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Course: PSY 4343, Spring 2008

School: UT Dallas

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1 Abnormal Psychology Test 1 Chapter 1 Criteria for Determining abnormality o Unusualness behavior that is unusual is often considered abnormal Rarity or statistical deviance is not a sufficient basis for labeling behavior abnormal; nevertheless it is one yardstick often used to judge abnormality o Social deviance all societies have norms (standards) that define the kinds of behaviors acceptable in given...

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Psychology 1 Abnormal Test 1 Chapter 1 Criteria for Determining abnormality o Unusualness behavior that is unusual is often considered abnormal Rarity or statistical deviance is not a sufficient basis for labeling behavior abnormal; nevertheless it is one yardstick often used to judge abnormality o Social deviance all societies have norms (standards) that define the kinds of behaviors acceptable in given context. Behavior deemed normal in one culture may be viewed as abnormal in another. Norms which arise form the practices and beliefs of specific cultures, are relative standards, not universal truths. Clinicians need to weigh cultural differences while determining what is normal and abnormal. What strikes one generation as abnormal may be considered normal by the next Standards we use in making judgments of abnormal behavior must take into account cultural norms o Faulty perceptions or interpretations of reality Normally our sensory systems and cognitive processes permit us to form accurate mental representations of the environment. Seeing things and hearing voices that are not present are considered hallucinations, which in out culture are generally taken as signs of an underlying mental disorder. Similarly, holding unfounded ideas of delusions, such as ideas of persecution that the CIA or mafia are out to get you may be regarded as signs of mental disturbance, unless of course they are. o Significant personal distress States of personal distress caused by troublesome emotions, such as anxiety, fear or depression, may be abnormal. Appropriate feelings of distress are not considered abnormal unless they persist long after the source of anguish has been removed (after most people would have adjusted) or if they are so intense that they impair the individual's ability to function o Maladaptive or self-defeating behavior Behavior that leads to unhappiness rather than self-fulfillment can be regarded as abnormal. Behavior that limits our ability to function in expected roles, or to adapt to our environments, may also be considered abnormal. o Dangerousness Behavior that is dangerous to oneself or to other people may be considered abnormal Social context is crucial Demonological model o In our culture, abnormal behavior has come to be viewed as the product of physical and psychosocial factors not demonic possession o Archeologists have unearthed human skeletons from the Stone Age with egg-sized cavities in the skull. One interpretation of these holes is that our prehistoric ancestors believed abnormal behavior was caused by the inhabitation of evil spirits. These holes might be the result of trephination the drilling of the skill to provide an outlet for those irascible spirits. Fresh bone growth indicates that some people did survive this medical procedure. o The notion of supernatural causes of abnormal behavior, or demonology was prominent in Western society until the Age of Enlightenment. Origins of the medical model o Hippocrates the celebrates physician of the Golden Age of Greece challenged the prevailing beliefs of his time by arguing that illness of the body and mind were the result of natural causes, not possession by supernatural sprites. He believed that the health of the body and mind depended on the balance of humors, or vital fluids, in the body Phlegm A lethargic or sluggish person was believed to have an excess of phlegm, from which we derive the word phlegmatic Black bile An overabundance of black bile was believed to cause depression, or melancholia. Blood An excess of blood created a sanguine disposition: cheerful, confident, and optimistic. Yellow bile An excess of yellow bile made people bilious and choleric quick tempered that is o Hippocrates classified abnormal behavior patterns, using three main categories that still find equivalents today: melancholia to characterize excessive depression Mania to refer to exceptional excitement Phrenitis to characterize bizarre behavior that might today typify schizophrenia Biological Perspective o Wilhelm Griesinger argued that abnormal behavior was rooted in diseased of the brain His views influenced another German physician, Emil Kraeplin who wrote an influential textbook on psychiatry in 1883 in which he likened mental disorders to physical diseases These two paved the way for the modern medical model which attempts to explain abnormal behavior on the basis of underlying biological defects or abnormalities, not evil spirits According to the medical model, people behaving abnormally suffer from mental illness or disorders that can be classified, like physical illnesses, according to their distinctive causes and symptoms. 2 Adopters of the medical model don't necessarily believe that every mental disorder is a product of defective biology, but they maintain that it is useful to classify patterns of abnormal behavior as disorders that can be identified on the basis of their distinctive features or symptoms Kraeplin specified two main groups of mental disorders or diseases Dementia praecox which we now call schizophrenia o Believed it was caused by a biochemical imbalance manic depressive psychosis, which is now labeled bi-polar disorder o believed it was caused by an abnormality in body metabolism his major contribution was the development of a classification system that forms the cornerstone for the current diagnostic systems o The medical model gained support in the late 19 th century with the discovery that an advanced stage of syphilis in which the bacterium that causes the disease directly invades the brain itself led to a form of disturbed behavior called general paresis. General paresis is associated with physical symptoms and psychological impairment, including personality and mood changes and with progressive deterioration of memory functioning and judgment o The medical model inspired the idea that abnormal behavior should be treated by learned professionals, not punished Psychological Perspective o Jean-martin charcot experimented with people with hysteria and showed that even though the belief of the time was that it was an affliction of the nervous system, he demonstrated that these symptoms could be removed in hysterical patients or conversely induced in normal patients by means of hypnotic suggestion o Freud reasoned that if hysterical symptoms could be made to disappear or appear through hypnosis, the mere suggestion of ideas they must be psychological, not biological in origin He concluded that whatever psychological factors give rise to hysteria, they must lie outside the range of conscious awareness. This insight underlies the first psychological perspective on abnormal behavior the psychodynamic model o Freud was influenced by Breuer Breuer labeled the therapeutic effect, catharsis, or emotional discharge of feelings Sociocultural perspective o Sociocultural theorists believe the causes of abnormal behavior may be found in the failures of society rather than in the person. Accordingly, psychological problems may be rooted in the ills of society, such as unemployment, poverty, family breakdown, injustice, ignorance and the lack of opportunity. Sociocultural factors also focus on relationships between mental health and social factors such as gender, social class, ethnicity, and lifestyle. o Sociocultural theorists observe that once a person is called mentally ill the label is hard to remove It also distorts other people's responses to the patient Mental patients are stigmatized and marginalized Biopsychosocial o Many leading scholars today endorse the view that abnormal behavior is best understood by taking into account multiple causes representing the biological, psychological and sociocultural domain. o The biopsychosocial perspective or interactionist model, informs this text's approach toward understanding the origins of abnormal behavior. It is essential to consider the interplay of biological, psychological and sociocultural factors in the development of psychological disorders Chapter 2 The biological perspective o The medical model, inspired by physicians from Hippocrates through Kraeplin, remains a powerful force in contemporary understanding of abnormal behavior. o The term biological perspective is preferred which is used to refer to attempts to understand biological bases of abnormal behavior and the use of biologically based approaches, such as drug therapy to treat psychological disorders. The biological perspective can be used without adopting the tenets of the medical model which treats abnormal behavior patterns as disorders and their feature symptoms o The nervous system The nervous system is made up of neurons, nerve cells that transmit signals or messages throughout the body Neurons transmit messaged to other neurons by means of chemical substances called neurotransmitters o Neurotransmitters induce chemical changes in receiving neurons These changes cause axons to conduct the message in electrical form o the junction or small gap between a transmitting neuron and a receiving neuron is termed a synapse o Each kind of neurotransmitter has a distinctive chemical structure. It will fit only into one kind of harbor, or receptor site, on the receiving neuron consider the analogy of a lock and key, only the right key (neurotransmitter) operates the lock, causing the postsynaptic (receiving) neuron to forward the message o the nervous system consists of two major parts central nervous system the brain and the spinal cord many nerves that link the spinal cord to higher brain levels pass through the medulla 3 The medulla plays roles in such vital functions as heart rate, respiration and blood pressure and also in sleep, sneezing and coughing. The pons transmits information about body movement and is involved in functions related to attention, sleep and respiration Behind the pons is the cerebellum o Involved in balance and motor (muscle) behavior. o Injury to the cerebellum may impair motor coordination and cause stumbling and loss of muscle tone Midbrain o The midbrain lies above the hindbrain and contains nerve pathways that link the hindbrain with the forebrain The reticular activating system starts in the hindbrain and rises through the midbrain into the lower forebrain. o The RAS which consists of weblike network of neurons, plays vital roles in sleep, attention and arousal. o RAS stimulation triggers messages that heighten alertness o Depressant drugs such as alcohol, which dampen central nervous system activity, lower RAS activity The thalamus relays sensory information (such as touch and vision) to high brain regions. o The thalamus is also involved in sleep and attention, in coordination with other structures, such as the RAS. The hypothalamus is a tiny structure located between the thalamus and the pituitary gland o The hypothalamus is vital in regulating body temperature, concentration of fluids, storage of nutrients and motivation and emotion. o By implanting electrodes in parts of the hypothalamus of animals and observing the effects when a current is switched on, researchers have found that the hypothalamus is involved in a range of motivational drives and behaviors, including hunger, thirst, sex, parenting behaviors and aggression The cerebrum is your crowing glory and is responsible for the round shape of the human head. o The surface of the cerebrum is convoluted with ridges and valleys o This surface is the cerebral cortex, the thinking, planning and executive center of the brain Notes o Central Talking about lower part of the brain including the medulla which is our breathing center Thalamus Frontal part of the brain Job to relay sensory information o Information about touch and vision o Important in sleep and attention difficulties Hypothalamus Problems with hypothalamus have difficulties with motivation, emotional regulation, eating and sleeping, sexual behavior, aggression Midbrain Reticular activation system Regulates attention and arousal Drugs that are represents like alcohol, anti-anxiety medications affect the RAS causing a depressant effect o Combining anzioltics with alcohol people accidentally kill themselves because they slow the brain down so much that they stop breathing Hind brain Cerebellum o balance o Fine motor control Medulla o Breathing o Heart rate o Blood pressure Surface of the brain Cerebrum o Cognition o Thinking o Planning o Executive functioning People who have a hard time monitoring their behavior o 4 May not realize that they are getting in your space Initiating things Getting started on tasks Checking for careless mistakes Working memory Divided attention test Remember 6 4 3 7 = rote memory 7 4 3 2 1 say those backwards = working memory A3 B4Z7L Put numbers in order first then letters = working memory o Most head injuries affect the cerebrum Neurotransmitter functions and relationships with abnormal behavior patterns Neurotransmitter Functions Associations with Abnormal Behavior Acetylcholine (Ach) Control of muscle Reduced levels found in patients with contractions and formation of Alzheimer's disease memories Dopamine Regulation of muscle Over utilization of dopamine in the brain contractions and mental may be involved in the development of processes involving learning, schizophrenia memory and emotions Norepinephrine Mental processes involved in Imbalances linked with mood disorders learning and memory such as depression Serotonin Regulation of mood states, Irregularities may be involved in depression satiety and sleep and eating disorders o Serotonin Involved in regulation of Mood Sleep Sexual activity Eating activity o Norepinephrine Mood Learning Memory o Dopamine Attention and arousal Thought processes Learning and memory Emotions or mood states o Acetylcholine Involves muscle contractions and memories Involved with Alzheimer's disease o GABA Gamma amino butyric acid Involved strongly with anxiety When people are anxious they have heightened arousal o GABA is an inhibitor peripheral nervous system connects the brain to the outer world two main divisions o somatic nervous system Transmits messages about sights, sounds, smells, temperature, and body position and so on to the brain. Messages from the brain and spinal cord to the somatic nervous system regulate intentional body movements such as raising an arm, winking or walking, breathing and subtle movements that maintain posture and balance o The autonomic nervous system Has two branches The sympathetic nervous system o Most involved in processes that mobilize the body's resources in times of stress, such as drawing energy from stored reserves to prepare the person to deal with imposing threats or dangers. 5 When we face a threat or dangerous situation, the sympathetic branch of the ANS accelerates the heart rate and breathing rate, which helps prepare our bodies to either fight or glee. Sympathetic activation in the face of a threatening stimulus is associated with emotional responses such as fear or anxiety. Because the sympathetic branch dominates when we are fearful or anxious, fear or anxiety can lead to indigestion because activation of the sympathetic nervous system Evaluating the biological perspectives on abnormal behavior Biological structures and processes are involved in many patterns of abnormal behavior Disturbances in neurotransmitter functioning and underlying brain abnormalities or defects are implicated in many psychological disorders We each possess a unique genetic code and scientists suspect that buried in that code are sequences of DNA that play important roles in determining our risk of developing many physical and mental disorders Evidence suggests that genes play a role in many psychological disorders, including schizophrenia, bipolar disorder, major depression, alcoholism , autism, dementia due to Alzheimer's The parasympathetic nervous system o When we relax the parasympathetic nervous branch decelerates the heart rate. o The parasympathetic division is most active during processes that replenish energy reserves, such as digestion. The psychological Perspective o Psychodynamic model psychodynamic theory is based on the contributions of Sigmund Freud and his followers. Freud's psychoanalytic theory is based on the belief that psychological problems such as hysteria are driven by unconscious motives and conflicts that can be traced to childhood These underlying conflicts revolve around our primitive sexual and aggressive instincts and the need to keep those primitive impulses out of conscious awareness In Freudian view, abnormal behavior patterns represent "symptoms" of the dynamic struggles taking place within the mind o The structure of the mind Freud's clinical experiences lead him to conclude that only the tip is visible. We have a conscious mind (the tip0 and a preconscious or subconscious mind In the preconscious are memories that are not in awareness, but that can be brought to awareness by focusing on them. The unconscious is the largest part of the mind and remains shrouded in mystery its contents can only be brought to awareness with great difficulty if at all o The structure of personality according to Freud's structural hypothesis, the personality is divided into three mental entities or psychic structures The Id The original psychic structure, present at birth. The repository of our baser drives and instinctual impulses, including hunger, thirst, sex and aggression Operates completely in the unconscious Follows the pleasure principal o It demands instant gratification of instincts without consideration of social rules or customs or the needs of others The Ego During the first year of life the child discovers that every demand is not instantly gratified and must learn to cope with the delay of gratification, The ego develops during this first year to organize reasonable ways of coping with frustration Stands for "reason and good sense" Seeks to curb the demands of the id and to direct behavior in keeping with social customs and expectations Gratification can thus be achieved, but not at the expense of social disapproval Governed by the reality principle o Considers what is practical and possible as well as the urging of the id o Lays the groundwork for developing a conscious sense of ourselves as distinct individuals Stands between the id and the superego o It endeavors to satisfy the cravings of the id without offending the moral standards of the superego The superego o 6 During middle childhood, the superego develops from the internalization of the moral standards and values of our parents and other key people in our lives. The superego serves as a conscience or internal moral guardian that monitors the ego and passes judgment on right and wrong It metes out punishment in the form of guilt and shame when it fins that the ego has failed to adhere to the superego's moral standards Defense mechanisms Although part of the ego rises to consciousness, some of its activity is carried out unconsciously In the unconscious the ego serves as a kind of watchdog, or censor that screens impulses form the id It uses defense mechanisms (psychological defenses0 to prevent socially unacceptable impulses form riding into consciousness If not for these defense mechanisms the darkest sins of out childhood, the primitive demands of out ids and the censures of out superegos might disable us psychologically Repression motivated forgetting the banishment of unacceptable ideas or motives to the unconscious The most basic of the defense mechanisms Defense mechanism Definition Examples Repression The ejection of anxiety-evoking A student forgets a difficult term ideas from awareness paper is due A patient in therapy forgets an appointment when anxiety evoking material is to be discussed Regression The return, under stress, to a form An adolescent cries when of behavior characteristic of an forbidden to use the family car earlier stage of development An adult becomes highly dependent on his parents following the breakup of his marriage Rationalization The use of self-deceiving A student blames her cheating on justifications for unacceptable her teacher's leaving the room behavior during a test A man explains his cheating on his income tax by saying "Everyone does it" Displacement The transfer of ideas and A worker picks a fight with her impulses from threatening or spouse after being criticized unsuitable objects onto less- sharply by a supervisor threatening objects Projection The thrusting of one's own A hostile person perceives the unacceptable impulses onto world as being a dangerous place others so that others are assumed A sexually frustrated person to harbor them interprets innocent gestures of others as sexual advances Reaction formation Assumption of behavior in A person who is angry with a opposition to one's genuine relative behaves in a "sickly impulses in order to keep sweet" manner toward that impulses repressed relative A sadistic individual becomes a physician Denial Refusal to accept the true nature Belief that one will not contract of a threat cancer or heart disease although one smokes heavily ("It can't happen to me") sublimination The channeling of primitive A person paints nudes for the impulses into positive, sake of beauty and art constructive efforts A hostile person directs aggressive energies into competitive sports Classical conditioning o The Russian physiologist Ivan Pavlov discovered the conditioned reflex (now called conditioned response) quite by accident In his laboratory he harnessed dogs to an apparatus to study their salivary response to food. Along the way he observed that the animals would salivate and secrete gastric juices even before they started to eat These responses appeared to be elicited by the sound of the food cart as it was wheeled into the room. So Pavlov undertook an experiment that showed that the animals could learn to salivate in response to other stimuli, such as the sound of a bell, if these stimuli were associated with feeding Because dogs don't normally salivate to the sound of bells, Pavlov reasoned that they had acquired this response o 7 o o He called it a conditioned response or conditioned reflex, because it had been paired with what he called an unconditioned stimulus in this case food- which naturally elicited the salivation The salivation to food, an unlearned response, Pavlov called the unconditioned response, and the bell, a previously neutral stimulus, he called the conditioned stimulus Role of Operant Conditioning o In operant conditioning responses are acquired and strengthened by their consequences. o We acquire responses or skills, such as raising our hand in class, that lead to reinforcement Reinforcers are changes in the environment (stimuli) that increase the frequency of the preceding behavior Humanistic models o Abraham Maslow believed that people have an inborn redundancy toward self-actualization to strive to become all they are capable of being. o Each of us possesses a singular cluster of traits and talents that gives us our own set of feelings and needs and out own perspective on life o By recognizing and accepting our genuine needs and feelings, by being true to ourselves, we live authentically, with meaning and purpose. o We may not decide to act out ever wish and fancy, but awareness of out authentic feelings and subjective experiences can help us make more meaningful choices o Carl Rogers held that abnormal behavior results from a distorted concept of the self Parents can help children develop a positive self-concept by showing them unconditional positive regard, that is by praising them and showing them that they are worthy of love irrespective of their behavior at any given time Parents may disapprove of a certain behavior but need to convey to their children that the behavior is undesirable , not the child. When parents show children conditional positive regard accept them only when they behave in a way the parents want them to behave- the children may learn to disown all the thoughts, feeling sand behaviors their parents have rejected. Children will develop conditions of worth, that is they will think of themselves as worthwhile only if they behave a certain way Rogers believed we become anxious when we sense our feelings and ideas are inconsistent with a distorted self-concept that mirrors what other expect us to be for example id our parents expect us to be docile and obedient but we sense ourselves becoming angry or defiant According to the humanists, we cannot fulfill all the wishes of others and remain true to ourselves. This does not mean that self-actualization invariably leads to conflict Rogers believed that people hurt one another or become antisocial in their behavior only when they are frustrated in their endeavors to reach their unique potentials In Roger's view, the pathway to self-actualization involves a process of self-discovery and self-acceptance, of getting in touch with out true feelings accepting them as out own and acting in way s that genuinely reflect them These are the goals of Roger's methods of psychotherapy, called client-centered therapy or person-centered therapy o Cognitive models Cognitive theorists study the cognitions the thoughts, beliefs, expectations and attitudes that accompany and may underlie abnormal behavior. They focus on how reality is colored by our expectations, attitude and so forth, and how inaccurate or biased processing of information about the world and out places within it can give rise to abnormal behavior. Cognitive theorists believe that out interpretations of the events in out lives, and not the events themselves, determine out emotional states Albert Ellis o A prominent cognitive theorist o Believes that troubling events in themselves do not lead to anxiety, depression or disturbed behavior. Rather it is the irrational beliefs we hold about unfortunately experiences that foster negative emotions and maladaptive behavior. Uses an ABC approach to explain the causes of the mister A activating event B Beliefs C consequence or ultimate outcome The activating event and the consequences are mediated by various beliefs Aaron Beck o Another prominent cognitive theorist, psychiatrist Aaron Beck, proposes that depression may result from errors in thinking or "cognitive distortion" such as judging oneself entirely on the basis of one's flaws or failures and interpreting events in a negative light (through blue-colored glasses, as it were). o Beck stressed the four basic types of cognitive distortions that contribute to emotional distress Selective abstraction People may selectively abstract (focus exclusively on) the parts of their experiences that reflect on their flaws and ignore evidence of their competencies. Overgeneralization 8 o People may over generalize from a few isolated experiences. Magnification o People may blow out of proportion or magnify the importance of unfortunate events Absolutist thinking o Absolutist thinking is seeing the world in black-and-white terms, rather than in shades of gray Sociocultural perspective o The sociocultural perspective proposes that a fuller accounting of abnormal behavior requires that we consider the roles of social and cultural factors, including factors relating to ethnicity, gender and social class o Sociocultural theorists seek causes of abnormal behavior in the failures of society rather than in the person o Some of the more radical social theorists even deny the existence of psychological disorders or mental illness They argue that abnormal is merely a label that society attaches to people whose behavior deviates from accepted social norms This label is used to stigmatize social deviants o A study in New Haven Connecticut showed that people from the lower socioeconomic groups were more likely to be institutionalized for psychiatric problems One reason may be that the poor have less access to private outpatient care An alternative view the social causation model holds that people form lower socioeconomic groups are at greater risk of severe behavior problems because living in poverty subjects them to a greater level of social stress than that faced by more well-to-do people Yet another view the downward drift hypothesis suggests that problem behavior such as alocholi9sm, lead people to drift downward in social status, thereby explaining the linkage between low socioeconomic status and severe behavior problems A test of the social causation model Indian casinos Four years after the money from the casino began to flow to the community, Indian children whose families were no longer below the poverty line showed a significant reduction in problem behaviors o Levels of anxiety and depression were not reduced, however o This researched lacked the experimental controls needed to firm up evidence of cause and effect, but it leads support to social causation model for at least some forms of problem behavior Biopsychosocial Perspective o Invites us to consider how multiple factors biological, psychological and social are linked in the development of abnormal behavior patterns o For some disorders the causes may be primarily or even exclusively biological in nature Mental retardation o Others may arise from learning experiences Phobias o Most psychological disorders have multiple causes involved Diathesis-Stress Model o Holds that psychological disorders arise from a combination or interaction of diathesis (vulnerability or predisposition, usually genetic in nature ) with stress. Whether the disorder actually develops depends on the type and severity of the stressors o the person experiences in life The stressors that may contribute to the development of disorders include birth complications, trauma or serious illness in childhood, childhood sexual or physical abuse, prolonged unemployment, loss of loved ones or other negative life events In some cases people with a diathesis for a particular disorder, say schizophrenia will remain free of the disorder or will develop a milder form of the disorder if the level of stress in their lives remains low or if they develop effective coping Reponses for handling the stress they encounter The stronger the diathesis the less stress that is required to trigger the disorder Originally developed as a framework for understanding schizophrenia Has since applied to other psychological disorders including depression Not all forms of the diathesis stress model are based on interaction of a biological vulnerability and life stress. Psychological diathesis may also be involves such as maladaptive personality traits and dysfunctional thinking o The strength of the biopsychosocial model its very complexity may also be its greatest weakness The model holds the view that with very few exceptions, psychological disorders or other patterns of abnormal behavior are complex phenomena that arise from multiple causes. Chapter 3 Why is classification important o For one thing, classification is the core o science o Without labeling and organizing patterns of abnormal behavior, researchers could not communicate their findings to one another, and progress toward understanding these disorders would come to a halt o Important decisions are made on the basis of classification 9 o o o Certain psychological disorders respond better to one therapy than another or to one drug than another Classification also helps clinicians predict behavior Schizophrenia for example follows a more or less predictable course Classification helps researchers identify populations with similar patterns of abnormal behavior By classifying groups of people as depressed researchers might be able to identify common factors that help explain the origins of depression DSM-IV o The DSM system, like the medical model, treats abnormal behaviors as signs or symptoms of underlying disorders or pathologies o The DSM does not assume that abnormal behaviors necessarily reflect biological causes or defects It recognizes that the caused of most mental disorders remain uncertain Some disorders may have purely biological causes where as other may have psychological causes The authors of the DSM recognize that their use of the term mental disorder is problematic because it perpetuates a long-standing but dubious distinction between mental and physical disorders We should recognize that the DSM is used to classify disorders not people Rather than classify someone as a schizophrenic or depressive, we refer to an individual with schizophrenia or a person with major depression o This difference in terminology is not simply a matter of semantics o To label someone as schizophrenic carries an unfortunate and stigmatizing implication that a person's identity is defined by the disorder he or she has Features of the DSM o The DSM is descriptive, not explanatory o It describes the diagnostic reassures or in medical terms symptoms of abnormal behaviors It does not attempt to explain their origins or adopt any particular theoretical framework, such as psychodynamic or learning theory o Using the DSM classification system, the clinician arrives at a diagnosis by matching a client's behaviors with the criteria that define particular patterns of abnormal behavior o Abnormal behavior patterns are categorized according to the features they share o The DSM recommends that clinicians assess an individual's mental state according to five factors, or axes o Together the five axes provide a broad range of information about the individual's functioning, not just a diagnosis Axis I: Clinical syndromes and other conditions that may be a focus of clinical attention This axis incorporates a wide range of clinical syndromes, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders, adjustment disorders and disorders usually first diagnosed during infancy, childhood or adolescence (except for mental retardation, which is coded on Axis II), Axis I also includes relationship problems, academic or occupational problems and bereavement, conditions that may be the focus of diagnosis and treatment but that do not in themselves constitute definable psychological disorders. Also coded on Axis I are psychological factors that affect medical conditions, such as anxiety that exacerbates an asthmatic condition or depressive symptoms that delay recovery from surgery Axis II: Personality Disorders and mental retardation Personality disorders are enduring and rigid patterns of maladaptive behavior that typically impairs relationships with others and social functioning. o These include antisocial, paranoid, narcisstic and borderline personality disorders Mental retardation which is also coded on Axis II, involved pervasive intellectual impairment People may be give either Axis I or Axis II diagnoses or a combination of the two when both apply Axis III: General medical conditions All medical conditions and diseases that may be important to the understanding or treatment of an individual's mental disorders are coded on Axis III. Medical conditions that affect the understanding or treatment of a mental disorder b (but are not direct causes of the disorder) are also listed on Axis III. o For instance a presence of a heart condition may determine whether a particular course of drug therapy should be used with a depressed person Axis IV: Psychosocial and environment problems The psychosocial and environmental problems that affect the diagnosis, treatment or outcome of a mental disorder are placed on Axis IV. o These include job loss, marital separation or divorce, homelessness or inadequate housing, lack of social support, the death or loss of a friend, or exposure to war or other disasters. o Some positive life events such as a job promotion may also be listed on Axis IV but only when they create problems for the individual such as difficulties adapting to a new job Axis V: Global Assessment of Functioning The clinician rates the clients' current level of psychological, social and occupational functioning . The clinician may also indicate the highest level of functioning achieved for at least a few months during the preceding year. 10 o o The level of current functioning indicates the current need for treatment or intensity of care The level of highest functioning is suggestive of the level of functioning that might be restored Criticisms of DAM o May psychologists and other professionals criticize the DSM on several grounds, such as relying too strongly on the medical model o In the DSM abnormal behavior patterns are classified as "mental disorders" o Mental disorders involve either emotional distress (typically depression or anxiety)m significantly impaired functioning (difficulty meeting responsibilities at work, in the family or in society at large) or behavior that places people at risk for personal suffering, pain disability or death Evaluating the DSM system o to be useful a diagnostic system such as the DSM must demonstrate reliability and validity o the DSM may be considered reliable or consistent if different evaluators using the system are likely to arrive at the same diagnoses when the evaluate the same cases o the most appropriate test of the validity of the DSM is its correspondence with observed behavior o if people diagnosed with social phobia show abnormal levels of anxiety in social situations, this evidence would help support claims of the validity of the diagnosis o we do not have evidence supporting the reliability and validity of most DSM anxiety disorder and mood disorder categories o overall it is fair to say that the validity of the DSM remains a subject of ongoing in debate and study o many diagnostic categories also show predictive validity, or ability to predict the course the disorder is likely to follow or its response to treatment o The DSM-IV-TR specifies that in order to make a diagnosis of mental disorder, the behavior in question must not merely represent a culturally expectable and sanctioned response to a particular even, even though it may seem odd in the light of the examiner's own cultural standards Advantages and Disadvantages of the DSM system o The major advantage of the DSM may be its designation of specific diagnostic criteria o The DSM Permits the clinician to readily match a client's complaints and associate features with specific standards to see which diagnosis best fits the case o The multiaxial system paints a comprehensive picture of clients by integrating information concerning abnormal behaviors, medical conditions that affect abnormal behaviors, psychosocial and environmental problems that may be stressful to the individual, and level of functioning o The possibility of multiple diagnoses prompts clinicians to consider presenting current problems (Axis I) along with the relatively long standing personality problems (Axis II) that may contribute to them o Criticisms have also been leveled against the DSM system Some critics challenge specific diagnostic criteria, such as the requirement that major depression be present for 23 or more weeks before diagnosis Others challenge the reliance on the medical model In the DSM system problem behaviors are viewed as symptoms of underlying mental disorders in much the same way that physical symptoms are signs of underlying physical disorders The very use of the term diagnosis presume the medical model is an appropriate basis for classifying abnormal behaviors Some clinicians feel that behavior, abnormal or otherwise, is too complex and meaningful to be treated as merely symptomatic They assert that he medical model focuses too much on what may happen within the individual and not enough on the external influences on behavior such as social factors and physical environment factors Another concern is that the medical model focuses on categorizing psychological (or mental) disorders rather than describing people's behavioral strengths and weakened Nor does the DSM attempt to place behavior within a framework that examines the settings, situations and cultural contexts in which behavior occurs. To behaviorally oriented psychologists the understanding of behavior, abnormal or otherwise is best approached by examining the interaction between the person and the environment. The DSM aims to determine what "disorders" people "have" not how well they can function in particular situations The behavioral model alternat5ively focuses more on behaviors that on underlying processes more on what people do than what they are or have Behaviorists and behavior therapists also use the DSM, of course in part because mental health centers and health insurance carriers require the use of a diagnostic code and in part because they want to communicate in a common language with other practitioners Reliability o The reliability of a method of assessment, like that of a diagnostic system, refers to its consistency o a reliable measure of abnormal behavior must also yield the same results on different occasions o an assessment technique has internal consistency of the different part soothe test yield consistent results o an assessment method has test-retest reliability if it yields similar results on separate occasions Validity o Assessment techniques must also be valid, o Instruments used in assessment must measure what they intend to measure 11 Using such a measure may lead an examiner to a wrong diagnosis There are different ways of measuring validity, including content, criterion and constrict validity Content validity The content validity of an assessment technique is the degree to which its content represents the behaviors associated with the trait in question Criterion validity Represents the degree to which the assessment technique correlates with an independent, external criterion (standard) of what the technique is intended to assess Predictive validity is a form of criterion validity o A test or assessment shows good predictive validity if it can be used to predict future performance or behavior Construct validity o The degree to which a test corresponds to the theoretical model of the underlying construct or trait it purports to measure Interview formats o In unstructured interview the clinician adopts his or her own style of questioning rather than following a standard format The major advantage to the unstructured interview is its spontaneity and conversational style Because the interviewer is not bound to follow any specific set of questions, there is an active give and take with the client o In a semi structured interview the clinician follows a general outline of questions designed to gather essential information but is free to ask the questions in any particular order and to branch off into other directions to follow up on important information o In a structured interview the interviewer follows a preset series of questions in a particular order Also called standard interviews Provide the highest level of reliability and consistency in reaching diagnostic judgments, which is hwy they are used frequently in research settings The Structured Clinical Interview for the DSM (SCID) includes closed-ended questions to determine the presence of behavior patterns that suggest specific diagnostic categories and open=ended questions that allow clients to elaborate their problems and feelings The SCID guides the clinician in testing diagnostic hypotheses as the interview progresses. In the course of the interview, the clinician may also assess the client's cognitive functioning with a mental status examination The specifics of the examination vary, but they typically include features such as Appearance o Appropriateness of the client's attire and grooming Mood o Prevailing emotions displayed during the interview Level of attention o Ability to maintain focus and attended to the interviewer's questions Perceptual and thinking processes o Ability to think clearly and discern reality from fantasy Orientation o Knowing who they are, where they are, and present date Judgment o Ability to make sound life decisions in a daily life Intelligence tests o Designed to measure intelligence, which is usually expressed in the form of an intelligence quotient, or an IQ o Different Wechsler scales of intelligence are used with different age groups o The Wechsler scales group questions into subtests or subscales with each subscale measuring a different intellectual ability The Wechsler scales are thus designed to offer insight into a person's relative strengths and weaknesses, and not simply yield an overall score Include both verbal and performance subtests to compare verbal and performance IQs Verbal subtests generally require knowledge of verbal concepts, performance subtests rely more on spatial relations skills Wechsler IQ scores are based on how respondent's answers deviate from those attained by their age-mates The mean whose test score at any age is defined as 100. o Another widely used intelligence test is the Stanford-Binet intelligence test Measures intelligence in children and young adults Self-report personality tests o Use structured items to measure personality traits such as emotional instability, masculinity-femininity and introversion o People are asked to respond to specific questions or statements about their feelings, thoughts, concerns attitudes , interests, beliefs and the like o Self-report personality inventories are also called objective tests because the range of possible responses is limited o Tests might ask respondents to check adjectives that apply to them, to mark statements as true or false, to select preferred activated from lists. Minnesota Multiphasic Personality Inventory (MMPI-2) o Contains more than 500 true-false statements that assess interests, habits, family relationships, physical (somatic) complaints, attitudes, beliefs and behaviors characteristic of psychological disorders o o 12 It is widely used as a test of personality as well as to assist clinicians in diagnosing abnormal behavior patters TheMMPI-2 consists of a number of individual scales composed of items that tended to be answered differently by members of carefully selected diagnostic groups such as patients diagnosed with schizophrenia or depression, than by members of normal comparison groups o The items on the MMPI are divided into various clinical scales A score of 65 or higher on a particular scale is considered clinically significant o The MMPI-2 also includes validity scales that assess tendencies to distort test responses in a favorable ("faking good") or unfavorable ("faking bad") direction o Other scales on the tests, called content scales, measure an individual's specific complaints and concerns such as anxiety, anger, family problems and problems of low self-esteem o MMPI-2 scales are regarded as reflecting continua of personality traits associated with diagnostic categories represented by the test o Because it is not tied specifically to DSM criteria, this score cannot be used to establish diagnosis o MMPI profiles may suggest possible diagnoses that can be considered in the light of other evidence o Many clinicians use the MMPI to gain general information about respondent's personality traits and attributes that may underlie their psychological problems, rather than a diagnosis per se o The validity of the MMPI-2 is supported by a large body of research findings o The test successfully discriminates between psychiatric patients and controls and between groups of people with different psychological disorders, such as anxiety versus depressive disorder o Clinical Scales of the MMPI-2 Scale number Scale label Items similar to those found on MMPI scale Sample traits of high scores 1 Hypochondrias is My stomach frequently bothers me. At times, my Many physical complains, body seems to ache all over cynical defeatist attitudes, often perceived as whiny, demanding 2 Depression Nothing seems to interest me anymore. My sleep is Depressed mood; pessimistic, often disturbed by worrisome thoughts worrisome, despondent, lethargic 3 Hysteria I sometimes become flushed for no apparent reason. Nave, egocentric, little insight I tend to take people at their word when they're into problems, immature; trying to be nice to me develops physical complaints in response to stress 4 Psychopathic deviate My parents often dislike my friends. My behavior Difficulties incorporating values sometimes got me into trouble at school of society, rebellious impulsive, antisocial tendencies; strained family relationships; poor work and school history 5 Masculinity-Femintity I like learning about electronics. (M) I would like to Males endorsing feminine work in a theater (F) attributes: have cultural and artistic interests effeminate, sensitive, passive Females endorsing male interests: Aggressive, masculine, self0confident, active, assertive, vigorous 6 Paranoia I would have been more successful in life but people Suspicious, guarded, blames didn't give me a fair break. It is not safe to trust others, resentful. Aloof, may anyone these days have paranoid delusions 7 Psychasthenia I'm one of those people who have to have some then Anxious, fearful, tense, worried, to worry about. I seem to have more fears than most insecure, difficulties people I know concentrating, obsessional, selfdoubting 8 Schizophrenia Things seem unreal to me at times. I sometimes hear Confused and illogical thinking, things that other people cannot hear. feels alienated and misunderstood, socially isolated or withdrawn, may have blatant psychotic symptoms such as hallucinations or delusional beliefs, or may lead detached, schizoid lifestyle 9 Hypomania I sometimes take on more tasks than I can possibly Energetic, possibly manic, get done. People have noticed that my speech is impulsive, optimistic, sociable, sometimes pressured or rushed active, flighty, irritable, may have overly inflated or grandiose self-image or unrealistic plans 10 Social Introversion I don't like loud parties. I was not very active in Shy, inhibited, withdrawn, school activities. introverted, lacks selfconfidence, reserved, anxious in social situations The Millon Clinical Multiaxial Inventory o o 13 THE MCMI was developed to help the clinician make diagnostic judgments within the multiaxial DSM system, especially in the personality disorders found on Axis II o The MCMI is the only objective personality test that focuses on personality style and disorders o The MMPI-2 in contrast focuses on personality patterns associated with Axis I diagnoses, such as mood disorders, anxiety disorders and schizophrenic disorders o Using the MCMI and MMPI-2 in combination may help the clinician make more subtle diagnostic distinctions than are possible with either test alone, because they assess different patterns of psychopathology o Such tests often reveal information that might not be revealed during a clinical interview or by observing the person's behavior o Test responses may therefore reflect underlying response biases such as a tendency to answer items in socially acceptable ways that may not reflect the person's true feelings o Tests are also only as valid as the criteria that were used to validate them o The original MMPI was limited in its role as diagnostic instrument by virtue of the obsolete diagnostic categories that were used to classify the original clinical groups If a test does nothing more than identify people who are likely to belong to a particular diagnostic category, its utility is usurped by more economical means of arriving at diagnoses such as the structured clinical interview Projective tests o A projective test, unlike an objective test, offers no clear, specified response options o Clients are presented with ambiguous stimuli such as inkblots and asked to respond to them o The tests are called projective because they derive from the psychodynamic belief that people impose or project their own psychological needs, drives and motives much of which like in the unconscious on their interpretations of ambiguous stimuli o More behaviorally oriented critics contend that the results of projective tests are based more on clinicians' subjective interpretations of test responses than on empirical evidence o Many projective tests have been developed including tests based on how people fill in missing words to complete sentence fragments or how they draw human figures and other objects o The two most prominent projective techniques are The Rorschach Inkblot Test Developed by a Swiss psychiatrist Herman Rorschach He found a group of 15 ink blots that seemed to do the job of helping in the diagnoses of psychological problems o Ten blots are used today because the publisher did not have the funds to reproduce all 15 ink blots in the first edition of the text on the subject Five of the inkblots are black and white and the other five have color Each inkblot is printed on a separate card which is handed to subjects in sequence Subjects are asked to tell the examiner what the blot might be or what it reminds them of o Then they are asked to explain what features of the blot (its color, form or texture) they used to form their perceptions Clinicians who use the Rorschach tend to interpret both the content and the form of the response o A response consistent with the form or contours of the blot is suggestive of adequate reality testing o People who see movement in the blots may be revealing intelligence and creativity The Thematic Apperception Test The thematic apperception test was developed by psychologist Henry Murray at Harvard University in the 1930s Apperception is a French word that can be translated as Interpreting (new ideas or impressions) on the basis of existing ideas (cognitive structures) and past experience The TAT consists of a series of cards, each depicting an ambiguous scene It is assumed that clients' responses to the cards will reflect their experiences and outlooks on life and perhaps shed light on their deep-seated needs and conflicts Psychodynamic theorists believe that people will identify with the protagonists in their stories and project underlying psychological needs and conflicts into their responses More superficially, the stories suggest how respondents might interpret or behave in similar situations in their own lives TAT results may also be suggestive of clients' attitudes toward others particularly family members and lovers Evaluation of Projective Techniques The reliability and validity of projective techniques have been the subject of extensive research and debate One problem is the lack of a standard scoring procedure o Interpretation of a person's responses depends to some degree on the subjective judgment of the examiner Critics claim that the Rorschach can lead to over predictions of psychopathology and has failed to meet overall tests of scientific utility or validity The debate over the validity and clinical utility of the Rorschach continues to rage between supporters and detractors with no resolution in sight One criticism of the TAT is that the stimulus properties of come of the cards, such as cues depicting sadness or anger, may exert too strong a stimulus pull on the subject o 14 o If so client's response may represent reactions to the stimulus cues rather than the projections of their personalities The Bender Visual Motor o One of the first neuropsychological tests to be developed and still one of the most widely used neuropsychological tests is the bender visual motor gestalt test o Consist of geometric figures that illustrate the various gestalt principles of perception o The client is asked to copy nine geometric designs o Signs of possible brain damage include rotation of the figures, distortions in shape and incorrect sizing of the figures in relation to one another o Although he bender remains a convenient and economical means of uncovering possible organic impairment, it has been criticized for producing too many false negatives that is persons with neurological impairment who make satisfactory drawings Psychological assessment the study of people's physiological responses o People sweat more heavily when they are anxious o When we sweat out skin becomes wet, increasing its ability to conduct electricity o Sweating can be measured by means of the electrodermal response or galvanic skin response o Measures of the GSR assess the amount of electricity that passes through two points on the skin, usually of the hand o We assume the person's anxiety level correlates with the amount of electricity conducted across the skin o The GSR is just one example of a physiological response measured through probes or sensors connected to the body Brain-imaging and recording techniques o Advances in medical technology have made it possible to study the workings of the brain without the need for surgery o One of the most common is the Electroencephalograph (EEG), which is a record of the electrical activity of the brain the EEG detects minute amounts of electrical activity in the brain, or brain waves, that are conducted between electrodes certain brain wave patterns are associated with mental states such as relaxation and with the different stages of sleep the EEF is used to examine brain wave patters associates with psychological disorders such as schizophrenia and with brain damage it is also used by medical personnel to reveal brain abnormalities such as tumors o Brain imaging techniques generate images that reflect the structure and functioning of the brain o In Computer tomography (ST) scan, a narrow X-ray beam is aimed at the head The tradition that passes through is measured from multiple angles The CT scan (also called CAT scan for computerized axial tomography) reveals abnormalities in shape and structure that may be suggestive of lesions, blood clots or tumors The computer enables scientists to integrate the measurements into a three-dimensional picture of the brain o Magnetic Resonance Imaging The person is placed in a donut-shaped tunnel that generates a strong magnetic field The basic idea of the MRI in the words of its inventor is to stuff a human being into a large magnet Radio waves of certain frequencies are integrated into a computer generated image of the brain, which can reveal brain abnormalities associated with psychological disorders, such as schizophrenia and obsessivecompulsive disorder A new type of MRI called functional magnetic resonance imaging (fMRI) is used to identify parts of the brain that become active when people engage in particular tasks such as vision and memory or use of speech Chapter 4 Psychodynamic therapy o Sigmund Freud was the first theorist to develop psychological model the psychodynamic model of abnormal behavior He was also the first to develop a model of psychotherapy which he called psychoanalysis, to help people who suffered from psychological disorders. Psychoanalysis was the first psychodynamic therapy Psychodynamic therapy helps the individual gain insight into and resolve the unconscious conflicts believe to lie at the root of abnormal behavior Working through these conflicts, the ego would be freed of the need to maintain defensive behaviors such as phobias, obsessive-compulsive behaviors, hysterical complaints and the like that shield it from recognition of inner turmoil Through confronting hidden impulses and the conflicts they produce, clients learn to sort out their feelings and find more constructive and socially acceptable ways of handling their impulses and wishes Free Association o The process of uttering uncensored thoughts as they come to mind o Believed to gradually break down the defenses that block awareness of unconscious processes o Clients are told not to censor or screen out thoughts but to let their minds wander "freely" from thought to though o Psychoanalysts do not believe that the process of free association is truly free Repressed impulses press for expression or release, leading to a compulsion to utter Although free association may begin with small talk, the compulsion to utter eventually leads the client to disclose more meaningful material o The ego continues to try to avert the disclosure of threatening impulses and conflicts 15 Consequently, clients may show resistance , and unwillingness or inability to recall or discuss disturbing or threatening material Clients may report that their minds suddenly go blank when they venture into sensitive areas, such a s hateful feelings toward family members or sexual yearnings Transference o Freud found that clients responded to him not only as an individual but also in ways that reflected their feelings and attitudes toward other important people in their lives o The process of analyzing and working through the transference relationship is considered an essential component of psychoanalysis o Freud believed that the transference relationship provides a vehicle for the reenactment of childhood conflicts with parents Clients may react to the analyst with the same feelings of anger, love or jealousy they felt toward their own parents Freud termed the enactment of these childhood conflicts the transference neurosis. This neurosis had to be successfully analyzed and worked through for clients to succeed in psychoanalysis o According to Freud, transference is a two-way street . o Freud felt he transferred his underlying feelings into his clients, perhaps viewing a young man as a competitor for a woman as a rejecting love interest o Freud referred to the feelings that he projected onto clients as counter transference o Psychoanalysts in training are expected to undergo psychoanalysis themselves to help them uncover motives that might lead to counter transferences in their therapeutic relationships Behavior Therapy o The systematic application of the principles of learning to the treatment of psychological disorders o Because the focus is on changing behavior not on personality change or deep probing into the past behavior therapy is relatively brief, lasting typically from a few weeks to a few months o Systematic desensitization involves a therapeutic program of exposure (in imagination or by means of pictures or slides) to progressively more fearful stimuli while one remains deeply relaxed. First the person uses a relaxation technique, such as progressive relaxation, to become deeply relaxed The client is then instructed to imagine (or perhaps view as through a series of slides) progressively more anxiety-arousing scenes. If fear is evoked the client focuses on restoring relaxation The process is repeated until the client can tolerate the scene without anxiety The client then progresses to the next scene in the fear-stimulus hierarchy The procedure is continued until the person can remain realized while imagining the most distressing scene in the hierarchy o Gradual exposure Also called in vivo, meaning in life exposure People troubled by phobias purposely expose themselves to the stimuli that evoke their fear Like systematic desensitization, the person progresses at his or her own pave through a hierarchy of progressively more anxiety-evoking stimuli Gradual exposure is often combined with cognitive techniques that focus on replacing anxiety-arousing irrational thoughts with calming rational thoughts o Modeling Individuals learn desired behaviors by observing other perform them After observing the model, the client may be assisted or guided by the therapist or the model in performing the target behavior The client receives ample reinforcement from the therapist for each attempt Modeling approaches were pioneered by Albert Bandura and his colleagues, who had remarkable success using modeling techniques with children to treat various phobias o Behavior therapists also use reinforcement techniques based on operant conditioning to shape desired behavior Parents and teachers may be trained to systematically reinforce children for appropriate behavior by showing appreciation and not extinguish inappropriate behavior by ignoring it o In institutional settings, token economy systems seek to increase adaptive behavior by rewarding patients with tokens for performing appropriate behaviors, such as self-grooming and making their beds the tokens can eventually be exchanged for desired rewards token systems have also been used to treat children with conduct disorders o Other techniques of behavior therapy include aversion conditioning Used in the treatment of substance abuse problems like smoking and alcoholism o Social skills training Used in the treatment of social anxieties and skills deficits associated with schizophrenia o Self-control techniques Used in helping people reduce excess weight and quit smoking Humanistic therapy o Focus on clients' subjective, conscious experiences o Like behavior therapists, humanistic therapists also focus more on what clients are experiencing in the present the here and now- than on the past o Seeks to expand client's self-insights o The major form of humanistic therapy is person-centered therapy (also called client centered therapy) which was developed by Carl Rogers 16 Person Centered therapy Rogers believed that people have natural motivational tendencies toward growth, fulfillment, and health In Roger's view, psychological disorders develop largely from the roadblocks that other people place in the path toward self-actualization When others are selective in their approval of our childhood feelings and behavior we may disown the criticized parts of ourselves To earn social approval we may don social masks or facades We learn to be seen and not heard and may become deaf even to our own inner voices Over time we may develop distorted self-concepts that are consistent with others' views of us As a result we may become poorly adjusted, unhappy and confused as to who and what we want Well-adjusted people make and choices take actions consistent with their personal values and needs Person-centered therapy creates conditions of warmth and acceptance in the therapeutic relationship that help clients become more aware and accepting of their true selves Rogers did not believe therapists should impose their own goals or values on their clients His focus of therapy is the person Person-centered therapy is nondirective The client, not the therapist, takes the lead and directs the course of therapy. The therapist uses reflection the restating or paraphrasing of the client's expressed feelings without interpreting them or passing judgment on them o This encourages the client to further explore his or her feelings and get in tough with deeper feelings and parts of the self that had become disowned because of social condemnation Rogers stressed the importance of creating a warm therapeutic relationship that would encourage the client to engage in self-exploration and self-expression The effective therapist should possess four basic qualities or attributes: unconditional positive regard, empathy, genuineness and congruence o First the therapist must be able to express unconditional positive regard of clients o Unconditional positive regard provides clients with a sense of security that encourages tem to explore their feelings without fear of disapproval o As clients feel accepted or prized for themselves, they are encouraged to accept themselves in turn Therapists who display empathy are able to reflect or mirror accurately their clients' experiences and feelings Therapists try to see the world through their clients' eyes or frames of reference o they listen carefully to clients and set aside their own judgments and interpretations of events o Showing empathy encouraged clients to get in touch with feelings of which they may be only dimly aware Genuineness is the ability to be open about one's feelings o Rogers admitted the had negative feelings at times during therapy sessions, typically boredom, but he attempted to express these feelings openly rather than hide them Congruence o Refers to the fit between one's thoughts, feelings and behavior o The congruent person is one whose behavior, thoughts and feelings are integrated and consistent Cognitive therapists o Focus on helping clients identify and correct maladaptive beliefs, automatic types of thinking and self-defeating attitudes that create or compound emotional problems o They believe that negative emotions such as anxiety and depression are caused by the interpretations we place on troubling events, not on the events themselves o Two prominent types of cognitive therapy Albert Ellis' relational emotive behavior therapy Believes that the adoption of irrational, self-defeating beliefs gives rise to psychological problems and negative feelings Argues that it is understandable to want other people's approval and love, but that it is irrational to believe we cannot survive without it Another irrational belief is that we must be thoroughly competent and achieving in virtually everything we seek to accomplish o We are doomed to eventually fall short of these irrational expectations and when we do, we may experience negative emotional consequences, such as depression and lowered self-esteem o Emotional difficulties such as anxiety and depression are not directly caused by negative events, rather by how we distort their meaning by viewing them through the dark-colored glasses of self-defeating beliefs In Ellis's rational emotive behavior therapy therapists actively dispute clients' irrational beliefs and the premises on which they are based and help clients to develop alternative adaptive beliefs in their place Aaron Beck's cognitive therapy Cognitive therapy, like REBT, focuses on clients maladaptive cognitions o 17 Cognitive therapists encourage clients to recognize and change errors in their thinking, called cognitive distortions, which affect their moods and impair their behavior, such as tendencies to magnify negative events and minimize personal accomplishments Cognitive therapists have clients record the thoughts that are prompted by upsetting events and note the connections between their thoughts and their emotional responses o They then help clients to dispute distorted thoughts and replace them with rational alternatives o They also use behavioral homework assignments o Carrying out such tasks counteracts the apathy and loss of motivation that tend to characterize depression and my also provide concrete evidence of competence, which helps combat self-perceptions of helplessness and inadequacy o Another type of homework assignment involves reality testing Clients are asked to test their negative beliefs in the light of reality Cognitive-behavioral Therapy o Today most behavior therapists identify with a broader model of therapy called cognitive behavioral therapy o Attempts to integrate therapeutic techniques that help individuals make changes not only in their overt behavior but also in their underlying thoughts, beliefs and attitudes o Cognitive behavior therapy draws on the assumption that thinking patterns and beliefs affect behavior and that changes in these cognitions can lead to desirable behavioral changes Group Therapy o A group of clients meets together with a therapist or a pair of therapists o Has several advantages over individual treatment Less costly to clients because several clients are treated at the same time More effective in treating groups of clients who have similar problems, such as complaints relating to anxiety, depression, lack of social skills or adjustment to divorce to other life stresses Clients learn how people with similar problems cope and receive social support from the group as well as the therapist Also provides members with opportunities to work through their problems in relating to others Group members may also rehearse social skills with one another in a supportive atmosphere o Despite these advantages, clients may prefer individual therapy for various reasons Clients may not wish to disclose their problems in a group Some clients prefer the individual attention of the therapist Some clients are too socially inhibited to feel comfortable in a group setting Because of such concerns, group therapists require that group disclosures be kept confident, that group members relate to each other supportively and nondestructively, and that group members receive the attention they need Psychopharmacology (Pharmacotherapy) o Biomedical therapies are generally administered by medical doctors, many of whom have specialized training in psychiatry or psychopharmacology. o Many family physicians or general practitioners also prescribe psychotherapeutic drugs for their patients o Biomedical approaches have had dramatic success in treating some forms of abnormal behavior, though they also have their limitations o Drugs have many unwelcome or dangerous side effects There is also the potential for abuse One of the most commonly prescribed minor tranquilizers, valium, has become a major drug of abuse among people who become psychologically and physiologically dependant on it o Anti-anxiety drugs Also called anxiolytics Combat anxiety and reduce states of muscle tension Include mild tranquilizers such as those of the benzodiazepines class of drugs Diazepam Alprazolan Also includes hypnotic sedatives Halcyon Dalmane Depress the level of activity in certain parts of the central nervous system In turn the CNS decreases the level of sympathetic nervous system activity, reducing the respiration rate and heart rate and lessening states of anxiety and tension People can die if they are addicted and abruptly stop taking them Side effects of using anti-anxiety drugs include fatigue, drowsiness and impaired motor coordination that can impair the ability to function or to operate automobiles Regular usage of the drugs can also produce tolerance, a physiological sign of dependence, which refers to the need over time for increasing dosages of a drug to achieve the same effect When used on a short-term basis antianxiety drugs can be safe and effective in treating anxiety and insomnia Rebound anxiety is another problem associated with regular use of tranquilizers Many people who regularly use antianxeity drugs report that anxiety or insomnia returns in a more severe form once they discontinue them o Antipsychotic Drugs Also called neuroleptics or major tranquilizers 18 Commonly used to treat the more flagrant features of schizophrenia and other psychotic disorders such as hallucinations, delusions and states of confusion Introduced during the 1950s many of these drugs including chlorpromazine (thorazine) thioridazine (mellaril) and fluphenazine (Prolixin) belong to the phenothiazine class of chemicals Phenothiazines appear to control psychotic features by blocking the action of the neurotransmitter dopamine at receptor sites in the brain Although the underlying cuases of schizophrenia remain unknown, researchers suspect an irregularity in the dopamine system in the brain may be involve CLozapine (CLozaril) a neuroleptic of a different chemical class than the phenothiazines is effective in treating many people with schizophrenia whose symptoms were unresponsive to other neuroleptics The use of clozapine must be carefully monitored, however because of potentially dangerous side effects The use of neuroleptics has greatly reduced the need for more restrictive forms of treatment for severely disturbed patients, such as physical restraints and confinement in padded cells and has lessened the need for long-term hospitalization o Antidepressants Tricyclics Increase the availability of the neurotransmitters norepinephrine and serotonin in the brain Imipramine (Tofranil) Amitrityline (Elavil) Doxepin (sinequan) Favored over MOAIs because they cause fewer potentially serious side effects Monoamine Oxidase Inibitors (MAOIs) Increase the availability of the neurotransmitters norepinephrine and serotonin in the brain Phenelzine (Nardil) Tranylcypromine (Parnate) Selective-serotonin Reuptake Inhibitors (SSRIs) Have more specific effects on serotonin function in the brain Fluoxetine (Prozac) Sertraline (Zoloft) They increase the availability of serotonin in the brain by interfering with its reuptake by the transmitting neuron Evidence indicaties that slightly more than half of the people with clinically significant depression who are treated with antidepressants of the tricyclic class will respond favorably o A favorable response to treatment does not mean depression is relived, however o Overall the effects of antidepressants appear to be modest at best o No particular antidepressant appears to be more clearly effective than any other Antidepressants also have beneficial effects in treating a wide range of psychological disorders, including panic disorder, social phobia, obsessive compulsive disorder and eating disorders o Lithium Lithium Carbonate A salt of the metal lithium in table form Helps stabilize the dramatic mood swings in many cases of people with bipolar disorder (formerly manic depression) People with bipolar disorder may have to continue using lithium indefinitely to control the disorder Because of potential toxicity associated with lithium, the blood levels of patients maintained on the drug must be carefully monitored Electroconvulsive Therapy o In 1939 Italian Psychiatrist Ugo Cerletti introduced the technique of electroconvulsive therapy (ECT) in psychiatric treatment he had observed the practice in some slaughterhouses of using electric shock to render animals unconscious he observed that the shocks also produced convulsions he incorrectly believed, as did other researchers in Europe at the time, that convulsions of the type found in epilepsy were incompatible with schizophrenia and that a treatment method that induced convulsions might be used to cure schizophrenia after the introduction of phenothiazines in the 50s the use of ECT became generally limited to the treatment of severe depression the introduction of the antidepressants has limited the use of ECT even further today evidence indicates that about 50% of people with major depressive disorder who fail to respond to antidepressants show significant improvement following ECT remains a source of controversy for several reasons many people including many professionals are uncomfortable about the idea of passing an electrical shock through a person's head, even if the level of shock is closely regulated and the convulsions are controlled by drugs ECT carries potential side effects, including some memory loss o Permanent loss of memory may occur for events that happen during the months that precede ECT and for several weeks afterwards o The relative effectiveness of ECT , as compared to antidepressant drugs and to alternative treatments, such as cognitive-behavioral therapy remain under study o It is associated with a high rate of relapse following treatment 19 Increasing evidence supports its effectiveness in helping people with severe depression, including cases in which depressed people fail to respond to psychotherapy or antidepressant medication ECT is generally considered a treatment of last resort Chapter 8 Mood disorders o People with mood disorders experience disturbances in mood that are unusually severe or prolonged and impair their ability to function in meeting their normal responsibilities o Types of mood disorders Depressive disorders are considered unipolar because the disturbance lies in only one emotional direction or pole down. Mood swing disorders are considered bipolar because they involve states of both depression and elation which usually appear in an alternating pattern Depressive Disorders (Unipolar disorders) Major Depressive Disorder Occurrence of one or more periods or episodes of depression (called major depressive episodes) without a history of naturally occurring manic or hypomanic episodes. People may have one major depressive episode, followed by a return to their usual state of functioning. The majority of people with a major depressive episode have recurrences that are separated by periods of normal or perhaps somewhat impaired functioning. Dysthymic Disorder A pattern of mild depression (but perhaps an irritable mood in children or adolescents) that occurs for an extended period of time in adults, typically for many years Mood Swing Disorders (Bipolar Disorders) Bipolar Disorder Disorders with one or more manic or hypomanic episodes (episodes of inflated mood and hyperactivity in which judgment and behavior are often impaired). Manic or hypomanic episodes often alternate with major depressive episodes with intervening periods of normal mood Cyclothymic Disorder A chronic mood disturbance involving numerous hypomanic episodes (episodes with manic features of a lesser degree of severity than manic episodes) and numerous periods of depressed mood or loss of interest or pleasure in activities, but no of the severity to meet the criteria for a major depressive episode Major Depressive Disorder Major depression Based on the occurrence of one or more major depressive episodes in the absence of a history of mania or hypomania In a major depressive episode the person experiences either a depressed mood (feeling sad, hopeless or "down in the dumps") or loss of interest or pleasure in all or virtually all activities for a period of at least two weeks Major depression is not simply a state of sadness People with major depressive disorder (MDD) may have poor appetite, lose or gain substantial amounts of weight, have trouble sleeping or sleep too much, and become physically agitated or at the other extreme show a marked slowing down in their motor activity People with major depression may lose interest in most of their usual activities and pursuits, have difficulty concentrating and making decisions and pursuits, have difficulty concentrating and making decisions, have pressing thoughts of death and attempt Many people with major depression believe they can handle the problem themselves. o These attitudes may explain why, despite the availability of safe and effective treatments only about half of the people with diagnosable major depression in recent nationwide survey received any treatment during the preceding year and fewer than one third of these received treatment from a mental health specialist All told about only one in five people with MDD in the nationwide survey received adequate treatment o Major depressive disorder is the most common type of diagnosable mood disorder with estimates of lifetime prevalence ranging from 10% to 25% for women and from 5% to 12% for men o Overall about 16% of the population suffer from MDD at some point in their lives, and about 7 suffer from the disorder in any given year o Effective treatment for depression leads not only to psychological improvement but also to more stable employment and increased income, as people return to a more productive level of functioning o Major depression, particularly in more severe episodes, may be accompanied by psychotic features, such as delusions that one's body is rotting from illness o Major depressive episodes may resolve in a matter of months or last for a year or more 20 o o Some people experience a single episode with a full major depression eventually have repeated occurrences Risk factors for major depression Age Initial onset is most common among young adults Socioeconomic status People lower down on the socioeconomic ladder are at greater risk than those who are better off Marital status People who are separated or divorced have higher rates than never married people Women are nearly twice as likely as men to be diagnosed with major depression Major depression typically develops in young adulthood, with an average age of onset in the mid-20s Common features of depression Changes in emotional states Changes in mood (persistent periods of feeling down, depressed, sad or blue) Evidence of tearfulness or crying Increased irritability, jumpiness or loss of temper Changes in motivation Feeling unmotivated, or having difficulty getting going in the morning or even getting out of bed Reduced level of social participation or interest in social activities Loss of enjoyment or interest in pleasurable activities Reduced interest in sex Failure to respond to praise or rewards Changes in functioning and motor behavior Moving about or talking more slowly than usual Changes in sleep habits (Sleeping too much or too little, awakening earlier than usual and having trouble getting back to sleep in early morning hours so-called early morning awakening) Changes in appetite (eating too much or too little) Changes in weight (gaining or losing weight) Functioning less effectively than usual at work or school Cognitive changes Difficulty concentrating or thinking clearly Thinking negatively about oneself and one's future Feeling guilty or remorseful about past misdeeds Lack of self-esteem or feelings of inadequacy Thinking of death or suicide o Diagnostic features of Major Depressive Episode DSM A major depressive episode is denoted by the occurrence of five or more of the following features or symptoms during a two week period, which represents a change from previous functioning. At least one of the features must involve either (1) depressed mood or (2) loss of interest or pleasure in activities. Moreover, the symptoms must cause either clinically significant levels of distress or impairment in at least one important area of functioning, such as social or occupational functioning, and must not be due directly to the use of drugs or medications, to a medical condition, or be accounted for by another psychological disorder. Further the episode must not represent a normal grief reaction to the death of a loved one that is bereavement. Depressed mood during most of the day, nearly every day. Can be irritable mood in children or adolescents Greatly reduced sense of pleasure or interest in all or almost all activities, nearly every day for most of the day A significant loss or gain of weight (more than 5% of body weight in a month) without any attempt to diet or an increase in appetite Daily (or nearly daily) insomnia or hypersomnia (oversleeping) Excessive agitation or slowing down of movement responses nearly every day Feelings of fatigue or loss of energy nearly every day Feelings of worthlessness or misplaced or excessive or inappropriate guilt nearly every day Reduced ability to concentrate to think clearly or make decisions nearly every day Recurrent thoughts of death or suicide without a specific plan or occurrence of a suicidal attempt or specific plan for committing suicide Seasonal Affective Disorder o Many peole report that their moods do vary with the weather o For some people the changing of the seasons from summer into fall and winter leads to a type of major depression called seasonal Affective (mood) disorder SAD o SAD is not a diagnostic category in its own right I the DSM-IV but it is a specific of mood disorders in which major depressive episodes occur Major depressive disorder that occurs seasonally would be diagnosed as major depressive disorder with season pattern The features of SAD include fatigue, excessive sleep, craving for carbohydrates, and weight gain 21 SAD tends to lift with the early buds of spring SAD affects women more often than men and is more common among young adults One possibility is that seasonal changes in light may alter the body's underlying biological rhythms that regulate such processes as body temperature and sleep-wake cycles Another possibility is that some parts of the central nervous system may have deficiencies in transmission of the mood-regulating neurotransmitter serotonin during the winter months Cognitive factors may play a part People with seasonal affective disorder report more automatic negative thoughts throughout the year than do non-depressed controls Whatever the underlying cause, a trial of intense light therapy, called phototherapy, often helps relieve depression Phototherapy typically consists of exposure to several hours of bright artificial light a day Postpartum depression Many perhaps even most new mothers experience mood changes periods of tearfulness and irritability following the birth of a child o These mood changes are commonly called the "maternity blues", "Postpartum blues" or "baby blues" o They usually last for a couple of days and are believed to be a normal response to hormonal changes that attend childbirth o Given these turbulent hormonal shifts, it would be "abnormal" for most women not to experience some changes in feeling states shortly following childbirth some mothers, however, undergo severe mood changes that persist for months or even a year or more o these problems in mood are referred to as postpartum depression o PPD is often accompanied by disturbances in appetite and sleep , low self-esteem and difficulties in maintaining concentration or attention An estimated 13% of mothers suffer from some form of postpartum depression o PPD is a form of major depression in which the onset of depressive episode begins within 4 weeks after childbirth o Investigators find that PPD typically is less severe than other forms of major depression and lifts relatively sooner than most o Some suicides are linked to PPD o Factors associated with a heightened risk of PPD include stress, single or first-time motherhood, financial problems, a troubled marriage, social isolation, lack of support from partners and family members, a history of depression or having an unwanted, sick or temperamentally difficult infant o Having PPD also increases the risk that the woman will suffer future depressive episodes Dysthymic Disorder o A milder form of depression seems to follow a chronic course of development that often begins in childhood or adolescence o The DSM classifies this form depression dysthmic disorder, or dysthymia, which derives from Greek roots dys, meaning "bad" or "hard" and thymos meaning "spirit" o Persons with dysthymic disorder do feel bad spirited or down in the dumps most of the time, but they are not so severely depressed as those with major depressive disorder o Whereas major depressive disorder tends to be severe and time limited, dysthymic disorder is relatively mild and nagging, typically lasting for years o Feelings of depression and social difficulties continue even after the person makes an apparent recovery o The risk of relapse is quite high, as is the risk of major depressive disorder 90% of people with dysthymia eventually develop major depression dysthymia affects about 6% of the general population at some point int heir lifetimes like major depressive disorder, dysthymic disorder is more common in women than men o in dysthymic disorder, complaints of depression may become such a fixture of people's lives that they seem to be intertwined with the personality structure the persistence of complaints may lead others to perceive the person as whining and complaining o although dysthymic disorder is less severe than major depressive disorder, persistent depressed mood and low selfesteem can affect the person's occupational and social functioning. o DSM criteria A. Depressed mood for most of the day, for more days than not, for at least 2 years. In children and adolescents, mood can be irritable and duration must be at least 1 year. B. Presence, while depressed, of two (or more) of the following: 1. poor appetite or overeating 2. insomnia or hypersomnia 3. low energy or fatigue 4. low self-esteem 5. poor concentration or difficulty making decisions 6. feelings of hopelessness C. During the 2-year period, of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time. Double depression o Some people are affected by both dysthymic disorder and major depression at the same time o The term double depression applies to those who have a major depressive episode superimposed on a longer -standing dysthymic disorder o People suffering from double depression generally have more severe depressive episodes than do people with major depression alone 22 Bipolar Disorder o A psychological disorder characterized by mood swings between states of extreme elation and depression o People with bipolar disorder ride an emotional roller coaster, swinging from the heights of elation to the depths of depression without external cause o The first episode may be either manic or depressive o Manic episodes, typically lasting from a few weeks to several months, are generally shorter in duration and end more abruptly than major depressive episodes o Bipolar I In bipolar I disorder the person experiences at least one full manic episode In many cases the person experiences mood swings between elation and depression with intervening periods of normal mood Some cases present with intervening periods of normal mood Some cases present with no evidence of major depressive episode but it is assumed that such cases, called the mixed type, a manic episode and major depressive episode occur simultaneously o Bipolar II Associated with a milder form of mania but with more frequent depressions The person has experienced one or more major depressive episodes and at least one hypomanic (mildly manic) episode But the person has never had a full-blown manic episode Whether bipolar I and bipolar II disorders represent qualitatively different disorders or different points along a continuum of severity of bipolar disorder remains to be determined Relatively uncommon with a reported lifetime prevalence rates from community surveys ranging from 0.4% to 1.6% for bipolar I and about 0.5% for bipolar II disorder Bipolar disorder typically develops around age 20 in both men and women and becomes a chronic, recurring condition requiring long-term treatment Unlike major depression, rates of bipolar I disorder appear about equal in men and women In men the onset of bipolar I disorder typically begins with a manic episode In women it usually begins with a major depressive episode The underlying reason for this gender difference remains unknown o Bipolar II disorder appears to be more common in women In some cases a pattern of "rapid cycling" occurs in which the individual experiences two or more full cycles of mania and depression within a year without any intervening normal periods o Rapid cycling is relatively uncommon o It occurs more often more often among women that men o It is usually limited to a year or less, but it is associated with poor social and job functioning Manic Episode o Manic episodes or periods of mania, typically begin abruptly gathering force within days o During a manic episode, there person experiences a sudden elevation or expansion of mood and feels unusually cheerful, euphoric or optimistic o The person seems to have boundless energy and is extremely sociable, although perhaps to the point of becoming overly demanding and overbearing toward others o Other people recognize the sudden shift in mood to be excessive in the light of the person's circumstances o People in a manic episode tend to show poor judgment and to become argumentative, sometimes going so far as destroying property o Roommates may find them abrasive and avoid them o They may become extremely generous and make large charitable contributions they can ill afford or give away costly possessions o People in a manic episode tend to speak very rapidly (with pressured speech) o Their thoughts and speech may jump from topic to topic in a rapid flight of ideas o Others find it difficult to get a word in edgewise o They typically e3xperience an inflated sense of self-esteem that may range from extreme self confidence to wholesale delusions of grandeur o They may feel capable of solving the world's problems or of composing symphonies, despite a lack of any special knowledge or talent o They also become highly distractible Their attention is easily diverted by irrelevant stimuli like the sounds of a ticking clock or people talking in the next room They tend to take on multiple tasks, more than they can handle They may suddenly quit their jobs to enroll in law school, wait tables at night, organize charity drives on weekends, and work on the great American novel in their "spare time." o Although they may have abundant stores of energy, they seem unable to organize their efforts constructively o Their elation impairs their ability to work and to maintain normal relationships o People in maniac episodes tend to exercise poor judgement and fail to weigh the consequences of their actions o They may get into trouble as a result of lavish spending, reckless driving, or sexual escapades o In severe cases they may experience hallucinations or become grossly delusional, believing for example, that they have a special relationship with God o DSM symptoms of Mania Symptoms of Mania: 23 Bipolar I Bipolar II Person shows an elevated, expansive, or irritable mood for at least one week, plus at least three of the following symptoms: 1. elevated, expansive or irritable mood 2. inflated self-esteem or grandiosity 3. decreased need for sleep 4. more talkative than usual, a pressure to keep talking 5. flight of ideas or sense that your thoughts are racing 6. distractibility 7. increase in activity directed at achieving goals 8. excessive involvement in potentially dangerous activities Major depressive episode can occur but not necessary for diagnosis Full episode of mania is required for diagnosis Hypomanic episodes can occur but not necessary Major depressive episode required for diagnosis Cannot have an episode of mania Hypomanic episodes required for diagnosis o o Cyclothymic Disorder o Derived from the Greek kyklos which means circle and thymos ("spirit") o The notion of a circular moving spirit is an apt description, because this disorder represents a chronic cyclical pattern of mood disturbance characterized by mild mood swings lasting at least 2 years o Usually beings in late adolescence or early adulthood and persists for years o Few, if any, periods of normal mood last for more than a month or two o Neither the periods of elevated or depressed mood are severe enough to warrant a diagnosis of bipolar disorder o Estimates from community studies indicate lifetime prevalence of cyclothymic disorder of between 0.4% and 1% with men and women being equally likely to be affected o The periods of elevated mood are called hypomanic episodes They are less severe than manic episodes and are not accompanied by the severe social or occupational problems associated with full blown manic episodes During hypomanic episodes people may have an inflated sense of self-esteem, may feel unusually charged with energy and may be more alert, restless and irritable than usual They may be able to work long hours with little fatigue or need for sleep Their projects may be left unfinished when their moods reverse Then they enter a mildly depressed mood state and feel lethargic and depressed, but not to the extent of a major depressive episode Approximately 33% of people with cyclothymic disorder eventually develop bipolar disorder Psychodynamic theories o The classic psychodynamic theory of depression of Freud and his followers holds that depression represents anger directed inward rather than against significant others o Anger may become directed against the self-following either the actual or threatened loss of these important others o Freus believed that mourning, or normal bereavement is a healthy process by which one eventually comes to separate oneself psychologically from a person who si lost through death, separate, divorce or other reason o Pathological mourning does not promote healthy separation it fosters lingering depression is likely to occur in people who hold powerful ambivalent feelings a combination of positive (love) and negative (anger, hostility) feelings toward the person who has departed or whose departure is feared o Freud theorized that when people lose of even if they fear losing an important figure about whom they feel ambivalent their feelings of anger turn to rage Yet rage triggers guilt which in turn prevents the person from venting anger directly at the lost person o To preserve a psychological connection to the lost object, people introject or bring inward a mental representation of the object they thus incorporate the other person into the self now anger is turned inward against the part of the self that represents the inward representation of the lost person this produces self-hatred which in turn leads to depression o from the psychodynamic viewpoint, bipolar disorder represents shifting dominance of the individual's personality between the ego and superego In the depressive phase, the superego is dominant, producing exaggerated notions of wrongdoing and flooding the individual with feelings of guilt and worthlessness After a time the ego rebounds and asserts supremacy, producing feelings of elation and self-confidence that characterize the manic phase. The excessive display of ego eventually triggers a return of guilt, once again plunging the individual into depression Learning theories o Learning theorist Peter Lewinsohn posed that depression results from an imbalance between behavior and reinforcement o A lack of reinforcement for one's efforts can sap motivation and induce feelings of depression o Inactivity and social withdrawal reduce opportunities for reinforcement Lack of reinforcement exacerbates withdrawal 24 The low rate of activity typical of depression may also be a source of secondary gain or secondary reinforcement Family members and other people may rally around people suffering from depression and release them from their responsibilities Sympathy may thus be a source of reinforcement that helps maintain depressed behavior o Reduction in reinforcement levels can occur for many reasons A person who is recuperating at home from a serious illness or injury may find little that is reinforcing to so Social reinforcement may plummet with people close to use who were suppliers of reinforcement die or leave us People who suffer social losses are more likely to become depressed when they lack the social skills for new relationships changes in life circumstances may also alter the balance of effort and reinforcement a prolonged layoff may reduce financial reinforcements, which may in turn force painful cutbacks in lifestyle a disability or an extended illness may also impair one's ability to ensure a steady flow of reinforcements there is a correspondence between depressed moods and lower rates of participation in potentially reinforcing activities people with depressive disorders were also found to report fewer pleasant activities than nondepressed people it is conceivable that depression precedes rather than follows a reduction in reinforcement Aaron Beck's cognitive Theory o One of the most influential cognitive theorist Aaron Beck, relates the development of depression to the adoption early in life of a negatively biased or distorted way of thinking the cognitive triad of depression The cognitive triad includes negative beliefs about oneself, the environment or the world at large and the future o Cognitive theory holds that people who adopt this negative way of thinking are at greater risk of becoming depressed in the face of stressful or disappointing life experiences, such as getting a poor grade or losing a jobs o Beck views these negative concepts of the self and the world as mental templates or cognitive schemes that are adopted in childhood on the basis of early learning experiences o Children may find that nothing they do is good enough to please their parents or teachers As a result they come to regard themselves as basically incompetent and to perceive their future prospects as dim These beliefs may sensitize them later in life to interpret any failure or disappointment as a reflection of something basically wrong or inadequate about themselves Even a minor disappointment becomes a crushing blow or a total defeat that can quickly lead to states of depression o The tendency to magnify the importance of minor failures is an example of an error in thinking that Beck labels a cognitive distortion He believes cognitive distortions set the stage for depression in the face of personal losses or negative life events o Psychiatrist David Burns enumerated a number of the cognitive distortions associated with depression All or nothing thinking Seeing events as either all good or all bad, as either black or white with no shades of gray Overgeneralization Believing that if a negative event occurs it is likely to occur again in a similar situation in the future Disqualifying the positive This refers to the tendency to snatch defeat from the jaws of victory by neutralizing or denying your accomplishments Jumping to conclusions Forming a negative interpretation of events, despite a lack of evidence Magnification and minimilization Magnification or catastrophizing, refers to the tendency to make mountains out of molehills to exaggerate the importance of the negative events, personal flaws, fears or mistakes Minimilization is the mirror image, a type of cognitive distortion in which one minimizes or underestimates one's good points Emotional reasoning Basing reasoning on emotions One interprets feelings and events based on emotions rather than on fair consideration of evidence Should statements Creating personal imperatives or self-commandments "shoulds" or "musts" Labeling and mislabeling Explaining behavior by attaching negative labels to oneself and others Personalization Assuming that you are responsible for other people's problems and behavior Distorted thinking tends to be experienced as automatic, as if the thoughts had just popped into one's head Learned Helplessness o The learned helplessness model proposes that people may become depressed because they learn to view themselves as helpless to change their lives for the better o o 25 The originator of the learned helplessness concept suggests that people learn to perceive themselves as helpless because o their experiences o The learned helplessness model therefore straddles the behavioral and the cognitive Situational factors foster attitudes that lead to depression o Seligman and his colleagues based the learned helplessness model on early laboratory studies of animals who were helpless to change their situation o Animals who developed learned helplessness showed behaviors that were similar to those of people with depression, including lethargy, lack of motivation and difficulty acquiring new skills o Seligman proposed that some forms of depression in humans might result from exposure to apparently uncontrollable situations Such experiences can instill the expectation that future reinforcements will also be beyond the individual's control A cruel vicious cycle may come into play in many cases of depression A few failures may produce feelings of helplessness and expectations of further failure o Seligman's model failed to account for the low self-esteem typical of people who are depressed Nor did it explain why depression persists in some people but not in others Deligman and his colleagues offered a reformulation of the theory to meet such shortcomings The revised theory help that perception of lack of control over reinforcement alone did not explain the persistence and severity of depression It was also necessary to consider cognitive factors, especially the ways in which people explain their failures and disappointments to themselves o Seligman and his colleagues recast helpless theory in terms of the social psychology concept of attributional style An attributional style is a personal style of explanation When disappointments or failures occur, we may explain them in various characteristic ways We may blame ourselves ( an internal attribution) We may blame the circumstances we face (an external attribution) We may see bad experiences as typical events (a stable attribution) We may see then as isolated events (an unstable attribution) We may see them as evidence of broader problems (a global attribution) We may see them as evidence of precise and limited shortcomings ( a specific attribution) The reformulated helplessness theory holds that people who explain the causes of negative events (like failure in school or romantic relationships) according to these three types of attribution are most vulnerable to depression Internal factors o Beliefs that failures reflect their personal inadequacies, rather than external factors or beliefs that failures are caused by environmental factors o Global factors, or beliefs that failures reflect sweeping flaws in personality rather than specific factors, or beliefs that failures reflect limited areas of functioning o Stable factors or beliefs that failures reflect fixed personality factors rather than unstable factors, or beliefs that the factors leading to failures are changeable The revised theory holds that each attributional dimension makes a specific contribution to feelings of helplessness Internal attributions for negative events are linked to lower self-esteem Stable attributions help explain the persistence or in medical terms the chronicity of helplessness cognitions Global attributions are associated with the generality or pervasiveness of feelings of helplessness following negative events Depressed people are more likely than nondepressed people to have a negative attributional style Biological factors o A growing body of knowledge implicates genetic factors in mood disorders We know that mood disorders, including major depression and especially bipolar disorder, tend to run in families Families, however, share environmental similarities as well as genes Family members may share blue eyes, bur also a common religion Yet evidence pointing to a genetic basis for mood disorders comes from studies showing that the closer the genetic relationship one shares with a person with major mood disorder, the greater the likelihood that one will also suffer from a major mood disorder o All in all, researchers believe that heredity plays an important role in major depression Genetics isn't the only determinant, nr is it necessarily the most important Environmental factors such as exposure to stressful life events appear to play at least as great a role o All in all it appears that major depression is a complex disorder that is caused by a combination of genetic and environmental factors Similarly, most scientists believe that there is no single cause for bipolar disorder, but that genetics plays and important role, perhaps even more important role than in major depressive disorder Biochemical factors and brain abnormalities o Early research on the biological underpinnings of depression focused on deficits in neurotransmitter levels in the brain o Brain imaging studies show lower metabolic activity of the prefrontal cortex in clinically depressed people as compared to healthy controls o 26 The prefrontal cortex lies in the frontal lobes of the cerebral cortex and is the area of the brain responsible for higher mental functions, such as thinking, problem solving and decision making and organizing thoughts and behaviors The neurotramsmitters serotonin and norepinephrine play important roles in regulating nerve impulses in the prefrontal cortex, so it is not surprising that evidence points to irregularities in this region of the brain Depression and other mood disorders involve the interplay of multiple factors Consistent with the diathesis-stress model, depression may reflect an interaction of biological factors (such as genetic factors, neurotransmitter irregularities or brain abnormalities), psychological factors (such as cognitive distortions or learned helplessness) and social and environmental stressors (such as divorce or loss of a job) o Stressful life events may have a depressing effect by reducing neurotransmitter activity in the brain These biochemical effects may be more likely to occur or may be more pronounced in people with a genetic predisposition or diathesis for depression o A depressive disorder may not develop or may develop in a milder form in people with more effective coping resources for handling stressful situations o Sociocultural factors can be sources of stress that influence the development r recurrence of mood disorders Poverty Overcrowding Exposure to racism Sexism Prejudice Violence in the home or community Unequal stressful burdens placed on women Family disintegration o Other sources of stress that can contribute to mood disorders include negative life events Loss of a job Development of a serious illness Breakup of a romantic relationship Loss of a loved one o The diathesis for depression may take the form of a psychological vulnerability involving a depressive thinking style, one characterized by tendencies to exaggerate the consequences of negative events, to heap blame on to oneself and to perceive oneself as helpless to effect positive change This cognitive diathesis may increase the risk of depression in the face of negative life events The cognitive influences may also interact with a genetically based diathesis to further increase the risk of depression following stressful life events The availability of social support from others may help bolster a person's resistance to stress during difficult times People with more effective social skills may be better able to garner and maintain social reinforcement from others and thus be better able to resist depression than people lacking social skills Biochemical changes in the brain might make it more difficult for the person to cope effectively and bounce back from stressful life events Gender-related differences in coping styles may also come into play According to Nolen Hoeksema, women e more likely to ruminate when facing emotional problems and men are more likely to abuse alcohol o May propel women into longer and more severe bouts of depression while setting the state for the development of drinking problems in men Psychodynamic Approaches o Traditional psychoanalysis aims to help people who become depressed understand their ambivalent feelings toward important people (objects) in their lives they have lost or whose loss was threatened By working through feelings of anger toward these lost objects, people can turn anger outward through verbal expression of feelings rather than leave it to fester and turn inward o Traditional psychoanalysis can take years to uncover and deal with unconscious conflicts o Modern psychoanalytic approaches also focus on unconscious conflicts, but they are more direct, relatively brief and focus on present as well as past conflicted relationships One contemporary example is interpersonal psychotherapy A brief form of therapy that focuses on the client's current interpersonal relationships The developers of ITP believe that depression occurs within an interpersonal context and that relationship issues should be emphasized in treatment Has been shown to be an effective treatment for major depression and shows promise in treating other psychological disorders, including dysthymic disorder and bulimia Behavioral Approaches o Lewinsohn and his colleagues developed a 12-session 8-week group therapy program organized as a course the Coping With Depression Course The course helps clients acquire relaxation skills, increase pleasant activities, and build social skills that enable them to obtain social reinforcement Participants are taught to generate a self-change plan, to think more constructively and to develop a lifetime plan for maintaining treatment gains and preventing recurrent depression The therapist is considered a teacher, the client a student and the session a class Each participant is a responsible adult who is capable of learning 27 The structure involves lectures, activities and homework and each session follows a structured lesson plan Cognitive approaches o Cognitive therapists believe that distorted thinking (cognitive distortions) play a key role in the development of depression o Depressed people typically focus on how they are feeling rather than on the thoughts that may underlie their feeling states They usually pay more attention to how bad they feel than to the thoughts that may trigger or maintain their depressed moods o Aaron beck and his colleagues have developed a multicomponent treatment approach, called cognitive therapy, which focuses on helping people with depression learn to recognize and correct their dysfunctional thinking patterns o cognitive therapy, like behavior therapy, is relatively brief frequently 14 to 16 week sessions o therapists use a combination of behavioral and cognitive techniques to help clients identify and change dysfunctional thoughts and develop more adaptive behaviors o the benefits of cognitive therapy appear to be at least equal to those of antidepressant medication in treating depression the combination of antidepressant medication and psychotherapy produced slightly better outcomes as compared to either psychotherapy or medication alone Biological Approaches o Antidepressant Drugs Drugs used to treat depression include several classes of antidepressants that increase the availability of key neurotransmitters in the brain Tricyclic antidepressants o Highly toxic, which raises the prospect of suicidal overdoese if used without close supervision Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors o Not only lift mood but in many cases eliminate delusions that may accompany severe depression o About equal in effectiveness to the older generation of tricyclics o Because they hold two major advantages they have largely replaced the earlier drugs Less toxic and so are less dangerous in overdose They have fewer of the common side effects (such as dry mouth, constipation, and weight gain) associated with the tricyclics and MAOis. Prozac and other SSRIs may produce side effects Upset stomach Headaches Agitation Insomnia Lack of sexual drive Delayed orgasm The precise mechanisms by which they work to relieve depression remain unclear Though antidepressants boost levels of neurotranmitters in the brain within a few days or even hours of use, it usually takes several weeks of treatment before the therapeutic benefit is achieved o The therapeutic benefits of these drugs involve more complex actions than simply increasing the availability of nerotranitters in the brain o One possibility is that they enhance the actions of effectiveness of neurotransmitters by altering the sensitivity of postsynaptic neurons to these chemical messengers Clearly effective in many cases in helping relieve major depression and dysthmia All antidepressants increase availability of neurotransmitters but do so in different ways Tricyclics o Includes imipramine (Tofranil) Amitrityline (Elavil) Despiramine (Norpramin) Doxepin (SInequan) o So named because of their three-ringed molecular structure o Increase brain levels of norepinephrine and serotonin by interfering with the reuptake of (the reabsorption by the transmitting cell) of these chemical messengers SSRIs o Work in a similar way to tricycles but are more specific on raising the levels of serotonin in the brain o Fluoxetine (Prozac) MAOis o Increase the availability of neurotransmitters by inhibiting the action of monoamine oxidase An enzyme that normally breaks down or degrades neurotransmitters in the synaptic cleft o Used less widely than other antidepressants because of potentially serious interactions with certain foods and alcoholic beverages 28 the potential side effects of tricyclics and MAOis include dry mouth, psychomotor retardation, constipation, blurred vision, sexual dysfunction and less frequently, urinary retention, paralytic ileus ( a paralysis of the intestines, which impairs the passage of intestinal contents), confusion, delirium and cardiovascular complications such as reduced blood pressure there is a high rate of relapse following discontinuation of medication psychology based therapies may provide greater protection against relapse o presumably because the learning that occurs during therapy carries past the end of active treatment o adding cognitive-behavioral therapy to medication treatment may help reduce the risk of relapse after the drugs are withdrawn Electroconvulsive therapy (ECT) More commonly called shock therapy Continues to evoke controversy The idea of passing an electric current through someone's brain may seem barbaric Generally dame and effective treatment for severe depression It can help relieve depression in many cases in which alternative treatments have failed An electrical current of between 70 and 130 volts is applied to the head to induce a convulsion that is similar to a grand mal seizure Usually administered in a series of 6 to 12 treatments given 3 times per week over several weeks The patient is put to sleep with a brief-acting general anesthetic and given a muscle relaxer to avoid wild convulsions that might result in injury Spasms may barely be perceptible to onlookers The patient awakens soon after the procedure and generally remembers nothing Had earlier been used in the treatment of a wide variety of psychological disorders, including schizophrenia and bipolar disorder The APA recommended in 1990 that ECT be used only to treat major depressive disorder in people who do not respond to antidepressant medication Leads to a significant improvement in a majority of people with major depression who have failed to respond to antidepressant medication Results in shorter less costly hospitalizations for major depression High rate of relapse About two thirds of patients whose depression had remitted following ECT experienced a relapse within 6 months Depression often returns even among patients who continue to be treated with antidepressant medication Many professionals view ECT as a treatment of last resort, to be considered only after other treatment approaches have been tried and failed 13% of US adults have experienced suicidal thoughts 4.^% make a suicide attempt Most people who have suicidal thoughts do not act on them Suicidal behavior is not a psychological disorder in itself Often a feature or symptom of an underlying psychological disorder, usually a mood disorder The federal government estimates that about 60% of the people who commit suicide duffer from a mood disorder Who commits suicide Suicide rates are highest among adults age 65 and older Especially white males Older people are more susceptible to disease such as cancer and Alzheimer's which can leave them with feelings of helplessness and hopelessness that in turn can give rise to suicidal thinking Many older adults also suffer a mounting accumulation of losses of friends and loved ones, leading to social isolation o These losses as well as the loss of good health and of a responsible role in the community may wear down the will to live o Higher rates are among those who are widowed or socially isolated More women attempt suicide but more men succeed For every female suicide there are four male suicides More males succeed in large part because they tend to choose quicker acting and more lethal means such as handguns Men are also more likely to have a history of alcohol and drug abuse and less likely to have children in the home o When these factors were taken into account, gender differences in suicide risk disappeared Suicide rates among adolescents are highest among white males Native Americans are at increased risk of suicide attempts and completed suicides o Have a suicide rate that is 50% higher than other groups o Native American adolescents and young adults have the highest suicide rates in the nation o Hopelessness and exposure to others who have attempted or complete suicide may contribute to the increased risk o Suicide o o o o o o 29 At greatest risk tend to be reared in communities that are largely isolated from US society at large They perceive themselves as having relatively few opportunities to gain skills necessary to join the workforce in the larger society and are also relatively more prone to substance abuse, including alcohol abuse Knowledge that peers have attempts or completed suicide renders suicide a highly visible escape from psychological pain Suicidal thinking does not necessarily imply loss of touch with reality, deep-seated unconscious conflict or a personality disorder Having thoughts about suicide generally reflects a narrowing of the range of options people think are available to them to deal with their problems That is they are discouraged by their problems and see no other way out The risk of suicide is greatly elevated among people with severe mood disorders such as major depression and bipolar disorder As many as 1 in 5 people with bipolar disorder eventually commits suicide Attempted or completed suicide is also linked to other psychological disorders such as alcoholism and drug dependence, schizophrenia, panic disorder, personality disorders, posttraumatic stress disorders, borderline personality disorder and a family history of suicide Not all suicides are connected with psychological disorders Some people suffering from painful and hopeless physical illness seek to escape further suffering by taking their own lives These suicides are sometimes labeled "rational suicides" in the belief that they are based on a rational decision that life is no longer worth living in the light of continual suffering In perhaps many of these cases the person's judgment and reasoning ability may be colored by an underlying and potentially treatable psychological disorder such as depression Other suicides are motivated by a deep-seated religious or political convictions such as the case of people who sacrifice themselves in acts of protest against their governments or who kill themselves and others in homicide bombings in the belief that their acts will be rewarded in an afterlife Suicidal attempts often occur in response to highly stressful life events, especially exit events such as the death of a spouse, close friend or relative, divorce or separation, a family member's leaving home or the loss of a close friend People who consider suicide in times of stress may lack problem-solving skills and be unable to find alternative ways of coping with stressors Theoretical perspectives on suicide The classic psychodynamic model views depression as the turning inward of anger against the internal representation of a lost love object Suicide then represents inward directed anger that turns murderous Suicidal people then do not seek to destroy themselves, instead they seek to vent their rage against the internalized representation of the love object o In so doing they destroy themselves as well in the 19th century social thinker emile durkheim noted that people who experienced anomie who feel lose without identity, rootless- are more likely to commit suicide. Sociocultural theorists likewise believe that alienation may play a role in suicide In our modern mobile society people frequently move hundred or thousand of miles to schools and jobs o Many people are thereby socially isolated or cut off from their support groups o Moreover, city dwellers tend to limit or discourage informal social contacts because of crowding, over stimulation and fear of crime o It is thus understandable that many people find few sources of support in times of crisis o In some cases the family support is available but not helpful o Family members may be perceived as part of the problem not part of the solution Learning theorists focus largely on the lack of problem solving skills for handling life stress According to shneidman those who attempt suicide wish to escape unbearable psychological pain and may perceive no other way out People who threaten or attempt suicide may also receive sympathy and support from loved ones and others perhaps making future and more lethal attempts likely o This is not to suggest that suicide attempts or gestures should be ignored People who threatened suicide are NOT merely seeking attention Although those who threaten suicide may not carry out the act they should be taken very seriously People who commit suicide often tell others of their intentions or provide clues Many people make aborted suicide attempts before they go on to make actual suicide attempts o Social cognitive theorists suggest that suicide may be motivated by positive expectancies and by approving attitudes toward the legitimacy of suicide o People who kill themselves may expect that they will be missed or eulogized after death, or that survivors will feel guilty for mistreating them o o o o o o 30 o o o o o Suicidal psychiatric patients hold positive expectancies concerning suicide They often express the belief that suicide may represent a desperate attempt to deal with one's problems in one fell swoop rather than piecemeal Social cognitive theorists also focus on the potential modeling effects of observing suicidal behavior in others, especially among teenagers who feel overwhelmed by academic and social stressors A social contagion or spreading of suicide in a community may occur in the wake of suicides that receive widespread publicity Teenagers who seem to be especially vulnerable to these modeling effects may even romanticize the suicidal cat as one of heroic courage The incidence of suicide among teenagers sometimes raised markedly in the period following news reports about suicide Suicidal behavior of a friend is a risk factor in suicide attempts among adolescents Copycat suicides may be more likely to occur when reports of suicides are sensationalized so that other teenagers expect their deaths to have broad impacts on their communities Biological factors are also implicated in suicide Reduced levels of the mood-regulating chemical serotonin are found in many people who attempt or commit suicide Because reduced availability of suicide is linked to depression the relationship with suicide is not surprising Serotonin acts to curb or inhibit nervous system activity, so perhaps decreased serotonin activity leads to disinhibition, or release, of impulsive behavior that takes the form of a suicidal act in vulnerable individuals Suicide also tends to fun in families, which hints at genetic factors Genes may influence susceptibility to suicide by affecting the utilization of serotonin in the brain Mood disorders in family members and parental suicide are also connected with suicide risk Suicide is connected with a complex web of factors and its prediction is no simpler Predicting suicide Evidence points to the pivotal role of hopelessness about the future in predicting suicidal thinking and suicide attempts People who commit suicide tend to signal their intentions often quite explicitly such as by telling others about their suicidal thoughts In fact most people who commit suicide make contact beforehand with a health care provider Some cloak their intentions Behavioral clues may still reveal suicidal intent o 90% of the people who committed suicide had left clear clues such as disposing of their possessions o People contemplating suicide may also suddenly try to sort out their affairs Drafting a will Buying a cemetery plot o They may purchase guns despite lack of prior interest in firearms o When troubled people decide to commit suicide, they may seem to be suddenly at peace, they feel relieved because they no longer have to contend with life problems This sudden calm may be a misinterpreted sign of hope