to only 13% experiencing it following a motor vehicle accident

4.   Posttraumatic Stress Disorder: a significant number of persons who experience an Acute Stress Disorder, also Develop PTSD

5.   Of persons who experience a traumatic event leading to physical injury, approximately 25% develop PTSD


     Three Categories of PTSD

1.   Reexperiencing the traumatic event: frequently recalling the event and usually having nightmares

2.   Avoidance of stimuli associated with the event or numbing of responsiveness

3.   Symptoms of increased arousal: difficulties in falling or staying asleep, concentration difficulties, hypervigilance, exaggerated startle response


      Other problems associated with PTSD

1.   other anxiety disorders

2.   Depression

3.   Substance abuse

4.   Marital problems

5.   Sexual dysfunction

6.   Occupation impairment


     PTSD in Young Children

1.    Nightmares about monsters are common

2.    Behavior changes – outgoing children becoming withdrawn; shy children becoming aggressive

3.   Losing acquired developmental skills such as speech or toilet training habits

4.   Difficulty in talking about past events – particularly in cases involving physical or sexual abuse


    Prevalence rate is about 1 to 3 percent in the general; population of the US


III. Etiology of OCD

1.   Psychoanalytic Theory: Fixation at the anal retentive phase of the anal stage of development

2.   Behavioral explanation -learned behaviors reinforced by fear reduction.

3.   Notion of a memory deficit leading to checking behaviors (largely unsupported)

4.   Cognitive explanations: OCD, more specifically, compulsive behavior is driven by an unreasonable need to feel competent or perfect –otherwise one might be worthless. Magical rituals may become the primary way of achieving a sense of control and competence

5.   Other Cognitive Explanations:  - the irrational belief that one should be able to prevent harm to others and control one’s thoughts

6.   Biological explanations: encephalitis, head injuries, and brain tumors have all been associated with the development of OCD. Areas of the brain that are thought to be involved are the frontal lobes and the basal ganglia (linked to control of motor behavior). A higher incidence of OCD is found in Tourette’s syndrome, a syndrome marked by motor and vocal tics that have been linked to basal ganglia dysfunction. Some evidence of a genetic predisposition based upon studies relatives


IV. Therapies for OCD: rarely are patients “cured” although significant improvement in

      obsessive compulsive tendencies can be achieved

1.   Psychoanalytic: approach is generally not effective if the approach focuses on lifting repression and dealing with unconscious conflicts

2.   Behavioral approaches: the most accepted, widely used approach combines exposure with response prevention (more recently renamed “ritual” prevention) Basically you expose the client to situations that elicit the compulsions, then prevent the person from performing the response or ritual. More than half of clients improve with behavior therapy such as just described

3.   Rational Emotive Therapy (RET): help patients give up the irrational belief that things have top be the way they want them to be and a perfect outcome must be achieved

4.   Biological Treatment: most often treatment involves drugs that increase serotonin levels (SSRIs) and some tricyclics (e.g. Elavil, Triavil). The treatment of choice appears to be the SSRIs (e.g. Prozac). In extreme cases, cingulatomies have been performed – small lesions in the white matter of the cingulum, an area near the corpus callosum.


V. Etiology of PTSD – Risk Factors

1.   Perceived threat to life

2.   Being female

3.   Early separation from parents

4.   Family history of the Disorder, Previous exposure to traumas

5.   A Preexisting disorder such as an anxiety disorder or depression

6.   Dissociative symptoms (including depersonalization, derealization, amnesia, and out-of-body experiences) at the time of the trauma increase the probability of developing PTSD


VI. Psychological Theories About PTSD

1.   Learning Theorists: assume that PTSD is related to classical conditioning of a fear – based on classically conditioned fear responses, avoidances develop (two factor theory)

2.   Psychoanalytic theorists focus upon repression of traumatic experiences

3.   Biological theories: focus on genetic predispositions – for example, differences autonomic activity involving the noradrenergic system – increased levels of nor epinephrine may increase fear reactions and startle responses


VII. Therapies for PTSD

1.   The primary effective treatment involves exposure to fear-provoking stimuli with the goal of extinguishing anxiety in the presence of the triggering stimuli

2.   Critical Incident Stress Debriefing (CISD): sometimes called traumatology, sometimes grief counseling, sometimes debriefing – goal is to intervene as soon as possible with as many of the victims as possible within a 24 to 72 hour period after a traumatic event. For example, the call for mental health professionals after 9-11 disaster. However, some research suggests that this approach (CISD) may do more harm than good – being with family and some distancing from the trauma may be important and CISD could intrude on that process. Suffering may be considered a normal part of life and the pain and grief should not be avoided but coped with and used to confront future traumas

3.   War-Time Approaches: PTSD did not appear as a well described diagnosis until 1980 in the DSM-III. Some years after Vietnam, rap groups were formed in New York City and begin to spread to other parts of the country. Operation Outreach – a network of 91storefront counseling centers for psychologically distressed Vietnam vets  received federal funding in 1979. Also more conventional group therapy sessions in 172 veterans hospitals across the nation


VIII. Cognitive and Behavioral Approaches to Treating PTSD

1.   Structured exposure to trauma related events – sometimes through imagined events as in systematic desensitization leads to improvement over other factors such as social support and medication

2.  Eye Movement Desensitization and Reprocessing (EMDR): the patient imagines the traumatic situation, then follows with his her eyes the therapist’s fingers as they move back and forth about a foot from the patient – this continues for a minute or two until the patient reports that the aversive ness of the image has been reduced. Then the therapist has the patient verbalize whatever negative thoughts they have while following the therapist’s fingers with his or her eyes. Finally the therapist encourages the client to think positive thoughts.

3.   The success of EMDR has been a bit controversial and well controlled  studies casts considerable doubt on its effectiveness










CHAPTER 8: Dissociative Disorders and Somatic Symptom Disorders




LECTURE 11     Tuesday, February 26, 2013


Text Assignment: pp. 226-251



Dissociative Disorders: all Dissociative Disorders involve a person’s sense of identity, memory, or consciousness. The four types are: Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, and Dissociative Identity Disorder (formerly multiple personality)


I. Dissociative Amnesia: memory loss following a stressful experience

1.    Information is not permanently lost but cannot be recalled during the episode of amnesia

2.    During amnesia, the persons\’s behavior (other than the memory loss) is not remarkable

3.     In total amnesia, person does not recognize relatives or friends but can talk, read, and maintained other kinds of previously acquired knowledge

4.    The amnesic episode may last several hours or as long as several years

5.    Usually disappears quickly and is unlikely to reoccur


II. Dissociative Fugue: memory loss associated with leaving home and forming a new  


1.    Memory loss is more extensive than in Dissociative Amnesia

2.   Fugues (flight) tend to occur after severe stress

3.   Recovery is usually complete although the person does nor recall events occurring during the episode of fugue


III. Depersonalization Disorder: experience of the self is altered

1.   Unlike other Dissociative Disorders, there is no memory loss

2.   It is typically triggered by stress

3.   The person suddenly loses their sense of self.

4.   They may have unusual sensory experiences such as a change in the size of their arms or legs or in their voice

5.   They may have the feeling that they are outside their bodies

6.   Usually begins in adolescence and tends to be chronic or long lasting

7.   Often comorbid with anxiety, depression, and personality disorders


IV. Dissociative Identity Disorder: at least two distinct ego states (alters) that act independently  

      of each other (formerly known as Multiple Personality Disorder)

1.   Example: celebrated case history of Chris Sizemore and three faces of Eve

2.   Requires that a person have at least two separate ego states, existing independent of each other that emerge and are in control at different times

3.   Gaps in memory are common and one alter (personality) may have no contact or memory of a second or third alter (personality)

4.    Each alter has its own memory and personality

5.   Different alters may have different handedness  (left or right), wear different prescription glasses, and have different allergies

6.   Sometimes mislabeled in popular press as schizophrenia although patients with DID do not show the thought disorder or behavioral disorganization typical of schizophrenia.


V. Controversy over Dissociative Identity Disorder (DID)

1.   Only one third of Board-Certified psychiatrists indicated that they have no reservations about the inclusion of DID in the DSM IV-R

2.    Earlier prevalence rates were thought to be one in a million – current prevalence rates, depending on the country, range from 0.4 (turkey) to 1.3 (Canada)

3.    The DSM  IV required that amnesia by one or more alters be present whereas the DSM III did not.

4.    Speculations are that celebrated case histories such as publicized in the movies Three Faces of Eve (1957) and Sybil (1973) resulted in a dramatic increase in the number of diagnosed cases


VI. Etiology of DID

1.   One problem with all explanations is that severe trauma usually enhances memory (as in PTSD) rather than leads to its repression

2.   Two major theories are:

(a) DID is a result of severe physical or sexual abuse

(b) DID is a learned social role enactment – alters appear in adulthood, typically due to suggestions by a therapist (not viewed as malingering or a conscious deception)

(c) A small number of clinicians contribute most of the diagnostic labels (fewer than 10% of psychiatrists)

3.   Typically, when DID cases enter therapy, they are unaware of their alters but the alters emerge during the process of therapy and the patients report that they began in childhood

4.  There are 11 cases of external documentation of severe abuse or even torture that occurred in the childhood of DID patients (support for the extreme stress in childhood theory)


VII. Therapy for DID

1.   Goal: integration of the personalities

2.   All alters treated by the therapist with fairness and empathy – no censorship of one and not the other

3.   Therapists encourages cooperation among the alter personalities

4.   Goal is to convince patient that splitting into different personalities is no longer necessary to deal with the traumas

5.   Follow up studies indicate that 103 (84%) of the original 123 patients achieved stable integration after a long term follow-up



I.  Pain Disorder: pain in which psychological factors play an important role in the onset,     

    severity, and maintenance of the pain

1.   Pain is not a simple sensory experience

2.   Accurate diagnosis is difficult

3.   Patients with physically based pain localize it more specifically, give more sensory detail, and can link it to situations that increase or decrease it than patients with a pain disorder in which there is presumed to be a psychological basis


II. Body Dysmorphic Disorder: an imagined or exaggerated defect in physical appearance

1.  Examples include wrinkles, size of the nose, etc.

2.   Some will compulsively check the feature in the mirror for hours whereas others will eliminate mirrors or attempt to camouflage the perceived defect

3.   Occurs mostly in women with an onset in adolescence

4.   Frequently comorbid with depression, social phobia, and personality disorders

5.   In one study, 70% of college students indicated at least some dissatisfaction with their appearance

6.   Unclear whether a specific diagnostic category is supported by the data – such behaviors as excessive preoccupation with appearance and frequent mirror checking could indicate OCD, or, perhaps, an eating disorder


III. Hypochondriasis: preoccupation with having a serious disease despite medical  

      evidence to the contrary

1.   Typically begins in early adulthood and has a chronic course

2.   Frequent contacts with physicians and often view them as uncaring and/or incompetent

3.   One theory is that such patients overreact to ordinary physical sensations and minor abnormalities

4.   Often make catastrophic interpretation of symptoms

5.   Hypochondriasis is not well differentiated from a Somatization Disorder


IV. Conversion Disorder: sensory or motor symptoms such as blindness or paralysis that     

      are generally without evidence of bodily impairment or neurological dysfunction

1.    May experience partial or complete paralysis of arms or legs, seizures, or anesthesias (insensitivity to pain or the loss or impairment of sensations)

2.   Aphonia: loss of voice – perhaps able to whisper

3.   Anosmia: loss or impairment of the sense of smell

4.   Hysteria: originally used to describe what are now called Conversion disorders. Hysteria is from the Greek word Hysteron which means womb or uterus. Hippocrates though that the symptoms of hysteria where caused by a wandering uterus or some form of uterus suffocation

5.   Conversion disorders frequently begin in adolescence and after a life stress

6.   Prevalence is less than 1% and is more common among women

7.   Important to distinguish between disorders which are associated with actual neurological pathways and therefore make sense as opposed to “glove” anesthesia

8.   Malingering: important to distinguish a conversion disorder from those which are under voluntary control and involve faking the symptoms. Conversion disoders are often associated with La Belle Indifference (apparent lack of concern or indifferent attitude toward the symptoms)

9.    Factitious Disorder: the person intentionally produces the physical symptoms – sometimes involving self-inflicted injury. The goal of the behavior is not as clear as the faking by a malingerer. In the Factitious disorder, the person for some unknown reason wants to assume the role of a patient

10.  Diagnostic problems: in one study, 60 percent of persons who had been

        diagnosed as having a conversion disorder nine years earlier, had either died or  

              developed symptoms of a disease with a high proportion have CNS diseases


VII. Somatization Disorder: Recurrent, multiple somatic complaints with no apparent  

       physical cause

1.   Diagnostic criteria are:

(a) Four pain symptoms in different locations

(b) Two gastrointestinal symptoms

(c) One sexual symptom – indifference, erectile failure

(d) One pseudoneurological symptom

2.   Symptoms are more pervasive than in hypochondiasis  and usually result in impairment of functioning and work

3.   More frequent in cultures that downplay the expression or display of emotions

4.   Comorbidity is high with anxiety, mood disorders, substance abuse, and personality disorders

5.   In one study, only a third of persons diagnosed with a somatization disorder, still met the criteria twelve months later – this suggests that the disorder is not as chronic or stable as implied by the DSM IV


VIII Causes of Somatoform Disorders (Somatization and Conversion Disorders)

1.   Behavioral view is that somatization disorders involve the manifestation of unrealistic anxiety in bodily systems The maladaptive pattern is reinforced by attention and providing excuses for avoiding work or other activities which are perceived as unpleasant

2.   Psychoanalytic Theory of Conversion Disorders: Conversion Disorders are extremely significant in the development of Psychoanalytic Theory. Freud suspected that conversion disorders in women involved an early, unresolved Electra Complex. If the parents responses to the child’s sexual feelings are harsh and disapproving, then the impulses are repressed and the person later becomes preoccupied with sex and avoidance of sex. Later sexual excitement awakens these repressed impulses and creates anxiety which is transformed into physical symptoms

3.   Research indicates that a dissociation between awareness and behavior has been reported in many perceptual and cognitive studies

4.  Sackeim, a psychodynamic theorist, hypnotized two susceptible participants, each given the suggestion of being totally blind. One was given instructions designed to highly motivate them in performing the task. It was found that the participant highly motivated to maintain “blindness” performed more poorly on a visual discrimination task than would be expected by chance whereas less motivated participants performed perfectly, even while reporting that they were blind. An example of a visual discrimination task is being able to identify which of three triangles is inverted when two are presented upright and one inverted. Results were interpreted to support the belief that hysterically blind clients who unconsciously need to deny receiving perceptual information will perform poorly on the discrimination task than those who do not need to deny having the information

5.   The psychodynamic theorists argue that verbal reports and behavior can be unconsciously separated from one another. In other words, hysterically blind individuals (conversion disorder) report that they cannot see yet they can be influenced by visual stimuli.

6.   Some Behavioral theorists simply view conversation disorder as malingering – they adopt the symptoms to secure some end – they will assume a disability if it can be expected ton reduce stress or result in positive consequences

7.   Social and cultural factors: conversion disorders are more common among persons from lower socioeconomic brackets and people from rural areas who presumably are less knowledgeable about medical and psychological information


VIII. Therapies for Somatoform Disorders

1.   The relative rarity of these disorders has resulted in less research about the effectiveness of therapy

2.   Case studies indicate that confrontation about the patient’s symptoms is not a productive approach

3.   Patients with Somatoform disorders already resent being referred to “Shrinks” because it is interpreted as meaning their disorders are psychological rather than physical in origin

4.   Therapists should be aware that these disorders are often comorbid with anxiety and depression and treatment of anxiety and depression can alleviate some of the physical complaints

5.   Reinforce a person for going to work and minimize reinforcers which tend to keep the person at home

6.   Research suggests that patients improve if physicians do not order expensive laboratory tests or medications and do not focus on disputing the physical basis for the complaint, but maintain contact with the patient regardless of whether he or she is complaining of the illness.

7.   Therapies for a pain disorder focus on validating if the pain is “real”, relaxation training, and rewarding behaviors inconsistent with the pain.






Unit II


CHAPTER 9:  Schizophrenia


LECTURE 12      Thursday, February 28, 2013


Text Assignment: pp. 252-286


Topic:  History of the Concept of Schizophrenia; Clinical Symptoms, Etiology and Treatment



I. Schizophrenia

    1.  Prevalence: slightly less than one percent

    2. Affects men and women equally

    3. Co-morbid substance abuse in about 50% of cases


II. Positive Symptoms (excesses and distortions: delusions and hallucinations)

1.      Delusions: marked distortions of reality – persecutory delusions occur in 65% of cases. Examples:

(a)    believing thoughts have been placed in your mind by external sources

(b)   believing thoughts are being transmitted or broadcast

(c)    believing thoughts have been stolen

(d)   believing feelings and behavior are controlled by external sources

2.      Hallucinations: sensory experience in absence of stimulation – 74% are auditory.   


(a)    Hearing your own thoughts spoken by someone else

(b)   Hearing voices arguing

(c)    Hearing voices comment on your behavior   


III. Negative Symptoms

  1. Avolition: lack of energy and or interest – failure to perform routine behaviors such as hygiene, persistence at work or school
  2. Alogia: impoverished content of speech
  3. Anhedonia: lack of interest in pleasurable activities, sex, and failure to develop close relationships
  4. Flat Affect: in about 66 % of cases – no overt emotional responses, although one study reports that although there was less facial expression among persons with schizophrenia, they reported emotions about the same as normal persons and were even more physiologically aroused
  5. Asociality: severe impairments in social relationships


IV. Disorganized Symptoms

  1. Disorganized speech: also known as a thought disorder – problems in organizing ideas and in speaking so a listener can understand. Incoherence and loose associations or derailment
  2. Bizarre Behavior: patients may show inexplicable rages or irritability, silly mannerisms, and sexually inappropriate behavior such as masturbating in public


V. Other Symptoms

     1. Catatonia: two forms

            (a) Catatonic immobility – maintaining unusual postures for very long periods of    


            (b) Catatonic Excitement: repeated gesturing , possible wild flailing of limbs,

                  increase in overall activity

2. Inappropriate Affect: e.g. laughing when a relative dies, becoming irrationally

    angry over seemingly irrelevant comments


VI. History of the Concept of Schizophrenia

  1. Emil Kraepelin: in 1898 presented his concept of Dementia Praecox (Dementia was used by Kraepelin to mean progressive intellectual deterioration; Praecox referred to early onset). Dementia Praecox included dementia paranoides, Catatonia, and Hebephrenia which had previously been regarded as separate entities.
  2. Eugin Bleuler: introduced the term Schizophrenia in 1908. Schizo was derived from the Greek word schizein which mean “to split” and phrenia from “phren” which meant mind. This lead to a popular distortion and an erroneous definition of schizophrenia as a “split personality”, which implied “multiple personality”. Bleuler introduced the concept of “breaking of associative threads” to explain disruption of thought, attention, and other cognitive processes


VII. The US Concept of Schizophrenia

1.      Initially, Schizophrenia was the diagnosis of about 20% of mental patients who were hospitalized in the 1930s

2.      The % diagnosed schizophrenic increased in thye 1940’s and by 1950 had reached 80% (in Europe the concept of schizophrenia remained relatively narrow - about 20%

3.      The broadened use in the US was due to the tendency to diagnose a person as schizophrenic if whenever there were delusions or hallucinations; to include in the diagnosis persons who would now be diagnosed as having a personality disorder, and to also include persons who had an acute onset and rapid recovery


VIII. The DSM IV diagnostic criteria for Schizophrenia

1.      The DSM IV narrowed the concept of schizophrenia considerably by:

(a)    presenting the criteria in explicit detail

(b)   excluding patients with mood disorders

(c)    requiring at least six months of the disturbance – at least one month involving an acute episode or active phase including at least two of the following: delusions, hallucinations, disorganized speech, catatonic behavior and negative symptoms.

(d)   Replacing what the DSM II considered milder forms with category of personality disorders

(e)    Differentiating between paranoid schizophrenia and a delusional disorder


IX. Categories of Schizophrenia in the DSM IV

  1. Disorganized Schizophrenia: Kraepelin’s “hebephrenic form of schizophrenia (sometimes referred to as silly schizophrenia) – characterized by incoherent speech, silliness or laughter, sometimes incontinence and complete neglect of personal hygiene and appearance
  2. Catatonic Schizophrenia: typically patients alternate between catatonic immobility and wild excitement – it is rare to see the catatonic form today, perhaps because of the relative success of drug therapy
  3. Paranoid Schizophrenia: a diagnosis frequently used for current admissions to mental hospitals – delusions of persecution are common but persons may experience grandiose delusions, delusional jealousy, and ideas of reference. Persons are often agitated, argumentative, angry, and sometimes violent. They also are more alert and verbal than patients diagnosed in other categories of schizophrenia– patients with this diagnosis often get into legal trouble
  4. Undifferentiated Schizophrenia: used when the criteria are not met for the other categories
  5. Residual Schizophrenia: when a person still shows signs of schizophrenia but no longer meets the full criteria for schizophrenia


X. The usefulness of the above subcategories of schizophrenia is questionable because of

     low diagnostic reliability and the fact that the subcategories do not help in treatment.



Etiology of Schizophrenia


I.  Genetics – Family Studies

        1.  Family studies: the risk increases as the genetic relationship between proband and 

             a relative become closer

2.      Patients who have schizophrenia in their family histories have more negative symptoms – there may be a stronger genetic factor involved in negative symptoms

3.      It is conceivable that the behavior of a parent with schizophrenia may create adjustment problems in children which could increase the risk for schizophrenia


II. Genetics – Twin Studies

1.      Concordance for identical twins (MZ) 44.3 % ass compared to a concordance for fraternal twins (DZ) of 12.08 %

2.      Concordance for identical twins increases when the proband is more severely ill

3.      A common deviant environment may account for a portion of the concordance rates

4.      A strong case for genetics involves the percentage of schizophrenia among the children of the non-schizophrenic twins ( 9.4%) compared to the percentage of schizophrenia among children born to the twins with schizophrenia (12.3%)


III. Genetics – Adoptions Studies (children of mothers with schizophrenia raised by

      adoptive parents)

1.      Heston (1966) followed 47 persons born between 1915 and 1945 who were adopted in infancy and whose mothers were diagnosed as having schizophrenia and were in a state mental hospital

2.      Thirty-one of the forty-seven children (66%) of mothers with schizophrenia were given a DSM diagnosis whereas only nine of the fifty controls ((18%) received a DSM diagnosis. None of the controls were diagnosed as having schizophrenia whereas five of the children (16.6%) of persons whose mothers had schizophrenia were diagnosed as having schizophrenia


IV Genetics - Conclusions

1.      Genetics do not completely determine schizophrenia, but is certainly a strong factor

2.      The nature of the inherited diathesis remains unknown


Biochemical Factors


I.   Dopamine Theory:

     1. Basic assumption is that Schizophrenia is caused by excess Dopamine activity

     2. Treating Schizophrenia with the phenothiazines may lead to Parkinson’s symptoms   

          (tremor, etc.). Parkinson’s symptoms are associated with decreased Dopamine


3.      Amphetamine psychosis has symptoms similar to schizophrenia. Amphetamines cause increases in norepinephrine and dopamine. Antipsychotics are also effective in treating amphetamine psychosis

4.      Later research reported that the major metabolite in dopamine was not found in excess among persons with schizophrenia. This led to a proposal that rather than excess dopamine, there may be an increase in dopamine receptors or an oversensitivity of dopamine receptors leading to an increase in dopamine activity

5.      Excess dopamine receptors appear to be related primarily to positive symptoms (e.g. delusions, hallucinations)

6.      Amphetamines worsen positive symptoms and lessen negative ones and antipsychotic medication lessens positive symptoms but have no effect on negative symptoms

7.     Conclusions regarding the biochemical data are limited as they pertain to dopamine.  Biochemical theorists are now considering a broader explanation which might involve a greater focus on Glutamate and serotonin



I. Schizophrenia and Brain Studies

      1.  A consistent finding has been that the ventricles are enlarged in schizophrenics


      2.  MRI studies have shown reductions in gray matter of the prefrontal cortex

      3.  Glucose metabolism studies of the frontal cortex  indicate that patients with

           schizophrenia do poorer on neuropsych tests and fail to show activation in the  

           prefrontal region

      4.  Possible causes of brain abnormalities could be damage occurring during gestation

           or at birth, possibly resulting from a virus or complications associated with


5.      It appears unlikely that a cause of schizophrenia would be a specific lesion in a

      localized area of the brain


II.   Psychological Stress

  1. Social Class: the highest rates of schizophrenia are found in urban areas  primarily

populated by low socioeconomic classes

  1. Sociogenic Hypothesis: stressors caused by the socioeconomic conditions cause schizophrenia
  2. Social-selection Theory: patients with schizophrenia gravitate downwardly to the lower class – supported by studies showing that the fathers of schizophrenic patients are mostly from the middle class
  3. Generally, the data are more in support of the Social-selection theory than the Sociogenic theory


III.  The Family and Schizophrenia:

1.      Shizophrengenic Mother hypothesis: mothers are thought to be cold, dominant,

conflict-inducing parents. There has been little or no support for the concept of the Shizophrengenic Mother hypothesis

2.      Expressed Emotion (EE); the belief that parents who are excessively critical and

make negative, critical comments, exacerbate problems with schizophrenia

3.      There is some evidence that parents high on Expressed Emotion (EE) have  

      schizophrenic offspring that are more likely to have relapses requiring     


4.      The causal direction is not clear – e.g. do high EE families cause more problems,

or does the stress of having a schizophrenic offspring lead parents to be more   

            critical and negative?


IV. Developmental Studies

  1. Some research indicates that children who develop schizophrenia have lower IQs
  2. Teachers described pre-schizophrenic boys as disagreeable and described both boys and girls as delinquent and withdrawn
  3. High risk studies by Mednick of males with mothers diagnosed as schizophrenic, indicate that 15 of 207 high risk children as compared to none of the 104 control children developed schizophrenia
  4. Negative symptoms of schizophrenia were predicted by a history of complications during pregnancy and delivery as well as a failure top show electrodermal responses to simple stimuli.
  5. Positive symptoms were predicted by a history of family instabilit


Treatment of Schizophrenia



Therapies for Schizophrenia


I. General Considerations

       1.  Hospital stay has little effect on enduring problems – re-hospitalization rates of 40

             to 50 % occur in the first year after discharge  and 75% after two years

2.   It is very difficult to get some cases to undergo treatment especially in

             paranoid schizophrenia

3.      Patients in the midst of an acutely psychotic phase are not going to be amenable

      to psychological interventions – they are not in sufficient touch with reality to



II. Biological Treatments

1.      Insulin therapy (Sakel) 1938: risk involved irreversible coma and death

2.      Prefrontal lobotomy: Moniz (1935): destroys the connecting fibers between the frontal lobes and lower centers of the brain

3.      Transorbital leucotomy: essentially the same clinical effects as a prefrontal lobotomy. Involves inserting a leucotome over the eye and through the soft orbital bone and cutting the connecting fibers beneath the frontal lobes. Procedure was sometimes done in the office

4.      Lobotomies were discontinued in 1959 after the introduction of the phenothiazines

5.      Phenothiazines: a derivative of antihistomines. Chlorpromazine (Thorazine) was introduced in the US in 1954. By 1970, 85% of all patients in mental hospitals were receiving this form of drug therapy

6.      The early antipsychotics affected positive symptoms of schizophrenia but not the negative ones.

7.      About 50% of patients quit taking them in the first year and up to 75% quit after two years

8.      Extrapyramidal side effects: similar to symptoms of Parkinson’s Disease – trembling, shuffling gait, drooling - even treated with anti-Parkinson drugs

9.      Other side effects were dizziness, blurred vision, restlessness, and sexual dysfunction

10.  Tardive Dyskinesia: lip smacking, chin wagging, involuntary sucking

11.  Neuroleptic malignant Syndrome: 1% - severe muscle rigidity, blood pressure increases, heart races, fever. Sometimes coma and death


III. Newer Drug Therapies

1.      Clozapine (Clozaril): generally produces greater therapeutic gains than the traditional antipsychotics

2.      Clozapine does have significant side effects: it can impair the functions of the immune system resulting in increased risk of infections. Also may produce dizziness, fatigue, drooling, and weight gain

3.      Two newer drugs are olanzapine (Zeprexa) and risperidone (Risperdal), both f which have fewer motor side effects than the traditional anti-psychotic drugs

4.      Risperidone improves short term memory and, as a result, appears to have a  positive effect on social skills


IV. Psychological Treatments

  1. Generally, Freud concerned himself with relatively healthy “neurotics” who could respond to analysis
  2. Harry Stack Sullivan  in the early 1920s proposed that schizophrenia involved regression to early childhood in regard to modes of communication. He proposed that the therapist must establish a very gradual, non threatening relationship then, after many sessions, encourage the patient to explore interpersonal relationships.
  3. Frieda Fromn-Reichmann proposed a model similar to Sullivan’s with an emphasis on patience and optimism
  4. There is virtually no evidence that psychoanalytic treatments are successful  and may contribute to the confusion of an already confused patient
  5. Newer approaches involve a more active, direct approach to help patients deal with everyday problems and cope with the limitations imposed by their illness. One focus is in dealing with daily social challenges


V. Social Skills Training

1.    Social skills training basically involves teaching people with schizophrenia how  

            to succeed in a variety of very specific social situations

2.   Techniques fort teaching these skills involves role-playing, modeling, and the use  

      of  positive reinforcement

  1. Social Skills training is now an important part of  of many treatmewnt programs


VI. Family Therapy and Expressed Emotion (EE)

1.      Families of persons with schizophrenia tend to be high on Expressed Emotion – they are more likely to be hostile, hypercritical, and overprotective

2.      Treatment approaches focus on the family, primarily in terms of providing information and educating families about schizophrenia

3.      The focus of education is on           the biological basis that predisposes one to schizophrenia, the importance of compliance with treatment – particularly taking medication as prescribed, avoiding blaming, encouraging social contacts – especially those involving support networks, and instilling a degree of optimism that things can improve


VII. Cognitive-Behavioral Therapy

1.      Personal Therapy: Hogarty used a broad-spectrum cognitive-behavioral approach. The emphasis is on teaching internal coping skills and new ways of controlling his or her affective reactions

2.      Personal Therapy also includes some rational-emotive behavior therapy to deal with daily frustrations

3.      There is a strong emphasis on teaching specific social skills and the importance of medication compliance

4.      Non-behavioral elements of Personal Therapy involve a warm and empathic acceptance of the patients turmoil and conveying a sense of optimism


VIII. Reattribution Theory

1.      For example, a patient believed that pressure points on his forehead were the result of outside forces. He was eventually taught, via muscle relaxation that the pressure points could be controlled – after which, he ceased to attribute them to outside forces

2.      The above approach, however is not likely to work with many schizophrenic patients, however, because of limitations on cognitive skills or to deal rationally

with their problems.


IX. Basic Cognitive functions – recent attempts have focused on normalizing

       fundamental cognitive functions such as attention and memory


X. Trends in Treatment

     1. Case managers: in view of the decrease in hospitalizations, the focus has been on

         managing in a structured way, the patient’s outpatient functions. To do this NIMH 

         established a grant program to develop specialties in case management

2. Family oriented treatment approaches are becoming increasingly recognized as a 

          necessary addition to drug therapy in order tro reduce relapses and  


  1. Post hospital treatment programs are likely to receive increased emphasis in the future

















LECTURE 13: Thursday, March 7, 2013




Lecture Topic: Substance Use Disorders: Kinds of Drugs


DSM V Drug Use Disorders versus DSM IV Drug Abuse and Dependence Terminology     


I.   General Terms

     1. Substance Dependence: taking more than intended, unsuccessful attempts to stop,

         physical and psychological problems, problems at work and socially. A primary

         feature is physiological dependence (addiction)

     2. Withdrawal Symptoms: negative physiological and psychological effects

          Associated with stopping use of the substance abruptly

3.      Tolerance: requires increasingly larger doses of a substance to produce an effect

4.      Dependence typically involves both tolerance and withdrawal symptoms with disuse

5.      Substance Abuse: use is associated with problems which may affect work,

relationships, and cause legal problems – not to be confused with dependence or addiction


DSM V Criticisms of "Substance or Drug Dependence" as used by the DSM IV: many prescription drugs involve, tolerance, dependence, and withdrawal





I. Alcohol Dependence

1.      Alcoholic or alcoholism: no precise meaning – does not distinguish between different patterns of excess

2.      Alcohol Dependence: usually involves both tolerance and withdrawal symptoms.

3.      Withdrawal: person becomes anxious, depressed, weak, restless, and experiences sleep difficulties

4.      Delirium Tremens (DTs): usually follows very heavy drinking for a number of years. Person becomes tremulous, visual hallucinations, tactile hallucinations such as biting insects or other vermin

5.      Tolerance: some persons may consume a quart of hard liquor a day without being obviously drunk – may even show low levels of blood alcohol

6.      Blackouts: typically increase with long term dependence but may occur after one night of intoxication

7.      Often, alcohol dependence is associated with poly-drug abuse


II. Alcohol Abuse

1.      Abuse typically does not involve tolerance or withdrawal as does dependence

2.      80 to 85% of abusers smoke


III. Prevalence

  1. Prevalence over the lifetime: 20% for men and slightly under 8% for women
  2. Prevalence declines with age – either dying or stopping
  3. Binge Drinking = 5 drinks in a short time, e.g. one hour
  4. Women more likely to develop health conseqiuences even though men drink more


IV. College , Age, Ethnic, and Gender Differences in Alcohol Abuse/Dependence

         1.  Fraternities and Sororities tend to have higher rates of drinking

         2.  However after college, members of fraternities and sororities do not have a    

             higher rate of abuse or dependence

3.      White adolescents and adults are more likely to abuse alcohol than African Americans

4.      Abuse and dependency is highest for ages 18 to 29

5.      Native American youth have higher rates of abuse than other groups. Alcohol is associated with 40% of the deaths among Native Americans and almost all crimes. In some tribes, over 50% abstain completely from alcohol use


V. Course of Alcohol Abuse and Dependence

1.      In 1952, Jellinek proposed four stages of progressive alcohol involvement which resulted in an inevitable decline, often until death

2.      Jellinek’s notions are still widely cited despite data to the contrary

3.      Of persons who abuse alcohol, only 3.5% develop dependency 5 years later

4.      The 3.5% differs little from the 2.5% of the population who develop dependency during the same five-year period

5.      Over one third of persons classified as dependent and over 50% classified as abusers fail to show alcohol problems one to five years later

6.      Generally, women’s problems progress quicker than men’s. More women tend to drink alone. However, women seek treatment sooner than men


VI.   Health and Social Costs

1.      The suicide rate is much higher among alcohol abusers

2.      A large proportion of new admissions to mental and general hospitals involve drinking problems, although the person usually is not seeking help for that reason

3.      Alcohol continues to be a major factor in traffic deaths with 4 out of every 10 fatalities being alcohol related. However, there has been a substantial decline in alcohol related fatalities in the last decade (from 22,000 in 1994 to 15,000 in 1999

4.      About one half of murders, rapes, and assaults are alcohol related


VII. Short Term Effects of Alcohol

1.      The concentration of alcohol in the bloodstream varies withy a number of factors: the amount of food in the stomach, size of the individual, efficiency of liver function, and gender (women reach higher blood alcohol concentrations sooner than men)

2.      The short term effects on behavior are strongly influenced by the drinker’s expectancy. For example, research indicates that person’s who are led to believe that they are consuming large amounts of alcohol when given alcohol free drinks, become more aggressive and report a greater degree of sexual arousal

3.      Persons who consume alcohol report greater degrees of sexual arousal although alcohol actually depresses physiological arousal


VIII.  Long Term Effects of Alcohol

1.      Long term chronic drinking affects almost all physiological systems: the liver, the heart, the brain, gastrointestinal functions are prominent

2.      Malnutrition: consumption of one pint of eighty proof alcohol is equal to about one half of a day’s caloric requirements

3.      Alcohol in excess impairs digestion of foods and the absorption of vitamins – particularly the B-complex, a deficiency of which is associated with an amnestic syndrome

4.      Cirrhosis of the liver (seventh leading cause of death in the US) – women develop cirrhosis and neurological impairment over a shorter period of time than men

5.      Korsakoff’s Psychosis and Wernicke’s Syndrome: Koraskoff’s Psychosis is associated with a shortage of water-soluble vitamins, especially thiamine. Confusion, amnesia, and disorientation are primary features. Wernicke’s Syndrome involves sudden paralysis of muscles controlling eye movements, an inability to maintain balance when walking (ataxia), disturbances in consciousness, amnesia and disorientation with respect to time and place.

6.      Fetal Alcohol Syndrome: growth of the fetus is slowed and there are cranial, facial, and limb abnormalities – these effects, although less severe, can be produced by even moderate drinking during pregnancy

7.      Light drinking – fewer than three drinks a day – particularly red wine - is associated with a decreased risk of coronary heart disease and stroke


Nicotine and Cigarette Smoking


I.   Nicotine

      1. Stimulates nicotine receptors in the brain and activates neural pathways which

           stimulate the mesolimbic area which is a reinforcement system for most drugs


II. Health Consequences of smoking

  1. An estimated 430,000 Americans die prematurely each year from smoking related causes
  2. One out of six deaths is smoking related
  3. Lung cancer kills more Americans than any other form of cancer – 87% of lung cancers are caused by smoking
  4. Other disorders include cancer of the larynx, esophagus, emphysema
  5. If a person quits, the health risk declines remarkably over the next 5 to 10 years
  6. Health risk for quitters after 5 tom10 years is only slightly greater than non-smokers


III. Results of Forty years of Federal Anti-smoking Campaign

  1. Prevalence from 1965 to 1997 decreased from 40% to 25%
  2. Fifty seven million Americans still smoke
  3. Rates in teenagers have increased since 1992 and are now comparable to rates in1977
  4. Beginning in 1995, rates among college students increased but leveled off in 1999
  5. In 1999, 35% of high schools students smoked at least once during the past 30 days – up 28% since 1991
  6. In 1999, 17% of high school students were frequent smokers – an increase of 13% since 1991


IV. Prevalence: Ethnic and Gender Differences

  1. Prevalence among White and Hispanic youths and adults higher than among African Americans
  2. Prevalence remains highest among Native Americans, blue collar workers, and the less educated. Prevalence is lowest among college graduates and persons over 75
  3. Prevalence has declined less among women than men
  4. Of 1,000 children and adolescents who smoke daily, an estimated 750 will die prematurely from smoking related  causes
  5. African Americans are less likely to quit smoking than Whites and are more likely to die from lung cancer
  6. African Americans retain nicotine in the blood stream longer than whites, take more puffs and inhale more deeply – perhaps because more Blacks prefer mentholated cigarettes which may be cooler to inhale
  7. African Americans are more likely than whites to die from smoking related heart and lung problems than Whites
  8. Asians metabolize less nicotine than             Whites or Latinos and have lower lung cancer rates
  9. Men who smoked have greater erectile problems – perhaps, because smoking constricts the blood vessels


V. Second Hand Smoke

      1.  Environmental tobacco smoked (ETS) contains higher concentrations of ammonia,

           carbon monoxide, nicotine, and tar than smoke actually inhaled by smokers

  1. The Environmental Protection Agency (EPA) classifies second hand smoke as

      equally hazardous as Asbestos and Radon

  1. Babies of smoking women are more likely to be born premature, have lower birth weights, and more birth defects that babies of non-smoking women
  2. Children of smokers are more likely to have upper respiratory infections,

       bronchitis, and inner ear infections




I.  General Findings and Information

     1.  Became illegal to sell in the US in 1937

     2.  Six percent of high school seniors smoked daily in 2000

     3.  Active ingredient is Tetrahydrocannabinol (THC)

     4.      Recent research supports early speculations regarding some cognitive impairment,   impaired memory, but not impairment of general intellectual abilities


II. General effects on body

1.      Blood shot eyes

2.      Dry mouth

3.      Increased appetite

4.      Contains some of the same harmful agents as tobacco such as carbonmonoxide and tar

5.      Two cannaboid brain receptors have been identified (CB 1 and CB 2) in the hippocampus region – probably accounts for memory disturbances

6.      Tolerance does occur but dependence (addiction) is still in question

7.      Understanding tolerance is complicated by the fact that there is sensitization to marijuana with repeated use that results that results in an immediate effect for users (after a few hits) but not for first time users. Tolerance usually means that you must increase the amount to get the same effect which is true for marijuana but users  have a more immediate response to the drug


III. Therapeutic Effects

  1. May reduce nausea following chemotherapy
  2. Has analgesic effects (reduces pain)
  3. However, it does suppress the immune system, so it is questionable as a treatment for AIDS
  4. Eight states have laws which permit doctor prescriptions for nausea and pain, however, the legal status of these laws remains in question after a Supreme Court decision

Sedatives (Downers)


I.  Opiates: Opium, Morphine, and Heroin

     1. Opium is the extract from the Poppy plant and has been in use thousands of years

     2. Morphine is an alkaloid which was separated from raw opium in 1806 and was

          frequently used to treat pain during the Civil war, often resulting in addiction

     3.  Heroin was a refinement of heroin in 1874 which, initially, was used as a treatment

          for morpheme dependence and was later used in cough syrup and various patented


     4.  Currently, pain relieving drugs which have a similar effect as heroin are 

          Hydrocodone and Oxycodone (Percodan) are

    frequently abused


II. Prevalence

1.      More than a million heroin addicts in the US

2.      Dependence is higher among physicians and nurses than among persons with comparable educational backgrounds

3.      New users of heroin have increased steadily since 1992

4.      From 1990 to 1997, hydrocodone abuse increased by 173 % and abuse of oxycodone increased by 43%


III. Psychological and Physical Effects

1.      Opiates have their effect by stimulating the neural receptors of the body’s own opoid system

2.      Similar effects are produced by endorphins following extreme exercise or stress (exercise to the point of endorphin release is not a good thing – should be regarding as the body’s early warning system of excess – example:  26 mile marathons do not represent moderate, healthy forms of exercise

3.      When heroin dependent users stop using the drug for eight hours, withdrawal reactions usually begin: muscle pain, sneezing, sweats, symptoms that resemble the flu – progressing to inability to sleep, vomiting, and diarrhea persisting up to 72 hours

4.      A follow-up study of 500 heroin addicts indicated that 28% died before age 40 – half of which were from suicides, homicides or accidents. About 1/3 died from overdose


IV. Synthetic Sedatives (the Barbiturates)

1.      The first barbiturate was produced in 1903

2.      Current, frequently abusedderivatives of barbituric acid are the Benzodiazepines (sometimes referred to as the “minor” tranquilizers to distinguish them from the Phenothiazines (Thorazine), which are considered “major” tranquilizers. The most frequent is probably Valium, which is commonly used as a tranquilizer and as a drug to alleviate alcohol withdrawal symptoms (the barbiturates are cross-tolerant with alcohol)

3.      The Barbiturates are frequently a choice for overdose in suicide attempts

4.      Ketamine: an anesthetic used as both a human and other animal anesthetic




I. Amphetamines

        1.  Resulted from efforts to produce a synthetic form of ephedrine.

        2.  The first amphetamine was Benzedrine which was synthesized in 1927

        3. First used bas an inhalant, then when its stimulating effects were documented, it

            was used to treat mild depression and as an appetite suppressant

        4. Amphetamines such as Benzedrine, Dexedrine, and Methedrine produce their

            effects by causing a release of norepinephrine and dopamine and blocking their


5.      Tolerance develops rapidly and dependence frequently follows

6.      Results are paranoid ideation, and, if tolerance develops, euphoric activity and sleeplessness may occur for a few days followed by a “crash”. After several cycles, paranoia, extreme irritability and hostility typically occur. The person may be a danger to themselves and others


II. Methamphetamines

1.      A derivative of amphetamine – 4.7 million persons in the Us have tried it at least once

2.      Currently, widespread use in the Midwest and in the Southwest

3.      In crystal form it is called “crystal meth” or “ice”

4.      Craving for the drug is powerful and may last for years after stopping its use

5.      Damage to the brain is possible as indicated by research with other animals

6.      When supplies of ephedrine became low, pseudoephedrine, a common over the counter decongestant, became a popular substitute for illegal manufacturing of Meth

7.      The Iowa House and Senate, in mid March of 2005, passed the nation’s most restrictive laws related to the acquisition of pseudoephedrine – the Governor has indicated he will sign the bill


III.  Cocaine

1.      Extracted from the leaves of the Coca plant in the mid 1800’s and has since been used as a local anesthetic

2.      Was an ingredient in the first Coca Colas bottled in Mississippi -  the stimulating effect of the new Coca Colas no doubt contributed to its early popularity

3.      Freud used cocaine to combat depression and enthusiastically endorsed its use  by others. He became disillusioned in the drug after recommending it to a physician friend then having to stay up all night with him after he had a psychotic reaction

4.      Results of the drug are a quick euphoric state, heightened arousal and typically heightened sexual pleasure. Continued use results in paranoid ideation, cognitive impairment, increased risk of stroke, and interference with the blood supply to a developing fetus (cocaine is a strong vasoconstrictant).

5.      Freebasing: heating cocaine with ether and smoking it with a water pipe

6.      Richard Pryor was badly burned in a fire resulting from freebasing

7.      There were rumors that freebasing may have caused the plane crash in which Ricky Nelson died.

8.      In the mid 1980’s a new form of freebase called crack was discovered and became a frequently abused drug because of its low cost and availability


IV. LSD and other Hallucinogens

1.      d-lysegic acid diethylamide (LSD) was first synthesized in 1938

2.      Because LSD produced psychotic like effects it was called a psychomimetic. Later the term psychedelic was introduced. Finally, the drug is referred to as an hallucinogen

3.      LSD Hallucinations are typically visual (as opposed to a predominance of auditory hallucinations in schizophrenia) and the user of LSD is aware that the drug produces the hallucinations

4.      LSD Flashbacks: reoccurrence of psychedelic experience after the physiological effects of LSD have worn off  - may occur weeks or months later (occurs in15 to 30% of users)

5.      Other Hallucinogens: Mescaline (from the Peote Catus); Psilocybin (from the Psilocybe Mexicana Mushroom); Synthetic compounds – methylenedioxymethamphetamine (MDMA) and methylenedioxyamphetamine (MDA)

6.      At Harvard in 1960, Timothy Leary and Richard Alpert gave psilocybin to prisoners for research purposes and reported that they were less likely to be rearrested. The investigators also took trip which led to a scandal and their dismissal from Harvard in 1962

7.      Hallucinogens were banned by congress in 1966

8.      Tolerance appears to develop with LSD but no discernible withdrawal symptoms

9.      Prolonged use may damage serotonin axons and nerve terminals – which may account for memory impairment

10.  Ecstasy:  includes both MDA and MDMA and is chemically similar to mescaline and amphetamines – it is the psychoactive agent in nutmeg. Prevalence rates are 8%, for High School, 9% for College students, and 7% for young adults


V. Phencyclidine (PCP) Also called “Angel Dust”

         1.  Developed as a tranquilizer for horses and other large animals

         2.  Can cause severe paranoia and violence

         3.   Reports from law enforcement officers suggest that, occasionally, PCP users

               seem to be unstoppable – even when shot several times. While this is a  

               frequently reported problem associated with arrests of users, it is not well









LECTURE 14: Tuesday, March 12, 2013




Lecture Topic: Etiology Treatment of Substance Use Disorders


1. Socio-cultural Variables and Substance Use

      1.  Ready availability: if a drug is readily available, it is more likely to be used. Some

           data, for example, indicates that bartenders and liquor store owners have higher

           rates of alcohol abuse

  1. Family Influences: if both parents smoke, children are 4 times as likely to smoke; if  parents drink, children more likely to drink
  2. Social milieu: friends’ behavior is an established influence, particularly in adolescence
  3. Media: Before 1988, less than 0.5% of 7th thru 12th graders preferred Camel cigarettes. After Joe Camel campaign, the % increased to 33% by 1991. (Incidentally, John Watson was supposedly the author of “I’d walk a mile for a Camel”)


II. Psychological Variables

1.      Mood alteration: results are somewhat mixed for alcohol and cigarettes as tension reducers

2.      Alcohol myopia: while persons are drinking, cognitive processes narrow as does attention

3.      Some persons drink when they are depressed and become even more depressed

4.      Research indicates that life stresses are associated with more relapses among alcohol abusers

5.      One study involved comparisons of the following sequences: stress then alcohol vs alcohol then stress. Findings were that tension reduction occurred only in the alcohol then stress sequence

6.      In women, alcohol consumption predicted later reductions in health and financial stress, and reductions in health stress for men

7.      Conclusion: Alcohol may be a potent tension reducer in many life situations when it is consumed after the stress has occurred


III. Does alcohol help you Unwind?

1.      People who expect alcohol to reduce stress are more likely to be frequent users

2.      The expectation that drinking will decrease anxiety increases drinking, which makes positive expectancies even stronger

3.      Alcohol may be particularly reinforcing for persons with anxiety problems

4.      Tension reduction is only one motive for drinking – others drink to reduce negative affect, others because they are bored or under aroused

5.      Although no research is cited, sexual motives are potentially a strong motive for drinking in adolescence (my inference – no supporting data in text)


IV. Beliefs and Expectancies

1.      Beliefs that a drug is harmful are associated with a reduction in the prevalence of its use

2.      Alcohol and tobacco use increase if persons overestimate the frequency of its use

3.      Whites report less perceived harmful risk of tobacco than do African Americans – use is higher among whites


V. Personality and Drug Use

        1.  Drug use is partly predicted by high levels of negative affect and an enduring

             desire for arousal leading to increased positive affect

2.      High anxiety predicts later alcohol abuse

3.      Depression depicts later cigarette use

4.      Antisocial personality – higher drug use associated with low arousal and thrill seeking

5.      ADHD in childhood (highly correlated with later antisocial behavior) is related to later alcohol abuse, tobacco and cannabis use, and cocaine abuse


VI. Biological Variables (Men)

1.      Genetic evidence: animals can be bred for alcohol preference, alcohol use and

      abuse by males tends to run in families, and twin research supports a genetic

               influence in males

2.      Tolerance: Asians have lower tolerance for alcohol and less abuse problems

3.      Tolerance: Alcohol abuse is more likely to occur among males who have high tolerance

4.      Sons of alcohol abusers experience fewer of the negative depressing effects of alcohol

5.      Conclusion: genetically predisposed men receive more reinforcement and less punishment for excessive drinking


VII.  Biological Variables (Women)

1.      There is less evidence of a genetic factor for alcohol abuse among women than for men

2.      However, recent studies on women indicate that a low levels of intoxication  and body sway after drinking may distinguish women with a positive family history for alcohol dependence


VIII. Specific Genes and Smoking Behavior

1.      Preliminary data indicates that there may be persons who have a particular gene which results in less reinforcement from nicotine use that makes it less likely that they will smoke and more likely that it will be easier to quit if they start




I. Admitting to the Problem

1.      Most abusers and dependent persons will deny any excessive use

2.      The text suggests a series of indirect questions (p. 389) designed to illicit more accurate information – however, a reasonably bright person would probably know the purpose of such questions and would probably persist in a pattern of denial

3.      Despite difficulties in getting a person to admit to a problem, it is viewed as a fundamental beginning point for suggesting treatment


II. Hospital Treatment

  1. Detoxification may take as long as one month
  2. Tranquilizers such as Librium or Valium may be used to ease the symptoms of withdrawal
  3. Another approach is not to use drugs which have the potential for abuse but to have the patient taper off alcohol consumption
  4. Dependent persons undergoing withdrawal may also need carbohydrate solutions, B vitamins, and possibly anticonvulsants
  5. In general, repeated detoxification hospitalizations are associated with a poorer treatment outcome
  6. In the last decade there has been a sizable increase in the number of for profit hospitals that specialize in inpatient treatme4nt for substance abuse
  7. The long range therapeutic effectiveness of hospital treatment is questionable – inpatient treatment has not be shown to be superior to outpatient treatment
  8. Short term hospital stays (less than eight days) appear to be as effective as longer stays
  9. For some patients who have minimal social support, hospitalization may be necessary to remove them from situations that might serve as a stimulus to resume drinking.


III. Biological Treatments

1.      Disulfiram (antibuse) must be taken every morning as prescribed. If patients drink while on antibuse, they become violently ill – vomit and other strongly negative effects. Eighty Percent of patients on antibuse drop out of treatment. Serious side effects such as inflammation of nerve tissue can occur

2.      Opiate antagonists such as Naltrexone and Naloxone have been used with mixed results. Both drugs block the activity of endorphins that are stimulated by alcohol and presumably reduce craving for the drug

3.      Buspirone: appears to have some value in reducing withdrawal effects

4.      Acamprosate (Campral) has been used extensively in Europe  and is currently under review by the FDA. Initial research is promising

5.      Other approaches may involve attempts to reduce symptoms which may contribute to the abuse – such as using antidepressants to treat depressive symptoms

6.      Biological approaches have to take into consideration possible impaired liver functions which can adversely effect metabolism of a drug or contribute to further impairment


IV Alcoholic Anonymous

1.      Largest self help group in the world – over 70,000 chapters and two million members

2.      Newcomers rise and announce that they are alcoholics (which tends to identify the person with the disorder such as calling a person with schizophrenia a “schizophrenic”)

3.      Seventy percent of Americans who have been treated for alcohol abuse have attended at least one AA session

4.      Programs for other forms of drug abuse have been modeledaft6er AA (for example: Cocaine Anonymous and Marijuana Anonymous)

5.      Core beliefs of AA are: that alcoholism is an incurable disease and even one drink can lead to a pattern of uncontrollable drinking and that there is a significant spiritual component as outlined in the 12 steps (AA is very close to being a religion)

6.      Related groups include Alanon for family members and Alateen for Children

7.      A group which makes no religious assumptions is called Rational Recovery – the focus is on self reliance rather than on higher powers. Many of the tenets of Rational Recovery resemble Albert Ellis’s Rational Emotive Therapy (RET)

8.      The long term effects of AA are difficult to assess. The drop out rate is high and many of the dropouts may not be considered in outcome studies.  Results of one carefully conducted long term study are mixed.

9.      Persons who choose AA and stay with it for greater than three months appear to remain abstinent – at least for a few years


V. Couples and Family Therapy

1.      Alcohol abusers often physically or sexually abuse other family members and family conflicts are strong

2.      These kinds of conflicts have led to a focus on Couples or Family Therapy approaches

3.      Behaviorally oriented couples and family approaches tend to have gains maintained for at least a year


VI. Cognitive/Behavioral Approaches

1.      Aversion therapy: person is shocked on made to feel nauseous when starting to drink or reaching for a drink. Covert Sensitization involves having the person imagine that they are violently ill or disgustingly sick by his or her drinking. The effectiveness of these techniques are questionable and they often cause great discomfort

2.      Contingency Management and Community Reinforcement (Operant Approaches): focus is on the complete environment and control by contingencies. Patients may receive training on job hunting and social skills, couples therapy is also used, the person might win prizes for sobriety or receive benefits in the form of a partial reduction in housing and food costs. There is also a focus on stimulus control – efforts to narrow the behavior of drinking to certain drinks and situations. For example, a person may be taught to sip (not gulp) only mixed drinks in certain social situations – thuds, narrowing the stimuli for drinking. Nathan Azrin is a prominent behavioral therapist who was one of the first to use operant techniques in the control of problem behaviors

3.      The problem is getting the drinker to abide by the restrictions and conditions and to maintain this form of self-control without constant external supervision


VII. Moderation in Drinking

1.      While AA emphasizes only abstinence, the approach my Mark and Linda Sobell focuses on moderation as a primary goal

2.      Patients are taught to avoid the extremes of both inebriation and abstinence.

3.      Initial techniques may involve shocks for choosing straight liquor rather than mixed drinks and shocks for gulping rather than sipping

4.      Patients may watch videotapes of themselves when inebriated and try to identify how to best maintain self control

5.      They are encouraged to exercise and maintain a healthy diet

6.      Relapses are regarded as learning experiences rather than losing the battle

7.      Recent focus by the Sobells is on Guided Self-Change – emphasizing personal responsibility and control.

8.      One self-help group is called Moderation Management. Persons may be required to have a period of abstinence before they are involved in controlled drinking programs

9.      Controlled Drinking as a treatment approach is much more popular in Canada and Europe than the US

10.  The Sobells have been strongly criticized by AA proponents and their success have been ignored or minimized


VIII. Clinical Considerations

1.      False assumption by those involved in treatment that people abuse alcohol for the same reasons

2.      Depression is co-morbid with alcohol abuse and the suicide risk must be evaluated

3.      Different approaches may be appropriate for different individuals – the importance of Client-Treatment Matching or Aptitude- Treatment Interaction (ATI) This is ignored by groups who espouse only one way such as AA

4.      There is often little focus on the fact that alcohol abusers are often poly-drug abusers. It is estimated that up to 90% of alcohol abusers are addicted to cigarettes

5.      No more than 10 % of persons with drinking problems are ever in treatment

6.      Forty percent apparently cure themselves

7.      How does non-treatment recovery occur? Possibly a new marriage, new job, religious experience, jarring experience related to alcohol abuse such as loss of a job or a near fatal accident

8.      More research needs to be done with former abusers or persons who were dependent who never received treatment but overcame their drinking problems


Therapy for Illicit Drugs


I. Biological Treatments

1.      Heroin Substitutes: similar drugs to heroin that will reducer the craving (such as Methadone)

2.      Heroin Antagonists: drugs which prevent the experiencing of a high should a person later use heroin (e.g. Naloxone)

3.      Methadone as a Heroin Substitute: person goes to a drug clinic daily and takes methadone orally in presence of staff. If a person goes of Methadone, withdrawal is not as severe. If they are maintained on methadone there are the following advantages: no diseases such as AIDS which may result from shared needles, less risky sexual behavior, reduction in criminal behaviors designed to secure drugs, a better control over dangers of overdose

4.      Treatment with Opiate Antagonists: person is first weaned from heroin, then given increasing dosages of a drug such as Naloxone. Patient compliance is poor and effectiveness of the approach is questionable

5.      Clonidine – a drug which nay be useful in easing the effects of withdrawal from heroin and a variety of addicting drugs


II. Psychological Treatments

  1. Cognitive and Behavioral approaches focus on avoiding high risk situations, learned strategies to cope with craving, and social support
  2. CBT approaches tend to be about as effective as Biological Treatments
  3. The Most widespread psychological approaches are self-help residential homes or communes modeled after Synanon and characterized by: separating persons from previous social contacts who are drug abusers, providing a no drug environment, role models involving former addicts, group therapy, and a focus on respect rather than stigmatizing
  4. Problems with the self-help residential programs are the high drop out rate and the fact that the majority of participants never achieve abstinence


Treatment of Cigarette Smoking


I. Background

  1. Since 1964, 40 million smokers have quit and 90% did so without professional help
  2. Each year 30% of smokers try to quit and 10% succeed
  3. Only 50% of persons who go through smoking cessation programs succeed during the program and only 20% remain quit after a year
  4. Best success of programs is with the more educated, older persons, or persons motivated by an acute medical condition
  5. Psychological treatments: as many as 95% are abstinent by the end of treatment, but most return to smoking within a year
  6. In the 1970’s, rapid smoking treatment approaches were popular – persons took quick, repeated puffs in a poorly ventilated room. This was as good as other approaches but the high relapse rates were comparable
  7. Scheduled Smoking: person is told by the smoking team to reduce smoking to a certain schedule fixed by the team – like ten cigs per day for the first week, five for the second, and zero for the third. Approach is fairly successful – 44 percent remained abstinent after the first year
  8. Physicians say no approach – undoubtedly scares a few into stopping
  9. Smoking Reduction Programs – goal is not to quit but to reduce the amount. In some cases, reduction eventually leads to cessation


II. Biological Treatments

  1. Nicotine Gums: may be dangerous for persons with cardiovascular diseases – nicotine replacement may minimize withdrawal, but withdrawal is minimally related to success in stopping smoking. Best results are achieved with gum in combination with behavioral approaches
  2. Patches: no good if a person continues to smoke – may result in dangerously high levels of nicotine
  3. Inhalers: in one study 28% of the treatment group quit compared with 18% of the placebo control group who quit


III. Relapse Prevention

1.      X smokers who live with non smokers fare much better in staying quit

2.      Social constraints such as laws prohibiting smoking in most buildings may help

3.      There is much more social support for non smoking than there has been in the past


IV. Substance Prevention

  1. Peer-pressure resistance training
  2. Correct information about actual prevalence
  3. Correcting positive images conveyed in mass media (inoculation)
  4. Discouraging imitation of parents with abuse problems
  5. Peer leadership
  6. Self-image enhancement
  7. Accurate information about harmful effects


CHAPTER 11  Eating Disorders




LECTURE 15       Thursday, March 14, 2013


Text Assignment: pp. 333-361


Eating Disorders


I. Anorexia Nervosa

    1. Four Criteria

       (a) Person refuses to maintain a normal body weight – weighs less than 85% of what   

             is considered normal

       (b) Person has an intense fear of gaining weight

       (c) A distorted sense of body shape

       (d) Extreme emaciation causes amenorrhea

     2. Tend to overestimate their own body size and prefer a thin figure as their ideal

     3. Two Types:

         (a) Restricting type: weight loss resulting from severe restriction of food intake

         (b) Binge-eating-purging-type:            the person also regularly engages bin binge eating           

               and purging

     4. Onset: early to middle teenage years

     5. Frequently co-morbid with depression, OCD, phobias, panic disorder, alcoholism,

         and personality disorders

6.      Ten times more frequent in women

7.      Depression frequent but rarely precedes onset – usually concurrent or after onset

8.      Physical changes include: kidney and gastrointestinal problems, bone mass declines, dry skin, change in hormone levels, electrolytes  (potassium and sodium are altered, cardiac arrythmias, sudden death, EEG abnormalities and neurological impairments

9.      Prognosis: 70% eventually recover – usually takes 6 or 7 years. Death rate is ten times higher than the general population and twice as high as other psychological disorders – death usually from cardiac complications and suicide


II. Bulimia Nervosa (Bulimia = Greek word “ox hunger”

1.      Rapid consumption of food followed by compensatory behavior (vomiting, excessive exercise, fasting)

2.      Unlike Anorexia, patients do not show a striking weight loss

3.      Foods preferred that can be rapidly consumed – especially ice cream and cake

4.      Laxative and diuretic abuse (usually do not reduce weight)

5.      DSM requires episodes of binging and purging of at least two per week

6.      People of normal weight frequently under-report their weight and over-report height, whereas Bulmia patients are more accurate

7.      Two subtypes: a purging type and a non purging type that shows compensatory behaviors of fasting and excessive exercise

8.      Onset: late adolescence or early adulthood

9.      Frequency: 1 to 2% of general population; 90% women

10.  Co-morbid with depression, personality disorders, anxiety disorders, substance abuse, and conduct disorders

11.  Suicide rates much higher than general population – comparable to major depression and anorexia nervosa

12.  Starvation may increase endogenous opioid levels and become reinforcing

13.  Serotonin levels – several studies report low, some report high


 III. Binge-Eating Disorder

  1. DSMIV-R includes it as a diagnosis in need of further study
  2. More prevalent than either Anorexia Nervosa or Bulimia
  3. Very difficult to distinguish this from the non-purging form of Bulimia


IV. Etiology

  1. Genetics: first degree relatives of women with anorexia are four times more likely to have the disorder
  2. Twin studies: higher concordance rates for MZ than DZ


V. Neurological Factors

      1.  Hypothalamus: animals with ablations that cease eating show no interest in food.  

           Anorexic patients continue to be interested in food despite self-starvation

      2.  Starvation in anorexia patients increases the level of endogenous opioids which  

            positively reinforces continued starvation

  1. Several studies report low levels of serotonin metabolites. Antidepressants increase serotonin levels and are often effective treatments for anorexia and bulimia


VI. Sociocultural Factors

1.      Playboy models havde become thinner since the 1950’s

2.      The prevalence of obesity has doubled since 1900

3.      Number of dieters since 1950 has increased from 7% in men to 29% and from 14% in women to 44% in 1999

4.      Obese persons are perceived by others as less smart and as lonely and shy

5.      Some evidence that African American women are less dissatisfied with their bodies than whites

6.      Very little data on Hispanics and Native Americans


VII. Psychoanalytic Theory

1.      Hilde Bruch believes that anorexia is an attempt by children who have been raised to feel ineffectual, to gain control over their lives. Presumably, parents would arbitrarily decide when a child was hungry and when he was tired. Children reared in this way have not learned to identify their own internal states and do not become self-reliant


VIII. Personality Factors

1.      MMPI indicates that anorexia and bulimia patients are high on neuroticism and anxiety and low on self-esteem

2.      Patients with anorexia were high on depression, social isolation, and anxiety, whereas persons with bulimia exhibited more  diffuse and serious psychopathology – scoring higher on several MMPI scales.

3.      Generally Anorexia patients scored higher than non patient controls on measures of perfectionism

4.      Patients with eating disorders consistently have lower self-esteem


IX. Characteristics of families

  1. Despite various speculations, the parents of children with eating disorders do not appear to be very different than control parents


X. Child Abuse and Eating Disorders

     1. The role of child sexual abuse remains uncertain

     2. High rates of child sexual abuse are found for many diagnostic categories – it is not   

         specific to eating disorders


XI. Cognitive-Behavioral views

  1. Self Starvation and weight loss are powerful reinforcers for fear of fatness and body image disturbances
  2. Dieting and weight loss may be positively reinforced by a sense of master











CHAPTER 12:  Sexual Disorders


LECTURE 16:  Tuesday, March 26, 2013


Sexual Norms and Behaviors


Text Assignment: pp 362-378



Normal Sexual Functions


I.  Normal Response Cycle

      1.   Four normal response cycles are believed to occur: 1) Appetitive, 2) excitement,  

            (3 Orgasm, and 4) Resolution

      2.   Appetitive: a stage introduced by Kaplan (1974) – refers to sexual interest or

            desire, often associated with arousing fantasies

  1. Excitement: masters and Johnson’s original first stage – sexual pleasure  

associated with physiological changes – increased blood flow to the genitalia and, in women, also to the breasts. In men, it results in an erection. In women, it results in enlargement of the breasts and changes in the vagina including lubrication

  1. Orgasm: in men, ejaculation almost always occurs. In women, the walls of the outer third of the vagina contract. In both sexes there is general muscle tension and involuntary pelvic thrusting
  2. Resolution: refers to relaxation and sense of well being that usually follows orgasm. In males, a refractory period follows in which further erection and arousal are not possible – Masters and Johnson originally proposed that the refractory period in males lasted at least 15 minutes. There is virtually no refractory period in females – a second orgasm is possible almost immediately


Sexual Dysfunctions


I.  Sexual Desire Disorders: the DSM lists two: Hypoactive Sexual Desire Disorder and 

    Sexual Aversion Disorder

1.      Hypoactive Sexual Desire Disorder: deficient or absent sexual desires and fantasies

2.      More than half of people seeking treatment for sexual dysfunctions complain of low sexual desire

3.      One problem is the lack of norms – how frequently and with what intensity do persons want sex?

4.      Low sexual desire is reported more often in men than women

5.      Women with a low sexual desire disorder appear to show normal sexual responses to sexual stimuli in laboratory studies – indicating that they are not incapable of becoming fully aroused

6.      Causes may include: relationship problems, low testosterone levels in men, anger – more so in men than women, poor communication and conflict resolution


Sexual Arousal Disorders


I.   Male Erectile Disorder

1.      Male Erectile Disorder: has been referred with the derogatory term “Impotence”

2.      Erectile failure may occur shortly after vaginal penetration (not as a result of premature ejaculation) or failure may occur when intercourse is imminent. For some erectile failure occurs if intercourse is attempted but may not occur during oral sex

3.      As many as two thirds of erectile problems have some form of biological basis – for example from drugs such as Thorazine, Prozac, some anti-hypertensive meds. May also result from diabetes, kidney problems, chronic alcoholism, or psychological problems such as anxiety and depression

4.      Prevalence: 3 to 9%


II. Female Sexual Arousal Disorder

      1.   Has been referred to by the derogatory term “Frigidity” which tends to imply a

            cold personality

      2.   Consistently inadequate vaginal lubrication

  1.  Prevalence: about 20%
  2.  Causes that have been suggested are: lack of knowledge about one’s own

anatomy, behavior of the partner may be un-stimulating or aversive, marital or relationship conflict, or possible medical problems such as estrogen deficiency or diabetes


Female Orgasmic Disorders


I. Female Orgasmic Disorder

     1.   Prevalence: depending on the study, ranges from 5 to 24%, the most recent

           estimate being 24%

2.   It is the problem that brings most women to therapy for sexual dysfunctions

3.      The negative response to females by most males if orgasm does not occur, may account for the fact that up to 60% of women admit to faking it on occasion

4.      As many as 10% of adult women have never experienced orgasm – far fewer than this are believed to be unaroused during sexual activity – laboratory studies indicate that women with an orgasmic disorder are as response to erotic stimuli as controls

5.      Women with little or no masturbation experience prior to intercourse are much more likely to be nonorgsamic with a partner

6.      Women appear to have different thresholds for orgasm  - some have orgasms quickly with minimal clitoral stimulation, others require prolonged and intense stimulation

7.      One speculation is that some women may not achieve orgasm because of a fear of losing control – possibly screaming uncontrollably, or fainting, or maybe fear of urination during orgasm


Males Orgasmic Disorder and  Premature Ejaculation


I. Premature Ejaculation

       1.   Probably the most prevalent sexual dysfunction among males – reported by as 

             many as 40% during some time in their lives

2.      Sometimes ejaculation occurs prior to the penis entering the vagina, but more

      commonly occurs shortly after entry

3.      The effect is to possibly deprive the female partner of orgasm because of the

Loss of the erectile response shortly after ejaculation

4.      Therapists typically advise couples to expand their sexual repertoire to activities

       not requiring continued erection or exclusive focus on vaginal or anal 



Sexual Pain Disorders


I.  Dyspareuna 

  1. Diagnosed when there is consistent or recurrent pain during sexual  intercourse
  2. Rarely diagnosed in men
  3. Some women report that pain starts at entry whereas others report pain only after penetration
  4. Women with Dyspareunia show normal arousal to erotic stimuli depicting oral sex but arousal declines when erotic stimuli depict sexual intercourse
  5. The diagnosis should not be made if the pain is due to lack of vaginal lubrication


II. Vaginismus

  1. Marked by involuntary spasms of the outer third of the vagina to the extent that intercourse becomes impossible
  2. Women with vaginismis have normal sexual arousal and orgasms from manual or oral stimulation that does not involve penetration
  3. Prevalence of Dyspareuna in women ranges from 8 to 15% and probably as little as 1% among males
  4. Prevalence of vaginismis among women seeking sex therapy ranges from 12 to 17%
  5. Genital pain associated with intercourse is usually caused by a medical problem such as vaginal, bladder, or uterus infections or infections of the glans of the penis in men
  6. The etiology of vaginismis may involve fear of pregnancy, anxiety, relationship problems or negative attitudes toward sex – however, while these factors may play a role in vaginismis, they may not be direct causes
  7. Masters and Johnson found that for a number of couples, the man’s inability to maintain an erection, preceded the development of vaginismis in the female partner


Theories of Sexual Dysfunction


I.  Masters and Johnson’s Theoretical Model

1.  Two major Current causes: (1) Fear of Performance (Performance Anxiety) –

            being overly concerned with how one is performing during sex, and (2) Spectator

            Role – a distraction resulting from being an observer rather than a participant

            During a sexual experience

2.      Both of the above impede sexual performance

3.      There is no conclusive evidence that either is a cause of sexual dysfunctions – there is no evidence that performance fears precede and cause dysfunctions


II. Historical Causes (According to Masters and Johnson)

1.      Religious Orthodoxy: extremely conservative views which result in negative views about sexuality

2.      Psychosexual  Trauma: may result from rape or other degrading encounters

3.      Homosexual Inclination: interferes with heterosexual expression if the basic inclination is homosexual

4.      Inadequate Counseling: for example, a cleric telling someone that a sexual dysfunction is caused by a punishment from God

5.      Excessive Intake of Alcohol: As stated by Shakespeare “ It provokes the desire but it takes away the performance”

6.      Biological causes: diseases of the vascular system or of the nervous system

7.      Sociocultural Factors: example: men have the advantage or society’s blessing to develop sexual expressiveness and to take the initiative


III. Contemporary Views

1.      Masters and Johnson considered sexual dysfunctions as the problem that could be treated directly – not symptoms of other intrapsychic or nonsexual  other intrapsychic or nonsexual personal difficulties

2.      Contemporary Sex Therapists assume that sexually dysfunctional couples have both sexual and interpersonal problems

3.      Performance Anxiety and assuming a Spectators role may be contributing causal factors but many other causes of sexual dysfunction have been identified such as lack of knowledge or skill or poor communication or marital conflict or fgear of sexually transmitted diseases


Therapies for Sexual Dysfunctions


I. Anxiety Reduction

     1.  Gradual and systematic exposure to the anxiety-provoking aspects of the sexual  


2.      Directed Masturbation: a multi-step therapy by Lopiccolo and Lobitz that

      supplements the Masters and Johnson program. The first step is self examination

           of the body to identify certain areas. The person is then instructed to increase the

           intensity of masturbation using erotic fantasies. If orgasm is not achieved, she is 

           asked to purchase a vibrator and taught how to use it in masturbation. Finally, the

           partner is asked to assist by using the techniques which she has been taught.

           Ultimately intercourse occurs in a position that allows him to stimulate the

           Appropriate genital areas

3.      Procedures to Change Attitudes and Thoughts: called sensory awareness procedures. Sensate-focus exercises  - forbidding intercourse and focusing on stimulating and providing pleasurable contact where none has existed for years

4.      Skills and Communication Training: involves showing clients explicit videotapes and films demonstrating sexual techniques. Clients tell their partners their preferences in sex.

5.      Couples Therapy: training in nonsexual communication skills to improve both their relationship and communication

6.      Psychodynamic Techniques and Perspectives: clients may not be able to express clearly their concerns because of social and gender specific pressures to not admit to sexual problems

7.      Medical and Physical Procedures: increasingly, therapists need to be aware of somatic factors which may underlie or cause sexual dysfunctions. For example, Dyspareunia  can be ameliorated in postmenopausal women by estrogen treatments which can reduce the thinning of the vaginal walls and improve lubrication.  For chronic erectile problems, one treatment has been the implantation of a semi-rigid silicone rod in the penis which can be made stiff by a pump implanted in the scrotum which forces fluid into the hollow rod. This approach has not been satisfactory in many cases. A nonsurgical proceedure involves placing the penis in cylinder attached to a vacuum pump. When the air is pumped out, blood is drawn into the penis and it becomes erect. The cylinder is removed and an elastic band is placed around the base of the penis which traps the blood and allows the erection to be maintained (this is one of the treatments recommended by the American Urological Association.  Most of the pharmaceutical interventions as well as mechanical ones have been replaced by the introduction of Viagra, which was approved by the FDA in 1998.  Viagra relaxes smooth muscles and allows the blood to flow into the penis during sexual stimulation, creating an erection. It is taken an hour before sex and lasts for about four hours (not the erection).  It does not cause an erection in absence of sexual stimulation. About 16 to 44% of men do not derive much benefit from Viagra. Side effects include headaches, indigestion and can be a real concern and dangerous for men who have a cardiovascular disease  or high blood pressure. This is an important concern because many older men who have a higher percentage of hypertension and cardiovascular problems may develop erectile problems and seek help from Viagra.








CHAPTER 12:  Sexual Disorders


LECTURE 17:  Thursday, March 28, 2013


The Paraphilias


Text Assignment: pp 379-392


Gender Dysphoria and the Paraphilias



Gender Identity Disorder (the DSM V may use the term Gender Dysphoria, requiring that marked distress or functional impairment should be a requirement for a Gender Dysphoria Disorder - See page 364 of your Text for a discussion or criticisms as the relate to the proposed changes). The authors of your text feel that the use of this diagnosis contributes to stigma and social ostracism. Therefore they have chosen not to include the diagnosis of Gender Identitty Disorder in their chapter on sexual disorders.


I. Gender Identity versus Sexual Identity: 

1.      Gender Identity refers to your biological status as a male or as a female.

2.      Sexual identity refers to your sexual orientation


II. Gender Identity Disorder (Transsexualism) as listed in the DSM IV

  1. Adult persons with a Gender Identity Disorder (GID) report believing that they are or should be of the opposite sex since early childhood
  2. Persons with GID feels attracted to a person of the same biological sex, they perceive it as a heterosexual attraction (since they think of themselves as being the opposite of their biological sex)
  3. Excluded from GID are persons with schizophrenia who rarely claim that they are of the opposite sex and hermaphrodites who have both male and female reproductive organs
  4. A person with a GID is a transsexual, but not a transvestite, which is a fetish for cross dressing (one of many paraphilias)
  5. The prevalence rate for GID is one in 30,000 for men and one in 100,000 to 150,000 for women


II. Gender Disorder in Childhood

  1. Gender Identity Disorder in Childhood may be recognized by parents when the child is 2 –4 years of age
  2. Most children with a gender disorder do not grow up to be disordered in the adult years although many show a homosexual orientation
  3. Gender disorder is 6 times more frequent in boys than girls
  4. It has been suggested that because of the frequency with which many children show behaviors which may be stereotypes for the opposite sex that GID in childhood be dropped as a diagnostic category from the DSM


IV. Biological Factors

1.      Research indicates that girls whose mothers took progestins (a precursor to male sex hormones) during pregnancy to prevent uterine bleeding showed more tomboyish behavior during the preschool years

2.      Boys whose mothers took female hormones during pregnancy were less athletic and less inclined to engage in rough and tumble play

3.      Among adults few if any hormonal differences have been found between men with GID, male homosexuals and male heterosexuals

4.      Some women with GID had elevated levels of male hormones but others did not

5.      No conclusive chromosomal or brain structure differences have been found between persons with GID and normals


V. Social and Psychological Factors in GID

  1. Many or most children engage in cross-gender behavior every now and then
  2. It is conceivable that male children may be viewed as cute when cross dressing and reinforced for the behavior
  3. For children with Gender identity problems such positive reinforcement may contribute to conflicts between biological sex and learning gender roles
  4. One unsupported assumption is that feminine behaviors in young boys are reinforced by mothers who wanted a little girl
  5. It may be concluded that GID is far less prevalent than would be predicted by the number of males who play with dolls and girls who engage in contact sports


Therapies for GID


I.  Body Alterations

  1. Persons with GID who wish to undergo body alterations are usually required to undergo 6 to 12 months of psychotherapy and to cross dress
  2. Persons with GID may elect to have fairly minimal cosmetic alterations such as electrolysis for hair removal in men or possibly surgery to reduce the size of the chin or Adam’s apple or take hormones
  3. Sex-reassignment surgery: first case in Europe in 1930 but the most  publicized was Christine Jorgensen (formerly George) in Denmark, 1952
  4. Surgery in males involves removal of the male genitalia, reserving anough tissue to construct a “vagina”. Tissue from the head of the penis has been used to construct a “clitoris”. Female hormones are administered for about a year prior to surgery (female hormones do not replace the need to electrolysis or have any effects on lowering the voice). Conventional heterosexual intercourse is possible but may be problematic for some.
  5. Surgery in females involves the construction of a small penis (not capable of normal erection) and extending the urethra into the penis to permit stand up urination. Male hormones alter the distribution of fat and stimulate hair growth to produce masculine characteristics
  6. Sex reassignment surgery is sought mostly by men
  7. John Hopkins University School of Medicine discontinued their sex reassignment  program after a 1979 study found no advantages in terms of “social rehabilitation”
  8. More resent research  involving a twenty year research period concluded  that there was an overall improvement in social-adaptation rates – more so with males than females.
  9. A review by Green and Fleming (1990) reported that 97% of 130 female to male surgeries   were judged as satisfactory and 87% of 220 male to female surgeries were satisfactory.  Satisfactory simply meant that patients had no regrets about having the surgery
  10. At least one research project  indicated that sex reassignment surgery for both sexes dramatically improved sexual satisfaction and sexual responsiveness.
  11. Finally a 2001 study reported that young men who had the surgery were no longer gender dysphoric, had no regrets, and functioned better than men who had been denied hormonal treatment and surgery
  12. It is estimated that more than 1,000 transsexuals are surgically altered to the opposite sex each in the US
  13. According to Carroll, 2000) many transsexuals decide against surgery and later realize that dissatisfactions with their lives are not going to be solved by changing the external signs of their biological sex
  14. In general 90 percent of persons who undergo sex reassignment surgery are satisfied with the results and do not regret their decision


II. Alterations of Gender Identity

  1. Sex reassignment surgery may not be the only option. There have been individual cases involving intensive behavior therapy where persons learn to think of themselves in terms of their biological sex and learn to be attracted to persons of the opposite sex.
  2. It is conceivable that clients who consent to a therapy focusing on changing gender identity, that they may not be representative of the many clients who would not want to participate in a study designed to change their gender identity
  3. Marks, et al (2000) report that gender identity may fluctuate over the years with some men losing all of their gender dysphoria without any form of therapy


The Paraphilias


I. General Characteristics

1.      a group of disorders involving sexual attraction to unusual objects or sexual activities

2.      Para = deviation and Philia = what the person is attracted to (in other words, a deviation in what the person is attracted to)

3.      To be considered a paraphilia, it must involve at least a six month duration and be a cause of significant distress or impairment

4.      If fantasies or behaviors are not recurrent or the person is not distressed by them, then they would be excluded from a diagnosis of paraphilia. For example, about 50% of males report voyeuristic fantasies of peeping at unsuspecting naked women

5.      There has been debate over the DSM requirement that there be distress or impairment – many persons who meet the behavioral criteria are neither distressed or impaired

6.      Accurate prevalence figures are not available for most of the paraphilias

7.      In all the paraphilias, men substantially outnumber women – even in areas like masochism or pedophilia in which do involve a number of women.

8.      These disorders often have legal consequences in that they frequently involve non-

      consenting victims


Kinds of Paraphilias


I. Fetishism

  1. Presence of the fetish object is strongly preferred or necessary for arousal
  2. Common objects are garments, stockings, rubber products, gloves, panties


II. Transvestic Fetish

  1. Ranges from wearing women’s underwear to cross-dressing
  2. Always male heterosexuals


III. Pedophilia

  1. Sexual contact with unrelated, prepubertal children. Offender must be at least 16 and five years older than the child
  2. More frequent in men than women
  3. Violence is seldom, but can occur
  4. A minority of pedophiles might be classified as sexual sadists or antisocial personalities – this is the group which may injure or murder the victim


IV. Incest

  1. Sexual relations between close relatives for whom marriage is forbidden
  2. Most common form is brother/sister; next is father/daughter
  3. Incest victims tend to be older than victims of pedophiles – fathers who  engage in incest are more likely to do  so with a daughter that begins to mature physically
  4. In one study, 25% of the men who were otherwise conventional in their sexual interests and behavior showed arousal to pedophilic stimuli (study highlights the importance between fantasy and behavior)
  5. One recent study indicated that pedophiles may not require child pornography to become aroused but may be aroused by conventional stimuli such as ads for clothing involving children
  6. Most often, pedophiles “know” the children they molest
  7. Pedophiles are low on social maturity, self esteem, impulse control, and social skills
  8. Most older heterosexual pedophiles are married. Up to half of all child molestations (including incest) are committed by adolescent males
  9. Overt physical force may not be used but manipulation and other forms of coercion involving power relationships are clearly evident
  10. A study of 796 college students found that 19% of women and 8.6 % of men reported that they had been sexually abused as children Of the abused persons, 28% of the women and 23 % of the men had had incestuous relations


V. Voyeurism

1.      Men who, by chance, observe naked women and are aroused may be engaged in voyeuristic behavior, but are not diagnosed as voyeurs unless that is a primary or exclusive form of arousal

2.      Typically, the voyeur achieves sexual satisfaction by masturbating while secretly watching

3.      A true voyeur may not find it arousing to watch a woman undressing for his benefit. It is the element of risk that creates excitement and heightened arousal

4.      Voyeurs are more often charged with loitering than peeping

5.      True voyeurs are almost always men

6.      Widespread legal availability of pornography significantly reduced voyeurism in Denmark


VI. Exhibitionism

1.      Marked preference for obtaining sexual gratification by exposing one’s genitals to an unwilling stranger – sometimes a child

2.      Exhibitionists masturbate while fantasizing exposure or during the actual exposure

3.      Much greater frequency among men

4.      They are usually oblivious to social and legal consequences while committing the act, but afterwards experience fear and remorse

5.      About half are married but do not report  satisfactory sexual relations with their spouse


VII. Frotteurism

1.      Sexually oriented touching of an unsuspected person

2.      More frequent in physically crowed places like buses that allow for a quick escape


VIII. Sexual Sadism and Sexual Masochism

  1. Sadism: A marked preference for obtaining sexual satisfaction by inflicting pain or psychological suffering
  2. Masochism: a marked preference for obtaining sexual gratification through subjecting oneself to pain or humiliation
  3. Both disorders are found in homosexual and heterosexual relationships
  4. About 20 to 30% of members of sadomasochistic clubs are women
  5. Alcoholism is a common problem
  6. Approximately 5 to 10% of the population admits to have engaged in some form of sexual behavior that may be described as sadism or masochism such as blind folding one’s partner – few, however, do this regularly
  7. Masochists outnumber sadists
  8. Occasionally sadists murder or mutilate or derive pleasure for torturing victims who are mostly strangers



I. Therapies for Paraphilias

  1. Psychoanalytic approaches are pessimistic about therapeutic change because of the assumption that the paraphilias are linked to a difficult to character disorder (psychopathy)
  2. In the past, behavior therapist have focused on aversion therapy (pair the fetish with a shock or an emetic to produce nausea) with varying degrees of success in terms of control of the behavior
  3. Orgasmic Reorientation: the client, almost always men,  may use his or paraphilia fantasies for arousal to acgieve an erection, then is asked to continue to masturbate while look at conventional pictures of nude women. If erection does not continue, then the client reinstitutes the paraphilia fantasy in order to achieve an erection then returns to masturbating with the conventional stimuli. The technique is of questionable success
  4. Cognitive Treatment:  Contemporary therapists are less likely to focus on classical conditioning to bring about responses to appropriate stimuli. Recent approaches tend to operate on the Masters and Johnson model which focuses on  the fact that some paraphilias are maintained because of unsatisfactory sexual relationships with consenting adults
  5. Biological Treatment:  Castration has been used in Western Europe forty to fifty years ago. However, the approach was used to treat a variety of sexual behaviors – at least some of which involved consensual homosexual behavior among adults. Recent approaches involve what has been called “chemical castration” by the uses of Depo-Provera or MPA). One study reported success with 17 of 20 sex offenders over a five to 20 year period. However, when the drug was discontinued,. The paraphilias returned. The drug also may have serious side effects such is infertility or diabetes


II. Megan’s Law

  1. Megan  was a second grader who was kidnapped while walking home from school, sexually abused and brutally murdered
  2. The law applies to sex offenders who have harmed either adults or children.
  3. Tracking of sex offenders is facilitated by a national computer network created by President Clinton in 1996
  4. An unintended consequence of Megan’s law  involves gay persons who were arrested years ago for consensual sex with adults who are now being asked by some police departments to register as sexual offenders
  5. Recent laws may prevent offenders to return to the areas where they committed earlier offenses and permit police to publicize there whereabouts of registered sex offenders
  6. Forced sexual contact occurs far more often between adults than with an adult and a c




I. Legal Issues and Treatment of Victims

1.  Two legal categories: (1) Forced Rape - involving sexual intercourse with an 

 unwilling partner, and (2) Statutory Rape – involves sexual intercourse with  

           someone under the age of consent (typically age 18). Statutory rape may or may

           not involve the willingness of the minor

3.      Some rapes are planned, some are committed on impulse

4.      Some rapes appear to be motivated by attempts to control or exert power, others are clearly sexually motivated

5.      Many rapists experience erectile failure or fail to reach orgasm

6.      Seventy percent of rapes are associated with intoxication

7.      In Sadistic Rape, the victim is deliberately severely injured and sometimes murdered

8.      In many jurisdictions rape is defined as forced oral or anal entry as well as vaginal penetration

9.      Rape is primarily an act committed by men against women

10.  One very damaging legal consequence of rape is that the woman is often put in a position of proving her role as a sexually discriminating person in order to offset defense arguments that she behaved in such a way as to contribute to the rape or was, at some level, a willing participant

11.   Acquaintance Rape or Date Rape: outnumbers stranger rapes three to one and victims are especially vulnerable to being blamed because of some level of presumed willingness, particularly if consensual relations with the same perswon occurred at some earlier time

12.  As many as 25% of American women will be raped during their lifetimes, most often by an acquaintance

13.  It is estimated that 80% of sexual assaults are not reported

14.  When one considers coerced sexual behavior that stops short of rape, as many as 75% of female college students have been subjected to unwanted sexual activity


II. Rohypnol: a tranquilizer commonly referred to as a date rape drug.

1.      It is odorless, tasteless, easy to use by slipping it into a victim’s drink.

2.      The effect is that it causes the person to pass out and may also strongly affect memory for what happened

3.      In 1996, a federal law was passed which would add up to 20 years to a conviction for rape or other violent crimes if Rohypnol had been used


I. The Victims

        1.   Females of all ages and appearance may be victims

        2.   Two weeks after rape, 94% suffer from an acute stress disorder and nine months

               later, 42% suffer from a post Traumatic Stress Disorder

4.      Resistance is often complicated by terror and fears for one’s life

5.      Many women feel guilty about being unable to fight harder

6.      Depression and loss of self esteem are common

7.      Realistic concerns about pregnancy and sexually transmitted diseases add to the stress

8.      Many women develop a post rape negative attitude toward sex which complicates their relationships

9.      The suicidal risk is higher

10.  Supportive relationships may mitigate against some of the negative consequences

11.  The rape trauma syndrome may include depression, anxiety, sleep disturbances and may be admissible as evidence supporting the allegation of rape in some jurisdictions. It may also explain why there may be belays in reporting the crime, memory loss, and inconsistent statements


II. The Rapist

1.      Brownmiller contends that the long history of rape by soldiers at war – including rape of Vietnamese women and girls by US soldiers, leads to an expectation of rape during war

2.      Browmiller believes that even being in the armed services encourages a perverse sense of masculine superiority which contributes to sexual abuse and rape by making the climate acceptable

3.      For the first time in history (1998), a soldier was found guilty for rape as a war crime

4.      There is no single characteristic of the rapist such as psychopathy, or other patterns of behavior  that are exclusively predictive of rape

5.      Many rapists probably have in common a high hostility toward women for a number of reasons

6.      In one controlled experiment, male college students were aroused by video portrayals of rape if the woman was depicted as having an orgasm during the assault – such pornography may encourage rape


III. Therapy for the Rapist

1.      Cognitive techniques focus on changing distorted beliefs or attitudes by the rapists such as “she wanted it” or “she was asking for it”

2.      Other approaches may involve anger control, efforts to increase empathy for the victim

3.      Biological treatments such as with Depo-Provera  may occasionally be used


IV. Therapy for the Victims

1.      Often the focus may be on normalizing the victims reactions, e.g. everyone goes through this kind of an emotional turmoil following and assault

2.      Supportive organizations such as rape centers, hospitals, or clinics may provide support for immediate needs such as arranging for child care, increasing home security supporting her decisions to pursue prosecution and assisting her with the process

3.      Longer range therapy may involve helping the victim relive the fearsome attacks by discussing them with the therapists in order (repeated exposure to the trauma may bring about extinction of the fear). A promising cognitive-behavioral approach by Patricia Resick involves exposure to memories of the trauma and other anxiety-reduction interventions along with cognitive restructuring  approaches similar to those used by Ellis or Beck

4.      A study of over a half million interviews with rape victims yielded three common reasons for being reluctant to report rape or sexual assault:

(1)   Considering rape as a private matter

(2)    Fearing reprisals from the rapist or members of his family

(3)   Believing that the police will be inefficient , ineffective, or insensitive

5.      Estimates are that only a very small percentage of rapists are ever convicted for their crimes

6.      Pursuing prosecution is particularly difficult in situations where the victim knows the perpetuator

7.      There is little question that our current judicial system makes going to trial very stressful for the victim – much more so than in other criminal prosecutions






CHAPTER 13: Disorders of Childhood




LECTURE  18    Tuesday, April 2, 2013


Text Assignment: pp. 393-406


Topic: Attention-Deficit/Hyperactivity Disorder (ADHD)


I.  Classification of Childhood Disorders

        1. Externalizing Disorders: outward directed behavior such as aggressiveness,

            noncompliance, over-activity, impulsiveness, found more often in boy

        2. Internalizing Disorders: inward focused experiences and behaviors such as

            depression, social withdrawal, anxiety, and mood disorders, found more often in



Attention-Deficit/Hyperactivity Disorder (ADHD)


I. Hyperactivity (predominantly hyperactive-impulsive behavior)

  1. A diagnosis of hyperactive is supposedly reserved for extreme cases, however, there are many problems with the term “hyperactive”
  2. There are no well established norms for activity at different age levels
  3. Cultural factors or ethnic origin may result in different tolerance levels and different patterns of reinforcement for active behavior
  4. Teachers, parents, and health professionals may very considerable in their threshold for referral or in tendency to use a diagnostic label
  5. Hyperactive behavior may be used selectively to apply to disruptive behavior which may or may not involve excess activity
  6. Families, cultures, and ethnic groups may have different reinforcement preferences for gross motor skills as opposed to fine motor skills


II. Attention Deficit (predominantly inattentive type)

1.      The diagnosis is supposedly reserved for children who are easily distracted and

       cannot maintain attention to any task for a sustained period of time

2.      There are no well established norms for attention span at different ages of development

3.      Inattention may refer primarily to academically related tasks

4.      Cultural, family, and ethnic factors may influence what forms of attention are appropriate for different types of tasks or activities

5.      The data does not support the view that children with this diagnostic label are easily distracted by “irrelevant” external stimuli

6.      It is conceivable that some children are under aroused and less responsive to all forms of external stimulation

7.      Labels of hyperactivity and inattentive behavior are almost used as synonymous terms with out real efforts to identify whether they are two distinctive, separately identifiable problems


III.   General Characteristics of ADHD

1.      There is overlap between a diagnosis of ADHD and a Conduct Disorder of 30 to 90% leading some to suggest that they are actually the same disorder

2.      A dual diagnosis of ADHD and Conduct Disorder has a very poor prognosis

3.      The symptoms of ADHD often have an earlier age of onset than the symptoms of a Conduct Disorder

4.      The worldwide Prevalence of ADHD is estimated to be between 3 to 7%

5.      Approximately 15 to 30% of children with ADHD  have a leaning disability and about half are placed in special education programs


IV. ADHD Research findings for Girls

1.      ADHD girls are more likely to have been adopted

2.      Girls with the combined type (hyperactive and inattentive) are more likely to be behaviorally disruptive, have a comorbid Conduct or Oppositional Defiant disorder, and to be perceived negatively by peers than girls with the inattentive type

3.      ADHD girls are more likely to have higher anxiety and depression


V. Longitudinal Studies of ADHD

        1.   65 to 80% of children still meet the ADHD criteria in adolescence and adulthood

        2.   Adolescents with ADHD are far more likely to drop out of high school and

              develop antisocial behavior

4.      As adults, most with ADHD as children are employed and financially


5.      Most reach a lower socioeconomic level and change jobs more frequently than their non ADHD peers

6.      In the adult years, although they continue to exhibit some symptoms of ADHD, they usually learn to adapt to these symptoms


VI. Biological Theories of ADHD

1.      The frontal lobes of ADHD children are underresponsive to stimulation

2.      Predictors of ADHD include lower birth weight, alcohol and/or tobacco use by the mother during pregnancy

3.      Feingold’s theory of ADHD being caused by food additives and the popular view that it is caused by sugar has not been supported by research

4.      It has been suggested that nicotine can adversely affect the dopaminergic system in the developing fetus

5.      Lead poisoning may not e a significant fact in ADHD – e.g. most children with lead poisoning do not develop ADHD and most ADHD children do not have elevate levels of lead in the blood


VII. Psychological Theories of ADHD

1.      Neurologic and genetic explanations for ADHD have far more support than psychological explanations for ADHD

2.      It is probable that the child’s behavior negatively affects the parents rather than the reverse.


VIII. Treatment of ADHD – Stimulant Medication

1.      Stimulant Medications: methylphenidate (Ritalin) is the most extensively used medication for ADHD

2.      Amphetamine, or Adderall and pemoline, or Cylert have also been used but Ritalin is far more common

3.      Generally the stimulants reduce disruptive behavior and improve concentration (but improved concentration is also true for non ADHD children and norfmal adults)

4.      Stimulant medication alone (Ritalin) results in greater improvement than behavioral approaches alone, a combined treatment of meds and behavioral approaches was slightly better than meds alone, however, the combined treatment required less Ritalin and there was more improvement of social skills

5.      In the long run, research suggests that the stimulant meds may not improve academic achievement

6.      Side effects of the stimulant meds include loss of appetite, sleep problems, and the misuse of the drug (E.g. snorting it) by friends and siblings

7.      Regardless of problems, Ritalin is probably the most effective treatment approach for ADHD


IX. Treatment of ADHD – Psychological approaches

1.      Other than meds, the most promising psychological approaches involve parent training and classroom management

2.      It is not clear whether training the parents improves ADHD behavior more than the meds

3.      It is suggested that intensive behavioral intervention may bed as effective as Ritalin with a less intense operant program





CHAPTER 13: Disorders of Childhood (continued)




LECTURE  19    Thursday, April 4, 2013


Text Assignment: pp. 407-432


Topic: Conduct Disorder and Learning Disabilities


Conduct Disorder


I.  DSM IV Criteria Violation of others rights or conventional norms in three or more of

     the following in the last 12 months and at least one in the last six months

1.      Aggression to people and animals

2.      Destruction of property

3.      Deceitfulness or theft

4.      Serious violation of rules


II. General factors involving Conduct Disorder

1.        Some debate as to whether Oppositional defiant Disorder is really distinct from a conduct disorder

2.        Conduct disorder is three to four times more common in boys, bout Oppositional Defiant Disorder  is about equal for boys and girls

3.        Conduct disorder often identified by legal authorities

4.        High degree of comorbity with ADHD

5.        Anxiety and depression common

6.        Conduct disorder among girls may indicate more severe psychopathology

7.        Prevalence is 4 to 16% among boys and 1.2 to 9% among girls

8.        Predictive of Antisocial behavior in adults, but more than half of  the children who are labeled as having a conduct disorder do not become antisocial

9.        Although half of boys with conduct disorder do not meet criteria one to four years later, almost all continued to show some conduct disorders

10.    Moffit suggests two forms of a conduct disorder – one that persists from age three and continuing through the adult years and the other is limited to adolescence

11.    Boys with a conduct disorder are more likely to persist in antisocial behavior into the adult years if at least one parent is antisocial


III. Etiological Factors – Biological

1.      Results of twin studies are mixed

2.      Evidence for genetic factors is stronger if the conduct disorder develops early and persists – also IQ is one standard deviation below children with no conduct disorder

3.      Genetic role for boys and girls is similar


IV. Etiological Factors – Psychological

1.      Children who are physically abused by parents are more likely to be aggressive

2.      Aggressive children interpret ambiguous acts as evidence of hostile intent

3.      Peer rejection is causally related to aggressive behavior

4.      Associating with delinquent peers associated with aggressive behavior

5.      Social class and urban living related to delinquency


V. Treatment

         1.  Children with antisocial behavior associated with conduct disorders are difficult

               To treat

         2.   A promising approach is Parent Management training with a focus on rewarding

               Prosocial behavior – benefits persist one to three years

3.    Multisystemic Appoach:  delivering intensive and comprehensive therapy

Services in the community – treatment via this approach is successful but very expensive

4.      Cognitive Approaches: anger control and self control training are effective – 

    particularly using distracting techniques  - children learn to withstand verbal

    attacks by distracting themselves

5.      Cognitive approaches may not have long range effectiveness – particularly

       when children return to unfavorable living situations


Learning Disabilities; Intellectual Disabilities


Learning Disabilities


Definition:  inadequate development in a specific are of academic, language, speech, or motor skills that is not due to mental retardation, autism, a demonstrable physical disorder, or deficient educational opportunities


I. Learning Disorders

       1.  Reading disorder (dyslexia): difficulties in word recognition, reading

            comprehension, and often spelling

       2  Disorder of written Expression: impairment of ability to compose the written word

3.      Mathematic Disorder: responding rapidsly and accurately recalling facts, counted objects correctly and quickly


II. Communication Disorders

  1. Expressive language disorder: difficulty in expressing ones self in speech
  2. Phonological Disorder: speech is not clear – is remedied fairly quickly by speech therapy
  3. Stuttering:  a disturbance in verbal fluency – may involve frequent repetition of sounds, long pauses, substituting easy words for difficult ones. Problem is three times more common among males. Disorder is usually evident by age five


III. Motor Skills Disorder: marked impairment in the development of motor coordination


Etiology of Learning Disabilities


I. Etiology of Dyslexia: recent findings dispute popular belief that dyslexia involves   

    perceiving letters in reverse order or as mirror images. The core deficits appear to 

    involve problems in visual and or auditory and language processes. Early language

     problems may be a significant predictor. There are usually problems in rapid

     processing of visual tasks. May involve problems in the activation of the  

     temporoparietal area


II. Etiology of Mathematics Disorder: three subtypes:

  1. Deficit in memory for the meaning of words – leads to problems in memorizing
  2. Developmentally immature strategies for solving problems
  3. Impaired visuospacial skills – leads to problems in arranging numbers in columns or putting decimals in the wrong places


Treatment of Learning Disabilities


I. Generally, most approaches involve specialized instruction focusing on a child’s

    strengths rather than weaknesses regarding particular academic problem – e.g.   

    phonics instruction for children with reading difficulties. Recent approaches have 

    utilized computer games audiotapes to modify sppech sounds in communication



Mental Retardation - DSM IV (will be Intellectual Disabilities in the DSM V)


I. IQ scores

    1.  Two thirds of the population achieve scores between 85 and 115

    2.  Scores below 70 to 75 meet the criterion of significant sub average intellectual


     3. The importance of individually administered tests


II. Adaptive Functioning

1.      Mastering childhood skills such as dressing by one’s self, using tools,

2.      Being able to be self supporting as an adult

3.      Capable of travel using public transportation

4.      Adaptive Behavior Scale: one of several tests designed to assess adaptive behavior


III. Age of Onset

  1. Must be manifest before age 18
  2. Severe impairments may be diagnosed in infancy
  3. The majority of children are not diagnosed as mentally retarded until they enter school


Classification of Mental Retardation (DSM IV)


I.  IQ Basis for Classifying Mental Retardation

     1. Mild (50-55 to 70 IQ) About 85% of all those who have IQs below 70 are classified

          As mildly retarded

     2.  Moderate (35-40 to 55-55) about 10% of those below 70 are classified as Moderate

     3.  Severe (20-25 to 35 – 40) About 3 to 4% of those with IQs below 70

     4.  Profound (below 20-25 IQ) About 1 to 2 % of those below 70


II. American Association of Mental Retardation (AAMR) Classification System

1.      Focuses on what a person can do rather than what they cannot do

2.      There is much variability in communication skills by persons with an IQ between 20 and 40

3.      The AAMR system emphasizes what is needed to maximize functioning

4.      Assumption is that building on what a person can do will lead to more progress


I.   Etiology of MR (Cause can be identified in only 25% of population of MR)

     1.  Persons with mild to moderate MR do not usually have an identifiable brain defect

     2.  Persons with identifiable biological causes are found in about equal numbers

          throughout socioeconomic, ethnic, and racial groups

3.  Persons with mild to moderate MR are greatly overrepresented in lower

     socioeconomic classes

4.   Known Biological Etiology: (25% of those below 70) – causes include genetic

           factors, infectious diseases, accidents, and environmental hazards


II. Specific Biological Abnormalities

       1.  Down’s Syndrome (Trisomy 21) – 1 in 800 to 1,200 live births. Individuals with

            trisomy 21 Have 47 chromosomes rather than 46 (23 pairs)  Trisomy 21  accounts

            for approximately 94% of Down’s Syndrome. About one in six will die during the

            first year. Mortality after age 40 is very high (40% have heart problems)

       2.  Fragile X Syndrome (the X chromosome breaks in two) – second leading cause

            after Down’s involving a chromosomal abnormality. Physical features include

            large, underdeveloped ears, long thin face, males may have enlarged testicles.

            Many have MR and behavior problems. Others have normal IQ but have

            Problems like learning disabilities

3.Recessive Gene Diseases – Example PKU (Phenylketonuria) infant is born with a 

            deficiency of a liver enzyme called phenylalanine hydroxylase. Because this 

            enzyme is deficient, the result is a build up of phenylpyruvic acid in the body

fluids resulting in brain damage due to interference with myelination. The incidence is about one in 14,000 live births. The severe effects can be largely controlled by a special diet low in phenylalanine.

4. Infectious Diseases:  Various diseases in pregnancy which can affect the developing






CHAPTER 13: Disorders of Childhood (continued)




LECTURE  20    Tuesday, April 9, 2013


Text Assignment: pp. 432-442


Topic: Autistic Spectrum Disorder


Autistic Disorder (DSM IV) The DSM V will eliminate Asperger's Syndrome and subsume the syndrome under Autistic Spectrum Disorder)


I.   Characteristics

     1. Identified in 1943 by Leo Kanner: considered the most significant symptom to be

         autistic aloneness. Also, severely limited in language and a strong desire to have 

         sameness in gtheir environment

     2. The DSM II treated autism as an early onset form of schizophrenia

     3. Schizophrenia and autism appear to be entirely separate disorders

     4. Prevalence is 2 to five infants in 10,000.

     5. DSM II introduced the term Pervasive Developmental Disorders

     6. In the DSM IV, autism is one several Pervasive Developmental Disorders

     7. Approximately 80% of autistic children score below 70 on IQ tests

     8. Low scores by autistic children probably are a result of language problems

     9.  Children with autism have profound social-skills problems

    10.  Become very upset over changes in routine and or surroundings


II. Prognosis

1.      Only 5 to 17% of autistic children make a relatively good adjustment as adults

2.      Children with higher IQs who learn to speak by age six have the best prognosis


III. Etiology

1.      Early theorists discounted importance of biological factors

2.      Current thinking emphasizes Biological etiology

3.      Family and twin studies strongly implicate genetic causation

















CHAPTER 14:  Late Life and Neurocognitive Disorders


LECTURE 20:  Tuesday, April `16, 2013


Text Assignment: 443-451


Topic: Aging: Issues and Methods; Psychological Disorders Late in Life


I.  General Information

      1.  Ageism:  discrimination against any person on the basis of age regardless of their 

           actual age

       2. Old: typically defined as those persons over age 65

       3.  Gerontologists often make the following distinctions:

(a)    65 to 74 = the young-old

(b)   75 to 84 = the old-old

(c)    85 plus   = the oldest-old

        4. Persons 65 and older comprise 12.4% of the population in the U.S. (35 million)

        5. By 2020,  it is estimated that there will be 52 million 65 and older


II. Age, Cohort, and Time of Measurement effects

1.      Age Effects: the consequences of being a given chronological age

2.      Cohort Effects: consequences of having been born in a given year in a particular time period and being influenced by the culture at that time

3.      Time of Measurement effects: confound resulting from events at a particular time may have an effect on the variable being studied (e.g. what is hot to study now may not be important ten years from now)

4.      Cross-sectional Studies (approach): studying different age groups at the same time

5.      Cross-sectional studies do not permit us to draw conclusions about age over a period of time in the same persons

6.      Longitudinal Studies (approach): studying the same individuals over an extended period of time

7.      Conclusions drawn from a longitudinal approach are restricted to the particular cohort group being studied. A Time-of –measurement effect could also influence results – for example, questions on sexual behavior that might be asked at present would not have been asked in the 1940’s

8.      Selective Mortality: for example, persons at the end of a 30 year longitudinal study may be healthier than the ones who died before the study was complete


Psychological Disorders in Late Life


I.  General Factors

      1. The primary problem of old age is cognitive impairment

      2. For men and women over age 65,  14% have mild cognitive impairment

      3. Severe cognitive impairment occurs in 5.5% of men and 4.5% of women over 65

      4. Approximately 10 to 20% of persons over 65 have psychological problems severe

          enough to warrant professional attention


II. Depression

1.      Mood disorders are less frequent in older adults than younger adults (under 3% as compared to high estimates of 20%)

2.      Unipolar depression is much more common than bipolar depression

3.      Whites have a higher incidence of depression than minorities

4.      Older adults who are depressed have fewer guilt feelings but more somatic complaints

5.      Older depressed adults have more motor retardation but less hostility and less suicidal ideation than younger depressed patients, but actual suicide attempts and completions increase in older men

6.      Sometimes the symptoms of depression (which may be reversible) are confused with dementia (not reversible)

7.      Approximately 44% of older individuals with depression are medically ill

8.      It is possible that individuals who are depressed may be predisposed to develop physical illnesses

9.      Older individuals who must assume a caretaker role, very often report depression

10.  Many of the treatment approaches effective for younger clients are also effective for older ones


III. Anxiety Disorder

  1. Anxiety disorders are more prevalent among the elderly than depression
  2. Symptoms of anxiety do not change with age
  3. Anxiety problems are often associated with medical illness
  4. Many older veterans still suffer from the effects of PTSD
  5. Treatment approaches for anxiety disorders are similar in effectiveness for older and younger persons
  6. Because of health and drug interactions, medication for anxiety disorders tends to be more risky


III. Delusional (paranoid) disorders

1.      Paranoia in the elderly may be a continuation of earlier problems or related to brain diseases

2.      Isolation may prevent the elderly from experiences which tend to minimize paranoid delusion systems

3.      Treatment of the elderly is similar to treatments with the young


IV. Schizophrenia

  1. Prevalence of schizophrenia in the elderly is lower than that for the general population
  2. Treatment is similar to younger adults and both medication and behavioral approaches  are effective in treating older persons with schizophresnia


Aging: Psychological Disorders, Treatment, and Care


Substance Abuse in Older Adults


I.  Alcohol Abuse and Dependence

     1.  Alcohol abuse is less prevalent in older populations – about 3.1 % for men and

           0.46% for women

     2.   Alcohol tolerance decreases with age

     3.   Cognitive deficits in older persons – lack memory problems are more pronounced


II.  Substance Abuse

1.      Older population abuses illegal drugs less -none over 65 and only 1% from 45-64

2.      Estimates are that illegal drug use will increase as new cohorts grow older


III. Medication Misuse

  1. Older persons are about 13% of the population but consume about a third of prescription drugs
  2. Benzodiazepine rates are about 14 to 37% of community dwelling older persons
  3. Older adults may be more likely to abuse tranquilizers, antidepressants, or sleep aids which may have been prescribed years earlier
  4. Medication related problems may result in slurred speech or other changes that may be erroneously attributed to age
  5. If an older person quits (cold Turkey) a drug for which physiological dependence has developed, the risk of cardiovascular complications is increased


IV Hypochondriasis

  1. The data indicates that only 0.1 % of persons 65 and older have been diagnosed as

       having a somatization disorder

  1. There is little data to support the belief that the elderly tend to whine more about

       somatic complaints


V. Sleep Disorders

       1.   Between ages 65 and 79, 25% have insomnia

       2.   Another 20% had sleep problems but less serious

       3.   Older adults sleep a little less or the same amount as younger persons, but they

              take longer to fall asleep and  have more sleep interruptions

  1. Older adults spend less time in rapid eye movement sleep (REM)
  2. Stage 4 is virtually absent in older persons
  3. Older men probably experience more disturbances than women because of prostate problems which may cause more frequent urination
  4. Pain, particularly arthritis, is a major disrupter of sleep in older persons
  5. Both snoring and sleep apnea increase as problems in older persons
  6. Research suggests that cognitive behavioral approaches alone may be more effective in treating insomnia in the elderly than medication alone. In terms of a two-year follow-up, the cognitive behavioral approach alone was more effective than either medication alone or the combined approach of medication and cognitive therapy


VI.  Suicide

1.      Suicide is a behavioral act, not a psychological disorder

2.      Over 65, suicide rates may be as high as three times that of younger persons

3.      For men, the suicide rate rises from youth  and continues in liner fashion

4.      For women, suicide peaks in their fifties then slightly and steadily declines

5.      Older persons are less likely to communicate suicidal intentions

6.      Older people more likely to use lethal methods

7.      Past age 65, attempts rarely fail

8.      Sub-intentioned suicide: letting one’s self die by deliberate neglect of health

9.      Suicide in older persons may be based more on a rational or philosophical decision

10.  reduced rates occur if depression in the elderly is identified and treated


VII. Sexuality and Aging

1.      Healthy 80 to 100 year-olds tend to prefer caressing and masturbation with some occasions of sexual intercourse

2.      The best predictor of continued sexual activity in the older years is past sexual enjoyment and frequency

3.      HIV infection among the elderly is a rapidly growing problem (may be in part due to Viagra)

4.      Research in the 1950’s and 1960’s indicated a decline in sexual activity beginning around age 30 and continuing, however, more recent research indicates no decline in sexual activity between ages 46 and 70 and that 15% of older persons increased their sexual activity as they grew older

5.      A later study reported that men with no cognitive impairment and residing in nursing homes expressed high levels of interest in sexual activity and sexual intercourse and other forms of sexual behavior if partners were available

6.      Earlier research reporting a decline in sexual activity, may have involved both cohort effects and time-of-measurement effects

7.      Much of our knowledge about physiological changes in sexual activity of older persons began with the research of Masters and Johnson

8.      Men: older men take longer to achieve an erection, a longer time before ejaculation, fewer contractions during the orgasm phase, less expulsion of seminal fluid, and have a longer refractory period than younger men

9.      Women: older women are capable of a t least as much sexual activity as younger women, they need more time to become sexually aroused, vaginal lubrication is slower and reduced, vaginal contractions during orgasm are fewer in number (sometimes spastic contractions of the vagina and uterus during orgasm rather than rhythmic ones can cause discomfort and possible pain), the return to a less aroused state tends to be faster than younger women

10.  As is true for men, women who have been sexually stimulated on a regular basis (once or twice a week) throughout their sexual lives, show less adverse physical changes with age such as discomfort or pain or less pleasurable responses to sexual stimulation

11.  Physical illness in the older person can adversely affect sexual behavior. For example, diabetes in both men and women can result in nerve damage and less blood supply to the genitalia (older women complain less than older men about negative effects)

12.  Tranquilizers and antihypertensive drugs can bring about sexual dysfunction

13.  Heart related problems can cause performance anxiety or distractions caused by fear of increased heart rate – however, the increase might even be therapeutic in the same fashion as aerobic activities

14.  Sexual activity of older women typically involves a healthy partner. Thus, older women without sexual partners may be less sexually active than older men.

15.  Older widowers have a remarriage rate seven times that of older women and tend to remarry younger women

16.  Nursing homes tend to be a little prudish and intolerant of sexual activity – some do not permit married individuals to share the same room

17.  Physicians tend to ignore sexual matters when treating older persons


Special Considerations Regarding Treatment


I.  General Factors

     1. Older people with psychological problems are less likely to be referred for mental

          Health services than younger people

2.  Clinicians tend to expect less success when treating older persons

3.      Research generally suggests that psychotherapy with older persons is no less successful than therapy with younger persons

4.      Most persons needing mental health treatment now live in nursing homes or receive community-based care


II. Nursing Homes

1.      Typically, families place individuals in nursing homes as a last resort and at least one report indicates the decision has a positive effect on family relations

2.      One study randomly assigned older adults to one of three conditions of care: (1) intensive, (2) intermediate, and (3) minimal. After six months, the death rate of those in intensive care was four times that of people in minimal care  and the death rate in the intermediate care group was twice that of the minimal care group

3.      Nursing care tends to foster dependency, e.g. feeding a person who can eat by themselves but takes longer and spills more food – lack of activity leads to poor muscle tone or atrophy

4.      Recently, an 18 month review released in 2002 by the Senate Special Committee on Aging indicated that nursing assistants inadequately trained, overworked, and underpaid. Many do not speak the same language as the residents, often are high school drop outs and homeless, and some work two jobs for 18 hours a day. Turnover is high.


III. Alternative Living Settings

1.      Assisted Living:  fastest growing category for housing of older adults

2.      The philosophy of assisted living is a stress on autonomy, independence, dignity, and privacy

3.      Living facilities resemble hotels – separate rooms, dining rooms, and on site amenities such as barber shops and beauty salons. Many have daily activities such as bingo and movies

4.      Continuing Care Retirement Communities: offer a continuum of care which enables residents to move depending on the level of their needs


IV. Community-Based Care

1.      Approximately 95% of older persons reside in the community

2.      Some communities provide a range of services such as telephone reassurance, meals on wheels, home visitors, senior centers, home visits by health professionals, etc.

3.      The bureaucracies  are often complicated and confusing as far as arranging for appropriate services

4.      Health care providers tend to be unsympathetic and impatient


V. Therapy Issues

        1.  Mental health workers need to know and understand the social environments in 

             which their older patients live

2.      There is no relationship between level of social activity and psychological well-being among old people

3.      There is a tendency for older or terminally ill persons to rely on social selectivity

4.      Attitudes toward marriage have change from an emphasis on stability and commitment for persons now in their seventies to an emphasis on happiness and personal fulfillment for persons entering marriage at present – if the expectations of the latter are not met, divorce is a frequent option

5.      Some therapeutic approaches for the elderly focus on here and now practical problems, a more directive approach, and providing information and arranging for services by agencies

6.      Some, in the tradition of Erik Erickson, attempt to deal with the conflict between ego integrity and despair. Ego integrity refers to finding meaning in the way one has lived and despair refers to unmet goals or ambitions.  In order to address this conflict, life review-methods may involve having the patient bring in old photographs, travel to a childhood home, or writing autobiographies

7.      Behavioral Gerontology is a growing specialization – emphasizes helping persons to enhance self-esteem by focusing behaviors such as increasing self-care and mobility







CHAPTER 14:  Late Life and Neurocognitive Disorders


LECTURE 21:  Thursday, April 18, 2013


Text Assignment: 451-464


Topic: Neurocognitive Disorders in Late Life: Dementia; Delirium



Old Age and Brain Disorders


I.   Dementia (layperson’s term is Senility)

  1. Deterioration of intellectual abilities to the point that social and occupational functions are impaired
  2. Difficulty remembering things – especially involving recent memory
  3. Judgment may be impaired, person may behave impulsively, may make inappropriate sexual overtures to strangers
  4. They may have intact sensory functions but fail to recognize aspects of their surroundings
  5. Prevalence: Dementia is estimated to be about 1% in persons aged 65 to 74, about 4% in persons aged 75 to 84, and 10% in persons over age 84


Four Types of Dementia


I.   Alzheimer’s Disease

  1. Accounts for 50% of dementia
  2. More common in women (because they live longer)\
  3. Initial difficulties are in concentration and memory for newly learned material
  4. May appear absent minded and irritable
  5. With progression there is increasing memory problems, disorientation, and agitation
  6. Depression is common in about 30% of the cases
  7. The main physiological change is atrophy of the cerebral cortex, first the entorhinal cortex and hypothalamus, and later, the frontal, temporal, and parietal lobes
  8. The ventricles become enlarged
  9. Plaques: small round areas composed of the remnants of neurons and amyloid deposits (a waxy protein)
  10. Neurofibrillary Tangles: tangled abnormal protein filaments
  11. Plaques and Neuorfibrillary tangles are present throughout the cortex and the hippocampus
  12. The cerebellum, spinal cord and sensory areas of the cortex are relatively unaffected – so physically, the person may appear fairly normal
  13. The evidence tends to suggests that the tangles are more specific to Alzheimer’s and are correlated with cognitive defects
  14. There are fewer acetylcholine terminals in the brains of persons with Alzheimer’s disease. The anti-cholinergic drugs (those that reduce acetylcholine) can produce memory impairments in normal individuals
  15. Genetic factors are strongly implicated in Alzheimer’s – chromosomal disorders have been identified as important etiological factors, however identical twin studies in which one twin develops Alzheimer’s and the other does not, indicate, that in most cases, some form of environmental factors plays a role
  16. There is some evidence that higher mental ability and continued cognitive activities may reduce the risk of Alzheimer’s


II. Frontal-Temporal Dementias

1.      Results in about 10 percent of the cases

2.      Marked by extreme behavioral and personality changes

3.      May be apathetic and unresponsive or overactive and impulsive

4.      Unlike Alzheimer’s, Frontal-Temporal dementias are not closely linked to loss of cholinergic neurons


III. Frontal-Subcortical Dementias

1.      Huntington’s Chorea: caused by a single dominant gene located on chromosome number 4

2.      Parkinson’s Disease: involves the basal ganglia and markedly affects movements – can lead to dementia

3.      Normal Pressure Hydocephalus: accumulation of cerebral spinal fluid in the ventricles leading to changes in pressure – potentially reversible via surgery

4.      Vascular Dementia: most common form of dementia after Alzheimer’s – risk increases with high cholesterol – impairs circulation, increases clots, and often associated with a series of TIAs (Transient Ischemic Attacks (mini strokes)


IV. Other causes of Dementia

1.      Infectious diseases such as Encephalitis, HIV and AIDS

2.      Head traumas

3.      Brain tumors

4.      Nutritional deficiencies – especially the B-complex – e.g. alcohol dementia

5.      Kidney or liver failure

6.      Exposure to toxins


 Treatment of Dementias


I. General Considerations

  1. No treatment is clearly effective in halting or reversing Alzheimer’s disease
  2. Attempts to increase the levels of acetylcholine have been disappointing as a treatment strategy
  3. Psychological approaches primarily involve supportive therapy for the family or caretakers
  4. Prominent clocks, strategic notes, automatic dialers on phones are all examples of environmental modifications which might assist in the management of Alzheimer’s
  5. One of the most difficult decisions facing a family is when or if to institutionalize the person




I.  General Information

  1. Typically described as a clouded state of consciousness
  2. Patient sometimes has great trouble concentrating or focusing attention and cannot maintain a coherence
  3. In severe delirium, speech is rambling and incoherent
  4. Person is disoriented for time place, and possibly person
  5. During a 24n hour interval, the person may periods of alertness, coherence, and lucidity
  6. Perceptual disturbances are frequent
  7. Mood swings are common and rapidly shifting emotions give the impression of an emotional Turmoil
  8. Delirium is more common in children and older adults – it is estimated that 15 to 20% of all hospitalized older adults experience delirium
  9. Mortality rate is high – almost 40% die
  10. Delirium cases (potentially reversible such as improved diet for a person who is severely malnourished) are frequently misdiagnosed as dementia (irreversible)
  11. Hallucinations are common in delirium but rarely seen in Dementia


II. Causes of Delirium

1.      Drug intoxications and drug withdrawal reactions

2.      Metabolic and nutritional imbalances

3.      Physical illnesses such as congestive heart failure, pneumonia, urinary tract infection, cancer, kidney or liver failure, malnutrition, cerebral vascular reactions or strokes

4.      Older adults are particularly subject to delirium because of physical declines that often accompany aging

5.      Older adults with dementing disorders are the most susceptible to delirium


III. Treatment of Delirium

1.      Complete recovery is possible if it is correctly identified and if the underlying cause is amenable to treatment (such as malnutrition)

2.      Persons with untreatable conditions such as Alzheimer’s may be institutionalized because of sudden severe changes resulting from delirium. If the delirium is treated and the Alzheimer’s patient returns to their earlier state, institutionalization might not be considered – at least until the condition worsen









CHAPTER 15:  Personality and Personality Disorders


LECTURE 22:  Tuesday, April 23, 2013


Text Assignment: 465-478


Topic: Personality Disorders; Obsessive Compulsive Pertsonality; Narcissitic Personality; Schizotypal Personality; Avoidant Personality



I.   Personality Disorders: long standing, pervasive, and inflexible patterns of behavior  

      that deviate from the expectations of one’s culture and impair social and occupational   


  1. Often comorbid with disorders on Axis I
  2. Because of improved, specific diagnostic criteria, inter-rater reliability of personality disorders has improved
  3. Antisocial personality has the highest interrater reliability and the highest test-retest reliability
  4. One problem with personality disorders is that clients often meet the criteria for several different personality disorders
  5. The characteristics of a personality disorder are typically on a continuum ranging from normal to extreme – the problem in diagnosis is how extreme must the behavior pattern be before it meets the DSM IV criteria. This means that a dimensional classification system is probably more appropriate for personality disorders than a categorical classification system


Three Clusters of Personality Disorders (Clusters A, B, and C)


Cluster A (Paranoid, Schizoid, and Schizotypal) Odd or Eccentric Cluster


I.  Paranoid Personality Disorder

  1. Persons are very suspicious of others and fear being exploited or mistreated
  2. Often hostile, angry, and defensive
  3. When at fault, a strong tendency to blame others – displacement of blame
  4. Often extremely jealous when in a relationship and attempt to severely restrict the other person’s social circle
  5. There are no9 symptoms of schizophrenia such as hallucinations or cognitive disorganization
  6. The paranoid delusional system may be well systematized and seemingly credible when first presented, occasionally making it difficult for the external observer to distinguish between what is real and what is part of the delusional system
  7. Prevalence rate is about 2% and it occurs more frequently in men


II. Schizoid Personality Disorder

  1. Do not desire or enjoy social relationships
  2. No close friends and disinterest in sex
  3. Not responsive to praise or criticism from others
  4. Prevalence is about 2% and slightly less common among women


III. Schizotypal Personality Disorder

1.      Originated as a result of the study of children of persons with schizophrenia – some children show what appeared to be a more attenuated form of schizophrenia

2.      Interpersonal difficulties and excessive social anxiety

3.      Often characterized by odd beliefs, magical thinking, superstitious ness

4.      May talk to themselves and/or wear dirty or disheveled clothing

5.      Affect constricted and flat

6.      Paranoid ideation, ideas of reference (belief that events have a particular and unusual meaning for the person), and illusions

7.      High percent of comorbidity with other personality disorders – e.g., also meeting the criteria for borderline, schizoid, avoidant, narcissistic, and paranoids personality disorders

8.      Very difficult to identify the Schizotypal Personality Disorder as having distinctive diagnostic features


IV.  Etiological factors

1.      Most common idea is that the Odd/eccentric cluster is genetically linked to schizophrenia – as less severe variants of the disorder

2.      Family studies provide some evidence supporting the above assumption








CHAPTER 15:  Personality and Personality Disorders


LECTURE 23:  Thursday, April 25, 2013


Text Assignment: 479-492


Topic: Antisocial Personality; Borderline Personality; Treatment of Personality Disorders



Cluster B (Antisocial, Borderline, Histrionic, and Narcissistic) Dramatic/Erratic Cluster


I. Borderline Personality

         1.  Adopted by the DSM as official diagnosis in 1980

         2.  Core features are instability in relationships and mood

         3.  Persons are argumentative, sarcastic, and very difficult to live with

         4.  Unpredictable and impulsive behavior in many areas 

         5.  Can’t stand being alone

         6. Often depressed, suicidal, and self mutilating

         7. Prevalence is about 1% and more common among women than men


II.  Etiology:

      1.  biological factors may involve frontal lobe impairment and increased  

           activation of the amygdala and possibly a smaller response to drugs designed  

            to activate serotonin systems

       2.  Object-Relations Theory: Kernberg proposes that patients engage in a a

             defense mechanism called splitting in which things are dichotomized into good

              bad – fail to integrate positive and negative aspects of other or the self into a


3.       Hypothesizes poor parenting – inconsistent love and attention – parents may

      provide praise for achievement but are unable to provide support and warmth

4.      Data indicates of borderlines less emotionally expressive, low in cohesion, and   

       high in conflict

5.      Main problem is that family problems are more evident in a variety of childhood

6.      Problems have not be shown to be specific to borderline personality

7.      Linehan’s Diathesis-Stress Theory: two important factors – dysregulation and invalidation. Dysregulation involves a child who makes enormous demands on the family. The parents may ignore or punish the emotional outburst  - invalidation of the child’s emotional experience. Another assumption is a high rate of physical and sexual abuse.  There is mixed support for the belief that abuse is higher among borderlines than other disorders


III. Histrionic Personality Disorder

  1. Use to be called an Hysterical Personality – Greek word hysteron refers to womb or uterus, so this disorder was mostly restricted to females
  2. Persons are overly dramatic and attention seeking
  3. Very often preoccupied with physical appearance – may dress or behave provocatively and become offended if there are advances
  4. More common among divorced or single persons and more common among women – prevalence rate is about 2% and has high comorbidity with borderline personality
  5. Etiology: minimal research. Has been hypothesized that fathers behave seductively towards daughters. Also that parents talk about sex as if something dirty but behave as if it is highly desirable and exciting


IV.   Narcissistic Personality

      1.  Grandiose view of their own uniqueness and abilities

      2.  Preoccupied with fantasies of great success

      3.  Interpersonal relationships are affected by lack of empathy, arrogance,

           manipulating and taking advantage of others

  1. Prevalence rate is less than 1%
  2. Etiology: theory proposes that grandiosity masks a very fragile self-esteem.  Children fail to develop self-esteem when parents do not respond to displays of competency with approval. Parents respond to their own needs and fail to respond to child  with respect, warmth, and empathy. Result is that children do not develop an internalized self-esteem  - narcissistic personality development to bolster their sense of self


V.   Antisocial Personality Disorder and Psychopathy

 1.   Antisocial Personality: two major DSM components: (1) the presence of a 

       conduct disorder before age 15, and (2) the continuation of the pattern of

            antisocial  behavior into the adult years

2        Psychopathy: refers less to behavior and more to nthoughts and feelings

3        Psychopathy refers less to criminal behavior whereas criminal behavior is a cardinal characteristic of Antisocial Personality (75 to 85% of convicted felons meet the DSM criteria for Antisocial Personality whereas only 25% meet the criteria for Psychopathy)

4        Psychopathy involves: a poverty of emotions – positive or negative, no sense of shame, superficial charm, behaving irresponsibly or cruelly to others, impulsive thrill seeking, . Basically a selfish, remorseless person with an inflated self-estem who exploits others

5        Only 20% of Antisocial Personalities scored high on the Hare checklist

6        The person with APD in DSM does not necessarily have the lack of remorse required for a diagnosis of psychopathy.


VI.    Etiology:

1.      The role of the family: speculation – lack of affection and severe rejection, inconsistency of discipline, physical abuse, parental loss

2.      In a controlled, longitudinal study, many of the behaviors reported for children for conduct disorder did predict psychopathic behavior in the adult

3.      inconsistent discipline and no discipline and antisocial behavior of the father all predicted later psychopathy

4.      Genetic factors: an influence of genetic factors supported by twin studies. Some of the characteristics of adoptive parents such as inconsistent discipline may be a result of adopting a difficult child

5.      Emotion and Psychopathy: Studies on conditioning indicate that psychopaths are low on anxiety and were poorer than controls in avoiding shock, in resting situations, psychopaths have lower levels of skin conductance and their skin conductance is less reactive when confronted with aversive stimuli. Psychopaths do not show an increased startle response while viewing stimuli designed to elicit negative emotions

6.      It appears that emotional deficits of psychopaths, not their antisocial behavior, is linked to emotional detachment.

7.      Psychopaths showed less responsiveness to slides depicting stress than controls, suggesting less capacity for empathy

8.      Impulsivity: studies indicate impaired performance on neuropsych tests assessing frontal lobe  functions and reduced gray matter in the frontal lobes

9.      In a task designed to assess ability to learn from failure as a consequence, psychopaths continued to play despite repeated failure (loss of money). Their responses improved if they were forced to have a five second waiting period before responding

10.  In summary, research shows that psychopaths have little anxiety, lack of empathy, and behave impulsively



Anxious/Fearful Cluster (Avoidant Personality Disorder, Dependent Personality Disorder, Obsessive-Compulsive Personality Disorder)


I.  Avoidant Personality Disorder

        1.  Fearfulness of criticism, rejection, or disapproval

        2.  Extreme fear of saying something foolish, being embarrassed, or blushing

        3.  Prevalence: about 5%

        4. Possibly a more chronic variant of generalized social phobia


II.  Dependent Personality

1.      A lack of self-confidence and a sense of autonomy

2.      When close relationship ends, the person urgently seeks a replacement

3.      Prevalence is about 1.5%, more frequent among women


III. Obsessive-Compulsive Personality Disorder

1.      Perfectionist, preoccupied with schedules, details to the point of never completing tasks

2.      Stubborn, demanding, control freaks

3.      Serious, rigid, formal, and inflexible

4.      Very different from OCD – personality disorder does not include obsessions and compulsions and rarely comorbid with OCD


IV. Etiological Factors

1.      Little data supporting etiological explanations

2.      Freudian explanation of fixation at anal stage for origin of obsessive compulsive personality


Therapies for Personality Disorders


I. Therapy for Borderline Personality

     1.  Very difficult to treat – most therapists complain about clients – usually because of

           the frequent phone calls, suicidal threats, refusing to keep appointments, and

           generally refusing cooperation in the therapy process

2   .The most successful therapy reports are based on research and treatment by   

              Marsha Linehan’s Dialectical Behavior Therapy

3.      The three primary goals of this approach are (1) to teach patients to modulate and control extreme emotionality and behaviors, (2) Teach patients to tolerate feeling distressed, and (3) Help patients learn to trust their own thoughts and emotions

4.      Key aspects of treatment are to accept the patient and attempt to achieve synthesis between a thesis and an antithesis – resolving the tension between opposites and reducing black and white dichotomies

5.      Even with successful treatment of significant target behaviors, most patients still appear to be quite miserable at one year follow-up


II. Therapy for Pyschopathy

1.      For years, many therapists have felt that treatment for psychopathy was a waste of time

2.      Generally, the younger the patient the more likely they will benefit from therapy

3.      Recent research suggest that therapy, to have any effect, must be intensive- four times per week for at least a year

4.      A concern regarding treatment is the difficulty in determining whether a client is faking good or if the changes are genuine

5.      Often, after age 40, many clients appear to “mellow” out










LECTURE 24        Tuesday, April 30, 2013


Text Assignment:  pp. 493-506



Topic: Legal and Ethical Issues: Criminal Commitment/The Insanity Defense



I. Criminal Commitment

1.      Insanity defense: a legal argument that a defendant should not be held responsible for an illegal act if it is a result of a mental illness affecting rational behavior or their ability to distinguish right from wrong

2.      Criminal law rests on the assumption that people have a free will

3.      The mentally ill are assumed to lack a degree of free and cannot be blamed or held accountable because they did not choose between right or wrong


II. Landmark cases

  1. Irresistible impulse: formulated in an 1834 Ohio case. Resulted in the irresistible impulse test
  2. The M’Naghten Rule: aftermath of a murder trial in 1843 in England in which the defendant (Daniel M’Naghten, attempted to kill the Prime minister because of a “voice from God”, but killed his male secretary by mistake – resulted in the right from wrong test
  3. Durham Rule:  in 1954, Judge Bazelon  held that the accused is no criminally responsible if the unlawful act was the product of a mental disease or defect.. Bazelon left it up to psychiatry to determine if the person knew right from wrong. The Durham test has not been used since 1972
  4. American Law institute: In 1962, established two guidelines. In the first, it essentially combined the Irrisistible Impulse test and the M’Naghten Rule. In the second guideline, it specifically excluded antisocial conduct.
  5. Insanity Defense Reform Act: in the 1980’s , after a furor over John Hinckley’s NGRI b(Not guilty by reason of insanity) Congress in 1984 enacted the Insanity Defense Reform Act  - the first time the problem was addressed at a federal level. The result was that it tightened the American Law Institute guidelines, abolished the pleas of diminished capacity or diminished responsibility based on extreme passion or “temporary insanity”. The burden of proof for insanity was shifted from the prosecution to the defense
  6. Guilty but Mentally Ill (GBMI): adopted by over a dozen states – allows an accused person to be found legally guilty of a crime, but allows for psychiatric judgment on how to deal with the convicted person if they were considered to be mental ill when the act was committed
  7. Thomas Szasz makes a distinction between “descriptively responsible for a crime” – we know they committed the cat and being “ascriptively responsible” – not having to suffer a negative consequence for the act because of mental illness.
  8. The GBMI allows the usual sentence to be imposed but also allows for the mentally ill person to be treated during the incarceration


III. Insanity and Mental Illness:

      1.  A person can be diagnosed as mentally ill and held  

            responsible for a crime.

       2.  Insanity is a legal concept. It allows for a person to be labeled mentally ill but also

            to be judged as “sane” and held legally responsible.

4.      For example, Jeffrey Dahmer was “mentally ill” but found to be Sane in terms of

Knowing right from wrong and being able to control his actions


IV. Jones Vs. the US

  1. Jones was arrested for attempting to steal a jacket in 1975
  2. He was court ordered for a test to determine if he was competent to stand trial
  3. Six months later, a psychologist reported to the court that Jones was competent to stand trial although he had paranoid schizophrenia
  4. The court found that he was not guilty by reason of insanity (NGRI) and committed him for treatment
  5. After 50 days, a psychologist testified that he still suffered from schizophrenia and was a danger to self and others
  6. 17 months after the crime the court denied his request for release even though Jones claimed he had been held longer  than the year he would have been sentenced if he were not mentally ill. Request denied
  7. In 1983, more than seven years after the original offense . The Supreme Court on a 5 to 4 vote upheld an earlier decision that he remain in the hospital


V. Competency to stand trial

  1. The insanity defense refers to the person’s mental sate at the time of the crime.
  2. Competency: the test is whether the defendant has sufficient ability to consult with his lawyer with a reasonable degree of rational understanding and whether he has a rational as well as a factual understanding of the proceedings against him.     
  3. Generally, the person declared incompetent can be held without bail until declared competent to stand trial


VI. Insanity, Mental Retardation and Capital Punishment

  1. Eighteen of 38 states hat allow capital punishment prohibit execution of the mentally retarded on grounds of the Eighth Amendment (cruel and inhuman punishment)
  2. An appeal to the Supreme Court could make the above the law of the land








LECTURE 25        Thursday, May 2, 2013


Text Assignment:  pp. 506-519


 Topic: Civil Commitment: Legal and Ethical Issues:


I.  Civil Commitments is not a commitment because of an illegal act

1.      In virtually all states, persons can be committed to a psychiatric hospital if: (1) they are mentally ill and (2) if they are a danger to themselves or others

2.      The principal criterion for a danger to others is imminent dangerousness

3.      A formal civil commitment involves a commitment by order of the court

4.      An informal commitment involves an emergency commitment without a court order

5.      An informal commitment can be done by two physicians, the police taking a person out of control to the emergency room, or by a hospital administrative board that judges a voluntarily admitted person to dangerous to be released 

6.      Detainment without a formal court order can be for 24 hours or as long as 20 days


II. Preventive Detention

  1. Except for mental Illness, the constitutional system is organized to protect persons from preventive attention
  2. The rationale for preventive detention for the mentally ill is the element of dangerousness
  3. Only 3% of violence in the US is linked to mental illness
  4. 90% of persons diagnosed as psychotic are not violent
  5. Prediction of dangerousness or violence is most accurate if

(a)   The person has been violent in the past

(b)   If past violence was a single, but very serious act

(c)   If a person appears on the brink of violence – e.g. is threatening someone with a loaded gun


IV. Outpatient Commitment

  1. Commitment to a halfway house or other least restrictive facility to increase medical compliance
  2. Sexually violent predator acts may allow for a mentally ill person that is about to be released from prison to be civilly committed to a prison hospital until cured by treatment


The Tarasoff Case


I. Background

1.      A counseling center psychologist in California was taking steps to have a person civilly committed because the person was considered dangerous

2.      The psychologist notified the campus police of the danger

3.      The police took no action other than referral back to the counseling center

4.      The supervising psychiatrists decided that further commitment efforts were not necessary

5.      Poddar, the client who made the threats, killed the girl that rejected him

6.      The courts held that the psychologist should have notified the victim as well as the police

7.      The Tarasoff ruling is now being applied in a number of other states


Newer Protections for the rights of Mentally ill persons


I. The Least Restrictive Alternative

1.      The least restrictive alternative: dictates that the client be treated first employing the least restrictive care

2.      Part of the assumption was that Community Centers would pride unrestrictive environments an be an option for treatment in the community

3.      The community centers, for the most part, were never built because of the economy


II. Right to Treatment

1.      The right to Treatment was extended to all civilly committed persons in a 1972 case called Wyatt v. Stickney

2.      The case resulted from widespread lack of treatment in Alabama institutions for civilly committed persons

3.      The Wyatt decision resulted in very specific requirements for the care and treatment of persons committed because of mental illness, e.g. two psychiatrists involved in the treatment of every 250 patients, three additional physicians, 12 registered nurses, 90 attendants, four psychologists and 7 social workers

4.      Subsequent court decisions may have modified or weakened the Wyatt decision to some extent


III. Right to Refuse Treatment

1.      A committed patient, with certain limitations, has the right to refuse treatment

2.      Some somatic therapies such as ECT and psychosurgery have for some time been subject to judicial review and control

3.      The patient may refuse medication, unless health professionals are of the opinion that the patient is a danger to self and others

4.      There is a trend for giving the right to refuse medication to both voluntarily an involuntarily committed patients

5.      Deciding when a patient is competent to refuse treatment is one of the most controversial topics in the mental health literature


IV. Free will and Ethics

1.      A hospitalized patient is under very strong pressure by hospital staff to accept treatment recommendations

2.      Many statements have laws recognizing Advanced Directives as legally binding. The documents, modeled after Living Wills, allow a competent individual to state how and by what means they should be treated if they become unfit to make such decisions in the future – for example, they may not want to receive ECT when depressed


V. De-institutionalization and Relevant Issues

1.      Since the 1960’s, many states have discharged as many patients as possible and limited the stays of those that are voluntarily or involuntarily admitted

2.      From a peak in the 1950s of almost a half million patients, by the late 90’s the population had dropped to around 70,000.

3.      The irony is that de-institutionalization may be contributing the problem it was suppose to alleviate – chronic mental illness – may become untreated homeless persons at the mercy of their surrounds

4.      In one large study it was found that that police officers were 20% more likely to arrest people showing signs of a mental disorder



Ethical Dilemmas in Therapy and Research


I. Ethical Dilemmas in Therapy and Research

  1. In the 1940s and 50’s, research participants were exposed to experimental situations which could have serious health consequences – like not be treated with antibiotics or given dosages of harmful radiation
  2. In most cases, the participants were of low socioeconomic status, mentally retarded, prisoners, or the object of racial prejudice – procedures were performed without informed consent
  3. Informed Consent: the recent concern about conducting research with mental patients underscores the all important concept of Informed Consent
  4. A competent person who understands that they may withdraw their participation at any time without penalty must freely give Informed Consent. They must be informed of the exact nature of their participation prior to their consent.
  5. Informed Consent cannot be presumed to obtained from disturbed individuals who do not fully understand or comprehend the nature of the research and their participation


II. Confidentiality and Privileged Communication

1.      Confidentiality: nothing must be revealed to a third party except to other professionals and those intimately involved in treatment such as a nurse or medical secretary

2.      Privileged Communication: a communication between parties that is protected by law – the recipient of the communication cannot be compelled to disclose it as a witness. The privilege applies to relationships between husbands and wives, physician and patient, pastors and the penitent, attorney and client, and psychologist and patient

3.      Confidentiality can be subject to limits when:

(a)    Therapists have been accused of malpractice and must disclose information in their defense

(b)   The patient is under sixteen and the therapist believes they are a victim of abuse or sexual molestation

(c)    The client initiates therapy to evade legal consequences after committing a crime

(d)   The client is judged by the therapist to be a danger to self and others


III. Choice of Techniques and other Ethical issues

  1. Controversy over aversion therapy
  2. Controversy over whether treatment designed to change sexual orientations should be prohibited even if requested by the client
  3. The ethical implications regarding Recovered Memories leading to the guidelines issued by the American Psychiatric Association that therapists should remain neutral when an adult patient reports sexual abuse as a child – it is not ethical according to APA to attribute such symptoms to repressed memories of childhood sexual abuse without corroborating evidence
  4. The scientific status of the validity of recovered memories is very much in dispute





FINAL EXAMS:        



SECTION 1: FINAL EXAM: TUESDAY, MAY 7, 2013: 8:00 a.m. to 9:50 a.m.



SECTION 2: FINAL EXAM: WEDNESDAY, MAY 8, 2013: 8:00 a.m. to 9:50 a.m.



NOTE: The Final exam will NOT be comprehensive but will cover only the material in Unit IV