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PSYC 430

You will complete a total of three (3) Case Study assignments.  For each assignment, read through the case study and complete the provided answer sheet of questions, utilizing information from the Comer textbook to formulate appropriate answers.  Submit the completed document as an attachment via the assignment submission link.
Grading will be based on the accuracy and quality of answers, the demonstration of higher-level critical thinking skills, and appropriate quantity/content of the answers.  Your answers should do the following:

Be in complete sentences.

Demonstrate focus and clarity of thought.

Display grammar, spelling, and sentence structure appropriate for college-level work.

Access the case study above, navigating through it using the tabs at the top of the page and using the Previous/Next buttons on the bottom.  (The animations on this page require the Flash plug-in, version 6.0 or later.  This page works best in the Internet Explorer browser.)  Thoroughly read the case study, making sure to read the Presenting Complaint and Social/Family History tabs.  See also the DSM Criteria listed in the Diagnosis tab (Generalized Anxiety Disorder, Specific Phobia, and Panic Disorder).  Use the information from the case study and your textbook to answer the 22 questions on the Case Study: Anxiety Answer Sheet.  Do not use the question and answer blocks provided in the case study.  Answer all the questions in the document and submit your finished document for grading through the assignment submission link below

Case Study: Anxiety Answer Sheet

Diagnosing Tina

Student Name:

Diagnosing Generalized Anxiety Disorder:

1a. Refer to the DSM-IV checklist for generalized anxiety disorder. Which of Tina’s symptoms meet any of the criteria? (Be sure to match specific symptoms with specific criteria.)

1b. Based upon your review of Tina’s symptoms and the diagnostic criteria, could Tina be diagnosed with generalized anxiety disorder or not (and if not, why not)?

Diagnosing Specific Phobia:

2a. Refer to the DSM-IV checklist for specific phobia. Which of Tina’s symptoms meet any of the criteria? (Be sure to match specific symptoms with specific criteria.)

2b. Does Tina have a specific phobia and if yes, what is the feared object?

Diagnosing Panic Disorder:

3a. Refer to the DSM-IV checklist for panic disorder with agoraphobia and the checklist for panic disorder without agoraphobia. Which of Tina’s symptoms meet any of the criteria? (Be sure to match any specific symptoms with specific criteria.)

3b. Does Tina meet the diagnostic criteria for panic disorder with agoraphobia or panic disorder without agoraphobia or neither? Explain why you believe your choice is the most appropriate diagnosis.

Understanding Tina’s Disorders:

1. How would the Socio-Cultural Perspective explain Tina’s GAD?

2. Explain Tina’s GAD from the Existential Perspective.

3. Explain Tina’s GAD from the Cognitive Perspective (please identify any basic irrational assumptions that Tina is making, even if they may be unspoken).

4. Explain Tina’s Phobia from a Behavioral Perspective (please use classical conditioning as a possible example).

5. Explain Tina’s Phobia from a Psychodynamic Perspective.

6. Considering the biological correlates or causes of Tina’s panic disorder, what role does the neurotransmitter norepinephrine play in her panic disorder?

7. What does Tina’s locus ceruleus have to do with her panic disorder?

8. What role might GABA play in her symptoms?

Treating Tina

1. Which Psychodynamic technique has been found to be the most useful in the treatment of GAD?

2. Explain why a humanistic approach would be helpful in treating Tina’s GAD.

3. How might you use Rational-Emotive Therapy to treat Tina’s GAD?

4. How would Systematic Desensitization be used to treat Tina’s phobia of bridges?

5. What medications have proven useful for treatment with panic disorder?

6. What role could cognitive therapy play in Tina’s treatment for panic disorder?

7. Considering that Tina may be treated for comorbid disorders, how do you see the treatments for the various disorders complementing each other?

8. Is there any reason to think that any of the treatments would be contraindicated when utilized together? Explain why/how or why/how not.

Page 26 of 26

Models of Abnormality :1/ 57

°family systems theory°A theory that views the family as a system of interact­ing parts whose interactions exhibit consistent patterns and unstated rules.
egroup theraprA therapy format in which a group of people with similar problems meet together with a therapist to work on those problems.
eself-help groupeA group made up of people with similar problems who help and support one another without the direct leadership of a clinician. Also called a mutual
help
group.

°family therapyoA therapy format in which the therapist meets with all
members of a family and helps them to change in therapeutic ways.
­
Family-Social Treatments
The family-social perspective has helped spur the growth of several treatment ap­proaches, including group therapy, family and couple
therapy, and community treatment. Therapists of any orientation may work with clients in these various formats, applying the techniques and principles of their preferred models. However, more and more of the clinicians who use these formats believe that psychological problems emerge in family and social settings and are best treated in such settings, and they include special sociocultural strategies in their work.
Group Therapy Thousands of therapists specialize in group therapy, a format in which a therapist meets with a group of clients who have similar problems. Indeed, one survey of clinical psychologists revealed that almost one-third of them devoted some portion of their practice to group therapy (Norcross & Goldfried, 2005).Typically, mem­bers of a therapy group meet together with a therapist and discuss the problems of one or more of the people in the group. Together they develop important insights, build social skills, strengthen feelings of self-worth, and share useful information or advice (Cox et al., 2008). Many groups are created with particular client populations in mind; for example, there are groups for people with alcoholism, for those who are physically handicapped, and for people who are divorced, abused, or bereaved.
Research suggests that group therapy is of help to many clients, often as helpful as individual therapy (Shaughnessy et al., 2007; Misters et al., 2006). The group format also has been used for purposes that are educational rather than therapeutic, such as “consciousness raising” and spiritual inspiration.
A format similar to group therapy is the self-help group (or mutual help group). Here people who have similar problems (for example, bereavement, substance abuse, illness, unemployment, or divorce) come together to help and support one another without the direct leadership of a professional clinician (Mueller et al., 2007).According to estimates, there are now between 500,000 and 3 million such groups in the United States alone, attended each year by 3 to 4 percent of the population.
Family Therapy Family therapy was first introduced in the 1950s. A therapist meets with all members of a family, points out problem behaviors and interactions, and helps the whole family to change its ways (Goldenberg & Goldenberg, 2008; Bowen, 1960). Here, the entire family is viewed as the unit under treatment, even if only one of the members receives a clinical diagnosis. The following is a typical interaction between family members and a therapist:
WavA
Altitudes toward Therapy
F.!
• ••••• •••••••••” •••• • •
r • •
Tommy sat motionless in a chair gazing out the window. He was fourteen and a bit small
for his age. . . . Sissy was eleven. She was sitting on the couch between her Mom and Dad
with a smile on her face. Across from them sat Ms. Fargo, the family therapist.
Ms. Fargo spoke. “Could you be a little more specific about the changes you have seen
in Tommy and when they came about?”

Mrs. Davis answered first. “Well, guess it was about two years ago. Tommy started getting in fights at school. When we talked to him at home he said it was none of our business. He became moody and disobedient. He wouldn’t do anything that we wanted
him to. He began to act mean to his sister and even hit her.”

“What about the fights at school?” Ms. Fargo asked.

This time it was Mr. Davis who spoke first. “tinny was more worried about them than
I was. I used to fight a lot when I was in school and I think it is normal. . . . But l was
very respectful to my parents, especially my Dad. If I ever got out of line he would smack
me one.”

“Have you ever had to hit Tommy?” Ms. Fargo inquired softly.
“Sure, a couple of times, but it didn’t seem to do any good.”

58 ://CHAPTER 2

*couple itherapy0A therapy format in which the therapist works with two peo­ple who share a long-term relationship. Also called marital therapy.

­
All at once
Tommy seemed to be paying attention, his eyes riveted on his father. “Yeah, he hit me a lot, for no reason at all!”

“Now, that’s not true, Thomas.” Mrs. Davis has a scolding expression on her face. “If you behaved yourself a little better you wouldn’t get hit. Ms. Fargo, l can’t say that 1 am
in favor of the hitting, but I understand sometimes how frustrating it may be for Bob.”

“You don’t know how frustrating it is for me, honey.” Bob seemed upset. “You don’t
have to work all day at the office and then come home to contend with all of this. Some­times 1 feel like l don’t even want to come home.”

Ginny gave him a hard stare. “You think things at home are easy all day? could use some support from you. You think all you have to do is earn the money and t will do every­
thing else. Well, I am not about to do that anymore.” .. .

Mrs. Davis began to cry. “I just don’t know what to do anymore. Things just
seem so hopeless. Why can’t people be nice in this family anymore? don’t think I am asking too much, am I?”

Ms. Fargo . . . looked at each person briefly and was sure to make eye contact.
“There seems to be a lot going on. . think we are going to need to understand a lot of things to see why this is happening.”
(Sheras & Worchel, 1979, pp. 108-110)

Family therapists may follow any of the major theoretical models, but more and more of them are adopting the principles of family systems theory. Today 3 percent of all clinical psychologists, 13 percent of social workers, and 1 percent of psychiatrists identify themselves mainly as family systems therapists (Prochaska & Norcross, 2007).
As you read earlier, family systems theory holds that each family has its own rules, structure, and communication patterns that shape the individual members’ behavior. In one family systems approach, struc­
tural family therapy, therapists try to change the family power structure, the roles each person plays, and the relationships between members (Goldenberg & Goldenberg, 2008; Minuchin, 1997, 1987, 1974). In another, conjoint family therapy, therapists try to help members recognize and change harmful patterns of communication (Sharf, 2008; Satir, 1987, 1967, 1964).
Family therapies of various kinds are often helpful to individuals,
although research has not yet clarified how helpful (Goldenberg &

Goldenberg, 2008). Some studies have found that as many as 65 percent of individuals treated with family approaches improve, while other studies suggest much lower success rates. Nor has any one type of family therapy emerged as consistently more helpful than the others (Alexander et al., 2002).
Coupk Therapy In couple therapy, or marital therapy, the therapist works with two individuals who are in a long-term relationship. Often they are husband and wife, but the couple need not be married or even living together. Like family therapy, couple therapy often focuses on the structure and communication patterns occurring in the re­lationship (Baucom et al., 2009, 2006, 2000).A couple approach may also be used when a child’s psychological problems are traced to problems in the parents’ relationship.
Although some degree of conflict exists in any long-term relationship, many adults in our society experience serious marital discord. The divorce rate in Canada, the United States, and Europe is now close to 50 percent of the marriage rate (Marshall & Brown, 2008). Many couples who live together without marrying apparently have similar levels of difficulty (Harway, 2005).
Couple therapy, like family and group therapy, may follow the principles of any of the major therapy orientations. Behavioral couple therapy, for example, uses many techniques from the behavioral perspective (Shadish & Baldwin, 2005; Gurman, 2003). Therapists

r.1
-Help Groups: Too Much of a Good Thing?
, {elf-help groups are widely accepted
j in our society by consumers and clini­cians alike (Isenberg et al., 2004). Indeed, one survey of mental health professionals revealed that almost 90 percent of all thera­pists in the United States often recommend such groups to their clients as a supplement to therapy (Clifford et al., 1998).
Small wonder that the number, range, and appeal of such groups have grown rap­idly over the past several decades and that 25 million people in the United States alone are estimated to attend self-help groups over the course of their lives. And this number does not even include the millions of chat group participants who seek online support, information, and help from fellow sufferers. The self-help group movement and its impact on our society are brought to life in the fol­lowing notice that was posted in a Colorado church, listing support groups that would
be meeting at the church during the coming week (Moskowitz, 2008, 2001):
­­­­Sunday

12:00 noon Cocaine Anonymous, main floor
5:30 p.m. Survivors of Incest, main floor
6:00 p.m. Al-Anon, 2nd floor
6:00 p.m. Alcoholics Anonymous, basement
Monday

5:30 p.m. Debtors Anonymous, basement
6:30 p.m. Codependents of Sex Addicts Anonymous,
2nd floor
7:00 p. m. Adult Children of Alcoholics,
2nd floor
8:00 p.m. Alcoholics Anonymous, basement
8:00 p.m. Al-Anon, 2nd floor
8:00 p.m. Alateen, basement
8:00 p.m. Cocaine Anonymous, main floor
Tuesday

8:00 p.m. Survivors of Incest Anonymous,
basement

Wednesday
5:30 p.m.
7:30 p.m.
8:00 p.m.

Thursday

7:00 p.m.
7:00 p.m.
Friday

5:30 p.m. 5:45 p.m. 7:30 p.m. 7:30 p.m. 8:00 p.m.

Saturday

10:00 a.m.
12:00 p.m.
Sex & Love Addicts Anonymous, basement Adult Children of Alcoholics, 2nd floor Cocaine Anonymous, main floor
Codependents of Sex Addicts Anonymous,
2nd floor
Women’s Cocaine Anonymous, main floor
Sex & Love Addicts Anonymous, basement Adult Overeaters Anonymous, 2nd floor Codependents Anonymous, basement Adult Children of Alcoholics, 2nd floor Cocaine Anonymous, main floor
Adult Children of Alcoholics, main floor Self-Abusers Anonymous, 2nd floor

Models of Abnormality :// 59

60 ://CHAPTER 2
help spouses recognize and change problem behaviors largely by teaching specific problem-solving and communication skills. A broader, more sociocultural version, called integrative
couple therapy, further helps partners accept behaviors that they cannot change and em­brace the whole relationship nevertheless (Christensen et al., 2006). Partners are asked to see such behaviors as an understandable result of basic differences between them.
Couples treated by couple therapy seem to show greater improvement in their relationships than couples with similar problems who fail to receive treatment (Fraser & Solovey, 2007), but no one form of couple therapy stands out as superior to others (Snyder et al., 2006; Harway 2005). Although two-thirds of treated couples experience improved marital functioning by the end of therapy, fewer than half of those who are treated achieve “distress-free” or “happy” relationships. Moreover, one-third of success­fully treated couples may relapse within two years after therapy.
Community Treatment Community mental health treatment programs allow clients, particularly those with severe psychological difficulties, to receive treatment in familiar social surroundings as they try to recover. In 1963 President John Kennedy called for such a “bold new approach” to the treatment of mental disorders—a com­munity approach that would enable most people with psychological problems to receive services from nearby agencies rather than distant facilities or institutions. Congress passed the Community Mental Health Act soon after, launching the community mental health movement across the United States. A number of other countries have launched similar movements.
As you read in Chapter 1, a key principle of community treatment is prevention. Here clinicians actively reach out to clients rather than wait for them to seek treatment. Research suggests that such efforts are often very successful (Rage et al., 2007). Com­munity workers recognize three types of prevention, which they call primary, secondary, and tertiary.

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Primary prevention consists of efforts to improve community at­titudes and policies. Its goal is to prevent psychological disorders altogether. Community workers may, for example, consult with a local school board or offer public workshops on stress reduction (Bloom, 2008).
Secondary prevention consists of identifying and treating psycholog­ical disorders in the early stages, before they become serious. Com­munity workers may work with schoolteachers, ministers, or police to help them recognize the early signs of psychological dysfunction and teach them how to help people find treatment (Ervin et al., 2007).
The goal of tertiary prevention is to provide effective treatment as soon as it is needed so that moderate or severe disorders do not become long-term problems. Today community agencies across the United States do successfully offer tertiary care for millions of people with moderate psychological problems, but, as we also observed in Chapter 1, they often fail to provide the services needed by hundreds of thousands with severe disturbances. One of the reasons for this failure is lack of funding, an issue that you will read about in later chapters (Weisman, 2004).

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How Do Multicultural Theorists Explain
Abnormal Functioning?

Culture refers to the set of values, attitudes, beliefs, history, and behaviors shared by a group of people and communicated from one generation to the next (Matsumoto, 2007, 2001). We are, without question, a society of multiple cultures. Indeed, in the coming decades, members of racial and ethnic minority groups in the United States will, col­lectively, outnumber white Americans (Gordon, 2005; U.S. Census, 2000).
Partly in response to this growing diversity, the multicultural, or culturally diverse, perspective has emerged ( Jackson, 2006). Multicultural psychologists seek

Models of Abnormality :// 61

to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of differ­ent cultures, races, and genders differ psychologically (Alegria et al., 2009, 2007, 2004). Today’s multicultural view is differ­ent from past—less enlightened—cultural perspectives: It does not imply that members of racial, ethnic, and other minority groups are in some way inferior or culturally deprived in com­parison with a majority population (Sue & Sue, 2003). Rather, the model holds that an individual’s behavior, whether normal or abnormal, is best understood when examined in the light of that individual’s unique cultural context, from the values of that culture to the special external pressures faced by members of the culture.
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The groups in the United States that have received the most attention from multicultural researchers are ethnic and racial minority groups (African American, Hispanic American, Native American, and Asian American groups) and groups such as economically disadvantaged persons, homosexual individu­als, and women (although women are not technically a minority group). Each of these groups is subjected to special pressures in American society that may contribute to feel­ings of stress and, in some cases, to abnormal functioning. Researchers have learned, for example, that psychological abnormality, especially severe psychological abnormality, is indeed mote common among poorer people than among wealthier people (Byrne et al., 2004; Draine et al., 2002). Perhaps the pressures of poverty explain this relationship. Of course, membership in these various groups overlaps. Many members of minority groups, for example, also live in poverty. The higher rates of crime, unemployment, overcrowding, and homelessness; the inferior medical care; and the limited educational opportunities typically experienced by poor persons may place great stress on many members of such minority groups.
Multicultural researchers have also noted that the prejudice and discrimination faced by many minority groups may contribute to certain forms of abnormal functioning (Carter, 2007; Nelson, 2006). Women in Western society receive diagnoses of anxiety and depressive disorders at least twice as often as men (McSweeney, 2004). Similarly, African Americans experience unusually high rates of anxiety disorders (Blazer et al., 1991). Hispanic Americans may have a greater vulnerability to posttraumatic stress disorder than members of other ethnic groups (Koch & Haring, 2008). And Native Americans display exceptionally high alcoholism and suicide rates (Beals et al., 2005). Although _many factors may combine to produce these differences, racial and sexual prejudice and the problems they pose may contribute to abnormal patterns of tension, unhappiness, low self-esteem, and escape (Carter, 2007; Nelson, 2006).
°community mental health treat­ment°A treatment approach that emphasizes community care.
°multicultural perspective°The view that each culture has a set of values and beliefs, as well as special external pres­sures, that help account for the behavior of its members. Also called culturally diverse perspective.

°culture-sensitive therapies® Approaches that seek to address the unique issues faced by members of minority groups.
°gender-sensitive therapies° Approaches geared to the pressures of being a woman in Western society. Also called feminist therapies.

­­
Muiticuiturai Treatments
Studies conducted throughout the world have found that members of ethnic and racial minority groups tend to show less improvement in clinical treatment (Comas-Diaz, 2006), make less use of mental health services, and stop therapy sooner than members of majority groups (Ward, 2007; Comas-Diaz, 2006; Wang et al., 2006).
A number of studies suggest that two features of treatment can increase a therapist’s effectiveness with minority clients: (1) greater sensitivity to cultural issues and (2) inclu­sion of cultural morals and models in treatment, especially in therapies for children and adolescents (Castro, Holm-Denoma, & Buckner, 2007; Lee & Sue, 2001). Given such findings, some clinicians have developed culture-sensitive therapies, approaches that seek to address the unique issues faced by members of cultural minority groups (Carter, 2006; Mio et al., 2006). Therapies geared to the pressures of being female in Western society, called gender-sensitive, or feminist, therapies, follow similar principles.
Culture-sensitive approaches typically include the following elements (Prochaska & Norcross, 2007;Wyatt & Parham, 2007):

62 ://CHAPTER 2

1. Special cultural instruction of therapists in their graduate training programs
2. Awareness by the therapist of a client’s cultural values
3. Awareness by the therapist of the stress, prejudices, and stereotypes to which minority clients are exposed
4. Awareness by therapists of the hardships faced by the children of immigrants
5. Helping clients recognize the impact of both their own culture and the dominant culture on their self-views and behaviors
6. Helping clients identify and express suppressed anger and pain
7. Helping clients achieve a bicultural balance that feels right for them
8. Helping clients raise their self-esteem—a sense of self-worth that has often been damaged by generations of negative messages

Assessing the Sociocultural Model

The family-social and multicultural perspectives have added greatly to the understand­ing and treatment of abnormal functioning. Today most clinicians take family, cultural, social, and societal issues into account, factors that were overlooked just 35 years ago. In addition, clinicians have become more aware of the impact of clinical and social roles. Finally, the treatment formats offered by the socio­cultural model sometimes succeed where traditional ap­proaches have failed.
At the same time, the sociocultural model has certain problems. To begin with, sociocultural research findings are often difficult to interpret. Indeed, research may reveal a relationship between certain family or cultural factors and a particular disorder yet fail to establish that they are its cause. Studies show a link between family conflict and schizophrenia, for example, but that finding does not nec­essarily mean that family dysfunction causes schizophrenia. It is equally possible that family functioning is disrupted by the tension and conflict created by the psychotic behavior of a family member.

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Another limitation of the sociocultural model is its in­ability to predict abnormality in specific individuals. If, for example, social conditions such as prejudice and discrimination are key causes of anxiety and depression, why do only some of the people subjected to such forces experience psychological disorders? Are still other factors necessary for the development of the disorders?
Given these limitations, most clinicians view the family-social and multicultural ex­planations as operating in conjunction with the biological or psychological explanations. They agree that family, social, and cultural factors may create a climate favorable to the development of certain disorders.They believe, however, that biological or psychological conditions—or both—must also be present for the disorders to evolve.
The Cociocultural
The sociocultural model looks outward to the social and cultural forces that affect members of a society. One of this model’s perspectives, the family-social perspective, points to three kinds of factors in its explanations of abnormal functioning: social labels and roles, social networks and supports, and the family system. Clinicians from the family-social perspective may practice group, family, or couple therapy or community treatment.

Models of Abnormality :1/ 63

Cultural Oyersidht
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The multicultural perspective, another perspective from the sociocultural model, holds that an individual’s behavior, whether normal or abnormal, is best under­stood when examined in the light of his or her unique cultural context, including the values of that culture and the special external pressures faced by members of the culture. Practitioners of this perspective may employ culture-sensitive therapies, approaches that seek to address the unique issues faced by members of cultural minority groups.
­

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Integration of the Models
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Today’s leading models vary widely (see Table 2-2).Yet none of the models has proved consistently superior. Each helps us appreciate a key aspect of human functioning, and each has important strengths as well as serious limitations.
With all their differences, the conclusions and techniques of the various models are often compatible. Certainly our understanding and treatment of abnormal behavior are more complete if we appreciate the biological, psychological, and sociocultural aspects of a person’s problem rather than only one of them. Not surprisingly, then, a growing number of clinicians favor explanations of abnormal behavior that consider more than one kind of cause at a time. These explanations, sometimes called biopsychosocial theories, state that abnormality results from the interaction of genetic, biological, developmen­tal, emotional, behavioral, cognitive, social, cultural, and societal influences (Olson & Sameroff, 2009).A case of depression, for example, might best be explained by pointing collectively to an individual’s inheritance of unfavorable genes, traumatic losses during childhood, negative ways of thinking, and social isolation.
Some biopsychosocial theorists favor a diathesis
–
stress explanation of how the various factors work together to cause abnormal functioning (“diathesis” means a predisposed

table:

Multicultural

External pressures or cultural conflicts
Moderate
Client
Cultural advocate/ teacher
Comparing the Models

Family‑

Biological

Psychodynamic Behavioral

Cognitive

Humanistic

Existential

Social

Cause of
Biological
Underlying Maladaptive Maladaptive Self-deceit
Avoidance of
Family or
dysfunction
malfunction
conflicts learning thinking
responsibility
social stress
Research support
Strong
Modest Strong
Strong
Weak
Weak
Moderate
Consumer designation
Patient
Patient Client
Client
Patient or client
Patient or client
Client
Therapist role
Doctor
Interpreter Teacher
Persuader
Observer
Collaborator
Family/ social facilitator

Key therapist Biological Free association Conditioning Reasoning Reflection
technique intervention and interpretation
Varied social
Family/ Culture‑
sensitive
intervention intervention
Therapy goal
Biological repair
Broad psychological change
Functional
behaviors
Adaptive Self‑
thinking actualization
Authentic life
Effective family or social system
Cultural awareness and comfort

64 1/CHAPTER 2

tendency).According to this theory, people must first have a biological, psychological, or sociocultural predisposition to develop a disorder and must then be subjected to episodes of severe stress. In a case of depression, for example, we might find that unfavorable genes and related biochemical abnormalities predispose the individual to develop the disorder, while the loss of a loved one actually triggers its onset.
In a similar quest for integration, many therapists are now combining treatment techniques from several models. In fact, 29 percent of today’s clinical psychologists, 34 percent of social workers, and 53 percent of psychiatrists describe their approach as “eclectic” or “integrative” (Prochaska & Norcross, 2007). Studies confirm that clinical problems often respond better to combined approaches than to any one therapy alone. For example, as you will see, drug therapy combined with cognitive therapy is some­times the most effective treatment for depression (TADS, 2007).
Given the recent rise in biopsychosocial theories and combination treatments, our examinations of abnormal behavior throughout this book will take two directions. As different disorders are presented, we will look at how today’s models explain each disorder, how clinicians who endorse each model treat people with the disorder, and how well these explanations and treatments are supported by researchiust as important, however, we will also be observing how the explanations and treatments may build upon and strengthen each other, and we will examine current efforts toward integration of the models.

\\\ flRITICIAL THOWTHITS
///

1. What might the enormous popular­ity of psychotropic drugs suggest about the needs and coping styles of individuals today and about problem solving in our technological society?
pp. 35

–

36

2.
In
Paradise Lost
Milton wrote, “The mind … can make a heaven of hell, a hell of heaven.” Which model(s) of abnormal functioning would agree with this statement?
pp. 37

–

50

3.
Freud’s influence on Western society has extended beyond the clinical realm. Can you think of ways that his theory has affected literature, movies, child-rearing, philosophy, and educa­tion?
pp.
37-43
4. Why might positive religious beliefs be linked to mental health? Why have so many clinicians been suspi­cious of religious beliefs for so long?

p. 53

5.

In Anna
Karenina
writer Leo Tolstoy wrote, “All happy families resemble one another; every unhappy family is unhappy in its own fashion.” Would family systems theorists agree with Tolstoy?
p. 56

6.
Group therapy may offer special therapeutic features for clients. What might some of those features be? p.
57

..\\\
KEY TEPqrShr

model, p. 32

neuron, p. 33

synapse,
p.
33

neurotransmitter, p. 33

endocrine system, p. 34

hormone,
p. 34
gene,
p.
34

evolution,
p. 35

psychotropic medication, p. 35

electroconvulsive therapy (ECT),
p.
36

psychosurgery, p. 36

4Y
‘
4/ 4,4
,4

unconscious, p.
37

transference, p. 41

dream, p. 41

catharsis, p. 41

working through, p. 41

short-term psychodynamic therapies,

p.
42

relational psychoanalytic therapy, p. 42

conditioning,
p. 44

operant conditioning, p. 44

modeling, p. 44

classical conditioning, p. 44

id,
p. 38

ego, p. 38

ego defense mechanism, p.
38
superego, p. 38

fixation,
p. 39

ego theory, p. 39

self theory, p.
39

object relations theory, p. 40

free association, p. 40 resistance, p. 40

/fir.
4
,
00Voi

Models of Abnormality :1/ 65

family systems theory, p. 56

group therapy, p. 57
self-help group, p. 57
family therapy, p. 57 couple therapy, p. 58

d.)”,,•,” • • •
4. What are the key principles of the psychodynamic (pp. 37
–
43), behavioral (pp. 43-47), cognitive (pp. 47
–
50), and humanistic-existential (pp. 50
–
55) models?
5. According to psychodynamic theorists, what roles do the id, ego, and superego play in the develop­ment of both normal and abnormal behavior? What are the key tech­niques used by psychodynamic therapists? pp. 37-43
6. What forms of conditioning do behaviorists rely on in their expla­nations and treatments of abnormal behaviors? pp. 44, 45

­­­7A%

systematic desensitization, p. 45
cognitive therapy, p. 48

self-actualization, p. 50

client-centered therapy, p. 51
gestalt therapy, p. 52

existential therapy, p. 54
· `•
:•• \\\ r)U11J1( nti 17 /// :••
§ 1. What are the key regions of the
· ek./7 .: brain, and how do messages travel
throughout the brain? Describe the 45::.7C1 biological treatments for psycho‑
logical disorders. pp. 33
–
36

2. Identify the models associated with 7 spirituality (p. 53), underlying
.
learned responses (p. 44), values (p. 50), responsibility (p. 53),

4.;

.14/: conflicts (p. 37), and maladaptive
#:assumptions (p. 47).
3. Identify the treatments that use unconditional positive regard
f (p. 51), free association (p. 40),

r classical conditioning (p. 45), skill‑
ful frustration (p. 52), and dream fiolo; interpretation (p. 41).

/9:
•••• ••
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1.0,, ** ,41
,
*** p
..

4
7:
#
“:
,’
” .” “44′
0”..0
/
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4
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community mental health
treatment,
p. 60

multicultural perspective, p. 60
culture-sensitive therapy, p. 6 7 gender-sensitive therapy, p. 61
diathesis-stress explanation, p. 63

e.
.72;227

7. What kinds of cognitive dysfunc­tioning can lead to abnormal behavior? p. 47

8. How do humanistic theories and therapies differ from existential ones? pp. 50
–
51

9. How might societal labels, social networks, family factors, and
culture relate to psychological func­tioning? pp. 55
–
57, 60
–
61

10. What are the key features of culture-sensitive therapy, group therapy, family therapy, couple therapy, and community treatment? How effective are these various approaches? pp. 57
–
60, 61
–
62

·
*********

• • • • ** * *
.1

“or.,

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CLINICAL ASSESSMENT,
DIAGNOSIS,
AND TREATMENT
CHAPTER

TOPIC OVERVIEW

Clinical Assessment:
How and Why Does the Client Behave Abnormally?
Characteristics of Assessment Tools Clinical Interviews
Clinical Tests
Clinical Observations
Diagnosis:
Does the Client’s Syndrome Match a Known Disorder? Classification Systems
DSM-IV-TR
Is DSM-IV-TR an Effective Classification System?
Can Diagnosis and Labeling Cause Harm?
Treatment: How Might the Client Be Helped?

Treatment Decisions
The Effectiveness of Treatment
Putting It Together:
Renewed Respect Collides with Economic Pressure

ngela Savanti was 22 years old, lived at home with her mother, and was employed as
a

secretary in a large insurance company. She . . . had had passing periods of “the blues”

before, but her present feelings of despondency were of much greater proportion. She
LI was troubled by a severe depression and frequent crying spells, which had not lessened over the past two months. Angela found it hard to concentrate on her job, had great difficulty
falling asleep at night, and had o poor appetite. . . . Her depression had begun after she and
her boyfriend Jerry broke up two months previously.

(Leon, 1984, p. 109)

Her feelings of despondency led Angela Savanti to make an appointment with a therapist at a local counseling center. The first step the clinician took was to learn as much as possible about Angela and her disturbance. Who is she, what is her life like, and what precisely are her symptoms? The answers might help to reveal the causes and probable course of her present dysfunction and suggest what kinds of strategies would be most likely to help her. Treatment could then be tailored to Angela’s needs and particular pattern of abnormal functioning.
In Chapters 1 and 2 you read about how researchers in abnormal psychol­ogy build a general understanding of abnormal functioning. Clinical practitioners apply this broad information in their work, but their main focus when faced with new clients is to gather idiographic, or individual, information about them (Bornstein, 2007). To help persons overcome their problems, clinicians must fully understand them and their particular difficulties. To gather such individual infor­mation, clinicians use the procedures of assessment and diagnosis. Then they are in a position to offer treatment.

.ti‘Clinkal Assessment: How and Why
Does the Client Behave Abnormally?

Assessment is simply the collecting of relevant information in an effort to reach a conclusion. It goes on in every realm of life. We make assessments when we decide what cereal to buy or which presidential candidate to vote for. College admissions officers, who have to select the “best” of the students applying to their college, depend on academic records, recommendations, achievement test scores, interviews, and application forms to help them decide (Sackett, Borneman, & Connelly, 2008). Employers, who have to predict which applicants are most likely to be effective workers, collect information from résumés, interviews, references, and perhaps on-the-job observations.
Clinical assessment is used to determine how and why a person is behaving ab­normally and how that person may be helped. It also enables clinicians to evaluate people’s progress after they have been in treatment for a while and decide whether the treatment should be changed. The hundreds of clinical assessment techniques
•

°idiographic understanding0An
understanding of the behavior of a particular individual.
*assessment°The process of collecting and interpreting relevant information about a client or research participant.
estandordizationeThe process in which a test is administered to a large group of people whose performance then serves as a standard or norm against which any individual’s score can be measured.
oreliabilitrA measure of the consis­tency of test or research results.
ovalidityeThe accuracy of a test’s or study’s results; that is, the extent to which the test or study actually measures or shows what it claims.
­68 •.HCHAPTER 3
and tools that have been developed fall into three categories: clinical interviews, tests, and observations. To be useful, these tools must be standardized and must have clear reliability and validity.

Characteristics of Assessment Tools
All clinicians must follow the same procedures when they use a particular technique of assessment. To standardize a technique is to set up common steps to be followed whenever it is administered. Similarly, clinicians must standardize the way they interpret the results of an assessment tool in order to be able to understand what a particular score means.They may standardize the scores of a test, for example, by first administering it to a group of research participants whose performance will then serve as a common standard, or norm, against which later individual scores can be measured. The group that initially takes the test must be typical of the larger population for whom the test is intended. If an aggressiveness test meant for the public at large were standardized on a group of marines, for example, the resulting “norm” might turn out to be misleadingly high.
Reliability refers to the consistency of assessment measures. A good assessment tool will always yield the same results in the same situation (Weiner & Greene, 2008). An assessment tool has high test—retest reliability, one kind of reliability, if it yields the same results every time it is given to the same people. If a woman’s responses on a particular test indicate that she is generally a heavy drinker, the test should produce the same result when she takes it again a week later. To measure test—retest reliability, participants are tested on two occasions and the two scores are correlated. The higher the correlation (see Chapter 1), the greater the test’s reliability.
An assessment tool shows high interrater (or interjudge) reliability another kind of reli­ability, if different judges independently agree on how to score and interpret it. True—false and multiple-choice tests yield consistent scores no matter who evaluates them, but other tests require that the evaluator make a judgment. Consider a test that requires the person to draw a copy of a picture, which a judge then rates for accuracy. Different judges may give different ratings to the same drawing.
Finally, an assessment tool must have validity: It must accurately measure what it is supposed to measure (Weiner & Greene, 2008). Suppose a weight scale reads 12 pounds every time a 10-pound bag of sugar is placed on it. Although the scale is reliable because its readings are consistent, those read­ings are not valid, or accurate.
A given assessment tool may appear to be valid simply because it makes sense and seems reasonable. However, this sort of validity, called face validity does not by itself mean that the instrument is trustworthy.A test for depres­sion, for example, might include questions about how often a person cries. Because it makes sense that depressed people would cry, these test questions have face validity. It turns out, however, that many people cry a great deal for reasons other than depression, and some extremely depressed people fail to cry at all. Thus an assessment tool should not be used unless it has high predictive validity or concurrent validity (Sackett et al., 2008).
–
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Predictive validity is a tool’s ability to predict future characteristics or behavior. Let’s say that a test has been developed to identify elementary schoolchildren who are likely to take up cigarette smoking in high school. The test gathers information about the children’s parents—their personal characteristics, smok­ing habits, and attitudes toward smoking—and on that basis identifies high-risk children. To establish the test’s predictive validity, investigators could administer it to a group of elementary school students, wait until they were in high school, and then check to see which children actually did become smokers.

Concurrent validity is the degree to which the measures gathered from one tool agree with the measures gathered from other assessment techniques. Participants’ scores on a new test designed to measure anxiety, for example, should correlate highly with their scores on other anxiety tests or with their behavior during clinical interviews.
•

Clinical Assessment, Diagnosis, and Treatment :11 69
•

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Clinical interviews
Most of us feel instinctively that the best way to get to know people is to meet with them face to face. Under these circumstances, we can see them react to what we do and say, observe as well as listen as they answer, and generally get a sense of who they are. A clinical
interview is just such a face-to-face encounter (Sommers-Flanagan & Sommers-Flanagan, 2007, 2003). If during a clinical interview a man looks as happy as can be while describing his sadness over the recent death of his mother, the clinician may suspect that the man actually has conflicting emotions about this loss.
Conducting the interview
The interview is often the first contact between client and clinician. Clinicians use it to collect detailed information about the person’s prob­lems and feelings, lifestyle and relationships, and other personal history.They may also ask about the person’s expectations of therapy and motives for seeking it.The clinician who worked with Angela Savanti began with a face-to-face interview:
Angelo was dressed neatly when she appeared for her first interview. She was attractive,
but her eyes were puffy and ringed with dark circles. She answered questions and related information about her life history in a slow, flat tone of voice, which had an impersonal
quality to it. She sat stiffly in her chair . .

The client stated that the time period just before she and her boyfriend terminated their relationship had been one of extreme emotional turmoil. She was not sure whether she wanted to marry Jerry, and he began to demand that she decide either one way or
the other. Mrs. Savanti [Angela’s mother] did not seem to like Jerry and was very cold and
aloof whenever he came to the house. Angela felt caught in the middle and unable to
make a decision about her future. After several confrontations with Jerry over whether she
would marry him or not he told her he felt that she would never decide, so he was not
going to see her anymore… .

Angelo stated that her childhood was a very unhappy period. Her father was seldom home, and when he was present, her parents fought constantly. . . .

Angela recalled feeling very guilty when Mr. Savant’ . . . She revealed that when‑

ever she thought of her father, she always felt that she hod been responsible in some way
for his leaving the family . . .

Angela described her mother as the “long-suffering type” who said that she hod sac­
rificed her life to make her children happy, and the only thing she ever got in return was
grief and unhappiness. . . When Angela and [her sister] began dating, Mrs. Savanti .. .
would make disparaging remarks about the boys they had been with and about men in
general. .

Angela revealed that she had often been troubled with depressed moods. During high
school, if she got a lower grade in a subject than she had expected, her initial response was one of anger, followed by depression. She began to think that she was not smart
enough to get good grades, and she blamed herself for studying too little. Angela also
became despondent when she got into an argument with her mother or felt that she was
being taken advantage of at work. .
‘iR

Spotting Depre5sio
The intensity and duration of the [mood change] that she experienced when she broke up with Jerry were much more severe. She was not sure why she was so depressed, but
she began to feel it was an effort to walk around and go out to work. Talking with others
become difficult. Angela found it hard to concentrate, and she began to forget things she was supposed to do. . . . She preferred to lie in bed rather than be with anyone, and she
often cried when alone.

(Leon, 1984, pp. 110-115)

•

“Can you describe this china shop?”

70 ://CHAPTER 3
Beyond gathering basic background data of this kind, clinical inter­viewers give special attention to whatever topics they consider most im­portant (Wright &Truax, 2008). Psychodynamic interviewers try to learn about the person’s needs and memories of past events and relationships. Behavioral interviewers try to pinpoint information about the stimuli that trigger responses and their consequences. Cognitive interviewers try to discover assumptions and interpretations that influence the person. Humanistic clinicians ask about the person’s self-evaluation, self-concept, and values. Biological clinicians look for signs of biochemical or brain dysfunction. And sociocultural interviewers ask about the family, social, and cultural environments.
Interviews can be either unstructured or structured (O’Brien & Tabaczynski, 2007; Rabinowitz et al., 2007). In an unstructured interview, the clinician asks open-ended questions, perhaps as simple as “Would you tell me about yourself?”The lack of structure allows the interviewer to follow leads and explore relevant topics that could not be anticipated before the interview.
In a structured interview, clinicians ask prepared questions. Some­times they use a published interview schedule
—
a standard set of ques­tions designed for all interviews. Many structured interviews include a mental status exam, a set of questions and observations that systematically evaluate the client’s awareness, orientation with regard to time and place, attention span, memory, judgment and insight, thought content and processes, mood, and appearance (Palmer, Fiorito, & Tagliareni, 2007). A struc­tured format ensures that clinicians will cover the same kinds of important issues in all of their interviews and enables them to compare the responses of different individuals.
Although most clinical interviews have both unstructured and structured portions, many clinicians favor one kind over the other. Unstructured interviews typically appeal to psychodynamic and humanistic clinicians, while structured formats are widely used by behavioral and cognitive clinicians, who need to pinpoint behaviors, attitudes, or thinking processes that may underlie abnormal behavior (Hersen, 2004).
What Are the Li itations of dinical interviews? Although interviews often produce valuable information about people, there are limits to what they can accomplish (Hersen & Thomas, 2007). One problem is that they sometimes lack validity, or accuracy. Individuals may intentionally mislead in order to present themselves in a positive light or to avoid discussing embarrassing topics. Or people may be unable to give an accurate re­port in their interviews. Individuals who suffer from depression, for example, take a pes­simistic view of themselves and may describe themselves as poor workers or inadequate parents when that isn’t the case at all.
Interviewers too may make mistakes in judgments that slant the information they gather. They usually rely too heavily on first impressions, for example, and give too much weight to unfavorable information about a client (Wu & Shi, 2005). Interviewer biases, including gender, race, and age biases, may also influence the interviewers’ inter­pretations of what a client says (Ungar et al., 2006).
°mental status exameA set of interview questions and observations designed to reveal the degree and nature of a client’s abnormal functioning.
eiesteA device for gathering informa­tion about a few aspects of a person’s psychological functioning from which broader information about the person con be inferred.
°projective test®A test consisting of ambiguous material that people interpret or respond to.
­Interviews, particularly unstructured ones, may also lack reliability (Wood et al., 2002). People respond differently to different interviewers, providing, for example, less information to a cold interviewer than to a warm and supportive one (Quas et al., 2007). Similarly, a clinician’s race, gender, age, and appearance may influence a client’s responses (Springman,Wherry, & Notaro, 2006).
Because different clinicians can obtain different answers and draw different conclu­sions, even when they ask the same questions of the same person, some researchers believe that interviewing should be discarded as a tool of clinical assessment. As you’ll see, however, the two other kinds of clinical assessment methods also have serious limitations.

alnico( Assessment, Diagnosis, and Treatment :// 71

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9

Clinical Tests
Tests are devices for gathering information about a few aspects of a person’s psycho­logical functioning, from which broader information about the person can be inferred (Gregory, 2004). On the surface, it may look easy to design an effective test. Every month, magazines and websites present new tests that supposedly tell us about our personalities, relationships, sex lives, reactions to stress, or ability to succeed. Such tests might sound convincing, but most of them lack reliability, validity, and standardization. That is, they do not yield consistent, accurate information or say where we stand in comparison with others.
More than 500 clinical tests are currently in use throughout the United States. Cli­nicians use six kinds most often: projective tests, personality inventories, response inventories,
psychophysiological tests, neurological and )7europsychological tests, and intelligence tests.

Proiective Tests Projective tests require that clients interpret vague stimuli, such as inkblots or ambiguous pictures, or follow open-ended instructions such as “Draw a person.”Theoretically, when clues and instructions are so general, people will “project” aspects of their personality into the task. Projective tests are used primarily by psycho-dynamic clinicians to help assess the unconscious drives and conflicts they believe to be at the root of abnormal functioning (Tuber et al., 2008; Hojnoski et al., 2006).The most widely used projective tests are the Rorschach test, the Thematic Apperception Test, sentence-
completion tests, and drawings.

RORSCHACH TEST In 1911 Hermann Rorschach, a Swiss psychiatrist, experimented with the use of inkblots in his clinical work. He made thousands of blots by dropping ink on paper and then folding the paper in half to create a symmetrical but wholly accidental design, such as the one shown in Figure 3-1. Rorschach found that everyone saw images in these blots. In addition, the images a viewer saw seemed to correspond in important ways with his or her psychological condition. People diagnosed with schizophrenia, for example, tended to see images that differed from those described by people experienc­ing depression.
Rorschach selected 10 inkblots and published them in 1921 with instructions for their use in assessment.This set was called the Rorschach Psychodynamic Inkblot Test. Ror­schach died just eight months later, at the age of 37, but his work was continued by others, and his inkblots took their place among the most widely used projective tests of the twentieth century.
Clinicians administer the “Rorschach,” as it is commonly called, by presenting one inkblot card at a time and asking respondents what they see, what the inkblot seems to be, or what it reminds them of. In the early years, Rorschach testers paid special atten­tion to the themes and images that the inkblots brought to mind (Weiner & Greene,

72 :Ai/CHAPTER 3
2008). Testers now also pay attention to the style of the responses: Do the clients view the design as a whole or see specific details? Do they focus on the blots or on the white spaces between them?
THEMATIC APPERCEPTION TEST The Thematic Apperception Test (TAT) is a pictorial projec­tive test (Tuber et al., 2008; Morgan & Murray, 1935). People who take the TAT are commonly shown 30 black-and-white pictures of individuals in vague situations and are asked to make up a dramatic story about each card.They must tell what is happen­ing in the picture, what led up to it, what the characters are feeling and thinking, and what the outcome of the situation will be.
Clinicians who use the TAT believe that people always identify with one of the characters on each card. The stories are thought to reflect the individuals’ own circum­stances, needs, and emotions. For example, a female client seems to be revealing her own feelings in this story about the TAT picture shown in Figure 3-2, one of the few TAT pictures permitted for display in textbooks:
This is a woman
who
has
been quite troubled by
memories of a mother she was resentful
toward. She has feelings of sorrow for the way she treated her mother, her
memories of her mother plague her. These feelings seem to be increasing as
she grows older and sees her children treating her the same way that she treated her mother.
(Aiken, 1985, p. 372)

SENTENCE
–
COMPLETION TEST The sentence-completion test, first developed in the 1920s
(Payne, 1928), asks people to complete a series of unfinished sentences, such as “I wish
” or “My father ….”The test is considered a good springboard for discussion and a quick and easy way to pinpoint topics to explore.
DRAWINGS On the assumption that a drawing tells us something about its creator, cli­nicians often ask clients to draw human figures and talk about them. Evaluations of these drawings are based on the details and shape of the drawing, solidity of the pencil line, location of the drawing on the paper, size of the figures, features of the figures, use of background, and comments made by the respondent during the drawing task. In the Draw
–
a
–
Person
(DAP) Test, the most popular of the drawing tests, individuals are first told to draw “a person” and then are instructed to draw another person of the opposite sex.

Clinical Assessment, Diagnosis, and Treatment
:11 73

WHAT ARE THE MERITS OF PROJECTIVE TESTS? Until the 1950s, projective tests were the most common technique for assessing personality. In recent years, however, clinicians and re­searchers have relied on them largely to gain “supplementary” insights (Huprich, 2006). One reason for this shift is that practitioners who follow the newer models have less use for the tests than psychodynamic clinicians do. Even more importantly, the tests have not consistently shown much reliability or validity (Wood et al., 2002).
In reliability studies, different clinicians have tended to score the same person’s pro­jective test quite differently. Similarly, in validity studies, when clinicians try to describe a client’s personality and feelings on the basis of responses to projective tests, their con­clusions often fail to match the self-report of the client, the view of the psychotherapist, or the picture gathered from an extensive case history (Bornstein, 2007).
Another validity problem is that projective tests are sometimes biased against minor­ity ethnic groups (Costantino, Dana, & Malgady, 2007) (see Table 3-1). For example, people are supposed to identify with the characters in the TAT when they make up stories about them, yet no members of minority groups are in the TAT pictures. In re­sponse to this problem, some clinicians have developed other TAT-like tests with African American or Hispanic figures (Costantino et al., 2007).
table:

Multicultural Hot Spots in Assessment and Diagnosis

Cultural Hot Spot

m
immigrant Client

Homeland culture may differ from current country’s dominant culture
May have left homeland to escape war or oppression May have weak support systems in this country
Lifestyle (wealth and occupation) in this country may fall below lifestyle in homeland
May refuse or be unable to learn dominant language
Effect on Assessment or Diagnosis

® Dominant-Culture Assessor

May misread culture-bound reactions as pathology
May overlook client’s vulnerability to posttraumatic stress May overlook client’s heightened vulnerability to stressors May overlook client’s sense of loss and frustration
May misunderstand client’s assessment responses, or may overlook or misdiagnose client’s symptoms

m
Ethnic-Minority Client
0 Dominant-Culture Assessor

May reject or distrust members of dominant culture, including May experience little rapport with client, or may misinterpret
assessor client’s distrust as pathology
May be uncomfortable with dominant culture’s values (e.g., assertiveness, confrontation) and so find it difficult to apply clinician’s recommendations
May view client as unmotivated
j May manifest stress in culture-bound ways (e.g., somatic May misinterpret symptom patterns
symptoms such as stomachaches)
May hold cultural beliefs that seem strange to dominant culture May misinterpret cultural responses as pathology
(e.g., belief in communication with dead) (e.g., a delusion)
May be uncomfortable during assessment May overlook and feed into client’s discomfort
m
Dominant-Culture Assessor
0
Ethnic-Minority Client

May be unknowledgeable or biased about ethnic minority Cultural differences may be pathologized, or symptoms may
j culture be overlooked
!
j May nonverbally convey own discomfort to ethnic minority client May become tense and anxious

Sources: Dana, 2005, 2000; Westermeyer, 2004, 2001, 1993; Loper & Guarnaccia, 2005, 2000; Kirmayer, 2003, 2002, 2001; Sue & Sue, 2003;Tsai et al., 2001; Thakker & Ward, 1998.

74 :IICHAPTER 3

S

“I’ll say a normal word, then you say the first
sick thing that pops into your head.”

Personality Inventories An alternative way to collect information about individu­als is to ask them to assess themselves. The personality inventory asks respondents a wide range of questions about their behavior, beliefs, and feelings. In the typical person­ality inventory, individuals indicate whether each of a long list of statements applies to them. Clinicians then use the responses to draw conclusions about the person’s personal­ity and psychological functioning.
By far the most widely used personality inventory is the Minnesota Multiphasic Person­
ality Inventory (MMPI) (Weiner & Greene, 2008). Two adult versions are available—the original test, published in 1945, and the MMPI-2, a 1989 revision which was itself revised in 2001.A special version of the test for adolescents, the NIMPI-A, is also used widely.
The MMPI consists of more than 500 self-statements, to be labeled “true,” “false,” or “cannot say.” The statements cover issues ranging from physical concerns to mood, sexual behaviors, and social activities. Altogether the statements make up 10 clinical scales, on each of which an individual can score from 0 to 120. When people score above 70 on a scale, their functioning on that scale is considered deviant.When the 10 scale scores are considered side by side, a pattern called a profile takes shape, indicating the person’s general personality.The 10 scales on the MMPI measure the following:
Hypochondriasis Items showing abnormal concern with bodily functions (“I have chest pains several times a week.”)

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Depression Items showing extreme pessimism and hopelessness (“I often feel hopeless about the future.”)
Hysteria Items suggesting that the person may use physical or mental symptoms as a way of unconsciously avoiding conflicts and responsibilities (“My heart frequently pounds so hard I can feel it.”)
Psychopathic deviate Items showing a repeated and gross disregard for social customs and an emotional shallowness (“My activities and interests are often criticized by others.”)
Masculinity-femininity Items that are thought to separate male and female respondents (“I like to arrange flowers.”)
Paranoia Items that show abnormal suspiciousness and delusions of grandeur or per­secution (“There are evil people trying to influence my mind.”)
Psychasthenia Items that show obsessions, compulsions, abnormal fears, and guilt and indecisiveness (“I save nearly everything I buy, even after I have no use for it.”)

Clinical Assessment, Diagnosis, and Treatment :1,/ 75

*personality inventoryoA test
designed to measure broad personality characteristics, consisting of statements about behaviors, beliefs, and feelings that people evaluate as either character­istic or uncharacteristic of them.
*response inventorieseTests designed to measure a person’s responses in one specific area of functioning,such as affect, social skills, or cognitive
processes.
­
Schizophrenia Items that show bizarre or unusual thoughts or behavior (“Things around me do not seem real.”)
Hypomania Items that show emotional excitement, overactivity, and flight of ideas (“At times I feel very ‘high’ or very ‘low’ for no apparent reason.”)
Social introversion Items that show shyness, little interest in people, and insecurity (“I am easily embarrassed.”)
The MMPI-2, the newer version of the MMPI, contains 567 items—many identical to those in the original, some rewritten to reflect current language (“upset stomach,” for instance, replaces “acid stomach”), and others that are new. Before being adopted, the MMPI-2 was tested on a more diverse group of people than was the original MMPI. Thus scores on the revised test are thought to be more accurate indicators of personality and abnormal functioning (Cox et al., 2009).
The MMPI and other personality inventories have several advantages over projec­tive tests (Wood et al., 2002). Because they are paper-and-pencil (or computerized) tests, they do not take much time to administer, and they are objectively scored. Most of them are standardized, so one person’s scores can be compared to those of many others. Moreover, they often display greater test-retest reliability than projective tests. For example, people who take the MMPI a second time after a period of less than two weeks receive approximately the same scores (Graham, 2006).
Personality inventories also appear to have greater validity; or accuracy, than projec­tive tests (Weiner & Greene, 2008; Lanyon, 2007). However, they can hardly be con­sidered highly valid.When clinicians have used these tests alone, they have not regularly been able to judge a respondent’s personality accurately (Braxton et al., 2007). One problem is that the personality traits that the tests seek to measure cannot be examined directly. How can we fully know a person’s character, emotions, and needs from self-reports alone?
Another problem is that despite the use of more diverse standardization groups by the MMPI-2 designers, this and other personality tests continue to have certain cultural limitations. Responses that indicate a psychological disorder in one culture may be normal responses in another (Butcher et al., 2007; Dana, 2005, 2000). In Puerto Rico, for example, where it is common to practice spiritualism, it would be normal to answer “true” to the MMPI item “Evil spirits possess me at times.” In other populations, that response could indicate psychopathology (Rogler, Malgady, & Rodriguez, 1989).
Despite such limits in validity, personality inventories continue to be popular (Weiner & Greene, 2008). Research indicates that they can help clinicians learn about people’s personal styles and disorders as long as they are used in combination with in­terviews or other assessment tools.
Response inventories Like personality inventories, response inventories ask people to provide detailed information about themselves, but these tests focus on one specific area of functioning. For example, one such test may measure affect (emotion), another social skills, and still another cognitive processes. Clinicians can use them to de­termine the role such factors play in a person’s disorder.
Affective inventories measure the severity of such emotions as anxiety, depression, and anger (Osin.an et al., 2008). In one of the most widely used affective inventories, the Beck Depression Inventory, shown in Table 3-2 on the next page, people rate their level of sadness and its effect on their functioning. Social skills inventories, used particularly by behavioral and family-social clinicians, ask respondents to indicate how they would react in a variety of social situations (Wright & Truax, 2008). Cognitive inventories reveal a person’s typical thoughts and assumptions and can uncover counterproductive patterns of thinking (Glass & Merluzzi, 2000).They are, not surprisingly, often used by cognitive therapists and researchers.
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Both the number of response inventories and the number of clinicians who use them have increased steadily in the past 25 years (Black, 2005).At the same time, how­ever, these inventories have major limitations.With the notable exceptions of the Beck

76 :A/CHAPTER 3
Sample Items from the Beck Depression Inventory
Items
Inventory

Suicidal ideas 0 I don’t have any thoughts of killing myself.

1 I have thoughts of killing myself but I would not carry them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
Work inhibition 0 I can work about as well as before.
1 It takes extra effort to get started at doing something.
2 l have to push myself very hard to do anything.
3 can’t do any work at all.
Loss of libido 0 I have not noticed any recent change
1 1 am less interested in sex than I used
2 1 am much less interested in sex now.
3 I have lost interest in sex completely.

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Psychophysiological Tests Clinicians may also use psychophysiological tests, which measure physiological responses as possible indicators of psychological problems (Vershuere et al., 2006). This practice began three decades ago after several studies sug­gested that states of anxiety are regularly accompanied by physiological changes, par­ticularly increases in heart rate, body temperature, blood pressure, skin reactions (galvanic
skin response), and muscle contraction.The measuring of physiological changes has since played a key role in the assessment of certain psychological disorders.
One psychophysiological test is the polygraph, popularly known as a lie detector (Verschuere et al., 2006). Electrodes attached to various parts of a person’s body detect changes in breathing, perspiration, and heart rate while the individual answers ques­tions. The clinician observes these functions while the person answers “yes” to control questions—questions whose answers are known to be yes, such as “Are your parents both alive?” Then the clinician observes the same physiological functions while the person answers test questions, such as “Did you commit this robbery?” If breathing, perspiration, and heart rate suddenly increase, the person is suspected of lying.
Like other kinds of clinical tests, psychophysiological tests have their drawbacks. Many require expensive equipment that must be carefully tuned and maintained. In ad­dition, psychophysiological measurements can be inaccurate and unreliable. The labora­tory equipment itself—elaborate and sometimes frightening—may arouse a participant’s nervous system and thus change his or her physical responses. Physiological responses may also change when they are measured repeatedly in a single session. Galvanic skin responses, for example, often decrease during repeated testing.
Neurological and Neuropsychological Tests Some problems in personality or behavior are caused primarily by damage to the brain or changes in brain activity. If a psychological dysfunction is to be treated effectively, it is important to know whether its primary cause is a physical abnormality in the brain.

Clinical Assessment,,piegnasis, and Treatment
77

ffi
•

The Truth, the Whole Truth, and Nothing but the Truth

,n movies, criminals being grilled
by the police reveal their guilt by sweating, shaking, cursing, or twitching. When they are hooked up to a polygraph (a lie detector), the needles bounce all over the paper. This image has been with us since World War I, when some clinicians developed the theory that people who are telling lies display systemic changes in their breathing, perspiration, and heart rate (Marston, 1917).
The danger of relying on polygraph tests is that, according to researchers, they do not work as well as we would like (Iacono, 2008; Vrir, 2004). The public did not pay much attention to this incon­venient fact until the mid-1980s, when the American Psychological Association of‑
ficially reported that polygraphs were often inaccurate and the United States Congress voted to restrict their use in criminal prose­cution and employment screening (Krapohl, 2002). Research indicates that 8 out of 100 truths, on average, are called lies in polygraph testing (Raskin & Hants, 2002; MacLaren, 2001). Imagine, then, how many innocent people might be convicted
­‑­of crimes if polygraph findings were taken as valid evidence in criminal trials.
Given such Findings, polygraphs are less trusted and less popular today than they once were. For example, few courts now admit results from such tests as evi­dence of criminal guilt (Daniels, 2002). Polygraph testing has by no means dis‑
­‑appeared, however. The FBI uses it exten­sively; parole boards and probation offices routinely use it to help decide whether to release convicted offenders; and in public-sector hiring (such as for police officers), the use of polygraph screening may actually be on the increase (Kokish et al., 2005).
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A number of techniques may help pinpoint brain abnormalities. Some procedures, such as brain surgery, biopsy, and X ray, have been used for many years. More recently, scientists have developed a number of neurological tests, designed to measure brain structure and activity directly. One neurological test is the electroencephalogram (EEG), which records brain waves, the electrical activity taking place within the brain as a result of neurons firing. In this procedure, electrodes placed on the scalp send brain-wave impulses to a machine that records them.
apsychophysiological testeA test that measures physical responses (such as heart rate and muscle tension) as possi­ble indicators of psychological problems.
*neurological test®A test that directly measures brain structure or activity.
oneuroimaging techniques. Neuro­logical tests that provide images of brain structure or activity, such as CT scans, PET scans, and MRIs. Also called brain
scans.

­
­
Other neurological tests actually take “pictures” of brain structure or brain activity. These tests, called neuroimaging, or brain scanning, techniques, include computer­
ized axial tomography (CAT scan or CT scan), in which X rays of the brain’s structure are taken at different angles and combined; positron emission tomography (PET scan), a computer-produced motion picture of chemical activity throughout the brain; and magnetic resonance imaging (MR1), a procedure that uses the magnetic property of certain atoms in the brain to create a detailed picture of the brain’s structure.
A more recent version of the MRI, functional magnetic resonance imaging UMRI), converts MRI pictures of brain structures into detailed pictures of neuron activity, thus offering a picture of the functioning brain. Partly because fMRI-produced images of brain functioning are so much clearer than PET scan images, the fMRI has generated enormous enthusiasm among brain researchers since it was first developed in 1990.
Though widely used, these techniques are sometimes unable to detect subtle brain abnormalities. Clinicians have therefore developed less direct but sometimes more

78 //CHAPTER 3

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revealing neuropsychological tests that measure cognitive, perceptual, and motor performances on certain tasks and interpret abnormal performances as an indicator of underlying brain problems (Axelrod & Wall, 2007). Brain damage is especially likely to affect visual perception, memory, and visual-motor coordination, so neuropsychological tests focus particularly on these areas. The famous Bender Visual-Motor Gestalt Test, for example, consists of nine cards, each displaying a simple geometrical design. Patients look at the designs one at a time and copy each one on a piece of paper. Later they try to redraw the designs from memory. Notable errors in accuracy after age 12 are thought to reflect organic brain impairment. Clinicians often use a battery, or series, of neuro­psychological tests, each targeting a specific skill area (Reitan & Wolfson, 2005, 1996).

Clinical Assessment, Diagnosis, and Treatment :// 79

0neuropsychological testeA test that detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.
°intelligence testoA test designed to measure a person’s intellectual ability.
°intelligence quotient (IQ)°An overall score derived from intelligence tests.
Inteiligence Tests An early definition of intelligence described it as “the capacity to judge well, to reason well, and to comprehend well” (Binet & Simon, 1916, p. 192). Because intelligence is an inferred quality rather than a specific physical process, it can be measured only indirectly. In 1905 French psychologist Alfred Binet and his associate Theodore Simon produced an intelligence test consisting of a series of tasks requiring people to use various verbal and nonverbal skills.The general score derived from this and later intelligence tests is termed an intelligence quotient, or IQ.There are now more than 100 intelligence tests available. As you will see in Chapter 14, intelligence tests play a key role in the diagnosis of mental retardation, but they can also help clinicians identify other problems.

HOME SEND

Tests, eBay, and the Public Good

BY MICHELLE ROBERTS, ASSOCIATED PRESS, DECEMBER 18, 2007

ntelligence tests . . . are for sale on eBay Inc.’s online auction site, and the test maker is worried they will be misused.
The series of Wechsler intelligence tests, made by San Antonio-based Harcourt Assessment, Inc., are supposed to be sold to and administered by only clinical psychologists and trained professionals.
Given more than a million times a year nationwide, accord­ing to Harcourt, the intelligence tests often are among numerous tests ordered by prosecutors and defense attorneys to determine the mental competence of criminal defendants. A low 10, for ex­ample, can be used to argue leniency in sentencing.
Schools use the tests to determine whether to place a student in a special program, whether for gifted or struggling students. Harcourt officials say they fear the tests for sale on eBay will be misused for coaching by lawyers or parents.
But eBay has denied their request to restrict the sale of the tests. EBay officials say there is nothing illegal about selling the tests, and it cannot monitor every possible misuse of items sold through its network of 248 million buyers and sellers. Company spokesman Hani Durzy said eBay does prohibit the sale of items that are illegal in some states, even if they’re legal in others. And it prohibits the sale of some legal items, like teacher editions of textbooks, as matter of public good. With regard to the Harcourt tests, he said, however, “at this point, this is our response.”
Five of the tests were listed for sale … for about $175 to $900. The latest edition of the adult test, which retails for $939, was offered on eBay for $249.99.
“In order for it to maintain its integrity, there needs to be limited availability” said Harcourt spokesman Russell Schweiss…. “Misinterpreting the results [of questions and tasks on the tests], even without malicious intent, could lead to mistakes in assess­ing a child’s intelligence,” said Aurelio Prifitera, the president of Harcourt’s clinical division. .
Schweiss said Harcourt was still considering how to respond to eBay’s refusal. It has taken out a full-page ad in The National Psychologist magazine, asking clinicians and test publishers to contact eBay to express their concern, he said.
Jack King, communications director for the National Associa­tion of Criminal Defense Lawyers, said it would be very difficult to fake the results of an IQ test because cognitive and psycho­logical tests are usually given as part of a battery of tests, and in most cases, there is a profile of scores that would be considered normal for certain disabilities or disorders. “Just flunking the test is not likely to be determinative of anything, and a person can always be tested again and again,” he said. In any event, “it would be unethical to suggest to the client that they try to fudge a psychological test.”
Copyright 0 2007. Reprinted by permission.

80 ://CHAPTER 3

(At,n
PERE LIES
l’FREDERIC JONES
Intelligence tests are among the most carefully produced of all clinical tests (Kellerman & Burry, 2007;Williams et al., 2007). Because they have been standardized on large groups of people, clinicians have a good idea how each individual’s score compares with the performance of the population at large. These tests have also shown very high reliability: People who repeat the same IQ test years later receive approximately the same score. Finally, the major IQ tests appear to have fairly high validity: children’s IQ scores often correlate with their performance in school, for example.
Nevertheless, intelligence tests have some key shortcomings. Factors that have nothing to do with intelligence, such as low motivation or high anxiety, can greatly influence test performance (Gregory, 2004). In addition, IQ tests may contain cultural biases in their language or tasks that place people of one background at an advantage over those of another (Ford, 2008; Edwards & Oakland, 2006). Similarly, members of some minority groups may have little experience with this kind of test, or they may be uncomfortable with test examiners of a majority ethnic background. Either way, their performances may suffer.

Clinical Observations
In addition to interviewing and testing people, clinicians may systematically observe their behavior. In one technique, called naturalistic observation, clinicians observe clients in their everyday environments. In another, analog observation, they observe them in an artificial setting, such as a clinical office or laboratory. Finally, in self
–
monitoring, clients are instructed to observe themselves.
Naturalistic and Analog Observations Naturalistic clinical observations usu­ally take place in homes, schools, institutions such as hospitals and prisons, or community settings. Most of them focus on parent-child, sibling-child, or teacher-child interactions and on fearful, aggressive, or disruptive behavior (Murdock et al., 2005). Often such observations are made by participant observers, key persons in the client’s environment, and reported to the clinician.
When naturalistic observations are not practical, clinicians may resort to analog observations, often aided by special equipment such as a videotape recorder or one-way mirror (Haynes, 2001).Analog observations often have focused on children interacting with their parents, married couples attempt­ing to settle a disagreement, speech-anxious people giving a speech, and fearful people approaching an object they find frightening.
Although much can be learned from actually witnessing behavior, clin­ical observations have certain disadvantages (Connor-Greene, 2007; Pine, 2005). For one thing, they are not always reliable. It is possible for various clinicians who observe the same person to focus on different aspects of behavior, assess the person differently, and arrive at different conclusions. Careful training of observers and the use of observer checklists can help reduce this problem.
Similarly, observers may make errors that affect the validity, or accuracy, of their observations (Aiken & Groth-Marnat, 2006). The observer may suffer from overload and be unable to see or record all of the important be­haviors and events. Or the observer may experience observer dryi, a steady decline in accuracy as a result of fatigue or of a gradual unintentional change in the standards used when an observation continues for a long period of time. Another possible problem is observer bias
—
the observer’s judgments may be influenced by information and expectations he or she already has about the person (Markin & Kivlighan, 2007).
A client’s reactivity may also limit the validity of clinical observations; that is, his or her behavior may be affected by the very presence of the

Clinical Assessment,.Piogpasis, and Treatment :1/ 81

observer (Kamphaus & Frick, 2002). If schoolchildren are aware that someone special is watching them, for example, they may change their usual classroom behavior, perhaps in the hope of creating a good impression.
Finally, clinical observations may lack cross
–
situational validity. A child who behaves aggressively in school is not necessarily aggressive at home or with friends after school. Because behavior is often specific to particular situations, observations in one setting cannot always be applied to other settings (Kagan, 2007).
Self-Monitoring As you saw earlier, personality and response inventories are tests in which persons report their own behaviors, feelings, or cognitions. In a related assessment procedure, self
–
monitoring, people observe themselves and carefully record the frequency of certain behaviors, feelings, or thoughts as they occur over time (Wright & Truax, 2008). How frequently, for instance, does a drug user have an urge for drugs or a head­ache sufferer have a headache? Self-monitoring is especially useful in assessing behavior that occurs so infrequently that it is unlikely to be seen during other kinds of observa­tions. It is also useful for behaviors that occur so frequently that any other method of observing them in detail would be impossible—for example, smoking, drinking, or other drug use (Tucker et al., 2007). Finally, self-monitoring may be the only way to observe and measure private thoughts or perceptions.
Like all other clinical assessment procedures, however, self-monitoring has drawbacks (Wright & Truax, 2008). Here too validity is often a problem. People do not always man­age or try to record their observations accurately. Furthermore, when people monitor themselves, they may change their behaviors unintentionally (Otten, 2004). Smokers, for example, often smoke fewer cigarettes than usual when they are monitoring themselves, and teachers give more positive and fewer negative comments to their students.

Clinical Assessment
Clinical practitioners are interested primarily in gathering individual information about their clients. They seek an understanding of the specific nature and origins of a client’s problems through clinical assessment.
Most clinical assessment methods fall into three general categories: clinical interviews, tests, and observations. A clinical interview may be either unstructured or structured. Types of clinical tests include projective, personality, response, psycho-physiological, neurological, neuropsychological, and intelligence tests. Types of ob­servation include naturalistic observation, analog observation, and self-monitoring. To be useful, assessment tools must be standardized, reliable, and valid. Each of the methods in current use falls short on at least some of these characteristics.
­

RI
:,1,1Diagnosis: Does the Client’s Syndrome
Match a Known Disorder?

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Clinicians use the information from interviews, tests, and observations to construct an integrated picture of the factors that are causing and maintaining a client’s disturbance, a construction sometimes known as a clinical picture (Kellerman & Burry, 2007). Clini­cal pictures also may be influenced to a degree by the clinician’s theoretical orientation (Garb, 2006). The psychologist who worked with Angela Savanti held a cognitive-behavioral view of abnormality and so produced a picture that emphasized modeling and reinforcement principles and Angela’s expectations, assumptions, and interpretations:

82 ://CHAPTER 3

odiagnosis0A determination that a person’s problems reflect a particular disorder.
•syndrorne0A cluster of symptoms that usually occur together.
ociossification systemeA list of disorders, along with descriptions of symptoms and guidelines for making appropriate diagnoses.
Angela was rarely reinforced for any of her accomplishments at school, but she gained her mother’s negative attention for what Mrs. Savanti judged to be poor performance at school or at home. Mrs. Savanti repeatedly told her daughter that she was incompetent, and any mishaps that happened to her were her own fault. . . . When Mr. Savanti de­
serted the family, Angela’s first response was that somehow she was responsible. From
her mother’s past behavior, Angela had learned to expect that in some way she would be
blamed. At the time that Angela broke up with her boyfriend, she did not blame Jerry for his behavior, but interpreted this event as a failing solely on her part. As a result, her level of self-esteem was lowered still more.
The type of marital relationship that Angela saw her mother and father model re­
mained her concept of what married life is like. She generalized from her observations of her parents’ discordant interactions to an expectation of the type of behavior that she
and Jerry would ultimately engage in… .
Angela’s uncertainties intensified when she was deprived of the major source of grati­
fication she hod, her relationship with Jerry. Despite the fact that she was overwhelmed
with doubts about whether to marry him or not, she had gained a great deal of pleasure through being with Jerry. Whatever feelings she had been able to express, she had shared
with him and no one else. Angela labeled ferry’s termination of their relationship as proof that she was not worthy of another person’s interest. She viewed her present unhappiness
as likely to continue, and she attributed it to some failing on her part. As a result, she be­came quite depressed.
(Leon, 1984, pp. 123-125)

With the assessment data and clinical picture in hand, clinicians are ready to make a diagnosis—that is, a determination that a person’s psychological problems constitute a particular disorder. When clinicians decide, through diagnosis, that a client’s pattern of dysfunction reflects a particular disorder, they are saying that the pattern is basically the same as one that has been displayed by many other people, has been investigated in a variety of studies, and perhaps has responded to particular forms of treatment. They can then apply what is generally known about the disorder to the particular individual they are trying to help. They can, for example, better predict the future course of the person’s problem and the treatments that are likely to be helpful.
Classification Systems

The principle behind diagnosis is straightforward. When certain symptoms occur to­gether regularly—a cluster of symptoms is called a syndrome—and follow a particular course, clinicians agree that those symptoms make up a particular mental disorder. If people display this particular pattern of symptoms, diagnosticians assign them to that diagnostic category. A list of such categories, or disorders, with descriptions of the symptoms and guidelines for assigning individuals to the categories, is known as a classification system.
In 1883 Emil Kraepelin developed the first modern classification system for abnor­mal behavior (see Chapter 1). His categories formed the foundation for the Diagnostic
and Statistical Manual of Mental Disorders (DSV1), the classification system currently written by the American Psychiatric Association (APA, 2000). The DSM is the most widely used classification system in the United States. Most other countries use a system called the International Classification of Diseases (ICD), developed by the World Health Organization. The DSM has been changed significantly over time. The current edition, called the DSM-IV Text Revision (DSM-IV-TR), includes a combination of classifica­tion changes produced in 1994 (when it was called DSM-IV) and in 2000 (when it became DSM-IV-TR).

Clinical Assessment, Diagnosis, and Treatment :11 83

DSM-1V-TR
DSM-IV-TR lists approximately 400 mental disorders (see Figure 3-3) . Each entry describes the criteria for diagnos­ing the disorder and its key clinical features.The system also describes features that are often but not always related to the disorder. The classification system is further accompanied by text information (that is, background information) such as research findings; age, culture, or gender trends; and each disorder’s prevalence, risk, course, complications, predispos­ing factors, and family patterns.
DSM-IV-TR requires clinicians to evaluate a client’s condition on five separate axes, or branches of information, when making a diagnosis. First, they must decide whether the person is displaying one or more of the disorders found on Axis I, an extensive list of clinical syndromes that typi‑
­­
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No disorders

18.7%
One disorder
10.4%
Two disorders
17.3%
Three or more disorders

tally cause significant impairment. Some of the most frequently diagnosed disorders listed on this axis are the anxiety disorders and mood disorders, problems you will read about later.
‘L
Anxiety disorders People with anxiety disorders may experience general feelings of anxiety and worry (generalized anxiety disorder), anxiety centered on a specific situation or object (phobias), periods of panic (panic disorder), persistent thoughts or repetitive behaviors or both (obsessive-compulsive disorder), or lingering anxiety reactions to un­usually traumatic events (acute stress disorder and posttraumatic stress disorder).

Mood disorders People with mood disorders feel excessively sad or elated for long periods of time. These disorders include major depressive disorder and bipolar disorders (in which episodes of mania alternate with episodes of depression).
Next, diagnosticians must decide whether the person is displaying one of the dis­orders listed on Axis II, which includes long-standing problems that are frequently overlooked in the presence of the disorders on Axis I. There are only two groups of Axis II disorders, mental retardation and personality disorders. You will also read about these patterns in later chapters.
Mental retardation People with this disorder display significantly subaverage intellec­tual functioning and poor adaptive functioning by 18 years of age.
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Personality disorders People with these disorders display a very rigid maladaptive pat­tern of inner experience and outward behavior that has continued for many years. People with antisocial personality disorder; for example, persistently disregard and violate the rights of others. People with dependent personality disorder are persistently depen­dent on others, clinging, obedient, and very afraid of separation.

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Although people usually receive a diagnosis from either Axis I or Axis II, they may receive diagnoses from both axes. Angela Savanti would first receive a diagnosis of major
depressive disorder from Axis I (a mood disorder). Let’s suppose that the clinician judged that Angela also displayed a life history of dependent behavior. She might then also receive an Axis II diagnosis of dependent personality disorder:

The remaining axes of DSM-IV-TR guide diagnosticians in reporting other fac­tors. Axis III asks for information concerning relevant general medical conditions from which the person is currently suffering. Axis IV asks about special psychosocial or environmental problems the person is facing, such as school or housing problems. And Axis V requires the diagnostician to make a global assessment of functioning (GAF), that is, to rate the person’s psychological, social, and occupational functioning overall.
If Angela Savanti had diabetes, for example, the clinician might include that under Axis III information. Angela’s recent breakup with her boyfriend would be noted on

84 ://CHAPTER 3

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Axis I: Major depressive disorder
Axis II: Dependent personality disorder
Axis III: Diabetes
Axis IV: Problem related to the social environment (termination of engagement) Axis V: GAF = 55 (current)

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A classification system, like an assessment method, is judged by its reliability and validity. Here reliability means that different clinicians are likely to agree on the diagnosis when they use the system to diagnose the same client. Early versions of the DSM were at best moderately reliable (Spiegel, 2005; Malik & Beutler, 2002). In the early 1960s, for example, four clinicians, each relying on DSM-I, the first edition of the DSM, indepen­dently interviewed 153 patients (Beck et al., 1962). Only 54 percent of their diagnoses were in agreement.
DSM-IV-TR appears to have greater reliability than the early DSMs (Keenan et al., 2007; Lyneham, Abbott, & Rapee, 2007). Its framers conducted extensive reviews of research to pinpoint which categories in past DSMs had been too vague and unreliable. They then developed a number of new diagnostic criteria and categories and ran field
trials to make sure that the new criteria and categories were in fact reliable. Nevertheless, research indicates that DSM-IV-TR does contain certain reliability problems (Black, 2005; Beutler & Malik, 2002). Many clinicians, for example, have difficulty distinguish­ing one kind of anxiety disorder from another.The disorder of a particular client may be classified as generalized anxiety disorder by one clinician, agoraphobia (fear of traveling outside of one’s home) by another, and social phobia (fear of social situations) by yet another.
The validity of a classification system is the accuracy of the information that its di­agnostic categories provide. Categories are of most use to clinicians, for example, when

Clinical Assessment, Diagnosis; and Treatment
:11 85

DeL’ Sites
s you have seen, clinicians try
to combat psychological dis­orders,either by preventive efforts or, if those fail, through assessment, diagnosis, and effective treatment. Unfortunately, today there are also other—more sinister—forces operat­ing that run counter to the work of mental health professionals. Among the most common are so-called dark
sites on the Internet—sites with the goal of promoting behaviors that the clinical community, and most of society, consider abnormal and destructive. Pro-anorexia sites and suicide
sites are two examples.
Pro-Anorexia Sites
The Eating Disorders Association reports that there are more than 500 pro-anorexia Internet sites with names such as “Dying
to Be Thin” and “Starving for Perfection” (Caton, 2007). Users of these sites ex­change tips on how they can starve them­selves and disguise their weight loss from family, friends, and doctors. The sites also offer support and feedback about starva­tion diets. One site of this kind sponsors
a contest, “The Great Ana Competition,” and awards a diploma to the girl who consumes the fewest calories in a two-week period (Caton, 2007). Another site
endorses what it calls the Pro
–
Anorexia Ten
Commandments
—
assertions such as “Being thin is more important than being healthy” and “Thou shall not eat without feeling guilty” (Barrett, 2000).
Suicide Sites
Suicide sites are another Internet phenom­enon. Suicide forums and chat rooms vary in their messages, but they pose clear risks to depressed or impressionable users. Some pro-suicide websites celebrate former users who have committed suicide; others help set up appointments for joint or partner sui­cides; and several offer specific instructions about suicide methods and locations and writing suicide notes (Becker & Schmidt, 2004).
During a two-month period in 2008, for example, 30 people committed suicide across Japan, all of them involving the use of detergent mixtures that produce a deadly hydrogen sulfide gas—a technique repeatedly described
and encouraged on Internet suicide sites (CNN, 2008). A 31-year-old man took his life in a car using
a mixture of detergent and bath salts, a 42-year-old woman killed herself in her bathroom using toilet cleaner and bath powder, and a 14-year-old girl mixed laundry detergent with cleanser to commit suicide in her apartment. Such detergent mixtures release powerful fumes that can also endanger in­nocent bystanders, so almost all of those who killed themselves in this way hung warning signs at the locations of their suicide saying “Stay Away” or “Poisonous Gas Being Emitted”—warnings apparently also suggested on the Internet suicide sites.
Many individuals worry that Internet sui­cide sites place vulnerable people at great risk, and they have called for the banning of these sites. Others argue, however, that de­spite their dangers,the sites represent basic freedoms that should not be violated—free­dom of speech, for example, and perhaps even the freedom to do oneself harm.

they demonstrate predictive validity—that is, when they help predict future symptoms or events. A common symptom of major depressive disorder is either insomnia or exces­sive sleep. When clinicians give Angela Savanti a diagnosis of major depressive disorder, they expect that she may eventually develop sleep problems even if none are present now. In addition, they expect her to respond to treatments that are effective for other depressed persons.The more often such predictions are accurate, the greater a category’s predictive validity.
DSM-IV-TR’s framers tried to ensure the validity of their new version of the DSM
by again conducting extensive reviews of research and running many field studies. As a
result, its criteria and categories appear to have stronger validity than those of the earlier
versions of the DSM (Reeb, 2000).Yet, again, many of today’s clinical theorists argue that
at least some of the criteria and categories in DSM-IV-TR are based on weak research
and that others reflect gender or racial bias (Lowe et al., 2008;Vieta & Phillips, 2007).
Beyond these concerns about the reliability and validity of certain categories, a
growing number of clinical theorists believe that two fundamental problems weaken
the current edition of the DSM (Widiger, 2007). One problem is DSM-IV-TR’s basic

86 ://CHAPTER 3

assumption that clinical disorders are qualitatively different from normal behavior. Per­haps this assumption is incorrect. It may be, for example, that the feelings of dejection occasionally experienced by everyone differ from clinical depression in degree only. If certain psychological disorders actually differ from normal behavior in degree rather than kind, many of today’s criteria and categories are, at the very least, misleading.
A related criticism centers on DSM-IV-TR’s use of discrete diagnostic categories, with each category of pathology considered to be separate from all the others. Some crit­ics believe that certain of its categories reflect, in fact, variations of a single, fundamental dimension of functioning rather than separate disorders. Let’s consider the dimension of negative emotionality, for example. Perhaps this dimension should be used when describ­ing abnormal patterns. When one individual’s negative emotionality is extreme and maladaptive, it may take on an appearance of high anxiety. Alternatively, another person’s negative emotionality may take on the appearance of depression. In short, rather than distinguish two kinds of disorders—an anxiety disorder versus a depressive disorder—it may be that the classification should list each pattern as a variation of a key dimension, negative emotionality. In support of this dimensional argument, research has often found high anxiety levels among clinically depressed people and high depression levels among clinically anxious people. If the dimensional view is appropriate, DSM-IV-TR is, once again, misleading clinicians when it asks them to determine whether persons are display­ing an anxiety disorder or a mood disorder.
Given such concerns, there is little doubt that DSM-V, the next edition of DSM, will include some key changes.A DSM-V task force has been assembled and is actively con­sidering a range of issues and research findings, and indications are that classifications of the anxiety disorders and the personality disorders are particularly likely to see changes in DSM-V (Regier et al., 2009), as you will see in Chapters 4 and 13. The new clas­sification system will not, however, be completed until 2012 or later (Garber, 2008).

Can Diagnosis and Labeling Cause Harm?
Even with trustworthy assessment data and reliable and valid clas­sification categories, clinicians will sometimes arrive at a wrong conclusion (Rohrer, 2005). Like all human beings, they are flawed information processors. Studies show that they are overly influ­enced by information gathered early in the assessment process (Dawes, Faust, & Meehl, 2002; Meehl, 1996, 1960). They some­times pay too much attention to certain sources of information, such as a parent’s report about a child, and too little to others, such as the child’s point of view (McCoy, 1976). Finally, their judgments can be distorted by any number of personal biases—gender, age, race, and socioeconomic status, to name just a few (Vasquez, 2007). Given the limitations of assessment tools, assessors, and classifica­tion systems, it is small wonder that studies sometimes uncover shocking errors in diagnosis, especially in hospitals (Caetano & Babor, 2007).

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Beyond the potential for misdiagnosis, the very act of classifying people can lead to unintended results. As you read in Chapter 2, for example, many family-social theorists believe that diagnostic labels can become self-fulfilling prophecies. When people are diagnosed as mentally disturbed, they may be viewed and reacted to correspondingly. If others expect them to take on a sick role, they may begin to consider themselves sick as well and act that way. Furthermore, our society attaches a stigma to abnormality (Spagnolo, Murphy, & Librera, 2008; Corrigan, 2007). People labeled mentally ill may find it difficult to get a job, especially a position of responsibility, or to be welcomed into social relationships. Once a label has been applied, it may stick for a long time.
Because of these problems, some clinicians would like to do away with diagnoses. Others disagree. They believe we must simply work to increase what is known about psychological disorders and improve diagnostic techniques. They hold that classification and diagnosis are critical to understanding and treating people in distress.

Clinical Assessment, Diagnosis, and Treatment
87

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Cutting Financial Ties
Diagnosis
After collecting assessment information, clinicians form a clinical picture and decide upon a diagnosis. The diagnosis is chosen from a classification system. The system used most widely in the United States is the Diagnostic and Statistical Manual of Mental Disorders iDSM). The most recent version of the DSM, known as DSM-IV-TR, lists approximately 400 disorders and includes five axes. The reliability and validity of this edition continue to be criticized by a number of clinical theorists.
Even with trustworthy assessment data and reliable and valid classification categories, clinicians will not always arrive at the correct conclusion. Moreover, the prejudices that labels arouse may be damaging to the person who is diagnosed.

Mreatment: How Might the Client Be Helped?

Over the course of 10 months,Angela Savanti was treated for depression and related symp­toms. She improved considerably during that time, as the following report describes:
Angela’s depression eased as she began to make progress in therapy. A few months before the termination of treatment, she and Jerry resumed dating. Angela discussed with Jerry
her greater comfort in expressing her feelings and her hope that Jerry would also become
more expressive with her. They discussed the reasons why Angela was ambivalent about getting married, and they began to talk again about the possibility of marriage. Jerry, how ever, was not making demands for a decision by a certain date, and Angela felt that she was not as frightened about marriage as she previously had been…
Psychotherapy provided Angela with the opportunity to learn to express her feelings to the persons she was interacting with, and this was quite helpful to her. Most important, she was able to generalize from some of the learning experiences in therapy and modify
her behavior in her renewed relationship with Jerry. Angela still had much progress to make
in terms of changing the characteristic ways she interacted with others, but she had al­ready made a number of important steps in a potentially happier direction.

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Clearly, treatment helped Angela, and by its conclusion she was a happier, more func­tional person than the woman who had first sought help 10 months earlier. But how did her therapist decide on the treatment program that proved to be so helpful?
Treatment Decisions
Angela’s therapist began, like all therapists, with assessment information and diagnostic decisions. Knowing the specific details and background of Angela’s problem (idiographic
data) and combining this individual information with broad information about the na­ture and treatment of depression, the clinician arrived at a treatment plan for her.
Yet the rapists may be influenced by additional factors when they make treatment decisions. Their treatment plans typically reflect their theoretical orientations and how they have learned to conduct therapy (Sharf, 2008).As therapists apply a favored model in case after case, they become more and more familiar with its principles and treatment techniques and tend to use them in work with still other clients.
Current research may also play a role. Most clinicians say that they value research as a guide to practice (Beutler et al., 1995). However, not all of them actually read research

88 ://CHAPTER 3

Culture-Bound Abnor di/1r
Red Bear sits up wild-eyed, his body drenched in sweat,
every muscle tensed. The horror of the dream is still with
him; he is choked with fear. Fighting waves of nausea,
he stares at his young wife lying asleep on the far side of
the wigwam, illuminated by the dying embers.

His troubles began several days before, when he come back from a hunting expedition empty-handed.
Ashamed of his failure, he fell prey to a deep, lingering
depression. . . . The signs of windigo were all there:
depression, lack of appetite, nausea, sleeplessness and,
now, the dream. Indeed, there could be no mistake.

He had dreamed of the windigo—the monster with a heart of ice—and the dream sealed his doom. Cold­
ness gripped his own heart. The ice monster had entered
his body and possessed him. He himself had become a
windigo, and he could do nothing to avert his fate.

Suddenly, the form of Red Bear’s sleeping wife
begins to change. He no longer sees a woman, but a
deer. His eyes flame. Silently, he draws his knife from under the blanket and moves stealthily toward the
motionless figure. . . A powerful desire to eat raw flesh
consumes him.

With the body of the “deer” at his feet, Red Sear raises the knife high, preparing the strike. Unexpectedly,
the deer screams and twists away. But the knife flashes
down, again and again. Too late, Red Bear’s kinsmen
rush into the wigwam. . . . Mhey drag him outside into
the cold night air and swiftly kill him.

(LINDHOLM & LINDHOLM, 1981, P. 52)
Red Bear was suffering from windigo, a disorder once common among Algonquin Indian hunters. They believed in a super­natural monster that ate human beings and had the power to bewitch them and turn them into cannibals. Red Bear was among the few afflicted hunters who actually did kill and eat members of their households.
Windigo is but one of numerous un­usual mental disorders discovered around the world, each unique to a particular culture, each apparently growing from that culture’s pressures, history, institutions, and ideas (Floskerud, 2009; Draguns, 2006).
Such disorders remind us that the classifica­tions and diagnoses applied in one culture may not always be appropriate in another.
Susto, a disorder found among mem­bers of Indian tribes in Central and South America and Hispanic natives of the Andean highlands of Peru, Bolivia, and Colombia, is most likely to occur in infants and young children. The symptoms are ex­treme anxiety, excitability, and depression, along with Foss of weight, weakness, and rapid heartbeat. The culture holds that this disorder is caused by contact with super­natural beings or with frightening strangers or by bad air from cemeteries.
People affected with amok, a disorder found in Malaysia, the Philippines, Java, and some parts of Africa, jump around violently, yell loudly, grab knives or other weapons, and attack any people and objects they encounter. Within the culture, amok is thought to be caused by stress, severe shortage of sleep, alcohol consump­tion, and extreme heat.
Koro is a pattern of anxiety found in Southeast Asia in which a man suddenly becomes intensely fearful that his penis will withdraw into his abdomen and that he will die as a result. Cultural lore holds that the disorder is caused by an imbalance
of “yin” and “yang,” two natural forces believed to be the fundamental components of life. Accepted forms of treatment include having the individual keep a firm hold on his penis until the fear passes, often with the assistance of family members or friends, and clamping the penis to a wooden box.
Latch is a disorder found in Malaysia. Certain circumstances (hearing someone say “snake” or being tickled, for example) trigger a fright reaction that is marked
by repeating the words and acts of other people, uttering obscenities, and doing the opposite of what others ask.

articles, so they cannot be directly influenced by them (Stewart & Chambless, 2007). In fact, according to surveys, therapists gather most of their information about the latest developments in the field from colleagues, professional newsletters, workshops, confer­ences, books, and the like (Carrie & Callanan, 2001). Unfortunately, the accuracy and usefulness of these sources vary widely.

Clinical Assessment, Diagnosis,
and
Treatment :1/ 89

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To help clinicians become more familiar with and apply research findings, there is an ever-growing movement in the United States, the United Kingdom, and elsewhere called empirically supported, or evidence-based, treatment (Pope & Wedding, 2008; Nathan & Gorman, 2007). Proponents of this movement have formed task forces that seek to identify which therapies have received clear research support for each disorder, to propose corresponding treatment guidelines, and to spread such informa­tion to clinicians. Critics of the movement worry that such efforts have thus far been simplistic, biased, and, at times, misleading (Weinberger & Rasco, 2007; Mahrer, 2005; Westen et al., 2005). However, the empirically supported treatment movement has been gaining momentum in recent years.

The Effectiveness of Treatment
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Altogether, more than 400 forms of therapy are currently practiced in the clinical field (Corsini, 2008). Naturally, the most important question to ask about each of them is whether it does what it is supposed to do. Does a particular treatment really help people overcome their psychological problems? On the surface, the question may seem simple. In fact, it is one of the most difficult questions for clinical researchers to answer.

The first problem is how to define “success.” If, as Angela’s therapist suggests, she still has much progress to make at the conclusion of therapy, should her recovery be considered successful? The second problem is how to measure improvement (Markin & Kivlighan, 2007; Luborsky, 2004). Should researchers give equal weight to the reports of clients, friends, relatives, therapists, and teachers? Should they use rating scales, inven­tories, therapy insights, observations, or some other measure?
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Perhaps the biggest problem in determining the effectiveness of treatment is the variety and complexity of the treatments currently in use. People differ in their problems, personal styles, and motivations for therapy.Therapists differ in skill, experience, orienta­tion, and personality. And therapies differ in theory, format, and setting. Because an indi­vidual’s progress is influenced by all these factors and more, the findings of a particular study will not always apply to other clients and therapists.
Proper research procedures address some of these problems. By using control groups, random assignment, matched research participants, and the like, clinicians can draw certain conclusions about various therapies. Even in studies that are well designed, how­ever, the variety and complexity of treatment limit the conclusions that can be reached (Kazdin, 2006, 2004, 1994).
Despite these difficulties, the job of evaluating therapies must be done, and clinical researchers have plowed ahead with it. Investigators have, in fact, conducted thousands of

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*empirically supported treatment® A movement in the clinical field that seeks to identify which therapies have received clear research support for each disorder, to develop corresponding treat­ment guidelines, and to spread such information to clinicians. Also known as evidence-based treatment.

“Are we there yet?”

90 //CHAPTER 3

What Is the Difference between Treatment Efficacy. and Treatment Effectiveness?
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therapy outcome studies, studies that measure the effects of various treatments. The studies typically ask one of three questions: (1) Is therapy in general effective? (2) Are particular therapies generally effective? (3) Are particular therapies effective for particular problems?
Therapy Generally Effective? Studies suggest that therapy often is more help­ful than no treatment or than placebos. A pioneering review examined 375 controlled studies, covering a total of almost 25,000 people seen in a wide assortment of therapies (Smith, Glass, & Miller, 1980; Smith & Glass, 1977).The reviewers combined the findings of these studies by using a special statistical technique called meta
–
analysis. According to this analysis, the average person who received treatment was better off than 75 percent of the untreated persons (see Figure 3-4). Other meta-analyses have found similar relation­ships between treatment and improvement (Bickman, 2005).
Some clinicians have concerned themselves with an important related question: Can therapy be harmful? A number of studies suggest that more than 5 percent of patients actually seem to get worse because of therapy (Nolan et al., 2004; Lambert & Bergin, 1994).Their symptoms may become more intense, or they may develop new ones, such as a sense of failure, guilt, reduced self-concept, or hopelessness, because of their inability to profit from therapy (Lambert et al., 1986; Hadley & Strupp, 1976).
Are Particul r Therapies Generally Effective? The studies you have read
about so far have lumped all therapies together to consider their general effectiveness. Many researchers, however, consider it wrong to treat all therapies alike. Some critics suggest that these studies are operating under a uniformity myth
—
a false belief that all therapies are equivalent despite differences in the therapists’ training, experience, theo­retical orientations, and personalities (Good & Brooks, 2005; Kiesler, 1995, 1966).
Thus, an alternative approach examines the effectiveness ofparticular therapies (Rickman, 2005). Most research of this kind shows each of the major forms of therapy to be superior to no treatment or to placebo treatment (Prochaska & Norcross, 2006). A number of other studies have compared particular therapies with one another and found that no one form of therapy generally stands out over all others (Luborsky et al., 2003, 2002, 1975).
If different kinds of therapy have similar successes, might they have something in common? A rapprochement movement has tried to identify a set of common strate­gies that may run through the work of all effective therapists, regardless of the clinicians’ particular orientation (Portnoy, 2008; Castonguay & l3eutler, 2006). Surveys of highly successful therapists suggest, for example, that most give feedback to clients, help clients focus on their own thoughts and behavior, pay attention to the way they and their cli­ents are interacting, and try to promote self-mastery in their clients. In short, effective therapists of any type may practice more similarly than they preach.
Are Particul r Therapies Effective for Particul tr Problems? People with
different disorders may respond differently to the various forms of therapy (Corsini,
2008). In an oft-quoted statement, influential clinical theorist Gordon Paul said decades

Clinical Assessment, Diagnosis, and Treatment :1/ 91

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ago that the most appropriate question regarding the effectiveness of therapy may be “What specific treatment, by whom, is most effective for this individual with that specific problem, and under mthich set of circumstances?” (Paul, 1967, p. 111). Researchers have investigated how effective particular therapies are at treating particular disorders, and they often have found sizable differences among the various therapies. Behavioral therapies, for example, appear to be the most ef­fective of all in treating phobias (Wilson, 2008), whereas drug therapy is the single most effective treatment for schizophrenia (Awad & Voruganti, 2007).
As you read previously, studies also show that some clinical problems may respond better to combined approaches (de Maat et al., 2007; TADS, 2007). Drug therapy is sometimes combined with certain forms of psychotherapy, for example, to treat depression. In fact, it is now common for clients to be seen by two therapists—one of them a psychopharmacologist, a psychiatrist who primarily prescribes medications, and the other a psychologist, social worker, or other therapist who conducts psychotherapy.
Obviously, knowledge of how particular therapies fare with particular disorders can help therapists and clients alike make better decisions about treatment (Clinton et al., 2007; Beutler, 2002, 2000) (see Figure 3-5).Thus this is a question to which this book will keep returning as it examines the various disorders.

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Treatment
The treatment decisions of therapists may be influenced by assessment information, the diagnosis, the clinician’s theoretical orientation and familiarity with research, and the field’s state of knowledge.
Determining the effectiveness of treatment is difficult. Nevertheless, therapy
outcome studies have led to three general conclusions: (1) People in therapy usually are better off than people with similar problems who receive no treatment, (2) the various therapies do not appear to differ dramatically in their general effectiveness, and (3) certain therapies or combinations of therapies do appear to be more effec‑
t five than others for certain disorders.
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Renewed Respect Collides with Economic Pressure
In Chapter 2 you read that today’s leading models of abnormal behavior often differ widely in their assumptions, conclusions, and treatments. It should not surprise you, then, that clinicians also differ considerably in their approaches to assessment and diag­nosis.Yet when all is said and done, no assessment technique stands out as superior to the rest. Each of the hundreds of available tools has major limitations, and each produces at best an incomplete picture of how a person is functioning and why.
°rapprochement movement0An
effort to identify a set of common strat­egies that run t rough the work of all effective therapists.
opsychopharmacologisteA psychiatrist who primarily prescribes medications.
­In short, the present state of assessment and diagnosis argues against relying exclu­sively on any one approach. As a result, more and more clinicians now use batteries of assessment tools in their work (Iverson et al., 2007). Such batteries already are providing invaluable Guidance in the assessment of Alzheimer’s disease and certain other disorders that are particularly difficult to diagnose, as you shall see later.
Attitudes toward clinical assessment have shifted back and forth over the past several decades. Be fore the 1950s, assessment was a highly regarded part of clinical practice. As

92 ://CHAPTER 3

•
\\\ THOUrTHTS///
the number of clinical models grew during the 1960s and 1970s, however, followers of each model favored certain tools over others, and the practice of assessment became fragmented. Meanwhile, research began to reveal that a number of tools were inaccurate or inconsistent. In this atmosphere, many clinicians lost confidence in and abandoned systematic assessment and diagnosis.
Today, however, respect for assessment and diagnosis is on the rise once again. One reason for this renewal of interest is the development of more precise diagnostic criteria, as presented in DSM-IV-TR.Another is the drive by researchers for more rigorous tests to help them select appropriate participants for clinical studies. Still another factor is the clinical field’s growing awareness that certain disorders can be properly identified only after careful assessment procedures.
Along with heightened respect for assessment and diagnosis has come increased research. Indeed, today’s researchers are carefully examining every major kind of assess­ment tool—from projective tests to personality inventories.This work is helping many clinicians perform their work with more accuracy and consistency—welcome news for people with psychological problems.
Ironically, just as today’s clinicians and researchers are rediscovering systematic assess­ment, rising costs and economic factors seem to be discouraging the use of assessment tools. In particular, managed care insurance plans, which emphasize lower costs and shorter treatments, often refuse to provide coverage for extensive clinical testing or observations (Wood et al., 2002).Which of these forces will ultimately have a greater in­fluence on clinical assessment and diagnosis—promising research or economic pressure? Only time will tell.

1. How would you grade the tests you take in school? That is, how reliable and valid are they? What about the tests you see on the Web or in maga­zines? pp. 68, 71, 76
2. Just about everybody has heard of and knows about the Rorschach, even though the test has limited reli­ability and validity. How might you explain the fame and popularity of this test throughout Western society? pp. 71-72, 73
3. How might 10 scores be misused by school officials, parents, or other individuals? Why do you think our society is so preoccupied with the concept of intelligence and with IQ scores? pp. 79-80

4. Many people argue for a “people first” approach to clinical labeling. For example, they recommend using the phrase “a person with schizophre­nia” rather than “a schizophrenic.”
Why might this approach to labeling be preferable? p. 86

5. A newspaper columnist has observed, “Newspapers usually take great care not to mention the race or religion of those accused of violent crimes. But how many times have you seen the sentence, ‘He had a history of men­tal illness’?” What does this double standard suggest about the status and rights of people with psychological disorders? p. 86

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standardization, p. 68

§
reliability, p. 68

·
A validity, p. 68

§ clinical interview, p. 69

mental status exam, p. 70

test, p. 71

7,
1
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••’

EEG, CAT, PET, MR1, fMR1, p. 77 neuroimaging techniques, p. 77 neuropsychological test, p. 78
battery, p. 78

intelligence test, p. 79
intelligence quotient (10), p. 79 naturalistic obsesrvation, p. 80
analog observation, p. 80

projective test, p. 71

Rorschach test, p. 71

Thematic Apperception Test (TAT), p. 72
personality inventory, p. 74
MMPI, p. 74

response inventories, p. 75 psychophysiological
test, p. 76 neurological tests, p. 77

:eixe

ClinicalAssessmont, Diagnosis, and Treatment :// 93

self-monitoring, p. 81

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classification system, p. 82

DSM-IV-TR, p. 83

empirically supported treatment, p. 89

therapy outcome study, p. 90
rapprochement movement, p. 90
psychopharmacololgist, p. 91

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2. What are the strengths and
7 weaknesses of structured and
unstructured interviews? p. 70

3. What are the strengths and weak­nesses4.:
j,. nesses of projective tests (p. 73),
; personality inventories (p. 75),
and other kinds of clinical tests
1.; (pp. 75-80)?

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List and describe today’s leading projective tests. pp. 71-72

5. What are the key features of the MMPI? pp. 74-75

6. How do clinicians determine whether psychological problems are linked to brain damage? pp. 76-78
7. Describe the ways in which clini­cians may make observations of clients’ behaviors. pp. 80-81

8. What is the purpose of clinical diagnoses? pp. 81-82

9. Describe DSM-IV-TR. What prob­lems may accompany the use of classification systems and the process of clinical diagnosis? pp. 83-86

10. According to therapy outcome studies, how effective is therapy? pp. 89-91

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Fundamentals of Abnormal Psychology
Video Tool Kit www.worthpublishers.com/apvik

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ANXIETY DISORDERS
CHAPTER

TOPIC OVERVIEW

Generalized Anxiety Disorder
The Sociocultural Perspective: Societal and Multicultural Factors
The Psychodynamic Perspective The Humanistic Perspective
The Cognitive Perspective The Biological Perspective
Phobias
Specific Phobias
Social Phobias
What Causes Phobias? How Are Phobias Treated?
Panic Disorder
The Biological Perspective
The Cognitive Perspective Obsessive-Compulsive Disorder
What Are the Features of Obsessions and Compulsions?
The Psychodynamic Perspective The Behavioral Perspective
The Cognitive Perspective The Biological Perspective
Putting It Together: Diathesis-Stress in Action

ob Donaldson was a 22-year-old carpenter
referred to the psychiatric outpatient depart­ment of
a community hospital. . . .
During the
initial interview Bob was visibly distressed. ;He appeared tense, worried, and frightened. He sat on the edge of his chair, tapping
his foot and fidgeting with a pencil on the psychiatrist’s desk. He sighed frequently, took

deep breaths between sentences, and periodically
exhaled audibly and changed his position as

he attempted to relate his story:

Bob: It’s been an awful month. I can’t seem to do anything. 1 don’t know
whether I’m coming or going. I’m afraid I’m going crazy or something. Doctor: What makes you think that?

Bob: I can’t concentrate. My boss tells me to do something and I start to do it, but before I’ve taken five steps I don’t know what I started out to do. I get dizzy and I can feel my heart beating and everything looks like it’s shim­
mering or far away from me or something—it’s unbelievable.

Doctor: What thoughts come to mind when you’re feeling like this?

Bob: I just think, “Oh, Christ, my heart is really beating, my head is swimming,
my ears are ringing—I’m either going to die or go crazy.”

Doctor: What happens then?
Bob: Well, it doesn’t last more than a few seconds, I mean that intense feeling.
I come back down to earth, but then I’m worrying what’s the matter with
me all the time, or checking my pulse to see how fast it’s going, or feeling my palms to see if they’re sweating.
Doctor: Can others see what you’re going through?

Bob: You know, I doubt it. I hide it. I haven’t been seeing my friends. You know, they say “Let’s stop for a beer” or something after work and I give them
some excuse—you know, like I have to do something around the house or with my car. I’m not with them when l’m with them anyway-1’m just
sitting there worrying. My friend Pat said I was frowning all the time. So,
anyway, I just go home and turn on the TV or pick up the sports page, but
I can’t really get into that either.
Bob went on to say that he had stopped playing softball because of fatigability and trouble concentrating. On several occasions during the post two weeks he was unable to go to work
because he was “too nervous.”

(Spitzer et al., 1983, pp. 11
–
12)

You don’t need to be as troubled as Bob Donaldson to experience fear and anxiety.
Think about a time when your breathing quickened, your muscles tensed, and your heart pounded with a sudden sense of dread. Was it when your car almost skidded off the road in the rain? When your professor announced a pop quiz? What about when the person you were in love with went out with someone else, or your boss suggested that your job performance ought to improve? Any time you face what seems to be a serious threat to your well-being, you may react with the state of immediate alarm known as fear (Garrett, 2009). Sometimes you cannot pinpoint a specific cause for your alarm, but still you feel tense and edgy,

96 ://CHAPTER 4

Two or more independent anxiety disorders (26%)
Two or more anxiety disorders, one caused by the other (55%)
•
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as if you expect something unpleasant to happen. The vague sense of being in danger is usually called anxiety, and it has the same features—the same increase in breathing, muscular tension, perspiration, and so forth—as fear.
Although everyday experiences of fear and anxiety are not pleasant, they often are useful: They prepare us for action—for “fight or flight”—when danger threatens. They may lead us to drive more cautiously in a storm, keep up with our reading assignments, treat our dates more sensitively, and work harder at our jobs. Unfortunately, some people suffer such disabling fear and anxiety that they cannot lead normal lives (Koury & Rapaport, 2007). Their discomfort is too severe or too frequent, lasts too long, or is triggered too easily. These people are said to have an anxiety disorder or a related kind of disorder.
Anxiety disorders are the most common mental disorders in the United States. In any given year around 18 percent of the adult population suffer from one or another of the six anxiety disorders identified by DSM-IV-TR, while close to 29 percent of all people develop one of the disorders at some point in their lives (Kessler et al., 2009, 2005). Only around one-fifth of these individuals seek treatment (Wang et al., 2005).
People with generalized anxiety disorder experience general and persistent feelings of worry and anxiety. People with phobias experience a persistent and irrational fear of a specific object, activity, or situation. Individuals with panic disorder have recurrent attacks of terror. Those with obsessive
–
compulsive disorder feel overrun by recurrent thoughts that cause anxiety or by the need to perform repetitive actions to reduce anxiety. And those with acute stress disorder and posttraumatic stress disorder are tormented by fear and related symptoms well after a traumatic event (for example, military combat, rape, tor­ture) has ended. Most individuals with one anxiety disorder suffer from a second one as well (see Figure 4-1). Bob Donaldson, for example, experiences the excessive worry found in generalized anxiety disorder and the repeated attacks of terror that mark panic disorder.
This chapter will look at generalized anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder. The other anxiety disorders—acute and posttraumatic stress disorders—will be examined in the next chapter, which considers the effects that particularly intense or ongoing stress have on both our psychological and physical functioning.
0Generaiized Anxiety Disorder
People with generalized anxiety disorder experience excessive anxiety under most circumstances and worry about practically anything. In fact, their problem is sometimes described asfree-floating
anxiety. Like the young carpenter Bob Donaldson, they typically feel restless, keyed up, or on edge; tire easily; have difficulty concentrating; suffer from muscle tension; and have sleep problems (see Table 4-1). The symptoms last at least six months. Nevertheless, most people with the disorder are able, although with some dif­ficulty, to carry on social relationships and job activities.
Generalized anxiety disorder is common in Western society. Surveys suggest that around 3 percent of the U.S. population have the symptoms of this disorder in any given year, a rate that holds across Canada, Britain, and other Western countries (Ritter, Blackmore, & Heimberg, 2010; Kessler et al., 2005). Altogether, close to 6 percent of all people develop generalized anxiety disorder sometime during their lives. It may emerge at any age, but usually it first appears in childhood or adolescence. Women diagnosed with the disorder outnumber men 2 to 1. Around one-quarter of individuals with gen­eralized anxiety disorder are currently in treatment (Burijon, 2007; Wang et al., 2005).
A variety of factors have been cited to explain the development of this disorder. Here you will read about the views and treatments offered by the sociocultural, psy­chodynamic, humanistic, cognitive, and biological models. The behavioral perspective will be examined when we turn to phobias later in the chapter because that model ap­proaches generalized anxiety disorder and phobias in basically the same way.

Anxiety Disorders
:// 97

The Sociocultural Perspective: Societal and Multicultural Factors
According to sociocultural theorists, generalized anxiety disorder is most likely to develop in people who are faced with ongoing societal conditions that are danger­ous. Studies have found that people in highly threatening environments are indeed more likely to develop the general feelings of tension, anxiety, and fatigue and the sleep disturbances found in this disorder (Andrews & Wilding, 2004).
Take, for example, a classic study that was done on the psychological impact of living near the Three Mile Island nuclear power plant after the nuclear reac­tor accident of March 1979 (Baum et al., 2004; Wroble & Baum, 2002). In the months following the accident, local mothers of preschool children were found to display five times as many anxiety or depression disorders as mothers living elsewhere. Although the number of disorders decreased during the next year, the Three Mile Island mothers still displayed high levels of anxiety or depression a year later. Similarly, a study conducted more recently found that in the months and years following Hurricane Katrina in 2005, the rate of generalized and other anxiety disorders was twice as high among area residents who lived through the disaster as among unaffected persons living elsewhere (Galea et al., 2007).
One of the most powerful forms of societal stress is poverty. People without financial means are likely to live in run-down communities with high crime rates, have fewer educational and job opportunities, and run a greater risk for health problems (Lopez & Guarnaccia, 2008, 2005, 2000). As sociocultural theorists would predict, such people also have a higher rate of generalized anxiety disorder. In the United States, the rate is twice as high among people with low incomes as among those with higher incomes (Kessler et al., 2005; Blazer et al., 1991). As wages de­crease, the rate of generalized anxiety disorder steadily increases (see Table 4-2).
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0anxiety0The central nervous system’s physiological and emotional response to a vague sense of threat or danger.
°generalized anxiety disorderoA
disorder marked by persistent and exces­sive feelings of anxiety and worry about numerous events and activities.
­Since race is closely tied to income and job opportunity in the United States, it is not surprising that it is sometimes also tied to the prevalence of generalized anxiety disorder (Blazer et al., 1991). In any given year approximately 6 percent of all African Americans suffer from this disorder, compared to 3.1 percent of white Americans. African American women, perhaps the country’s most socially stressed group, have the highest rate of all-6.6 percent.
Multicultural researchers have not found a heightened rate of generalized anxiety disorder among Hispanics in the United States. They have, however, noted that many Hispanics in both the United States and Latin American suffer from nervios (“nerves”), a

Eye on Culture: Anxiety Disorders

Prevalence of Anxiety Disorders (Compared to Rate in Total Population)

Low
African
Hispanic

Female
Income
American
American
Elderly
Generalized anxiety disorder
Higher
Higher
Higher
Same
Higher
Specific phobias
Higher
Higher
Higher
Higher
Lower
Social phobia
Higher
Higher
Higher
Same
Lower
Panic disorder
Higher
Higher
Same
Same
Lower
Obsessive-compulsive disorder
Same
Higher
Same
Same
Lower
Source: Hopko et al., 2008; Nazarian & Craske, 2008; Schultz e: al., 2008; Kessler et al., 2005; Lopez & Guarnaccia, 2005, 2000; Glazer et al., 2004.

98 ://CHAPTER 4

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culture-bound disorder that bears great similarity to generalized anxiety disorder (Lopez & Guarnaccia, 2005, 2000; APA, 2000). People with nervios experience enormous emo­tional distress, somatic symptoms such as headaches and stomachaches, so-called brain aches marked by poor concentration and nervousness, and symptoms of irritability, tearfulness, and trembling.
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Although poverty and various societal and cultural pressures may help create a climate in which generalized anxiety disorder is more likely to develop, sociocultural variables are not the only factors at work. After all, most people in poor or dangerous environments do not develop this disorder. Even if sociocultural factors play a broad role, theorists still must explain why some people develop the disorder and others do not. The psychodynamic, humanistic-existential, cognitive, and biological schools of thought have all tried to explain why and have offered corresponding treatments.

The Psychodynamic Perspective
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Sigmund Freud (1933, 1917) believed that all children experience some degree of anxi­ety as part of growing up and that all use ego defense mechanisms to help control such anxiety (see page 38). Children experience realistic anxiety when they face actual danger; neurotic anxiety when they are repeatedly prevented, by parents or by circumstances, from expressing their id impulses; and moral anxiety when they are punished or threatened for expressing their id impulses. According to Freud, some children experience particularly high levels of such anxiety, or their defense mechanisms are particularly inadequate, and these individuals may develop generalized anxiety disorder.

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Psychodynamic Explanations: When Childhood Anxiety Goes Unre‑

solved According to Freud, when a child is overrun by neurotic or moral anxiety, the stage is set for generalized anxiety disorder. Early developmental experiences may pro­duce an unusually high level of anxiety in such a child. Say that a boy is spanked every time he cries for milk as an infant, messes his pants as a 2-year-old, and explores his genitals as a toddler. He may eventually come to believe that his various id impulses are very dangerous, and he may experience overwhelming anxiety whenever he has such impulses.
Alternatively, a child’s ego defense mechanisms may be too weak to cope with even normal levels of anxiety. Overprotected children, shielded by their parents from all frustrations and threats, have little opportunity to develop effective defense mechanisms. When they face the pressures of adult life, their defense mechanisms may be too weak to cope with the resulting anxieties.
Today’s psychodynamic theorists often disagree with specific aspects of Freud’s ex­planation for generalized anxiety disorder. Most continue to believe, however, that the disorder can be traced to inadequacies in the early relationships between children and their parents (Sharf, 2008). Researchers have tested the psychodynamic explanations in various ways. In one strategy; they have tried to show that people with generalized anxiety disorder are particularly likely to use defense mechanisms. For example, one team of investigators examined the early therapy transcripts of patients with this diag­nosis and found that the patients often reacted defensively. When asked by therapists to discuss upsetting experiences, they would quickly forget (repress) what they had just been talking about, change the direction of the discussion, or deny having negative feelings (Luborsky, 1973).
Insecurtiy, Adult Style
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In another line of research, investigators have studied people who as children suf­fered extreme punishment for id impulses. As psychodynamic theorists would predict, these people have higher levels of anxiety later in life (Burijon, 2007; Chiu, 1971). In addition, several studies have supported the psychodynamic position that extreme pro­tectiveness by parents may often lead to high levels of anxiety in their children (Hudson & Rapee, 2004; Jenkins, 1968).
Although these studies are consistent with psychodynamic explanations, some scien­tists question whether they show what they claim to show.When people have difficulty talking about upsetting events early in therapy, for example, they are not necessarily

Anxiety Disorders :1,1 99

repressing those events. They may be focusing purposely on the positive aspects of their lives, or they may be too embarrassed to share personal negative events until they develop trust in the therapist.
Psychodyn t5 lc Ther pies Psychodynamic therapists use the same general tech­niques to treat all psychological problems:free association and the therapist’s interpretations of transference, resistance, and dreams. Freudian psychodynamic therapists use these methods to help clients with generalized anxiety disorder become less afraid of their id impulses and more successful in controlling them. Other psychodynamic therapists, particularly object
relations therapists, use them to help anxious patients identify and settle the childhood re­lationship problems that continue to produce anxiety in adulthood (Lucas, 2006).
Controlled studies have typically found psychodynamic treatments to be of only modest help to persons with generalized anxiety disorder (Goisman et al., 1999). An exception to this trend is short-term psychodynamic therapy (see Chapter 2), which has in some cases significantly reduced the levels of anxiety, worry, and social difficulty of patients with this disorder (Crits-Christoph et al., 2004).
The Humanistic Perspective
GReq.Ky

“Dear Mom and Dad: Thanks for the
happy childhood.You’ve destroyed any
chance I had of becoming a writer.”

Humanistic theorists propose that generalized anxiety disorder, like other psychologi­cal disorders, arises when people stop looking at themselves honestly and acceptingly. Repeated denials of their true thoughts, emotions, and behavior make these people extremely anxious and unable to fulfill their potential as human beings.
The humanistic view of why people develop this disorder is best illustrated by Carl Rogers’s explanation. As you saw in Chapter 2, Rogers believed that children who fail to receive unconditional positive regard from others may become overly critical of them­selves and develop harsh self-standards, what Rogers called conditions of worth. They try to meet these standards by repeatedly distorting and denying their true thoughts and experiences. Despite such efforts, however, threatening self-judgments keep breaking through and causing them intense anxiety. This onslaught of anxiety sets the stage for generalized anxiety disorder or some other form of psychological dysfunctioning.
Practitioners of Rogers’s treatment approach, client-centered therapy, try to show unconditional positive regard for their clients and to empathize with them. The therapists hope that an atmosphere of genuine acceptance and caring will help clients feel. secure enough to recognize their true needs, thoughts, and emotions.When clients eventually are honest and comfortable with themselves, their anxiety or other symptoms will subside. In the following excerpt, Rogers describes the progress made by a client with anxiety and related symptoms:
Therapy was an experiencing of herself, in all its
aspects,
in a safe relationship … the ex­
periencing of self as having a capacity for wholeness . . . a self that cared about others.
This last followed … the realization that the therapist cared, that it really mattered to
him how therapy turned out for her, that he really valued her. . . . She gradually became
aware of the fact that … there was nothing fundamentally bad, but rather, at heart she
was positive and sound.

(Rogers, 1954, pp. 261-264)

°client-centered theraprilie human­istic therapy developed by Carl Rogers in which clinicians try to help clients by being accepting, empathizing accurately, and conveying genuineness.
­In spite of such optimistic case reports, controlled studies have failed to offer strong support for this approach. Although research does suggest that client-centered therapy is usually more helpful to anxious clients than no treatment, the approach is only sometimes superior to placebo therapy (Prochaska & Norcross, 2006, 2003). In addi­tion, researchers have found, at best, only limited support for Rogers’s explanation of generalized anxiety disorder and other forms of abnormal behavior. Nor have other humanistic theories and treatment received much research support.

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Worrying about Worrying:
Items from the Metaworry
Questionnaire

I am going crazy with worry.
My worrying will escalate and cease to function.

I’m making myself ill with worry.
I’m abnormal for worrying.
My mind can’t take the worrying.
I’m losing out in life because of
worrying.
My body can’t take the worrying.
100 ://CHAPTER 4
The Cognitive Perspective
Followers of the cognitive model suggest that psychological problems are often caused by dysfunctional ways of thinking. Given that excessive worry—a cognitive symptom—is a key characteristic of generalized anxiety disorder (see Figure 4-2), it is not surprising that cognitive theorists have had much to say about the causes of and treatments for this particular disorder (Ritter et al., 2010; Holaway, Rodebaugh, & Heimberg, 2006).
Maladaptive Assumptions Initially, cognitive theorists suggested that generalized anxiety disorder is primarily caused by maladaptive assumptions, a notion that continues to be influential.Albert Ellis, for example, proposed that many people are guided by irratio­nal beliefs that lead them to act and react in inappropriate ways (Ellis, 2008, 2002, 1962). Ellis called these basic irrational assumptions, and he claimed that people with gen­eralized anxiety disorder often hold the following ones:
“It is a dire necessity for an adult human being to be loved or approved of by virtually every significant other person in his community.”
“It is awful and catastrophic when things are not the way one would very much like them to be.”
“If something is or may be dangerous or fearsome, one should be terribly con­cerned about it and should keep dwelling oil the possibility of its occurring.”
“One should be thoroughly competent, adequate, and achieving in all possible respects if one is to consider oneself worthwhile.”
(Ellis, 1962)

When people who make these assumptions are faced with a stressful event, such as an exam or a blind date, they are likely to interpret it as dangerous, to overreact, and to experience fear. As they apply the assumptions to more and more events, they may begin to develop generalized anxiety disorder (Warren, 1997).
Similarly, cognitive theorist Aaron Beck argued that people with generalized anxi­ety disorder constantly hold silent assumptions (for example, “A situation or a person is unsafe until proven to be safe” or “It is always best to assume the worst”) that imply they are in imminent danger (Beck & Weishaar, 2008; Beck & Emery, 1985). Since the time of Ellis’s and Beck’s initial proposals, researchers have repeatedly found that people with generalized anxiety disorder do indeed hold maladaptive assumptions, particularly about dangerousness (Riskind & Williams, 2005).
New Wave Cognitive Explanations In recent years, three new explanations for generalized anxiety disorder, sometimes called the new wave cognitive explanations, have emerged (Ritter et al., 2010). Each of them builds on the work of Ellis and Beck and their emphasis on danger.
The metacognitive theory, developed by the researcher Adrian Wells (2009, 2005), suggests that people with generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying. On the positive side, they believe that worrying is a useful way of appraising and coping with threats in life. And so they look for and examine all possible signs of danger—that is, they worry constantly.
At the same time, Wells argues, individuals with generalized anxiety disorder also hold negative beliefs about worrying, and these negative attitudes are the ones that open the door to the disorder. Because society teaches them that worrying is a bad thing, the individuals come to believe that their repeated worrying is in fact harmful (mentally and physically) and uncontrollable. Now they further worry about the fact that they always seem to be worrying (so-called metaworries) (see Table 4-3).The net effect of all this worrying: generalized anxiety disorder.
This explanation has received considerable research support. Studies indicate, for example, that individuals who generally hold both positive and negative beliefs about worrying are particularly prone to developing generalized anxiety disorder (Khawaja &

BeasER II
Anxiety Disorders :1/ 101

Fears, Shmears: The Odds Are Usually on Our Side

loople with anxiety disorders have
‘many unreasonable fears, but millions of other people, too, worry about disaster every day. Most of the catastrophes they fear are not probable. Perhaps the ability to live by laws of probability rather than possibility is what separates the fearless from the fearful. What are the adds, then, that commonly feared events will happen? The range of probability is wide, but the odds are usually heavily in our favor.
A city resident will be a victim of a violent crime … 1 in 60
A suburbanite will be a victim of a violent crime … 1 in 1,000
A small-town resident will be a victim of a violent crime … 1 in 2,000
A child will suffer a high chair injury this year .. . 1 in 6,000
You will develop a tooth cavity .. . 1 in 6
You will contract AIDS from a blood transfusion … 1 in 100,000
You will die in a tsunami . 1 in 500,000
You will be attacked by a shark .. 1 in 4 million
You will be killed on your next automo­bile outing . . . 1 in 4 million
Condom use will eventually fail to pre­vent pregnancy . . . 1 in 10
An IUD will eventually fail to prevent pregnancy . 1 in 10
Coitus interruptus will eventually fail to prevent pregnancy … 1 in 5
You will die as a result of a collision between an asteroid and the earth . . 1 in 500,000
You will die as a result of a lightning strike . . . 1 in 84,000
(ADAPTED FROM BRI1T, 2005)
­­The IRS will audit you this year . 1 in 100
You will be murdered this year . . 1 in 12,000
You will be killed on your next bus ride .. 1 in 500 million
You will be hit by a baseball at a major league game … 1 in 300,000
You will receive a diagnosis of cancer this year . . . 1 in 8,000
A woman will develop breast cancer during her lifetime … 1 in 9
A piano player will eventually develop lower back pain . . . 1 in 3
You will drown in the tub this year .. . 1 in 685,000
Your house will have a fire this year . 1 in 200
Your carton will contain a broken egg . . 1 in 10

Chapman, 2007; Wells, 2005) and that repeated metaworrying is a powerful predictor of developing the disorder (Wells & Carter, 1999).
°basic irrational assumptionsoThe inaccurate and inappropriate beliefs held by people with various psychologi­cal problems, according to Albert Ellis.
­According to another new explanation for generalized anxiety disorder, the intoler­
ance
of uncertainty theory, certain individuals believe that any possibility of a negative event occurring, no matter how slim, means that the event is likely to occur. Given this intolerance of uncertainty, such persons are inclined to worry and are, in turn, more prone to develop generalized anxiety disorder (Dugan, Buhr, & Ladouceur, 2004).Think of when you meet someone you’re attracted to and how you then feel prior to texting or calling call him or her for the first time—or how you feel while you’re waiting for that person to contact you for the first time. The worry that you experience in such

102
.//CHAPTER 4

instances—the sense of sometimes unbearable uncertainty—is, according to this theory, how people with generalized anxiety disorder feel all the time.
According to this theory, people with generalized anxiety disorder keep worrying and worrying in efforts to find “correct” solutions for their various problems and to restore certainty to their situations. However, because they can never really be sure that a given solution is a correct one, they are always left to grapple with intolerable levels of uncertainty, triggering new rounds of wor­rying and new efforts to find correct solutions. Like the metacognitive theory of worry, considerable research supports this theory. Studies have found, for example, that people with generalized anxiety disorder display greater levels of intolerance of uncertainty than people with normal degrees of anxiety (Dugas et al., 2009, 2005, 2002).
Finally, a third new explanation for generalized anxiety disorder, the avoidance
theory, developed by researcher Thomas Borkovec, suggests that people with this disorder have greater bodily arousal (higher heart rate, perspiration, respiration) than other people and that worrying actually serves to reduce this arousal, perhaps by distracting the individuals from their unpleasant physical feelings. In short, the avoidance theory holds that people with generalized anxiety disorder worry repeatedly in order to reduce or avoid uncomfortable states of bodily arousal. When, for example, they find themselves in an uncomfortable job situation or social relationship, they implicitly choose to intellectualize (that is, worry about) losing their job or losing their friend rather than having to stew in a state of intense negative arousal.The worrying serves as a quick, though ultimately maladaptive, way of coping with unpleasant bodily states.

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Borkovec’s explanation has also been supported by numerous studies. Research reveals that people with generalized anxiety disorder experience particularly fast and intense bodily reactions, find such reactions overwhelming and unpleasant, worry more than other people upon becoming aroused, and successfully reduce their arousal whenever they worry (Mennin et al., 2005, 2004, 2002; Roemer et al., 2005; Turk et al., 2005).

p
Cognitive § Tnerapoes Two kinds of cognitive approaches are used in cases of gen‑
eralized anxiety disorder. In one, based on the pioneering work of Ellis and Beck, thera­pists help clients change the maladaptive assumptions that characterize their disorder. In the other, new-wave cognitive therapists help clients to understand the special role that worrying may play in their disorder and to change their views about and reactions to worrying.
CHANGING MALADAPTIVE ASSUMPTIONS In Ellis’s technique of rational-emotive therapy, therapists point out the irrational assumptions held by clients, suggest more appropriate assumptions, and assign homework that gives the individuals practice at challenging old assumptions and applying new ones (Ellis, 2008, 2005, 2002). Studies suggest that this approach and similar cognitive approaches bring at least modest relief to persons suffering from generalized anxiety (Ellis, 2008, 2005; Tafet et al., 2005). Ellis’s approach is illustrated in the following discussion between him and an anxious client who fears failure and disapproval at work, especially over a testing procedure that she has devel­oped for her company:
Client: I’m so distraught these days that I can hardly concentrate on anything for more
than a minute or two at a time. My mind just keeps wandering to that damn test­ing procedure I devised, and that they’ve put so much money into; and whether

°rational-emotive therapy®A cogni­tive therapy developed by Albert Ellis that helps clients identify and change the irrational assumptions and thinking that help cause their psychological disorder.
­it’s going to work well or be just a waste of all that time and money. . .

Ellis: Point one is that you must admit that you are telling yourself something to start
your worrying going, and you must begin to look, and I mean really look, for the specific nonsense with which you keep reindoctrinating yourself . . The false

Anxiety Disorders : it 103

Top-Grossing Fear Movies of the Twenty-first Century
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statement is: “If, because my testing procedure doesn’t work and I am function­
ing inefficiently on my job, my co-workers do not want me or approve of me, then I shall be a worthless person.” .. .

Client: But if I want to do what my firm also wants me to do, and I am useless to them,
aren’t 1 also useless to me?

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unhappy because you are frustrated? And need you deem yourself completely un­
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FOCUSING ON WORRYING Alternatively, some of today’s new-wave cognitive therapists specifically guide clients with generalized anxiety disorder to recognize and change their dysfunctional use of worrying (Ritter et al., 2010; Beck, 2008).They begin by educating the clients about the role of worrying in their disorder and have them observe their bodily arousal and cognitive responses across various life situations. In turn, the clients come to appreciate the triggers of their worrying, their misconceptions about worrying, and their misguided efforts to control their lives by worrying. As their insights grow, clients are expected to see the world as less threatening (and so less arousing), try out more constructive ways of dealing with arousal, and worry less about the fact that they worry so much. Research has begun to indicate that a concentrated focus on worrying is indeed a helpful addition to the traditional cognitive treatment for generalized anxiety disorder (Ritter et al., 2010; Waters & Craske, 2005).
Treating individuals with generalized anxiety disorder by helping them to recog­nize their inclination to worry is similar to another cognitive approach that has gained popularity in recent years. The approach, mindfidness
–
based cognitive therapy, was devel­oped by psychologist Steven Hayes and his colleagues as part of their broader treatment approach called acceptance and commitment therapy (Hayes et al., 2004; Hayes, 2004, 2002). Here therapists help clients to become aware of their streams of thoughts, including their worries, as they are occurring and to accept such thoughts as mere events of the mind. By accepting their thoughts rather than trying to eliminate them, the clients are expected to be less upset and affected by them. Mindfulness-based cognitive therapy has also been applied to a range of other psychological problems such as depression, post-traumatic stress disorder, personality disorders, and substance abuse, often with promising results (Blackledge et al., 2009; Hayes et al., 2004).

*family pedigree studyeA research design in which investigators determine how many and which relatives of a person with a disorder have the same disorder.
obenzodiazepineseThe most com­mon group of antianxiety drugs, which includes Valium and Xanax.
eGABAoThe neurotransmitter gamma­aminobuiyric acid, whose low activity has been linked to generalized anxiety disorder.
*sedative-hypnotic drugseDrugs that calm people at lower doses and help them to Fall asleep at higher doses.
*relaxation training0A treatment pro­cedure that teaches clients to relax at will so they can calm themselves in stressful situations.
obiofeedbackeA technique in which a client is given information about physi­ological reactions as they occur and learns to control the reactions voluntarily.
,.electrornyograph (EMG)*A device that provides Feedback about the level of muscular tension in the body.
­­­­104
://CHAPTER 4
The Biological Perspective

Biological theorists believe that generalized anxiety disorder is caused chiefly by bio­logical factors. For years this claim was supported primarily by family pedigree studies, in which researchers determine how many and which relatives of a person with a disorder have the same disorder. If biological tendencies toward generalized anxiety disorder are inherited, people who are biologically related should have similar prob­abilities of developing this disorder. Studies have in fact found that biological relatives of persons with generalized anxiety disorder are more likely than nonrelatives to have the disorder also (Wetherell et al., 2006; Hettema et al., 2005, 2003). Approximately 15 percent of the relatives of people with the disorder display it themselves—much more than the prevalence rate found in the general population. And the closer the rela­tive (an identical twin, for example), the greater the likelihood that he or she will also have the disorder (APA, 2000).
Biological Explanations: GABA inactivi In recent decades important dis­coveries by brain researchers have offered clearer evidence that generalized anxiety disorder is related to biological factors. One of the first such discoveries occurred in the 1950s, when researchers determined that benzodiazepines, the family of drugs that includes aiprazolam (Xanax), lorazepam (Ativan), and diazepam (Valium), provide relief from anxiety. At first, no one understood why benzodiazepines reduce anxiety. Eventu­ally, however, the development of radioactive techniques enabled researchers to pinpoint the exact sites in the brain that are affected by benzodiazepines (Mohler & Okada, 1977). Apparently certain neurons have receptors that receive the benzodiazepines, just as a lock receives a key.
Investigators soon discovered that these benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA), a common neurotransmitter in the brain. As you read in Chapter 2, neurotransmitters are chemicals that carry messages from one neuron to another. GABA carries inhibitory messages:When GABA is received at a re­ceptor, it causes the neuron to stop firing.

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On the basis of such findings, biological researchers eventually pieced together several scenarios of how fear reactions may occur. A leading one began with the no­tion that in normal fear reactions, key neurons throughout the brain fire more rapidly, triggering the firing of still more neurons and creating a general state of excitability throughout the brain and body. Perspiration, breathing, and muscle tension increase.This state is experienced as fear or anxiety. Continuous firing of neurons eventually triggers a feedback system—that is, brain and body activities that reduce the level of excitability. Some neurons throughout the brain release the neurotransmitter GABA, which then binds to GABA receptors on certain neurons and instructs those neurons to stop firing. The state of excitability ceases, and the experience of fear or anxiety subsides (Ator, 2005; Costa, 1985, 1983).
Some researchers have concluded that a malfunction in this feedback system can cause fear or anxiety to go unchecked (Roy-Byrne, 2005). In fact, when investigators reduced GABA’s ability to bind to GABA receptors, they found that animal subjects reacted with a rise in anxiety (Costa, 1985; Mohler et al., 1981). This finding suggested that people with generalized anxiety disorder might have ongo­ing problems in their anxiety feedback system. Perhaps they have too few GABA receptors, or perhaps their GABA receptors do not readily capture the neurotransmitter.
This explanation continues to have many supporters, but it is also prob­lematic. First, according to recent biological discoveries, other neurotransmit­ters may also play important roles in anxiety and generalized anxiety disorder, either acting alone or in conjunction with GABA (Garrett, 2009; Burijon, 2007). Second, biological theorists are faced with the problem of establishing a causal relationship.The abnormal GABA responses of anxious persons may be the result, rather than the cause, of their anxiety disorders. Perhaps long-term anxiety eventually leads to poorer GABA reception, for example.

Anxiety Disorders 105

table:
Bidogica Treatments The leading biological treatment for generalized anxiety disorder is drug therapy (see Table 4-4). Other biological interventions are relaxation train­
ing and biofeedback.

Drugs That Reduce Anxiety

Generic Name
Benzodiazepines

A[prazolam Chlorazepate Chlordiazepoxide CIonazepam Diazepam Estazolam Halazepam Lorazepam Midazolam Oxazepam Prazepam Temazepam

Trade Name

Xanax
Tranxene Librium
Klonopin Valium
ProSom Paxipam Ativan
Versed
Serax
Centrax Rostoril
BuSpar
Inderal
Tenorm in

ANTIANXIETY DRUG THERAPY In the late 1950s benzodiazepines were originally marketed as sedative—hypnotic drugs—drugs that calm people in low doses and help them fall asleep in higher doses. These new antianxiety drugs seemed less addictive than previ­ous sedative-hypnotic medications, such as barbiturates, and they appeared to produce less tiredness (Meyer & Quenzer, 2005). Thus, they were quickly embraced by both doctors and patients.
Only years later did investigators come to understand the reasons for the effective­ness of benzodiazepines. As you have read, researchers eventually learned that there are specific neuron sites in the brain that receive benzodiazepines and that these same receptor sites ordinarily receive the neurotransmitter GABA. Apparently, when benzo­diazepines bind to these neuron receptor sites, particularly those receptors known as GABA-A receptors, they increase the ability of GABA to bind to them as well, and so im­prove GABA’s ability to stop neuron firing and reduce anxiety (Dawson et al., 2005).
Others

Buspirone Propranolol Atenolol
Studies indicate that benzodiazepines often provide temporary relief for people with generalized anxiety disorder (Burijon, 2007). However, clinicians have come to realize the potential dangers of these drugs. First, when the medications are stopped, many persons’ anxieties return as strong as ever. Second, we now know that people who take benzodiazepines in large doses for an extended time can become physically dependent on them. Third, the drugs can produce undesirable effects such as drowsiness, lack of coordination, memory loss, depression, and aggressive behavior. Finally, the drugs mix badly with certain other drugs or substances, such as alcohol.
In recent decades, still other kinds of drugs have become available for people with generalized anxiety disorder ( Julien, 2008). In particular, it has been discovered that a number of antidepressant medications, drugs that are usually used to lift the moods of depressed persons, are also helpful to many people with generalized anxiety disorder. In fact, a number of today’s clinicians are more inclined to prescribe such antidepressants to treat generalized anxiety disorder than the GABA-enhancing benzodiazepines (Burijon, 2007; Liebowitz et al., 2005).
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RELAXATION TRAINING A nonchemical biological technique commonly used to treat gen­eralized anxiety disorder is relaxation training. The notion behind this approach is that physical relaxation will lead to a state of psychological relaxation. In one version, therapists teach clients to identify individual muscle groups, tense them, release the ten­sion, and ultimately relax the whole body. With continued practice, they can bring on a state of deep muscle relaxation at will, reducing their state of anxiety.

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Research indicates that relaxation training is more effective than no treatment or placebo treatment in cases of generalized anxiety disorder. The improvement it produces, however, tends to be modest (Leahy, 2004), and other techniques that are known to relax people, such as meditation, often seem to be equally effective (Bourne et al., 2004). Relaxation training is of greatest help to people with generalized anxiety disorder when it is combined with cognitive therapy or with biofeedback (Lang, 2004).
BIOFEEDBACK In biofeedback, therapists use electrical signals from the body to train people to control physiological processes such as heart rate or muscle tension. Clients are connected to a monitor that gives them continuous information about their bodily activities. By attending to the signals from the monitor, they may gradually learn to control even seemingly involuntary physiological processes.
The most widely applied method of biofeedback for the treat­ment of anxiety uses a device called an electromyograph (EMG), which provides feedback about the level of muscular tension in the

106 :1/cHAPTER 4

body. Electrodes are attached to the client’s muscles—usually the forehead muscles—where they detect the minute electri­cal activity that accompanies muscle tension (see Figure 4-3). The device then converts electric potentials coming from the muscles into an image, such as lines on a screen, or into a tone whose pitch changes along with changes in muscle tension. Thus clients “see” or “hear” when their muscles are becoming more or less tense. Through repeated trial and error, the individuals become skilled at voluntarily reducing muscle tension and, theoretically, at reducing tension and anxiety in everyday stressful situations.
next
Research finds that, in most cases, EMG biofeedback, like relaxation training, has only a modest effect on a per­son’s anxiety level (Brambrink, 2004).As you will see in the chapter, biofeedback has had its greatest impact when it plays adjunct roles in the treatment of certain medical problems, including headaches and back pain (Astin, 2004; Engel et al., 2004).
Generalized An:,.ie:y Disorder
People with generalized anxiety disorder experience excessive anxiety and worry about a wide range of events and activities. Most explanations and treatments for this disorder have received only limited research support, although recent cognitive and biological approaches are promising.
According to the sociocultural view, societal dangers, economic stress, or re­lated racial and cultural pressures create a threatening climate in which cases of generalized anxiety disorder are more likely to develop.
In the original psychodynamic explanation, Freud said that this disorder may develop when anxiety is excessive and defense mechanisms break down. Psycho-dynamic therapists use free association, interpretation, and related psychodynamic techniques to help people overcome this problem.
Carl Rogers, the leading humanistic theorist, believed that people with general­ized anxiety disorder fail to receive unconditional positive regard from significant others during their childhood and so become overly critical of themselves. He treated such individuals with client-centered therapy.
Cognitive theorists believe that generalized anxiety disorder is caused by mal­adaptive assumptions that lead people to view most life situations as dangerous. Many cognitive theorists also propose that implicit beliefs about the power and value of worrying further contribute to this disorder. Cognitive therapists help clients change such thinking and find more effective ways of coping during stressful situations.
Biological theorists hold that generalized anxiety disorder results from low ac­tivity of the neurotransmitter GABA. Common biological treatments are antianxiely drugs, particularly benzodiazepines, and certain antidepressant drugs. Relaxation training and biofeedback are also applied in many cases.
-rPhobias

ophobia•A persistent and unreasonable fear of a particular object, activity, or situation.
°specific phobia°A severe and persis­tent fear of a specific object or situation (other than agoraphobia and social phobia).
­A phobia (from the Greek word for “fear”) is a persistent and unreasonable fear of a particular object, activity; or situation. People with a phobia become fearful if they even think about the object or situation they dread, but they usually remain comfortable as long as they avoid it or thoughts about it.
We all have our areas of special fear, and it is normal for some things to upset us more than other things. How do such common fears differ from phobias? DSM-IV-TR

Anxiety Disorders
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indicates that a phobia is more intense and persistent and the desire to avoid the object or situation is greater (APA, 2000). People with phobias often feel so much distress that their fears may interfere dramatically with their lives.
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Most phobias technically fall under the category of specific phobias, DSM-IV-TR’s label for an intense and persistent fear of a specific object or situation. In addition, there are two broader kinds of phobias: social phobia, a fear of social or performance situations in which embarrassment may occur, and agoraphobia, a fear of venturing into public places, especially when one is alone. Because agoraphobia is usually, perhaps always, experienced in conjunction with panic attacks, unpredictable attacks of terror, we shall examine that phobia later within our discussion of panic disorders.
Specific Phobias

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A specific phobia is a persistent fear of a specific object or situation (see Table 4-5). When sufferers are exposed to the object or situation, they typically experience im­mediate fear. Common specific phobias are intense fears of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood. Here Andrew talks about his phobic fear of flying:

We got on board, and then there was the take-off There it was again, that horrible feel­
ing as we gathered speed. It was creeping over me again, that old feeling of panic. I kept seeing everyone as puppets, all strapped to their seats with no control over their destinies, me included. Every time the plane did a variation of speed or route, my heart would leap and I would hurriedly ask what was happening. When the plane started to lose height, I
was terrified that we were about to crash.

(Melville, 1978, p. 59)

Each year close to 9 percent of all people in the United States have the symptoms of a specific phobia (Kessler et al., 2009, 2005). More than 12 percent of individuals develop such phobias at some point during their lives, and many people have more than one at a time. Women with the disorder outnumber men by at least 2 to 1. For reasons that are not clear, the prevalence of specific phobias also differs among racial and ethnic minority groups. In some studies, African Americans and Hispanic Americans report having at least 50 percent more specific phobias than do white Americans, even when economic factors, education, and age are held steady across the groups (Hopko et al., 2008; Breslau et al., 2006). It is worth noting, however, that these heightened rates are at work only among African and Hispanic Americans who were born in the United States, not those who emigrated to the United States at some point during their lives (Hopko et al., 2008).

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The impact of a specific phobia on a person’s life depends on what arouses the fear (Scher et al., 2006). People whose phobias center on dogs, insects, or water will keep encountering the objects they dread. Their efforts to avoid them must be elaborate and may greatly restrict their activities. Urban residents with snake phobias have a much easier time. The vast majority of people with a specific phobia do not seek treatment. They try instead to avoid the objects they fear (Roth & Fonagy, 2005).
Social Phobias

Many people worry about interacting with others or about talking or performing in front of others. A number of entertainers, from singer Barbra Streisand to actor Sir Laurence Olivier, have described major bouts of anxiety before performing. Social fears of this kind are unpleasant and inconvenient, but usually the people who have them manage to function adequately, some at a very high level.

108 //CHAPTER 4

People with a social phobia, by contrast, have severe, per­sistent, and irrational fears of social or performance situations in which embarrassment may occur (see Table 4-6). A social phobia may be narrow, such as a fear of talking in public or writing in front of others, or it may be broad, such as a general fear of functioning poorly in front of others. In both forms, people repeatedly judge themselves as performing less adequately than they actually do.
A social phobia can interfere greatly with one’s life (Koury & Rapaport, 2007).A person who is unable to interact with others or speak in public may fail to perform important responsibilities. One who cannot eat in public may reject dinner invitations and other social opportunities. Since most people with this phobia keep their fears secret, their social reluctance is often misinterpreted as snob­bery, lack of interest, or hostility.
Surveys indicate that 7.1 percent of people in the United States and other Western countries—around three women for every two men—experience a social phobia in any given year (see Table 4-7). Around 12 percent develop this problem at some point in their lives (Ruscio et al., 2008). It often begins in late childhood or adolescence and may continue into adulthood (APA, 2000).

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In several studies African and Asian American participants have scored higher than white Americans on surveys of social anxiety (Schultz et al., 2008, 2006; Okazaki et al., 2002,APA, 2000). In addition, a culture-bound disorder called taf in kyofusho seems to be particularly common in Asian countries such as Japan and Korea. Although this disorder is traditionally defined as a fear of making other people feel uncomfortable, a number of clinicians now suspect that its sufferers primarily fear being evaluated negatively by other people, a key feature of social phobias.
What Causes Phobias?

Each of the models offers explanations for phobias. Evidence tends to support the be­havioral explanations. Behaviorists believe that people with phobias first learn to fear certain objects, situations, or events through conditioning (Wolfe, 2005). Once the fears are acquired, the individuals avoid the dreaded object or situation, permitting the fears to become all the more entrenched.
Behavioral Explanations: How Are Fears Learned? Behaviorists propose classical conditioning as a common way of acquiring phobic reactions. Here, two events that occur close together in time become closely associated in a person’s mind, and, as you saw in Chapter 2, the person then reacts similarly to both of them. If one event triggers a fear response, the other may also.
In the 1920s a clinician described the case of a young woman who apparently ac­quired a phobia of running water through classical conditioning (Bagby, 1922). When she was 7 years old she went on a picnic with her mother and aunt and ran off by herself into the woods after lunch. While she was climbing over some large rocks, her feet were caught between two of them. The harder she tried to free herself, the more trapped she became. No one heard her screams, and she grew more and more terrified. In the language of behaviorists, the entrapment was eliciting a fear response.
Entrapment r Fear response
As she struggled to free her feet, the girl heard a waterfall nearby. The sound of the running water became linked in her mind to her terrifying battle with the rocks, and she developed a fear of running water as well.
Running water Fear response
Eventually the aunt found the screaming child, freed her from the rocks, and com­forted her, but the psychological damage had been done. From that day forward, the

Anxiety Disorders
1 09

Percentage

Prevalence

Currently

Female

Typical

among

Receiving

One-Year

to Male

Age at

Close

Clinical

Prevalence

Ratio

Onset

Relatives

Treatment

3.0%
2:1
0-20 years
Elevated
25.5%
8.7%
2:1
Variable
Elevated
19.0%
7.1%
3:2
10-20 years
Elevated
24.7%
2.8%
5:2
15-35 years
Elevated
34.7%
1.0%
1:1
4-25 years
Elevated
41.3%

Source: Ruscio et al., 2007; Kessler et al., 2005, 1999, 1994; Wang et al., 2005; Regier et at., 1993.
Anxiety Disorders Profile

Social phobia
Panic disorder Obsessive-compulsive disorder
girl was terrified of running water. For years family members had to hold her down to bathe her.When she traveled on a train, friends had to cover the windows so that she would not have to look at any streams. The young woman had apparently acquired a phobia through classical conditioning.
In conditioning terms, the entrapment was an unconditioned stimulus (US) that under­standably elicited an unconditioned response (UR) of fear.The running water represented a conditioned stimulus (CS), a formerly neutral stimulus that became associated with en­trapment in the child’s mind and came also to elicit a fear reaction.The newly acquired fear was a conditioned response (CR).

US: Entrapment -,- UR: Fear
CS: Running water -> CR: Fear
Another way of acquiring a fear reaction is through modeling, that is, through observation and imitation (Bandura & Rosenthal, 1%6). A person may observe that others are afraid of certain objects or events and develop fears of the same things. Consider a young boy whose mother is afraid of illnesses, doctors, and hospitals. If she frequently expresses those fears, before long the boy himself may fear illnesses, doctors, and hospitals.
Why should one or a few upsetting experiences or observations develop into a long­term phobia? Shouldn’t the trapped girl see later that running water will bring her no harm? Shouldn’t the boy see later that illnesses are temporary and doctors and hospitals helpful? Behaviorists believe that after acquiring a fear response, people try to avoid what they fear. They do not get close to the dreaded objects often enough to learn that the objects are really quite harmless.
°social phobiaoA severe and persistent fear of social or performance situations in which embarrassment may occur.
*classical conditioningoA process of learning in which two events that repeat­edly occur close together in time become tied together in a person’s mind and so produce the same response.
omodelingeA process of learning in which a person observes and then imi­tates others. Also, a therapy approach based on the same principfe,
•stimulus generalizationeA phenom­enon in which responses to one stimulus are also produced by similar stimuli.

­­­Behaviorists also propose that specific learned fears will blossom into a generalized anxiety disorder when a person acquires a large number of them. This development is presumed to come about through stimulus generalization: Responses to one stimu­lus are also elicited by similar stimuli. The fear of running water acquired by the girl in the rocks could have generalized to such similar stimuli as milk being poured into a glass or even the sound of bubbly music. Perhaps a person experiences a series of upsetting events, each event produces one or more feared stimuli, and the person’s reactions to each of these stimuli generalize to yet other stimuli. That person may then build up a large number of fears and eventually develop generalized anxiety disorder.
How Have Behavioral Explanations Fared in Research? Some labora‑
tory studies have found that animals and humans can indeed be taught to fear objects

1 1 0 ://CHAPTER 4

through classical conditioning (Miller, 1948; Mowrer, 1947, 1939). In one famous report, psychologists John B.Watson and Rosalie Rayner (1920) described how they taught a baby boy called Little Albert to fear white rats. For weeks Albert was allowed to play with a white rat and appeared to enjoy doing so. One time when Albert reached for the rat, however, the experimenter struck a steel bar with a hammer, making a very loud noise that frightened Albert. The next several times that Albert reached for the rat, the experimenter again made the loud noise. Albert acquired a fear and avoidance response to the rat.
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Research has also supported the behavioral position that fears can be acquired through modeling. Psychologists Albert Bandura and Theodore Rosenthal (1966), for example, had human research participants observe a person apparently being shocked by electricity whenever a buzzer sounded.The victim was actually the experimenter’s accomplice—in research ter­minology, a coqfederate—who pretended to experience pain by

twitching and yelling whenever the buzzer went on. After the unsuspecting participants had observed several such episodes, they themselves experi­enced a fear reaction whenever they heard the buzzer.

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Although these studies support behaviorists’ explanations of phobias, other research has called those explanations into question (Ressler & Davis, 2003). Several laboratory studies with children and adults have failed to condition fear reactions. In addition, although most case studies trace phobias to incidents of classical conditioning or mod­eling, quite a few fail to do so. So, although it appears that a phobia can be acquired by classical conditioning or modeling, researchers have not established that the disorder is ordinarily acquired in this way.
A Behavioral-Evolutionary Explanation Some phobias are much more com­mon than others. Phobic reactions to animals, heights, and darkness are more common than phobic reactions to meat, grass, and houses. Theorists often account for these dif­ferences by proposing that human beings, as a species, have a predisposition to develop certain fears (Scher et al., 2006; Seligman, 1971).This idea is referred to as preparedness because human beings, theoretically, are “prepared” to acquire some phobias and not others.The following case makes the point:
A four-year-old girl was playing in the park. Thinking that she saw a snake, she ran to her
parents’ car and jumped inside, slamming the door behind her. Unfortunately, the girl’s hand was caught by the closing car door, the results of which were severe pain and sev­eral visits to the doctor. Before this, she may have been afraid of snakes, but not phobic.
After this experience, a phobia developed, not of cars or car doors, but of snakes. The snake phobia persisted into adulthood, at which time she sought treatment from me.

(Marks, 1977, p. 192)

· preparedness0A predisposition to develop certain fears.
In a series of studies on preparedness, psychologist Arne Ohman and his colleagues conditioned different kinds of fears in human participants (Lundqvist & Ohman, 2005; Ohman et al., 1975). In one study they showed all participants slides of faces, houses, snakes, and spiders. One group received electric shocks whenever they observed the slides of faces and houses, while the other group received shocks when they looked at snakes and spiders.Were participants more prepared to fear snakes and spiders? Using skin reactions, or galvanic skin responses (GSRs), as a measure of fear, the experimenters

Anxiety Disorders :// 1 1 1

Night—nyctophobia
Noise or loud talking —phonophobia
Odors — osmophobia Pleasure— hedonophobia Poison —toxi phobia Poverty— peniaphobia Pregnancy— maieusiophobia
Railways—siderodromophobia
Rain —ombrophobia Rivers— potamophobia Robbers— harpaxophobia Satan —Satanophobia
Sexual intercourse— coitophobia,
cypridophobia
Shadows sciophobia Sleep— hypnophobia Snakes —ophidiophobia Snow—chionophobia Speed —tachophobia Spiders — arachnophobia Stings—cnidophobia Strangers—xenophobia Sun— Fel iophobia
Surgery—ergasiophobia Teeth —odontophobia Travel— hodophobia Trees — dendrophobia Wasps spheksophobia Water—hydrophobia Wind —anemophobia
Worms— helm inthophobia Wounds, injury—traumatophobia
(VAN WAGNER, 2007; MELVILLE, 1978)
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Phobias, Familiar and Not So Familiar
Animals— zoophobia Beards —pogonophobia Being afraid— phobophobia
Blood —hematophobia Books—bibliophobia Church es —ecclesiaphobia Corpses— necrophobia
Crossing a bridge—gephyrophobia Crowd s —ochlophobia
Darkness— achluophobia, nyctophobia Demons or devils —demonophobia Dogs— cynophobia
Dolls— pediophobia Drugs — pharmacophobia
Enclosed spaces—claustrophobia Eyes— ommatophobia
Feces —coprophobia Fire— pyrophobia
Flood —antlophobia Flowers —a nthophobia Flying —aerophobia Fog— horn ichlophobia Fur doraphobia
Germs —spermophobia Ghosts —phasmophobia God —theophobia
Machinery— mechanophobia Marriage—gamophobia
Meat— carnophobia
Mice— musophobia Mirrors—eisoptrophobia Money —chrometrophobia
Graves —taphophobia Heat— thermophobio Heights—acrophobia Homosexuality— homophobia
Horses —hippophobia Ice, frost —cryophobia Insects —entomophobia

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found that both groups learned to fear the intended objects after repeated shock pairings. But then they noted an interesting difference:After a short shock-free period, the persons who had learned to fear faces and houses stopped registering high GSRs in the presence of those objects, while the persons who had learned to fear snakes and spiders continued to show high GSRs in response to them for a long while. One interpretation is that animals and insects are stronger candidates for human phobias than faces or houses.

112 :41/CHAPTER 4

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Where might such predispositions to fear come from? According to some theo­rists, the predispositions have been transmitted genetically through an evolutionary process. Among our ancestors, the ones who more readily acquired fears of animals, darkness, heights, and the like were more likely to survive long enough to reproduce and to pass on their fear inclinations to their offspring (Ohman & Mineka, 2003; Mineka Ohman, 2002).&
How Are Phobias Treated?
Surveys reveal that 19 percent of individuals with specific phobias and almost 25 per­cent of those with social phobia are currently in treatment (Wang et al., 2005). Every theoretical model has its own approach to treating phobias, but behavioral techniques are more widely used than the rest, particularly for specific phobias. Research has shown such techniques to be highly effective and to fare better than other approaches in most head-to-head comparisons. Thus we shall focus primarily on the behavioral interventions.
Treatments for Specific Phobias Specific phobias were among the first anxiety disorders to be treated successfully in clinical practice. The major behavioral approaches to treating them are and Together, these approaches are called exposure treatments because in all of them individuals are exposed to the ob­jects or situations they dread.desensitization,flooding, modeling.
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People treated by systematic desensitization, a technique developed by Joseph Wolpe (1997,1987, 1969), learn to relax while gradually facing the objects or situations they fear. Since relaxation and fear are incompatible, the new relaxation response is thought to substitute for the fear response. Desensitization therapists first offer
to clients, teaching them how to bring on a state of deep muscle relaxation at will. In addition, the therapists help clients create a a list of feared objects or situations, ordered from mildly to extremely upsetting.relaxation training fear hierarchy,
Then clients learn how to pair relaxation with the objects or situations they fear. While the client is in a state of relaxation, the therapist has the client face the event at the bottom of his or her hierarchy. This may be an actual confrontation, a process called A person who fears heights, for example, may stand on a chair or climb a stepladder. Or the confrontation may be imagined, a process called In this case, the person imagines the frightening event while the therapist describes it.The client moves through the entire list, pairing his or her relax‑in vivo desensitization. covert desensitization.

13Anxiety Disorders 1

°exposure treatments0Behavioral treatments in which persons are exposed to the objects or situations they dread.
osystematic desensitizationoA behavioral treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to the objects or situations they dread.
ofloodingeA treatment for phobias in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless.
ation responses with each feared item. Because the first item is only mildly frightening, it is usually only a short while before the person is able to relax totally in its presence. Over the course of several sessions, clients move up the ladder of their fears until they reach and overcome the one that frightens them most of all.
Another behavioral treatment for specific phobias is flooding. Flooding therapists believe that people will stop fearing things when they are exposed to them repeatedly and made to see that they are actually quite harmless. Clients are forced to face their feared objects or situations without relaxation training and without a gradual buildup. The flooding procedure, like desensitization, can be either in vivo or covert.
When flooding therapists guide clients in imagining feared objects or situations, they often exaggerate the description so that the clients experience intense emotional arousal. In the case of a woman with a snake phobia, the therapist had her imagine the following scene, among others:
•
Close your eyes
its
it. it. Squeeze it feel Feel it start
it. there, feel
again. Picture the snake out in front of you, now make yourself pick it up. Reach down, pick it up, put it in your lap, feel it wiggling around in your lap, leave your hand on it put your hand out and feel it wiggling around. Kind of explore body with your fingers and hand. You don’t like to do it, make yourself do Make yourself do Really grab onto the snake. a little bit, it. kind of to wind around your hand. Let Leave your hand it touching your hand and winding around it curling around your wrist.

(Hogan, 1968, p. 423)

In it is the therapist who confronts the feared object or situation while the fearful person observes (Bandura, 2004, 1977, 1971; Bandura et al., 1977). The behavioral therapist acts as a model to dem­onstrate that the person’s fear is groundless. After several sessions many clients are able to approach the objects or situations calmly. In one ver­sion of modeling, the client is actively encouraged to join in with the therapist.modeling participant modeling, Clinical researchers have repeatedly found that each of the exposure treatments helps people with specific phobias (Farmer & Chapman, 2008; Pull, 2005).The key to success in all of these therapies appears to be contact with the feared object or situation. In vivo desensitiza­tion is more effective than covert desensitization, in vivo flooding more effective than covert flooding, and participant modeling more helpful than strictly observational modeling. In addition, a growing number of therapists are using computer graphics that simulate real-world objects and situations—as a useful exposure tool (Winerman, 2005).actual virtual reality-3D Trea mer ts for Social Phobias Only in recent years have clinicians been able to treat social phobias successfully (Rosenberg, Ledley, & Heimberg, 2010; Ruscio et al., 2008).Their newfound success is due in part to the growing recognition that so­cial phobias have two distinct features that may feed upon each other: (1) People with such phobias may have overwhelming social fears, and (2) they may lack skill at starting conversations, communicating their needs, or meeting the needs of others. Armed with this insight, clinicians now treat social phobias by trying to reduce social fears, by pro­viding training in social skills, or both.HOW CAN SOCIAL FEARS BE REDUCED? Unlike specific phobias, which do not typically re­spond to psychotropic drugs, social fears are often reduced through medication (Julien, 2008). Son-Lewhat surprisingly, it is that seem to be the drugs of most help t-or this disorder, often more helpful than benzodiazepines or other kinds of antianxiety medications (Burijon, 2007).antidepressant medications

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At the same time, several types of psychotherapy have proved to be at least as effective as medication at reducing social fears, and people helped by such psychological treat­ments appear less likely to relapse than those treated with medications alone (Rodebaugh, Holaway, & Heitnberg, 2004). This finding suggests to some clinicians that the psycho­logical approaches should always be included in the treatment of social fears.One psychological approach is the behavioral intervention so ef­fective with specific phobias. Exposure therapists encourage clients with social fears to expose themselves to the dreaded social situations and to remain until their fears subside. Usually the exposure is gradual, and it often includes homework assignments that are carried out in the social situations. In addition, group therapy offers an ideal setting for exposure treatments by allowing people to face social situations in an atmosphere of support and caring (McEvoy, 2007). In one group, for example, a man who was afraid that his hands would tremble in the presence of other people had to write on a black­board in front of the group and serve tea to the other members (Emmelkamp, 1982).exposure therapy,
have also been widely used to treat social fears, often in combina­tion with behavioral techniques (Rosenberg et al., 2010; McEvoy, 2007). In the fol­lowing discussion, Albert Ellis uses rational-emotive therapy to help a man who fears he will be rejected if he speaks up at gatherings. The discussion took place after the man had done a homework assignment in which he was to identify his negative social expectations and force himself to say anything he had on his mind in social situations, no matter how stupid it might seem to him:Cognitive therapies

After two weeks session
“I me to do…. [Every] see it, there be sentences. are they?’ And I there were
the same
of this assignment, the patient came into his next of therapy and reported: did what you told time, just as you said, I found myself retreating from people, I said to myself ‘Now, even though you can’t must some What finally found them. And many of them! And they all seemed to say thing.”

“What thing?”

to be rejected…. related to them I was going to be re­jected. be perfectly be rejected. there to be rejected that
“That I, uh, was going [10 I And wouldn’t that awful if I was to And was no rea­son for me, uh, take that, uh, sort of thing, and in awful manner.” ..

1 15Anxiety Disorders :1,1
°social skills trainingoA therapy approach that helps people learn or improve social skills and assertiveness through role playing and rehearsing of desirable behaviors.

“And did you do the second part of the homework assignment?” “The forcing myself to speak up and express myself?”

“Yes, that part.”

“That was worse. That was really hard. Much harder than 1 thought it would be. But I did it.”

`And?”

spoke up several times; I’ve ever people were spoke ..”Oh, not bad at all. I more than done before. Some very surprised. Phyllis was very surprised, too. But I up.”

yourself like
`And how did you feel after expressing that?”

felt really something to times week I
“Remarkable! I don’t remember when I last this way. I felt, uh, just remarkable—good, that is. It was feel! But it was so hard. I almost didn’t make it. And a couple of other during the had to force myself again. Butt did. And was glad!”

(Ellis, 1962, pp. 202-203)
Studies show that rational-emotive therapy and other cognitive approaches do in­deed help reduce social fears (Rosenberg et al., 2010; Hollon et al., 2006). And these reductions typically persist for years. On the other hand, research also suggests that while cognitive therapy often reduces social fears, it does not consistently help people perform effectively in social settings.This is where social skills training has come to the forefront.

In social skills training, therapists combine several behavioral techniques in order to help people improve their social skills. They usually appropriate social behaviors for clients and encourage the individuals to try them out. The clients then with the therapists, their new behaviors until they become more effective. Throughout the process, therapists provide and (praise) the clients for effective performances.HOW CAN SOCIAL SKILLS BE IMPROVED? model role-play rehearsing frank feedback rein force

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,0:-nputing Systems, 7,005; ZONFT, 2005)PhobiasA phobia is a severe, persistent, and unreasonable fear of a particular object, activity, or situation. There are three main categories of phobias: specific phobias, social phobias, and agoraphobia. Behavioral explanations of phobias, particularly specific phobias, are the most influential. Behaviorists believe that phobias are learned through classical conditioning or modeling, and then are maintained by avoidance behaviors.Specific phobias have been treated most successfully with behavioral exposure techniques. The exposure may be gradual and relaxed (desensitization), intense (flooding), or vicarious (modeling).Therapists who treat social phobias typically separate two features of this dis­order: social fears and poor social skills. They try to reduce clients’ social fears by drug, exposure, group, or cognitive therapy—or a combination of these interven­tions. They may try to improve social skills by social skills training.­­Reinforcement from other people with similar social difficulties is often more powerful than reinforcement from a therapist alone. In and
members try out and rehearse new social behaviors with other group members. The group can also provide guidance on what is socially appropriate. According to research, social skills training, both individual and group formats, has helped many people perform better in social situations (Fisher et al., 2004).social skills training groups as­sertiveness training groups,

116 ://CHAPTER 4

OPanic Disorder

Sometimes an anxiety reaction takes the form of a smothering, nightmarish panic in which people lose control of their behavior and, in fact, are practically unaware of what they are doing.Anyone can react with panic when a real threat looms up suddenly. Some people, however, experience panic attacks—periodic, short bouts of panic that occur suddenly, reach a peak within 10 minutes, and gradually pass.

The attacks feature at least four of the following symptoms of panic: palpitations of the heart, tingling in the hands or feet, shortness of breath, sweating, hot and cold flashes, trembling, chest pains, choking sensations, faintness, dizziness, and a feeling of unreality. Small wonder that during a panic attack many people fear they will die, go crazy, or lose control.

very
like It got wet seemed to felt
to collapse; it if I
were move. been token over people me—just faces,
to stop. 1 see people but
get escape the
I was inside a busy shopping precinct and all of a sudden it happened: in a matter of seconds I was a mad woman. was like a nightmare, only I was awake; everything went black and sweat poured out of me—my body, my hands and even my hair through. All the blood drain out of me; 1 went as white as a ghost. I as if I were going was as had no control over my limbs; my back and legs were very weak and I felt as though it impossible to It was as if I had by some stronger force. I saw all the looking at no bodies, all merged into one. My heart started pounding in my head and in my ears; I thought my heart was going could black and yellow lights. I could hear the voices of the from a long way off I could not think of anything except the way I was feeling and that now I had to out and run quickly or I would die. I must and get into fresh air.

(Hawkrigg, 1975)

attacksoPeriodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.•panic

panic disordereAn anxiety disorder marked by recurrent and unpredictable panic attacks.
anxiety disorder in which a person is afraid to be in places or situations from which escape might be difficult (or embarrassing) or help unavailable if panic-like symptoms were to occur.ocagoraphobiaoAn More than one-quarter of all people have one or more panic attacks at some point in their lives (Kessler et al., 2006). Some people, however, have panic attacks repeatedly and unexpectedly and without apparent reason. They may be suffering from panic disorder. In addition to the panic attacks, people who are diagnosed with panic disor­der experience dysfunctional changes in their thinking or behavior as a result of the at­tacks (see Table 4-8).They may, for example, worry persistently about having additional attacks, have concerns about what such attacks mean (“Am I losing my mind?”), or plan their lives around the possibility of future attacks.Panic disorder is often accompanied by agoraphobia, one of the three categories of phobia mentioned earlier. People with agoraphobia are afraid to leave the house and travel to public places or other locations where escape might be difficult or help unavail­able should panic symptoms develop. In severe cases, people become virtual prisoners in their own homes. Their social life dwindles, and they cannot hold a job.Until recently, clinicians failed to recognize the close link between agoraphobia and panic attacks.They now realize that panic attacks, or at least some panic-like symptoms, typically set the stage for agoraphobia: After experiencing one or more unpredictable attacks, certain individuals become fearful of having new attacks in public places where help or escape might be difficult.Not everyone with panic disorder develops agoraphobia, but many such persons do. Thus DSM-IV-TR_ distinguishes from
Around 2.8 percent of all people in the United States suffer from one or the other of these patterns in a given year; close to 5 percent develop one of the pat­terns at some point in their lives (Kessler et al., 2009, 2006, 2005). Both kinds of panic disorder tend to develop in late adolescence or early adulthood and are at least twice as common among women as among men (APA, 2000).The prevalence of panic disor­der is the same across various cultural and racial groups in the United States. Similarly,panic disorder without agoraphobia panic disorder with agoraphobia.

1 17Anxiety Disorders ://
enorepinephrineeA neurotransmitter whose abnormal activity is linked to panic disorder and depression.°locus ceruleusoA small area of the brain that seems to be active in the regu­lation of emotions. Many of its neurons use norepinephrine.oomygdolaoA small, almond-shaped structure in the brain that processes emotional information.­the disorder seems to occur in equal numbers in cultures across the world, although its specific context differs from country to country (Nazarian & Craske, 2008). Surveys indicate that around 35 percent of individuals with panic disorder in the United States are currently in treatment (Wang et al., 2005).
The Biological Perspective

In the 1960s, clinicians made the surprising discovery that panic disorder was helped more by certain drugs that are usually used to reduce the symptoms of depression, than by most of the benzodiazepine drugs, the drugs useful in treating generalized anxiety disorder (Klein, 1964; Klein & Fink, 1962).This observation led to the first biological explanations and treatments for panic disorder.antidepressant drugs, What Biological Factors Contribute to Panic Disorder? To understand thebiology of panic disorder, researchers worked backward from their understanding of the antidepressant drugs that seemed to control it.They knew that these particular antidepres­sant drugs operate in the brain primarily by changing the activity of norepinephrine, yet another one of the neurotransmitters that carry messages between neurons. Given that the drugs were so helpful in eliminating panic attacks, researchers began to suspect that panic disorder might be caused in the first place by abnormal norepinephrine activity.Several studies produced evidence that norepinephrine activity is indeed irregular in people who suffer from panic attacks. For example, the locus ceruleus is a brain area rich in neurons that use norepinephrine.When this area is electrically stimulated in monkeys, the monkeys have a panic-like reaction, suggesting that panic reactions may be related to changes in norepinephrine activity in the locus ceruleus (Redmond, 1981, 1979, 1977). Similarly, in another line of research, scientists were able to produce panic attacks in human beings by injecting them with chemicals known to affect the activity of norepinephrine (Bourin et al., 1995; Charney et al., 1990, 1987).Ventromedialnutieus of thehypothalamusThese findings strongly tied norepinephrine and the locus ceruleus to panic attacks. However, research conducted in recent years indicates that the root of panic attacks is probably more complicated than a single neurotransmitter or single brain area. Re­searchers have determined, for example, that emotional reactions of various kinds are tied to brain
of brain structures that work together, triggering each other into action and producing a particular kind of emotional reaction. It turns out that the circuit that produces panic reactions includes brain areas such as the
and (Ninan & Dunlop, 2005) (see Figure 4-4).When a person confronts a frightening ob­ject or situation, the amygdala, a small almond-shaped structure that processes emotional information, is stimulated. In turn, the amygdala stimulates the other brain areas in the circuit, temporar­ily setting into motion an “alarm-and-escape” response (increased heart rate, respiration, blood pressure, and the like) that is very similar to a panic reaction (Gray & McNaughton, 1996). Most of today’s researchers believe that this brain circuit—including the neu­rotransmitters at work throughout the circuit—probably functions improperly in people who experience panic disorder (Burijon, 2007; Bailey et al., 2003).circuits—networks ainygdala, ventromedial nucleus of the hypothalamus, central gray matter; locus ceruleus It is worth noting that the brain circuit responsible for panic reactions appears to be different from the circuit responsible for reactions (reactions that are more diffuse, ongoing, and worry-dominated than panic reactions) (see Figure 4-5 on the next page).The anxiety brain circuit, which functions improperly in people with generalized anxiety disorder, includes the
and (McClure et al., 2007).anxiety amygdala, prefrontal cortex, anterior cingulate cortex
1 20 ://CHAPTER 4

*anxiety sensitivity®A tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful.oobsessionoA persistent thought, idea, impulse, or image that is experienced repeatedly, feels intrusive, and causes anxiety.ocompulsion®A repetitive and rigid behavior or mental act that a person feels driven to perform in order to pre­vent or reduce anxiety.°obsessive-compulsive disorder®A disorder in which a person has recurrent and unwanted thoughts, a need to per­form repetitive and rigid actions, or both.­­Why might some people be prone to such misinterpretations? One possibility is that panic-prone individuals generally experience, through no fault of their own, more frequent or more intense bodily sensations than other people do (Nardi et al., 2001). In fact, the kinds of sensations that are most often misinterpreted in panic disorders seem to be carbon dioxide increases in the blood, shifts in blood pressure, and rises in heart rate—bodily events that are controlled in part by the locus ceruleus and other regions of the panic brain circuit.Whatever the precise causes of such misinterpretations may be, research suggests that panic-prone individuals generally have a high degree ofwhat is called anxiety sensitivity; that is, they focus on their bodily sensations much of the time, are unable to assess them logically, and interpret them as potentially harmful (Wilson Hayward, 2005). One study found that people who scored high on an anxiety sensitivity survey were five times more likely than other people to develop panic disorder (Mailer & Reiss, 1992). Other studies have found that individuals with panic disorder typically earn higher anxiety sensitivity scores than other persons do (Dattilio, 2001; McNally, 2001).Sc Cognitive Therapy Cognitive therapists try to correct people’s misinterpretations of their body sensations (McCabe & Antony, 2005). The first step is to educate clients about the general nature of panic attacks, the actual causes of bodily sensations, and the tendency of clients to misinterpret their sensations. The next step is to teach clients to apply more accurate interpretations during stressful situations, thus short-circuiting the panic sequence at an early point. Therapists may also teach clients to cope better with anxiety—for example, by applying relaxation and breathing techniques—and to distract themselves from their sensations, perhaps by striking up a conversation with someone.In addition, cognitive therapists may use biological challenge procedures to induce panic sensations, so that clients can apply their new skills under watchful supervision (Meuret et al., 2005). Individuals whose attacks typically are triggered by a rapid heart rate, for example, may be told to jump up and down for several minutes or to run up a flight of stairs.They can then practice interpreting the resulting sensations appropriately, without dwelling on them.According to research, cognitive treatments often help people with panic disorder (Marchand et al., 2009; Otto & Deveney, 2005). In a number of international studies, 85 percent of participants given these treatments have been found to be free of panic for two years or more, compared to only 13 percent of control participants. Such cognitive

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son I didn’t hear what you said. I was listening to my body.”

1 21Anxiety Disorders :11

_’,’L::::.,1
1 .4-i…,4-4-,i 1-,,:ilif,-…, Ijiri-, ”i,s”’,1 ll.=t-.:1,,y,-Fiti’;’,I…T..,lifir.)1711tiii’.%-f-lit°–qijif,(141c,-J-W1IITI-X1 l’)/,,L Y 1,J,•=11V•50,:i,111“:”.ra.-S1,(4e.treatments also are helpful for many persons whose panic disorders are accompanied by agoraphobia. For some individuals with the agoraphobic pattern, therapists further add exposure techniques to the cognitive treatment program—an addition that has produced p articularly high success rates.Cognitive therapy has proved to be at least as helpful as antidepressant drugs or alprazolam in the treatment of panic disorder, sometimes even more so (McCabe Antony, 2005). In view of the effectiveness of both cognitive and drug treatments, many clinicians have tried combining them (Julien, 2008; Baskin, 2007). It is not yet clear, however, whether this strategy is more effective than cognitive therapy alone.&
Panic DisorderPanic attacks are periodic, short bouts of panic that occur suddenly. Sufferers of panic disorder experience such attacks repeatedly and unexpectedly and without apparent reason. When panic disorder leads to agoraphobia, it is termed panic disorder with agoraphobia.Some biological theorists believe that abnormal norepinephrine activity in the brain’s locus ceruleus is the key to panic disorder. Others believe that related neurotransmitters and structures in the panic brain circuit also play key roles. Biological therapists use certain antidepressant drugs or powerful benzodiazepines to treat people with this disorder.Cognitive theorists suggest that panic-prone people are very sensitive to their bodily sensations and misinterpret them as signs of medical catastrophe. Such per­sons have a high degree of anxiety sensitivity and also experience greater anxiety during biological challenge tests. Cognitive therapists teach patients to interpret their physical sensations more accurately and to cope better with anxiety.
Obsessive-Corn puisive Disorder
Obsessions are persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness. Compulsions are repetitive and rigid behaviors or mental acts that people feel they must perform in order to prevent or reduce anxiety. As Figure 4-6 on the next page indicates, minor obsessions and compulsions are familiar to almost everyone.You may find yourself filled with thoughts about an upcoming performance or exam or keep wondering whether you forgot to turn off the stove or lock the door. You may feel better when you avoid stepping on cracks, turn away from black cats, or arrange your closet in a particular manner.

Minor obsessions and compulsions can play a helpful role in life. Little rituals often calm us during times of stress. A person who repeatedly hums a tune or taps his or her fingers during a test may be releasing tension and thus improving performance. Many people find it comforting to repeat religious or cultural rituals, such as touching a mezuzah, sprinkling holy water, or fingering rosary beads.According to DSM-IV-TR, a diagnosis of obsessive-compulsive disorder is called for when obsessions or compulsions feel excessive or unreasonable, cause great distress, take up much time, or interfere with daily functions (see Table 4-9).The disor­der is classified as an anxiety disorder because the obsessions cause intense anxiety, while the compulsions are aimed at preventing or reducing anxiety. In addition, anxiety rises if individuals try to resist their obsessions or compulsions.A woman with this disorder observed: “I can’t get to sleep unless I am sure everything in the house is in its proper place so that when I get up in the morning, the house is organized. I work like mad to set everything straight before I go to bed, but, when I get up in the morning, I can think of a thousand things that I ought to do…. I can’t stand to know something needs doing and I haven’t done it” (McNeil, 1967, pp. 26-28).
122 ://CHAPTER 4
– I ( I,– I ,ThEil – l 0 1 .’Jails ‘1, n i 11112 I H. I1c II a dll”irl : , ,,of r) ,I f 1,,1111, il-n 1, 1 -‘ ‘—r. 1’1’1,,i’l.r— 1 1, r, I+,Irroiji I’l Il ,,_-,1?{Ilnr, ‘, 1,111-5’ .Brush teeth up and down Change towels ‘1 daily or after every showera)
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Sleep on left side

Sleep on right sideSleep on stomachSleep on backPercentage of Population Who Follow Routine50%50%Between 1 and 2 percent of the people in the United States and other countries throughout the world suffer from obsessive-compulsive disorder in any given year (Bjorgvinsson & Hart, 2008; Wetherell et al., 2006). As many as 3 percent develop the disorder at some point during their lives. It is equally common in men and women and among people of different races and ethnic groups.The disorder usually begins by young adulthood and typically persists for many years, although its symptoms and their severity may fluctuate over time (Angst et al., 2004). It is estimated that more than 40 percent of people with obsessive-compulsive disorder seek treatment (Kessler et al., 1999, 1994).4 id
What Are the Features of Obsessions and Compulsions?Obsessive thoughts feel both intrusive and foreign to the people who experience them. Attempts to ignore or resist these thoughts may arouse even more anxiety, and before long they come back more strongly than ever. Like the woman quoted at the bottom of page 121, people with obsessions are quite aware that their thoughts are excessive.Obsessions often take the form of obsessive (for example, repeated wishes that one’s spouse would die), (repeated urges to yell out obscenities at work or in church), (fleeting visions of forbidden sexual scenes), (notions that germs are lurking everywhere), or (concerns that one has made or will make a wrong decision). In the following excerpt, a clinician describes a 20-year-old college junior who was plagued by obsessive doubts.wishes impulses images ideas doubts . .::;:11111.••:.•: I f;;.)’-F1:!rj.i;’ ‘; r I 1. :”.:1q.ri.!1.1carinur, ‘1995)He now the events,
teachers,
process to videotape of over

orspent hours each night “rehashing” day’s especially interactions with friends and endlessly making “right” in his mind any and all regrets. He likened the playing a each event and over again in his mind, ask­ing himself if he had behaved properly and telling himself that he had done his best,

123Anxiety Disorders :1/
0Avili41-4i,!FcrAn Obsession That Changed the World
this while sitting desk, to the
note that, to three elapsed.had said the right thing every step of the way. He would do at his supposedly studying; and it was not unusual for him look at clock after such a period of rumination and his surprise, two or hours had
(Spitzer et al., 1981, pp. 20-21)

•
4.

1.1? `: (“:”97,

•ITI ICertain basic themes run through the thoughts of most people troubled by obsessive thinking (Abramowitz, McKay, & Taylor, 2008). The most common theme appears to be dirt or contamination (Tolin & Meunier, 2008). Other common ones are violence and aggression, orderliness, religion, and sexuality. The prevalence of such themes may vary from culture to culture. Religious obsessions, for example, seem to be more com­mon in cultures or countries with strict moral codes and religious values (Bjorgvinsson & Hart, 2008).Compulsions are similar to obsessions in many ways. For example, although compul­sive behaviors are technically under voluntary control, the people who feel they must do them have little sense of choice in the matter. Most of these individuals recognize that their behavior is unreasonable, but they believe at the same time something terrible will happen if they don’t perform the compulsions. After performing a compulsive act, they usually feel less anxious for a short while. For some people the compulsive acts develop into detailed They must go through the ritual in exactly the same way every time, according to certain rules.rituals. Like obsessions, compulsions take various forms. are very common. Like the woman we heard from earlier, people with these compulsions feel compelled to keep cleaning themselves, their clothing, or their homes. The cleaning may follow ritualistic rules and be repeated dozens or hundreds of times a day. People with check the same items over and over—door locks, gas taps, important papers—to make sure that all is as it should be (Radomsky et al., 2008). Another common compulsion is the constant effort to seek or (Coles & Pietrefesa, 2008). People with this com­pulsion keep placing certain items (clothing, books, foods) in perfect order in accordance with strict rules.
and compulsions are also common.Cleaning compulsions checking compulsions order balance Touching, verbal, counting Although some people with obsessive-compulsive dis­order experience obsessions only or compulsions only, most of them experience both (Clark & Guyitt, 2008). In fact, compulsive acts are often a response to obsessive thoughts. One study found that in most cases, compulsions seemed to represent a to obsessive doubts, ideas, or urges (Akhtar et al., 1975).A woman who keeps doubting that her house is secure may yield to that obsessive doubt by repeatedly checking locks and gas jets. Or a man who obsessively fears contamination may yield to that fear by performing cleaning rituals.yielding pulsioni, In eed rituals often give ni to their practitioners. Here, Buddhist monks splash Water oyer themselve: during their annualwinter prayers at temple in Tokyo This -cleansing riival erformecl. o pro r good luck Isor cry , ir% ea in com•uisionsMany people with obsessive-compulsive disorder worry that they will act out their obsessions. A man with obsessive images of wounded loved ones may worry that he is but a step away from committing murder, or a woman with obsessive urges to yell out in church may worry that she will one day give in to them and embarrass herself. Most such concerns are unfounded. Although many obsessions lead to compulsive acts—particularly to cleaning and checking compulsions—they usually do not lead to violence or immoral conduct.
Obsessive-compulsive disorder was once among the least understood of the psy­chological disorders. In recent decades, however, researchers have begun to learn more about it. The most influential explanations and treatments conic from the psychody­namic, behavioral, cognitive, and biological models.
124 ://CHAPTER 4

The Psychodynamic Perspective
As you have seen, psychodynamic theorists believe that an anxiety disorder develops when children come to fear their own id impulses and use ego defense mechanisms to lessen the resulting anxiety. What distinguishes obsessive-compulsive disorder from other anxiety disorders, in their view, is that here the battle between anxiety-provoking id impulses and anxiety-reducing defense mechanisms is not buried in the unconscious but is played out in overt thoughts and actions. The id impulses usually take the form of obsessive thoughts, and the ego defenses appear as counterthoughts or compulsive

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Dining Out: The Obsessive-Compulsive Experience
INew York Times an this February 2008 article, Jeff Bell,

a
radio news anchor, describes the ordeal that he and other people with similar obsessive-compulsive disorders confront whenever they go to a restaurant for “pleasurable” night out.
[R]estaurants are designed to be calming and relaxing. That is one of the main reasons people like to eat out. To many of us with obsessive-compulsive disorder, those pleasures are invis­ible. We walk into a calm and civilized dining room and see things we won’t be able to control. . . .

Personally, lam fine with just about any table, although the wobbly onescan spell big trouble. I have harm obses­sions, which means I am plagued by the fear that other people will be hurt by something I do, or don’t do. Seated ata less-than-sturdy table, I conjure images of fellow diners being crushed or other­wise injured should I fail to notify the restaurant’s management. This is called a reporting compulsion in the vernacular of the disorder, and before I learned to fight these urges, many a manager heard from me.Forget the tabletop, my friend Matt S. tells me; it’s what’s on top of the table,and precisely where, that really matters. Mr. S. is a 39-year-old lawyer in Fort Worth with order compulsions. To enjoy a meal he needs to separate the salt and pepper shakers, and, ide­ally, place a napkin holder or other divider midway between them.. . .Some of our other concerns may seem familiar. I imagine most diners, for example, have noticed and perhaps even struggled to remove white detergent spots that can sometimes be seen on silverware. But few, I suspect, have gone to the lengths Jared K. has to get rid of them. Mr. is a 24-year-old research assistant living outside of Boston who has obsessive fears of con­tamination. . . . Last year he visited a Chinese restaurant with K.
several friends, one of whom pointed out that their silverware was spotted and seemed dirty. Mr. K. collected all the utensils at the table and attempted to sterilize them by holding them above a small flame at the center of a pu-pu platter, quickly attracting the attention of their waiter. .
As part of my harm obsession, one of my concerns is that germs from my mouth will hurt others. Although I try to keep my fingers away from my lips and their germs while I’m eat­ing, I’m rarely successful fit’s not as easy as it sounds]. By the 4 end of the meal I believe that my hands
are contaminated. The problem is that I need them to scribble my signature on the check. If I’m lucky, I will have re­membered to bring my own pen; if not, I may feel compelled to “table-wash” my hands, a little trick I developed over the years: I use the condensation on theoutside of a cold water glass to rinse off the germs. . . .Once the check is signed, I must be sure that it is really signed. At my worst, I have opened and closed the vinyl check holder again and again, seeing my signature each time, yet unable to feel certain. I’ve left the table, only to re­turn to check again. And again. . . .
therapy][Postscript: After exposure and response prevention Today I travel extensively, sharing my recovery story and working with groups like the Obsessive Compulsive Foundation to raise awareness. . . . I wind up eating in a lot of restaurants. I can honestly say I’m starting to enjoy it. In fact, while I still like ice water with my meal, I often find myself drinking from the glass, not washing with it.Now when I say check, please, I’m simply asking for my bill.Jeff Bell, “When Anxiety Is at the Table,” Neu,February 6, 2008. York Times, Copyright © 2008 New York Times Company. Reprinted by permission of PARS International, Inc. All rights reserved.

1 25Anxiety Disorders :11

IffiA

“Is the Its), Bits), Spider obsessive-compulsive?”

Abnormal Psychology

Chapter 03:

CLINICAL ASSESSMENT, DIAGNOSIS, AND TREATMENT

Ronald J. Comer

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Abnormal Psychology
Chapter 04:
ANXIETY DISORDERS
Ronald J. Comer

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