paper

Psych Research Paper due on Thursday November 8, 2012  DSM-IV

body no less than 7 pages no more than 10 pages.  Not to include title, abstract, reference page

PSYC 430

Research Paper Instructions

Research a specific mental disorder within the realm of Abnormal Psychology. The topic must be one which is discussed in the Comer text and described in the DSM-IV. The length of the body of the paper should be at least 7 pages, and should not exceed 10 pages of summarized research findings in APA format. In addition to this, include an APA-style title page, abstract, and references; these do not count toward the minimum number of pages required. The paper must be organized with sub-headings reflecting the required sections (I–IX).

The research paper will address the following aspects, organized in this order:

*
Title Page: APA-style

*
Abstract: APA-style

I. Introduction: Introduce and describe the topic. Discuss the DSM classification for the disorder, including a discussion of the specific criteria as described in the DSM-IV (1/2 page).

II. Historical: The disorder in its historical context (1 page).

III. Cause of the Illness: Current research as to the cause of the illness (1 page).

IV. Treatment: Various treatment approaches for this disorder, including the benefits of the treatment (1 page).

V. Prevention: Research as to the prevention of the illness (1 page).

VI. Cross Cultural: Cross-cultural issues pertaining to the topic (1 page).

VII. Biblical Worldview: Discuss the topic from a Christian worldview perspective, including disorder’s cause, treatment, and prevention. Utilize the Bible and a book or journal source written from a biblical/theological perspective on the topic (1 page).

VIII. Conclusion: Include a closing summary of the research, including ideas for future research on the topic (1/2 page).

IX.
References: APA-style

*
Organize paper according to directions. Include APA-style Level 1 sub-titles

*
Use the references you found for your References Assignment.

*
The use of 3RD person point of view is expected for this type of scholarly research assignment.

*
Correct spelling, grammar, and punctuation is expected in writing at this level.

*
Include not more than ½ page of directly quoted material. Directly quoted material in excess of ½ page of the body of the paper would not count towards length/content requirement.

*
APA formatting is required.

The reference page should include five (5) or more references with the following guidelines:

· Include five (5) or more references that stem from scholarly journal articles or books dated within the past 10 years.

· Include one (1) or more references that stem from a theological and/or biblical perspective.

· The paper may include citations from the Bible

· Websites are not considered as scholarly and should not be listed on this reference page.

Page 1 of 2

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
-1,
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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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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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-IV-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 IV. And because she seemed fairly dysfunctional at the time of diagnosis, Angela’s GAF would probably be around 55 on AxisV, indicating a moderate level of dysfunction. The complete diagnosis for Angela Savanti would then be:
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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DSM-IV-TR an Effective Classification System?

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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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1;1 idiographic understanding, p. 67
·
assessment, p. 67
·
standardization, p. 68

§
reliability, p. 68

·
A validity, p. 68

§ clinical interview, p. 69
mental status exam, p. 70

test, p. 71

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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

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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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4.
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

DSA/1-1V-TR Categories: Bias against Females?
Assessing Psychopathy

“Brain Fingerprinting”: Detecting
Hidden Thoughts A Video case discussions, study guides, and questions

041″j A Chapter 3 Video Cases 7,4
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A Chapter 3 outline, learning objectives, research exercises, study tools, and practice test questions
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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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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).
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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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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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must have worried yourself to death.”

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?

Ellis: No—not unless you think you are. You are frustrated, of course, if you want to set up a good testing procedure and you can’t. But need you be desperately

unhappy because you are frustrated? And need you deem yourself completely un­
worthwhile because you can’t do one of the main things you want to do in life?

(Ellis, 1962,
pp.
160-165)

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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 disordergirl 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 that under­standably elicited an (UR) of fear.The running water represented a 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
unconditioned stimulus (US) unconditioned response conditioned stimulus (CS), conditioned response (CR).
US: Entrapment -,- UR: Fear
CS: Running water -> CR: Fear

Another way of acquiring a fear reaction is through 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.modeling, & 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 what they fear. They do not get close to the dreaded objects often enough to learn that the objects are really quite harmless.avoid
severe and persistent fear of social or performance situations in which embarrassment may occur.°social phobiaoA
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.*classical conditioningoA
process of learning in which a person observes and then imi­tates others. Also, a therapy approach based on the same principfe,omodelingeA
phenom­enon in which responses to one stimulus are also produced by similar stimuli.•stimulus generalizationeA
­­­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 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.stimulus generalization:

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.9

a

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 pretended to experience pain bycoqfederate—who
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.
· .tm anzeeln l~_) ans may acquire4offSpring. Altho 0bias by either modeling, resew es atom rpore likelI HIlliliF4F0.11f,Lt:_tc,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 be acquired by classical conditioning or modeling, researchers have not established that the disorder is acquired in this way.can ordinarily 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:
the she
the door the the results were severe sev­eral Before snakes,
experience, developed, not of The treatment
A four-year-old girl was playing in park. Thinking that she saw a snake, ran to her parents’ car and jumped inside, slamming behind her. Unfortunately, the girl’s hand was caught by closing car door, of which pain and visits to the doctor. this, she may have been afraid of but not phobic. After this a phobia cars or car doors, but of snakes. snake phobia persisted into adulthood, at which time she sought 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 as a measure of fear, the experimentersgalvanic skin responses (GSRs),
Anxiety
Disorders :// 1 1 1

Night—nyctophobiaNoise or loud talking —phonophobiaOdors — osmophobia Pleasure— hedonophobia Poison —toxi phobia Poverty— peniaphobia Pregnancy— maieusiophobiaRailways—siderodromophobiaRain —ombrophobia Rivers— potamophobia Robbers— harpaxophobia Satan —SatanophobiaSexual intercourse— coitophobia,cypridophobiaShadows sciophobia Sleep— hypnophobia Snakes —ophidiophobia Snow—chionophobia Speed —tachophobia Spiders — arachnophobia Stings—cnidophobia Strangers—xenophobia Sun— Fel iophobiaSurgery—ergasiophobia Teeth —odontophobia Travel— hodophobia Trees — dendrophobia Wasps spheksophobia Water—hydrophobia Wind —anemophobiaWorms— helm inthophobia Wounds, injury—traumatophobia(VAN WAGNER, 2007; MELVILLE, 1978)
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Animals— zoophobia Beards —pogonophobia Being afraid— phobophobiaPhobias, Familiar and Not So Familiar
Blood —hematophobia Books—bibliophobia Church es —ecclesiaphobia Corpses— necrophobiaCrossing a bridge—gephyrophobia Crowd s —ochlophobiaDarkness— achluophobia, nyctophobia Demons or devils —demonophobia Dogs— cynophobiaDolls— pediophobia Drugs — pharmacophobiaEnclosed spaces—claustrophobia Eyes— ommatophobiaFeces —coprophobia Fire— pyrophobiaFlood —antlophobia Flowers —a nthophobia Flying —aerophobia Fog— horn ichlophobia Fur doraphobiaGerms —spermophobia Ghosts —phasmophobia God —theophobiaMachinery— mechanophobia Marriage—gamophobiaMeat— carnophobiaMice— musophobia Mirrors—eisoptrophobia Money —chrometrophobiaGraves —taphophobia Heat— thermophobio Heights—acrophobia Homosexuality— homophobiaHorses —hippophobia Ice, frost —cryophobia Insects —entomophobia
******************************************************************************** .11,71,•!.11,11,..••11111••…11.••••••••••••••••••••••••••••••••••,..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. 1111.111, 1, IIII!i!11111 1Il=:li iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii
‘..1%1DIF.*;….1 1! V010..:1 1 • Arfl. 4.i i .1011/111 ,,,i1111111.1People 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

1 14 ://CHAPTER 4e rize winner in iterature
d o accept this prestigi7Dus honor’ and present her_Nobel lectu y video trans, :mission because she harsea social phobia that prevented her from oitending the ha
igestivities in Stokholrn in peeson.

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

‘311h,v4-5)=1; ‘Of
Playiist Anxiety

‘0; S 101: r • :

•A S .1

–onfetence on Humiri Factors in

,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

0 The Hew Yaker .0It1

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)
4.z
Crack knuckles
ce
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

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9

cording to research, such combinations often yield higher levels of symptom reduction
and bring relief to more clients than do each of the approaches alone—improvements
that may continue for years (Kordon et al., 2005; Rufer et al., 2005).

Obviously, the treatment picture for obsessive-compulsive disorder has improve

d

greatly over the past 15 years, and indeed, this disorder is now helped by several forms
of treatment, often used in combination. In fact, at least two studies suggest that the be-
havioral, cognitive, and biological approaches may ultimately have the same effect on the
brain. In these investigations, both participants who responded to cognitive-behavioral
treatments and those who responded to antidepressant drugs showed marked reductions
in activity in the caudate nuclei (Stein & Fineberg, 2007; Baxter et al., 2000, 1992).

Obsessive-Compulsive

Disorder

People with obsessive -compulsive disorder experience obsessions and/or perform
compulsions. Compulsions are often a response to a person’s obsessive thoughts.

According to the psychodynamic view, obsessive-compulsive disorder arises
out of an overt battle between id impulses and ego defense mechanisms. Behavior-
ists, on the other hand, believe that compulsive behaviors develop through chance
associations. The leading behavioral treatment combines prolonged exposure with
response prevention. Cognitive theorists believe that obsessive-compulsive disorder
grows from a normal human tendency to have unwanted and unpleasant thoughts.
The misguided efforts of some people to understand, eliminate, or avoid such
thoughts actually lead to obsessions and compulsions. Cognitive therapy for this dis-
order includes correcting and helping clients change their misinterpretations of their
unwanted thoughts. Research suggests that a combined cognitive-behavioral ap-
proach often is more effective than either cognitive or behavioral therapy alone.

Biological researchers have tied obsessive-compulsive disorder to low serotonin
activity and abnormal functioning in the orbitofrontal cortex, the caudate nuclei, or
other regions in the obsessive-compulsive brain circuit. Antidepressant drugs tha

t

raise serotonin activity are a useful form of treatment.

PUTTING IT… together
Diathesis-Stress in Action

Clinicians and researchers have developed many ideas about generalized anxiety disorder,
phobias, panic disorder, and obsessive-compulsive disorder. At times, however, the sheer
quantity of concepts and findings makes it difficult to grasp what is really known about
the disorders.

Overall, it is fair to say that clinicians currently know more about the causes
of phobias, panic disorder, and obsessive-compulsive disorder than about generalized
anxiety disorder. It is worth noting that the insights about panic disorder and obsessive-
compulsive disorder—once among the field’s most puzzling patterns—did not emerge
until clinical theorists took a look at the disorders from more than one perspective and
integrated those views. Today’s cognitive explanation of panic disorder, for example,
builds squarely on the biological idea that the disorder begins with abnormal brain
activity and unusual physical sensations. Similarly, the cognitive explanation of obsessive-
compulsive disorder takes its lead from the biological position that some people are
predisposed to experience more unwanted and intrusive thoughts than others.

It may be that a fuller understanding of generalized anxiety disorder awaits a similar
integration of the various models. In fact, such an integration has already begun to unfold.
Recall, for example, that one of the new wave cognitive explanations for generalized

130 ://CHAPTER 4

°stress management prograrn•An
approach to treating generalized and
other anxiety disorders that teaches
clients techniques for reducing and con-
trolling stress.

anxiety disorder links the cognitive process of worrying to heightened bodily arousal in
individuals with the disorder.

Similarly, a growing number of theorists are adopting a diathesis-stress view of general-
ized anxiety disorder. They believe that certain individuals have a biological vulnerability
toward developing the disorder—a vulnerability that is eventually brought to the surface
by psychological and sociocultural factors. Indeed, genetic investigators have discovered
that certain genes may determine whether a person reacts to life’s stressors calmly or in
a tense manner, and developmental researchers have found that even during the earli-
est stages of life some infants become particularly aroused when stimulated (Burijon,
2007; Kahn, 1993). Perhaps these easily aroused infants have inherited defects in GABA
functioning or other biological limitations that predispose them to generalized anxiety
disorder. If over the course of their lives, the individuals also face intense societal pres-
sures, learn to interpret the world as a dangerous place, or come to regard worrying as

a

useful tool, they may be candidates for developing generalized anxiety disorder.

Diathesis-stress principles may also be at work in the development of phobias. Several
studies suggest, for example, that certain infants are born with a style of social inhibition
or shyness that may increase their risk of developing a social phobia (Smoller et al., 2003;
Kagan & Snidman, 1999, 1991). Perhaps people must have both a genetic predisposition
and unfortunate conditioning experiences if they are to develop particular phobias.

In the treatment realm, integration of the models is already on display for each of
the anxiety disorders. Therapists have discovered, for example, that treatment is at least
sometimes more effective when medications are combined with cognitive techniques
to treat panic disorder and when medications are combined with cognitive-behavioral
techniques to treat obsessive-compulsive disorder. Similarly, cognitive techniques are now
often combined with relaxation training or biofeedback in the treatment of generalized
anxiety disorder—a treatment package known as a stress management program (Lee
et al., 2007; Taylor, 2006). And treatment programs for social phobias often include a
combination of medications, exposure therapy, cognitive therapy, and social skills training.
For the millions of people who suffer from these various anxiety disorders, such treat-
ment combinations are a welcome development.

\\\ IA1E41, THOUT-ITSw/
1. If fear is such an unpleasant experi-

7/„. ence, why do many people enjoy

/
and even seek out the feelings of

7z.. fear brought about by amusement

7A park rides, scary movies, bungee
jumping, and other such experi-
ences? pp. 95-96, 102, 103, 712

05: 2. Why are antianxiety drugs so popu-
lar in today’s world? p. 10

5

40?: ,
•••••••

3. Why do so many professional per-
formers seem particularly prone
to social anxiety? Wouldn’t their
repeated exposure to audiences lead
to a reduction in fear? pp. 107- 108,
112- 114

4. Today’s human-participant research
review boards probably would not
permit Watson and Rayner to con-

6 1

duct their study on Little Albert. What
concerns might they raise about the
procedure? pp. 109- 1

10

5 Can you think of instances when you
instinctively tried a simple version of
exposure and response prevention
in order to stop behaving in certain
ways? Were your efforts successful?
p. 126

•
#’ esiAlegife,

\\\ KEY TEPNIS/// 4.!

7
6

fear, p. 95

generalized anxiety disorder, p. 96

unconditional positive regard, p. 99

client-centered therapy, p. 99
basic irrational assumptions, p.

100

metacognitive and avoidance theories,
pp. 100, 102

rational-emotive therapy, p. 102

mindfulness-based cognitive therapy,
p. 103

family pedigree study, p. 104

benzodiazepines, p. 104

gamma-aminobutyric acid (GABA),
p. 104

relaxation training, p. 105

……………..

Anxiety Disorders :1/ 131

biofeedback, p. 105

d specific phobia, p. 107
01 social phobia, p. 108

. classical conditioning, p. 108
modeling, p. 109

27 preparedness, p. 110
exposure treatments, p. 112

/.”. systematic desensitization, p.
7′,„

••

.”.40″.-.•••••

social skills training, p. 715
panic disorder, p. 116

agoraphobia, p. 116

norepinephrine, p. 117

locus ceruleus, p. 117

biological challenge test, p. 118

anxiety sensitivity, p. 1

20

112 obsessive-compulsive disorder, p. 121

• • –

exposure and response prevention,
p. 126

neutralizing, p. 127

serotonin, p. 127

orbitofrontal cortex, p. 128

caudate nuclei, p. 128

.!! ! • ;p:(Y.I.,„ ..:40,”

1: AA
VA
/7
egj
#7 i

,,,o,,;:;:: 2. How effective have treatments been
4/:

pp. 97-106 7;0_,

for generalized anxiety disorder?

4 3. Define and compare the three

;4″,.. kinds of phobias. pp. 107- 108

4. How do behaviorists explain pho-

O,O

: bias? What evidence exists for

: these explanations? pp. 108- 112
I-,

•

5. Describe the three behavioral
exposure techniques used to treat
specific phobias. pp. 112- 113

6. What are the two components of
a social phobia, and how is each
of them addressed in treatment?
pp. 113- 115

7. How do biological and cognitive
theorists explain panic disorder?
What are the leading biological
and cognitive treatments for this
disorder? pp. 117-121

• }1.,•! 9, • ••,6? **** ee

. ./.”.”0″.”.”

8. Describe various types of obsessions
and compulsions. pp. 121 – 123

9. Which factors do psychodynamic,
behavioral, cognitive, and biologi-
cal theorists believe are at work
in obsessive-compulsive disorder?
pp. 124- 129

10. Describe and compare the effec-
tiveness of exposure and response
prevention and antidepressant
medications as treatments for obsessive-
compulsive disorder. pp. 126,
128-129

1. What are the key principles in
the sociocultural, psychodynamic,
humanistic, cognitive, and biologi-
cal explanations of generalized
anxiety disorder? pp. 97-106

\\\ qUIGK 1U1 ///

! ,• s. e e.••

Search the Fundamentals of Abnormal Psychology Video Tool Kit
www.worthpublishers.com/apvtk

A Chapter 4 Video Cases

Worrying: Key to Generalized Anxiety
Overcoming a Fear of Flying

The Impact of Obsessions and Compulsions

A Video case discussions, study guides, and questions

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www.worthpublishers.com/eomer

A Chapter 4 outline, learning obiectives, research exercises, study tools,
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STRESS DISORDERS

pecialist Lovell Robinson, a 25-year-old single African American man, was an activated
National Guardsman [serving in the Iraq war]. He [had been] a full-time college student
and competitive athlete raised by a single mother in public housing. .

Initially trained in transportation, he was called to active duty and retrained as a military
policeman to serve with his unit in Baghdad. He described enjoying the high intensity of his
deployment and [became] recognized by others as an informal leader because of his aggres-
siveness and self-confidence. He [had] numerous [combat] exposures while performing convoy
escort and security details [and he came] under small arms fire on several occasions, witnessing
dead and injured civilians and Iraqi soldiers and on occasion feeling powerless when forced to
detour or take evasive action. He began to develop increasing mistrust of the [Iraq] environ-
ment as the situation “on the street” seemed to deteriorate. He often felt that he and his fellow
soldiers were placed in harm’s way needlessly.

On a routine convoy mission [in 2003], serving as driver for the lead HUMVEE, his vehicle was
struck by an Improvised Explosive Device showering him with shrapnel in his neck, arm, and
leg. Another member of his vehicle was even more seriously injured. . . He was evacuated
to the Combat Support Hospital (CSH) where he was treated and returned to duty … after
several days despite requiring crutches and suffering chronic pain from retained shrapnel in his
neck. He began to become angry at his command and doctors for keeping him in [Iraq] while
he was unable to perform his duties effectively. He began to develop insomnia, hypervigilance
and a startle response. His initial dreams of the event became more intense and frequent and
he suffered intrusive thoughts and flashbacks of the attack. He began to withdraw from his
friends and suffered anhedonia, feeling detached from others, and he feared his future would
be cut short. He was referred to a psychiatrist at the CSH. . .

After two months of unsuccessful rehabilitation for his battle injuries and worsening depressive
and anxiety symptoms, he was evacuated to a . military medical center [in the United States].
. He was screened for psychiatric symptoms and was referred for outpatient evaluation and
management. He met DSM-IV criteria for acute PTSD and was offered medication manage-
ment, supportive therapy, and group therapy . . He was ambivalent about taking passes or
convalescent leave to his home because of fears of being “different, irritated, or aggressive”
around his family or girlfriend. After three months at the military service center, he was [deac-
tivated from service and] referred to his local VA Hospital to receive follow-up care.

National Center for PTSD, 2008

During the horror of combat, soldiers often become highly anxious and depressed
and physically ill. Moreover, for many, like Latrell, these reactions to extraordinary
stress continue well beyond the combat experience itself.

But it is not just combat soldiers who are affected by stress. Nor does stress
have to rise to the level of combat trauma to have a profound effect on psycho-
logical and physical functioning. Stress comes in all sizes and shapes, and we are
all greatly affected by it.

We feel some degree of stress whenever we are faced with demands or op-
portunities that require us to change in some manner. The state of stress has two
components: a stressoi; the event that creates the demands, and a stress response, the

TOPIC OVERVIEW
Stress and Arousal: The
Fight-or-Flight Response

The Psychological Stress
Disorders: Acute and
Posttraumatic Stress Disorders
What Triggers a Psychological
Stress Disorder?

Why Do People Develop a
Psychological Stress Disorder?

How Do Clinicians Treat the
Psychological Stress Disorders?

The Physical Stress Disorders:
Psychophysiological Disorders
Traditional Psychophysiological
Disorders
New Psychophysiological
Disorders
Psychological Treatments for
Physical Disorders

Putting It Together: Expanding
the Boundaries of Abnormal
Psychology

“-Afir

he Smell of Stress

1 34 ://CHAPTER 5

person’s reactions to the demands. The stressors of life may include annoying everyday
hassles, such as rush-hour traffic; turning-point events, such as college graduation or
marriage; long-term problems, such as poverty or poor health; or traumatic events, such
as major accidents, assaults, tornadoes, or military combat. Our response to such stressors
is influenced by the way we judge both the events and our capacity to react to them in
an effective way (Russo & Tartaro, 2008; Lazarus & Folkman, 1984). People who sense
that they have the ability and the resources to cope are more likely to take stressors in
stride and to respond well.

When we view a stressor as threatening, a natural reaction is arousal and a sense of
fear—a response frequently on display in Chapter 4. As you saw in that chapter, fear is
actually a package of responses that are physical, emotional, and cognitive. Physically, we per-
spire, our breathing quickens, our muscles tense, and our hearts beat faster. Turning pale,
developing goose bumps, and feeling nauseated are other physical reactions. Emotional
responses to extreme threats include horror, dread, and even panic, while in the cognitive
realm fear can disturb our ability to concentrate and distort our view of the world. We
may exaggerate the harm that actually threatens us or remember things incorrectly.

Stress reactions, and the sense of fear they produce, are often at play in psychologi-
cal disorders. People who experience a large number of stressful events are particularly
vulnerable to the onset of the anxiety disorders that you read about in Chapter 4.
Similarly, increases in stress have been linked to the onset of depression, schizophrenia,
sexual dysfunctioning, and other psychological problems.

In addition, stress plays a more central role in certain psychological and physical
disorders. In such disorders, the features of stress become severe and debilitating, linger
for a long period of time, and may make it impossible for the individual to live a normal
life. The key psychological stress disorders are acute stress disorder and posttraumatic stress
disorder (PTSD). DSM-IV-TR technically lists these patterns as anxiety disorders, but as
you will see, their features extend far beyond the symptoms of anxiety.The physical stress
disorders are typically called psychophysiological disorders, problems that DSM-IV-TR
now lists under the heading psychological factors qffecting medical condition. These psycho-
logical and physical stress disorders are the focus of this chapter. Before examining them,
however, you need to understand just how the brain and body react to stress.

*Stress and Arousal: The Fight-or-Flight Response
The features of arousal and fear are set in motion by the brain area called the hypo-
thalamus. When our brain interprets a situation as dangerous, neurotransmitters in the
hypothalamus are released, triggering the firing of neurons throughout the brain and
the release of chemicals throughout the body. Actually, the hypothalamus activates two

Sympathetic
nervous system

Parasympathetic
nervous system

Contracts
pupil

Dilates
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Inhibits
salivation Constricts

bronchi

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Slows heartbeat

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Stimulates
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Stress Disorders 1 35

important systems—the autonomic nervous system and the endocrine system, The auto-
nomic nervous system (ANS) is the extensive network of nerve fibers that connect
the central nervous system (the brain and spinal cord) to all the other organs of the body.
These fibers help control the involuntary activities of the organs—breathing, heartbeat,
blood pressure, perspiration, and the like (see Figure 5-1).The endocrine system is the
network ofglands located throughout the body. (As you read in Chapter 2, glands release
hormones into the bloodstream and on to the various body organs.) The autonomic ner-
vous system. and the endocrine system often overlap in their responsibilities. There are
two pathways, or routes, by which these systems produce arousal and fear reactions—the
sympathetic nervous system pathway and the hypothalamic -pituitary-adrenal pathway.

When we face a dangerous situation, the hypothalamus first excites the sympathetic
nervous system, a group of autonomic nervous system fibers that work to quicken
our heartbeat and produce the other changes that we experience as fear or anxiety.
These nerves may stimulate the organs of the body directly—for example, they may
directly stimulate the heart and increase heart rate. The nerves may also influence the
organs indirectly, by stimulating the adrenal glands (glands located on top of the kidneys),
particularly an area of these glands called the adrenal medulla. When the adrenal medulla
is stimulated, the chemicals epinephrine (adrenaline) and norepinephrine (noradrenaline) are
released. You have already seen that these chemicals are important neurotransmitters
when they operate in the brain (page 117). When released from the adrenal medulla,

‘autonomic nervous system (ANS)•
The network of nerve fibers that connect
the central nervous system to all the other
organs of the body.

‘endocrine system•The system of
glands located throughout the body that
help control important activities such as
growth and sexual activity.

“sympathetic nervous system•The
nerve fibers of the autonomic nervous
system that quicken the heartbeat and
produce other changes experienced as
arousal and fear.

1 36 ://CHAPTER 5

t

Hypothalmus

Corticosteroids

Pituitary gland

Secretion of
ACTH

Adrenal cortex

however, they act as hormones and travel through the bloodstream to
various organs and muscles, further producing arousal and fear.

When the perceived danger passes, a second group of autonomic
nervous system fibers, called the parasympathetic nervous system,
helps return our heartbeat and other body processes to normal. To-
gether the sympathetic and parasympathetic nervous systems help
control our arousal and fear reactions.

The second pathway by which arousal and fear reactions are pro-
duced is the hypothalamic-pituitary-adrenal (HPA) pathway
(see Figure 5-2). When we are faced by stressors, the hypothalamus
also signals the pituitary gland, which lies nearby, to secrete the adreno-
corticotropic hormone (ACTH), sometimes called the body’s “major stress
hormone.” ACTH, in turn, stimulates the outer layer of the adrenal
glands, an area called the adrenal cortex, triggering the release of a group
of stress hormones called corticosteroids, including the hormone
cortisol. These corticosteroids travel to various body organs, where they
further produce arousal and fear reactions.

The reactions on display in these two pathways are collectively
referred to as the fight – or-flight response, precisely because they arouse
our body and prepare us for a response to danger. Each person has a
particular pattern of autonomic and endocrine functioning and so a

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particular way of experiencing arousal and fear. Some people are almost always relaxed,
while others typically feel tension, even when no threat is apparent. A person’s general
level of arousal and anxiety is sometimes called trait anxiety because it seems to be a
general trait that each of us brings to the events in our lives (Spielberger, 1985, 1972,
1966). Psychologists have found that differences in trait anxiety appear soon after birth
(Leonardo & Hen, 2006; Kagan, 2003).

People also differ in their sense of which situations are threatening (Fisher et al.,
2004). Walking through a forest may be fearsome for one person but relaxing for an-
other. Flying in an airplane may arouse terror in some people and boredom in others.
Such variations are called differences in situation, or state, anxiety.

•parasympathetic nervous system.
The nerve fibers of the autonomic ner-
vous system that slow organ functioning
after stimulation and return other bodily
processes to normal.

•hypothalamic-pituitary-adrenal
(HPA) pathwarOne route by which
the brain and body produce arousal and
fear.

•corticosteroids•A group of hormones,
including cortisol, released by the adre-
nal glands at times of stress.

‘::.ifThe Psychological Stress Disorders:
Acute and Posttraumatic Stress Disorders
Of course when we actually confront stressful situations, we do not think to ourselves,
“Oh, there goes my autonomic nervous system,” or “My fight-or-flight seems to be
kicking in.” We just feel aroused psychologically and physically and experience a grow-
ing sense of fear. If the stressful situation is truly extraordinary and unusually dangerous,
we may temporarily experience levels of arousal, anxiety, and depression that are beyond
anything we have ever known. For most people, such reactions subside soon after the
danger passes. For others, however, the symptoms of anxiety and depression, as well as
other kinds of symptoms, persist well after the upsetting situation is over. These people
may be suffering from acute stress disorder or posttraumatic stress disorder; patterns that arise
in reaction to a psychologically traumatic event. The event usually involves actual or
threatened serious injury to the person or to a family member or friend. Unlike the
anxiety disorders that you read about in Chapter 4, which typically are triggered by
situations that most people would not find threatening, the situations that cause acute
stress disorder or posttraumatic stress disorder—combat, rape, an earthquake, an airplane
crash—would be traumatic for anyone (Burijon, 2007).

If the symptoms begin within four weeks of the traumatic event and last for less
than a month, DSM-IV-TR assigns a diagnosis of acute stress disorder (APA, 2000).
If the symptoms continue longer than a month, a diagnosis of posttraumatic stress
disorder (PTSD) is given.The symptoms of PTSD may begin either shortly after the
traumatic event or months or years afterward.

a

Stress Disorders :111 137

Studies indicate that as many as 80 percent of all cases of acute stress disorder develop
into posttraumatic stress disorder (Burijon, 2007; Bryant et al., 2005). Think back to
Latrell, the soldier in Iraq whose case opened this chapter. As you’ll recall, Latrell became
overrun by anxiety; insomnia, worry, anger, depression, irritability, intrusive thoughts,
flashback memories, and social detachment within days of the attack on his convoy
mission—thus qualifying him for a diagnosis of acute stress disorder. As his symptoms
worsened and continued beyond one month—even long after his return to the United
States—this diagnosis became PTSD. Aside from the differences in onset and duration,
the symptoms of acute stress disorder and PTSD are almost identical.

Reexperiencing the traumatic event People may be battered by recurring thoughts,
memories, dreams, or nightmares connected to the event (Clark, 2005).A few relive
the event so vividly in their minds (flashbacks) that they think it is actually happen-
ing again.

Avoidance People will usually avoid activities that remind them of the traumatic
event and will try to avoid related thoughts, feelings, or conversations (Marx & Sloan,
2005).

Reduced responsiveness People feel detached from other people or lose interest in
activities that once brought enjoyment. Some experience symptoms of dissociation,
or psychological separation (Marx & Sloan, 2005): They feel dazed, have trouble
remembering things, or have a sense of derealization (feeling that the environment
is unreal or strange).

Increased arousal, anxiety, and guilt People with these disorders may feel overly alert
(hyperalertness), be easily startled, have trouble concentrating, and develop sleep
problems (Breslau et al., 2005). They may feel extreme guilt because they survived
the traumatic event while others did not. Some also feel guilty about what they may
have had to do to survive.

You can see these symptoms in the recollections of a Vietnam combat veteran years
after he returned home:

can’t get the memories out of my mind! The images come flooding back in vivid detail,
triggered by the most inconsequential things, like a door slamming or the smell of stir-
fried pork. Last night I went to bed, was having a good sleep for a change. Then in the
early morning a storm-front passed through and there was a bolt of crackling thunder. I
awoke instantly, frozen in fear. I am right back in Vietnam, in the middle of the monsoon
season at my guard post. I am sure get hit in the next volley and convinced I will die.
My hands are freezing, yet sweat pours from my entire body. l feel each hair on the back
of my neck standing on end. I can’t catch my breath and my heart is pounding. 1 smell a
damp sulfur smell.

(Davis, 1992)

What Triggers a Psychological Stress Disorder?
An acute or posttraumatic stress disorder can occur at any age, even in childhood, and
can affect one’s personal, family, social, or occupational life. People with these stress
disorders may also experience depression, another anxiety disorder, or substance abuse
or become suicidal (Koch & Haring, 2008). Surveys indicate that at least 3.5 percent
of people in the United States experience one of the stress disorders in any given year;
7 to 9 percent suffer from one of them during their lifetimes (Taylor, 2010; Kessler
et al., 2009, 2005). Around two-thirds of these individuals seek treatment at some point
in their lives, but few do so when they first develop the disorder (Wang et al., 2005).
Women are at least twice as likely as men to develop stress disorders: Around 20 percent

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•ocute stress disorder•An anxiety
disorder in which fear and related
symptoms are experienced soon after
a traumatic event and last less than a
month.

•posttraumatic stress disorder (PTSD)•
An anxiety disorder in which fear and
related symptoms continue to be experi-
enced long after a traumatic event.

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Worst Natural Disasters of the Past 100 Years

Disaster Year Location Number Killed
Flood 1931 Huang He River, China 3,700,000

Tsunami 2004 South Asia 280,000

Earthquake 1976 Tangshan, China 242,419

Heat wave 2003 Europe 35,000

Volcano 1985 Nevado del Ruiz, Colombia 23,000

Hurricane 1998 (Mitch) Central America 18,277

Landslide 1970 Yungay, Peru 17,500

Avalanche 1 916 Italian Alps 10,000

Blizzard 1972 Iran 4,000

Tornado 1989 Shaturia, Bangladesh 1,300

Adapted from CSC, 2008; CNN, 2005; Ash, 2001, 1999, 1998.

of women who are exposed to a serious trauma may develop one, compared to
8 percent of men (Koch & Haring, 2008; Russo & Tartaro, 2008).

Any traumatic event can trigger a stress disorder; however, some are particularly likely
to do so. Among the most con-unon are combat, disasters, and abuse and victimization.

Combat and Stress Disorders For years clinicians have recognized that many
soldiers develop symptoms of severe anxiety and depression during combat. It was called
“shell shock” during World War I and “combat fatigue” during World War II and the
Korean War (Figley, 1978). Not until after the Vietnam War, however, did clinicians learn
that a great many soldiers also experience serious psychological symptoms after combat
(Koch & Haring, 2008).

By the late 1970s, it became apparent that many Vietnam combat veterans were still
experiencing war-related psychological difficulties (Roy-Byrne et al., 2004). We now
know that as many as 29 percent of all Vietnam veterans, male and female, suffered an
acute or posttraumatic stress disorder, while another 22 percent experienced at least
some stress symptoms (Krippner & Paulson, 2006;Weiss et al., 1992). In fact, 10 percent
of the veterans of that war still experience posttraumatic stress symptoms, including
flashbacks, night terrors, nightmares, and persistent images and thoughts.

A similar pattern is currently unfolding among veterans of the wars in Iraq and
Afghanistan. In 2008, the RAND Corporation, a nonprofit research organization, com-
pleted a large-scale study of military service members who have served in those two wars
since 2001 (Geyer, 2008; RAND Corporation, 2008). It found that of the 1.6 million
Americans deployed to the wars, nearly 20 percent have so far reported symptoms of
posttraumatic stress disorder. Given that not all of the individuals studied were in fact ex-
posed to prolonged periods of combat-related stress, this is indeed a very large percentage.
Half of the veterans interviewed in this study described traumas in which they had seen
friends seriously wounded or killed, 45 percent reported seeing dead or gravely wounded
civilians, and 10 percent said they themselves had been injured and hospitalized.

It is also worth noting that the war in Iraq involves repeated deployments of many
of the combat veterans and that those individuals who serve such multiple deployments
are 50 percent more likely than those with one tour of service to experience severe
combat stress, significantly raising their risk of developing posttraumatic stress disorder
(Tyson, 2006).

Disasters and Stress Disorders Acute and posttraumatic stress disorders may also
follow natural and accidental disasters such as earthquakes, floods, tornadoes, fires, airplane
crashes, and serious car accidents (see Table 5-1). In fact, because they occur more often,

civilian traumas have been the trigger of stress disorders

138 ://CHAPTER 5

at least 10 times as often as combat traumas (Bremner,
2002). Studies have found, for example, that as many as

40

percent of victims of serious traffic accidents—adult or
child—may develop PTSD within a year of the accident
(Hickling & Blanchard, 2007).

Victimization and Stress Disorders People who
have been abused or victimized often experience linger-
ing stress symptoms. Research suggests that more than
one-third of all victims of physical or sexual assault de-
velop posttraumatic stress disorder (Burijon, 2007). Simi-
larly, as many as half of all people who are directly exposed
to terrorism or torture may develop this disorder (Basoglu
et al., 2001).

SEXUAL ASSAULT A common form of victimization in our
society today is sexual assault. Rape is forced sexual
intercourse or another sexual act committed against a
nonconsenting person or intercourse with an underage

Stress Disorders :1/ 1 39

person. Surveys suggest that in the United States more
than 300,000 persons are victims of rape or attempted rape
each year (Ahrens et al., 2008). Most rapists are men and
most victims are women. Around 1 in 6 women is raped
at some time during her life (Ahrens et al., 2008). Surveys
also suggest that most rape victims are young: 29 percent
are under 11 years old, 32 percent are between the ages
of 11 and 17, and 29 percent are between 18 and 29 years
old. Approximately 70 percent of the victims are raped by
acquaintances or relatives (Ahrens et al., 2008).

The rates of rape appear to differ from race to race. In
2000, 46 percent of rape victims in the United States were
white American, 27 percent were African American, and
19 percent were Hispanic American (Ahrens et al., 2008;
Tjaden & Thoennes, 2000). These rates were in marked
contrast to the 2000 general population distribution of 75
percent white American, 12 percent African American, and
13 percent Hispanic American.

The psychological impact of rape on a victim is immediate and may last a long time
(Russo & Tartar°, 2008; Koss, 2005, 1993). Rape victims typically experience enormous
distress during the week after the assault. Stress continues to rise for the next 3 weeks,
maintains a peak level for another month or so, and then starts to improve. In one study,
94 percent of rape victims fully qualified for a clinical diagnosis of acute stress disorder
when they were observed around 12 days after the assault (Rothbaum et al., 1992).
Although most rape victims improve psychologically within 3 or 4 months, the effects
may persist for up to 18 months or longer. Victims typically continue to have higher-
than-average levels of anxiety, suspiciousness, depression, self-esteem problems, self-blame,
flashbacks, sleep problems, and sexual dysfunction (Ahrens et al., 2008). The lingering
psychological impact of rape is apparent in the following case description:

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Mary Billings is a 33-year-old divorced nurse, referred to the Victim Clinic at Bedford Psy-
chiatric Hospital for counseling by her supervisory head nurse. Mary had been raped two
months ago. The assailant gained entry to her apartment while she was sleeping, and she
awoke to find him on top of her. He was armed with a knife and threatened to kill her
and her child (who was asleep in the next room) if she did not submit to his demands. He
forced her to undress and repeatedly raped her vaginally over a period of I hour. He then
admonished her that if she told anyone or reported the incident to the police he would
return and assault her child.

After he left, she called her boyfriend, who came to her apartment right away. He
helped her contact the Sex Crimes Unit of the Police Department, which is currently
investigating the case. He then took her to a local hospital for a physical examination
and collection of evidence for the police (traces of sperm, pubic hair samples, fingernail
scrapings). She was given antibiotics as prophylaxis against venereal disease. Mary then
returned home with a girlfriend who spent the remainder of the night with her.

Over the next few weeks Mary continued to be afraid of being alone and had her girl-
friend move in with her. She became preoccupied with thoughts of what had happened
to her and the possibility that it could happen again. Mary was frightened that the rapist
might return to her apartment and therefore had additional locks installed on both the door
and the windows. She was so upset and had such difficulty concentrating that she decided
she could not yet return to work. When she did return to work several weeks later, she was
still clearly upset, and her supervisor suggested that she might be helped by counseling.

During the clinic interview, Mary was coherent and spoke quite rationally in a hushed
voice. She reported recurrent and intrusive thoughts about the sexual assault, to the extent
that her concentration was impaired and she had difficulty doing chores such as making
meals for herself and her daughter. She felt she was not able to be effective at work, still

•rape•Forced sexual intercourse or
another sexual act committed against a
nonconsenting person or intercourse with
an underage person.

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felt afraid to leave her home, to answer her phone, and had little interest in contacting
friends or relatives.

.. [Mary] talked in the same tone of voice whether discussing the assault or less
emotionally charged topics, such as her work history. She was easily startled by an un-
expected noise. She also was unable to fall asleep because she kept thinking about the
assault. She had no desire to eat, and when she did attempt it, she felt nauseated. Mary
was repelled by the thought of sex and stated that she did not want to have sex for a
long time, although she was willing to be held and comforted by her boyfriend.

(Spitzer et al., 1983, pp. 20-21)

Although many rape victims are severely injured by their attacker or experience
other physical problems as a result of their assault, only half receive the kind of formal
medical care afforded Mary (Logan et al., 2006). Between 4 and 30 percent of victims
develop a sexually transmitted disease (Koss, 1993; Murphy, 1990) and 5 percent become
pregnant (Beebe, 1991; Koss et al., 1991), yet surveys reveal that 60 percent of rape
victims fail to receive pregnancy testing, preventive measures, or testing for exposure to
HIV (National Victims Center, 1992).

Female victims of rape and other crimes are also much more likely than other women
to suffer serious long-term health problems (Leibowitz, 2007; Koss & Heslet, 1992). In-
terviews with 390 women revealed that such victims had poorer physical well-being for
at least five years after the crime and made twice as many visits to physicians.

As you will see in Chapter 14, ongoing victimization and abuse in the family—
specifically child and spouse abuse—may also lead to psychological stress disorders. Be-
cause these forms of abuse may occur over the long term and violate family trust, many
victims develop other symptoms and disorders as well (Dietrich, 2007; Woods, 2005).

TERRORISM People who are victims of terrorism or who live under the threat of terror-
ism often experience posttraumatic stress symptoms (La Greca & Silverman, 2009;
Galea et al., 2007). Unfortunately, this source of traumatic stress is on the rise in our
society. Few will ever forget the events of September 11, 2001, when hijacked airplanes
crashed into and brought down the World Trade Center in NewYork City and partially
destroyed the Pentagon in Washington, DC, killing thousands of victims and rescue
workers and forcing thousands more to desperately run, crawl, and even dig their way
to safety. One of the many legacies of this infamous event is the lingering psychologi-
cal effect, particularly severe stress reactions, that it has had on those people who were
immediately affected, on their family members, and on tens of millions of others who
were traumatized simply by watching images of the disaster on their television sets as
the day unfolded. Studies of subsequent acts of terrorism, such as the 2004 commuter
train bombings in Madrid and the 2005 London subway and bus bombings, tell a similar
story (Charon &Vecina, 2007).

TORTURE Torture refers to the use of “brutal, degrading, and disorienting strategies in
order to reduce victims to a state of utter helplessness” (Okawa & Hauss, 2007). Often,
it is done on the orders of a government or another authority to force persons to yield
information or make a confession (Gerrity, Keane, &Tuma, 2001). The question of the
morality of torturing prisoners who are considered suspects in the “war on terror” has
been the subject of much discussion over the past few years (Okawa & Hauss, 2007;
Danner, 2004).

It is hard to know how many people are in fact tortured around the world because
such numbers are typically hidden by governments (Basoglu et al., 2001). It has been
estimated, however, that between 5 and 35 percent of the world’s 15 million refugees
have suffered at least one episode of torture and that more than 400,000 torture survi-
vors from around the world now live in the United States (ORR, 2006;AI, 2000; Baker,
1992). Of course, these numbers do not take into account the many thousands of victims
who have remained in their countries even after being tortured.

40 ://CHAPTER 5

VAY/1, 1 LJ

1 3r 11, 2001: The Psychological Aftermath
n September 11, 2001, the United
States experienced the most cata-

strophic act of terrorism in history when
four commercial airplanes were hijacked
and three of them were crashed into the
twin towers of the World Trade Center
in New York City and the Pentagon in
Washington, DC. Studies conducted since
that fateful day have confirmed what
psychologists knew all too well would
happen—that in the aftermath of Septem-
ber 11, many individuals experienced
immediate and long-term psychological
effects, ranging from brief stress reac-
tions, such as shock, fear, and anger, to
enduring psychological disorders, such as
posttraumatic stress disorder (Galea et al.,
2007; Tramontin & Hcilpern, 2007).

reactions (Tramontin & Halpern, 2007;
Adorns & Boscarino, 2005; Blanchard
et al., 2005). Indeed, even years after
the attacks, 42 percent of all adults in the
United States and 70 percent of all New
York adults report high terrorism fears;
23 percent of all adults in the United States
report feeling less safe in their homes;
15 percent of all U.S. adults report drink-
ing more alcohol than they did prior to the
attacks; and 9 percent of New York adults
display PTSD, compared to the national
annual prevalence of 3.5 percent.

In a survey conducted the week
after the terrorist attacks, 560 ran-
domly selected adults across the
United States were interviewed.
Forty-four percent of them reported
substantial stress symptoms;

90

percent reported at least some
increase in stress (Schuster et al.,
2001). Individuals closest to the
disaster site experienced the great-
est stress reactions, but millions of
other people who had remained
glued to their TV sets throughout the
day experienced stress reactions
and disorders as well.

Follow-up studies suggest that
many such individuals continue to
struggle with terrorism-related stress

Stress Disorders 141

People from all walks of life are subjected to torture worldwide—from suspected
terrorists to student activists and members of religious, ethnic, and cultural minority
groups.The techniques used on them may include physical torture (beatings, waterboard-
ing, electrocution), psychological torture (threats of death, mock executions, verbal abuse,
degradation), sexual torture (rape, violence to the genitals, sexual humiliation), or torture
through deprivation (sleep, sensory, social, nutritional, medical, or hygiene deprivation).

Torture victims often experience physical ailments as a result of their ordeal, from
scarring and fractures to neurological problems and chronic pain. But many theorists
believe that the lingering psychological effects of torture are even more problematic
(Okawa & Flauss, 2007; Basoglu et al., 2001). It appears that between 30 and 50 per-
cent of torture victims develop posttraumatic stress disorder (Basoglu et al., 2001). Even
for those who do not develop a full-blown disorder, symptoms such as nightmares,

•torture•The use of brutal, degrading,
and disorienting strategies to reduce
victims to a state of utter helplessness.

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1 42 ://CHAPTER 5

flashbacks, repressed memories, depersonalization, poor concentration, anger outbursts,
sadness, and suicidal thoughts are common (Okawa & Hauss, 2007; Okawa et al., 2003;
Ortiz, 2001).

by Do People Develop a Psychological Stress Disorder?
Clearly, extraordinary trauma can cause a stress disorder. The stressful event alone, how-
ever, may not be the entire explanation. Certainly, anyone who experiences an unusual
trauma will be affected by it, but only some people develop a stress disorder (Koch &
Haring, 2008).To understand the development of these disorders more fully, researchers
have looked to the survivors’ biological processes, personalities, childhood experiences,
social support systems, and cultural backgrounds and to the severity of the traumas.

Biological and Genetic Factors Investigators have learned that traumatic events
trigger physical changes in the brain and body that may lead to severe stress reactions and,
in some cases, to stress disorders.They have, for example, found abnormal activity of the
hormone cortisol and the neurotransmitter/hormone norepinephrine in the urine, blood,
and saliva of combat soldiers, rape victims, concentration camp survivors, and survivors
of other severe stresses (Burij on, 2007; Delahanty et al., 2005).

Evidence from brain studies also shows that once a stress disorder sets in, individu-
als experience further biochemical arousal and this continuing arousal may eventually
damage key brain areas (Carlson, 2008; Mirzaei et al., 2005).Two areas in particular seem
to be affected—the hippocampus and the amygdala. Normally, the hippocampus plays a
major role both in memory and in the regulation of the body’s stress hormones. Clearly,
a dysfunctional hippocampus may help produce the intrusive memories and constant
arousal found in posttraumatic stress disorder (Bremner et al., 2004). Similarly, as you
observed in Chapter 4, the amygdala helps control anxiety and other emotional responses.
It also works with the hippocampus to produce the emotional components of memory.
Thus, a dysfunctional amygdala may help produce the repeated emotional symptoms and
strong emotional memories experienced by persons with posttraumatic stress disorder
(Protopopescu et al., 2005). In short, the arousal produced by extraordinary traumatic
events may lead to stress disorders in some people, and the stress disorders may produce
yet further brain abnormalities, locking in the disorders all the more firmly.

It may also be that posttraumatic stress disorder leads to the transmission of bio-
chemical abnormalities to the children of persons with the disorder. One team of
researchers examined the cortisol levels of women who had been pregnant during the
September 11, 2001, terrorist attacks and had developed PTSD (Yehuda & Bierer, 2007).
Not only did these women have higher-than-average cortisol levels, but the babies to

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Stress Disorders :1/ 1 43

whom they gave birth after the attacks also displayed higher cortisol levels, suggesting
that the babies inherited a predisposition to develop the same disorder.

Many theorists believe that people whose biochemical reactions to stress are un-
usually strong are more likely than others to develop stress disorders (Carlson, 2008;
Burijon, 2007). But why would certain people be prone to such strong biological reac-
tions? One possibility is that the propensity is inherited. Clearly, this is suggested by
the mother-offspring studies just discussed. Similarly, studies conducted on thousands
of pairs of twins who have served in the military find that if one twin develops stress
symptoms after combat, an identical twin is more likely than a fraternal twin to develop
the same problem (Koenen et al., 2003; True & Lyons, 1993).

Personali Some studies suggest that people with certain personalities, attitudes, and
coping styles are particularly likely to develop stress disorders (Burijon, 2007; Chung
et al., 2005). In the aftermath of Hurricane Hugo in 1989, for example, children who had
been highly anxious before the storm were more likely than other children to develop
severe stress reactions (Hardin et al., 2002). Research has also found that people who
generally view life’s negative events as beyond their control tend to develop more severe
stress symptoms after sexual or other kinds of criminal assaults than people who feel
greater control over their lives (Taylor, 2006; Bremner, 2002). Similarly, individuals who
generally find it difficult to derive anything positive from unpleasant situations adjust
more poorly after traumatic events than people who are generally resilient and who typi-
cally find value in negative events (Bonanno, 2004).

Childhood Experiences Researchers have found that certain childhood experi-
ences seem to leave some people at risk for later acute and posttraumatic stress disorders.
People whose childhoods have been marked by poverty appear more likely to develop
these disorders in the face of later trauma. So do people whose family members suffered
from psychological disorders; who experienced assault, abuse, or catastrophe at an early
age; or who were younger than 10 when their parents separated or divorced (Koch &
Haring, 2008; Koopman et al., 2004).

Social Support It has been found that people whose social and family support sys-
tems are weak are also more likely to develop a stress disorder after a traumatic event
(Charuvastra & Cloitre, 2008; Ozer, 2005) . Rape victims who feel loved, cared for, valued,
and accepted by their friends and relatives recover more successfully. So do those treated
with dignity and respect by the criminal justice system (Murphy, 2001). In contrast, clini-
cal reports have suggested that poor social support contributes to the development of
posttraumatic stress disorder in some combat veterans (Charuvastra & Cloitre, 2008).

Multicultural Factors There is a growing suspicion among clinical researchers that
the rates of posttraumatic stress disorder may differ from ethnic group to ethnic group in
the United States. In particular, Hispanic Americans may have a greater
vulnerability to the disorder than other cultural groups (Koch & Haring,
2008; Galea et al., 2006). Some cases in point: (1) Studies of combat vet-
erans from the wars in Vietnam and Iraq have found higher rates of post-
traumatic stress disorder among Hispanic American veterans than among
white American and African American veterans (RAND Corporation,
2008; Kulka et al., 1990). (2) In surveys of police officers, Hispanic Amer-
ican officers typically report more severe duty-related stress symptoms
than their non-Hispanic counterparts (Pole et al., 2001). (3) Data on
hurricane victims reveal that after some hurricanes Hispanic American
victims have had a significantly higher rate of PTSD than victims from
other ethnic groups (Perilla et al., 2002). (4) Surveys of New York City
residents conducted in the months following the terrorist attacks of Sep-
tember 11, 2001, revealed that 14 percent of Hispanic American residents
developed PTSD, compared to 9 percent of African American residents
and 7 percent of white American residents (Galea et al., 2002).

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144 //CHAPTER 5

Why might Hispanic Americans be more vulnerable to posttraumatic stress disorder
than other racial or ethnic groups? Several explanations have been suggested. One holds
that as part of their cultural belief system, many Hispanic Americans tend to view trau-
matic events as inevitable and unalterable, a coping response that may heighten their risk
for posttraumatic stress disorder (Perilla et al., 2002). Another explanation suggests that
their culture’s emphasis on social relationships and social support may place Hispanic
American victims at special risk when traumatic events deprive them—temporarily or
permanently—of important relationships and support systems. Indeed, a study con-
ducted more than two decades ago found that among Hispanic American Vietnam
combat veterans with stress disorders, those with poor family and social relationships
suffered the most severe symptoms (Escobar et al., 1983).

Severity of Trauma As you expect, the severity and nature of traumatic events
help determine whether one will develop a stress disorder. Some events can override
even a nurturing childhood, positive attitudes, and social support (Tramontin & Halpern,
2007). One study examined 253 Vietnam War prisoners five years after their release.
Some 23 percent qualified for a clinical diagnosis, though all had been evaluated as well
adjusted before their imprisonment (Ursano et al., 1981).

Generally, the more severe the trauma and the more direct one’s exposure to it, the
greater the likelihood of developing a stress disorder (Burijon, 2007). Mutilation and
severe physical injury in particular seem to increase the risk of stress reactions, as does
witnessing the injury or death of other people (Koren et al., 2005; Ursano et al., 2003).

2)Ti:D ]r •

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How Do Clinicians Treat the Psychological Stress Disorders?
Treatment can be very important for persons who have been overwhelmed by traumatic
events (Taylor, 2010; DeAngelis, 2008). Overall, about half of all cases of posttraumatic
stress disorder improve within six months (Asnis et al., 2004). The remainder of cases
may persist for years, and, indeed, more than one-third of people with PTSD fail to
respond to treatment even after many years (Burijon, 2007).

Today’s treatment procedures for troubled survivors typically vary from trauma to
trauma. Was it combat, an act of terrorism, sexual molestation, or a major accident? Yet
all the programs share basic goals: They try to help survivors put an end to their stress
reactions, gain perspective on their painful experiences, and return to constructive living
(Taylor, 2010; Ehlers et al., 2005). Programs for combat veterans who suffer from PTSD
illustrate how these issues may be addressed.

Treatment for Combat Veterans Therapists have used a variety of techniques
to reduce veterans’ posttraumatic symptoms. Among the most common are drug therapy
behavioral exposure techniques, insight therapy, family therapy, and group therapy. Typically the

approaches are combined, as no one of them successfully reduces all the
symptoms (DeAngelis, 2008; Munsey, 2008).

Antianxiety drugs help control the tension that many veterans ex-
perience. In addition, antidepressant medications may reduce the occur-
rence of nightmares, panic attacks, flashbacks, and feelings of depression
(Koch & Hating, 2008; Davidson et al., 2005).

Behavioral exposure techniques, too, have helped reduce specific
symptoms, and they have often led to improvements in overall adjust-
ment (Koch & Haring, 2008). In fact, some studies indicate that expo-
sure treatment is the single most helpful intervention for persons with
stress disorders (Wiederhold &Wiederhold, 2005).This finding suggests
to many clinical theorists that exposure of one kind or another should
always be part of the treatment picture. In one case, the exposure tech-
nique of flooding, along with relaxation training, helped rid a 31-year-
old veteran of frightening flashbacks and nightmares (Fairbank & Keane,
1982).The therapist and the veteran first singled out combat scenes that
the man had been reexperiencing frequently.The therapist then helped

Media

HOME SEND

Combat Trauma Takes the Stand
BY DEBORAH SONTAG AND LIZETTE ALVAREZ,

NEW YORK TIMES, JANUARY 27,200B

hen it came time to sentence James Allen Gregg for his
conviction on murder charges, the judge in South Dakota

took a moment to reflect on the defendant as an Iraq combat
veteran who suffered from severe post-traumatic stress disorder.
“This is a terrible case, as all here have observed,” said Judge
Charles B. Kornmann of United States District Court. “Obviously
not all the casualties coming home from Iraq or Afghanistan
come home in body bags.”.

When combat veterans like Mr. Gregg stand accused of
killings and other offenses on their return from Iraq and Afghani-
stan, prosecutors, judges and juries are increasingly prodded
to assess the role of combat trauma in their crimes. . . [M]ore
and more, with the troops’ mental health a rising concern, these
defendants .. . are arguing that war be seen as the backdrop
for these crimes, most of which are committed by individuals
without criminal records. . . “I think they should always re-
ceive sonic kind of consideration for the fact that their mind has
been broken by war,” said [a] Western regional defense counsel
for the Marines. . . .

On the evening of July 3, 2004, Mr. Gregg, then 22, spent
the night with friends in a roving pre-Independence Day celebra-
tion on the reservation where he grew up, part of a small non-
Indian population. They drank at a Quonset but bar … and
finally at a mint farm where they built a bonfire, roasted marsh-
mallows and made s’mores.

According to the prosecutor, Mr. Gregg got upset because
a young woman accompanying him gravitated to another man.
This, the prosecutor said, led to Mr. Gregg spinning the wheels
of his truck and spraying gravel on a car belonging to James
Fallis, 26, a former high school football lineman. . . . Some time
later, a confrontation ensued. Mr. Gregg was severely beaten

Stress Disorders :// 145

the veteran to imagine one of these scenes in great detail and urged him to hold on to
the image until his anxiety stopped.After each of these flooding exercises, the therapist
had the veteran switch to a positive image and led him through relaxation exercises.

A widely applied form of exposure therapy is eye movement desensitization and
reprocessing (EMDR), in which clients move their eyes in a rhythmic manner from
side to side while flooding their minds with images of the objects and situations they
ordinarily try to avoid. Case studies and controlled studies suggest that this treatment
can often be helpful to persons with posttraumatic stress disorder (Luber, 2009). Many
theorists argue that it is the exposure feature of EMDR, rather than the eye movement,
that accounts for its success with the disorder (Lamprecht et al., 2004).

Although drug therapy and exposure techniques bring some relief, most clinicians
believe that veterans with posttraumatic stress disorder cannot fully recover with these
approaches alone:They must also come to grips in some way with their combat experi-
ences and the impact those experiences continue to have (Burijon, 2007).Thus clinicians

°eye movement desensitization and
reprocessing (EMDR).A behavioral
exposure treatment in which clients move
their eyes in a saccadic (rhythmic) man-
ner from side to side while flooding their
minds with images of objects and situa-
tions they ordinarily avoid.

EXPLORE

by Mr. Fallis and, primarily, by another man, suffering facial
fractures. Later that night, with one eye swollen shut and a fat
lip, he drove to Mr. Fallis’s neighborhood.

Mr. Fallis emerged from a trailer, removed his jacket, asked
Mr. Gregg if he had come back for more and opened the door
to Mr. Gregg’s pickup truck. Mr. Gregg then reached for the
pistol that he carried with him after his return from Iraq. He
pointed it at Mr. Fallis and warned him to back away. Mr. Fallis
moved toward the trunk of his car, and Mr. Gregg testified that
he believed Mr. Fallis was going to get a weapon. He started
shooting to stop him, he said, and then Mr. Fallis veered toward
his house. Mr. Gregg fired nine times, and struck [and killed]
Mr. Fallis with five bullets.

Mr. Gregg drove quickly away, ending up in a pasture near
his parents’ house. According to Mr. Gregg’s testimony, he then
put a magazine of more bullets in his gun, chambered a round
and pointed it at his chest. “Jim, why were you going to kill
yourself?” his lawyer asked in courf. . . . “Because it felt like
Iraq had come back,” Mr. Gregg said. “I felt hopeless. . . . I
never wanted to shoot him. Never wanted to hurt him. Never.
Everything happened just so fast. I mean, it was almost instinct
that I had to protect myself.”

Mental health experts for the defense said, as one psychiatrist
testified, that “PTSD was the driving force behind Mr. Gregg’s
actions” when he shot his victim. Having suffered a severe
beating, they said, he experienced an exaggerated “startle
reaction”—a characteristic of PTSD—when Mr. Fallis reached for
his car door, and responded instinctively… ,

The jury found Mr. Gregg guilty of second-degree but not
first-degree murder. . . . The Sentence: 21 Years. . . If all
efforts to free him fail, he is projected to be released on July 22,
2023, a few weeks shy of his 42nd birthday.

Copyright CD 2008 New York Times. All rights reserved.
Reprinted by permission of PARS International, Inc.

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1 46 ://CHAPTER 5

•rap group•A group that meets to talk
about and explore members’ problems in
an atmosphere of mutual support.

• sychological debriefing•A form of
crisis intervention in which victims are
helped to talk about their feelings and
reactions to traumatic incidents. Also
called critical incident stress debriefing,

often try to help veterans bring out deep-seated feelings, accept what they have done
and experienced, become less judgmental of themselves, and learn to trust other people
once again (Turner et al., 2005). In a similar vein, cognitive therapists typically guide such
veterans to examine and change the dysfunctional attitudes and styles of interpretation
that have emerged as a result of their traumatic experiences (DeAngelis, 2008).

Veterans who have a psychological stress disorder may be further helped in a couple,
family, or group therapy format (DeAngelis, 2008; Johnson, 2005). The symptoms of
posttraumatic stress disorder are particularly apparent to family members, who may be
directly affected by the client’s anxieties, depressive mood, or angry outbursts.With the
help and support of their family members, individuals may come to examine their im-
pact on others, learn to communicate better, and improve their problem-solving skills.

In group therapy, often provided in a form called rap groups, the veterans meet
with others like themselves to share experiences and feelings (particularly guilt and
rage), develop insights, and give mutual support (Burijon, 2007; Lifton, 2005).

Today hundreds of small Veterans Outreach Centers across the country, as well as treat-
ment programs in Veterans Administration hospitals and mental health clinics, provide
group treatments (Welch, 2007).These agencies also offer individual therapy, counseling
for spouses and children, family therapy, and aid in seeking jobs, education, and benefits.
Clinical reports suggest that these programs offer a necessary, sometimes life-saving,
treatment opportunity.

Psychological Debriefing: The Sociocultural Model in Action People
who are traumatized by disasters, victimization, or accidents profit from many of the same
treatments that are used to help survivors of combat. In addition, because their traumas
occur in their own community, where mental health resources are close at hand, these
individuals may, according to many clinicians, further benefit from immediate commu-
nity interventions. The leading such approach is called psychological debriefing, or
critical incident stress debriefing.

Psychological debriefing is actually a form of crisis intervention that has victims
of trauma talk extensively about their feelings and reactions within days of the critical
incident (Mitchell, 2003, 1983). Because such sessions are expected to prevent or reduce
stress reactions, they are often applied to victims who have not yet displayed any symp-

Stress Disorders 147

toms at all, as well as those who have. During the sessions, often
conducted in a group format, counselors guide the individuals
to describe the details of the recent trauma, to vent and relive
the emotions provoked at the time of the event, and to express
their current feelings. The clinicians then clarify to the victims
that their reactions are perfectly normal responses to a terrible
event, offer stress management tips, and, when necessary, refer
the victims to professionals for long-term counseling.

Thousands of counselors, both professionals and nonprofes-
sionals, are now trained in psychological debriefing each year,
and the intense approach has been applied in the aftermath of
countless traumatic events (McNally, 2004).When the traumatic
incident affects numerous individuals, debriefing-trained coun-
selors may come from far and wide to conduct debriefing ses-
sions with the victims. One of the largest mobilization programs
of this kind is the Disaster Response Network (DRN), developed
by the American Psychological Association and the American
Red Cross. The network is made up of several thousand volun-
teer psychologists who have offered free emergency mental health services at disaster
sites such as the 1999 shooting of 23 persons at Columbine High School in Colorado,
the 2001 World Trade Center attack, the 2004 tsunami in South Asia, and the floods
caused by Hurricane Katrina in 2005 (APA, 2008, 2005).

In such community-wide mobilizations, the counselors may knock on doors or
approach victims at shelters. Although victims from all socioeconomic groups may be
engaged, sonic theorists believe that those who live in poverty are in particular need of
such community-level interventions. Relief workers, too, can become overwhelmed by
the traumas they witness (Carl, 2007).

Does Psychological Debriefing Work? Research and personal testimonials for
rapid mobilization programs have often been favorable (Watson & Shalev, 2005; Mitchell,
2003). Nevertheless, a number of studies have called into question the effectiveness of
these kinds of interventions (Pender & Prichard, 2009; Tramontin & Halpern, 2007).

An investigation conducted in the early 1990s was among the first to raise con-
cerns about disaster mental health programs (Bisson & Deahl, 1994). Crisis counselors
offered debriefing sessions to 62 British soldiers whose job during the GulfWar was
to handle and identify the bodies of individuals who had been killed. Despite such
sessions, half of the soldiers displayed posttraumatic stress symptoms when interviewed
nine months later.

In a properly controlled study conducted a few years later on hospitalized burn vic-
tims, researchers separated the victims into two groups (Bisson et al., 1997). One group
received a single one-on-one debriefing session within days of their burn accidents,
while the other (control) group of burn victims received no such intervention. Three
months later, it was found that the debriefed and the control patients had similar rates
of posttraurnatic stress disorder. Moreover, researchers found that 13 months later, the
rate of posttraumatic stress disorder was actually higher among the debriefed burn victims
(26 percent) than among the control victims (9 percent).

Several other studies, focusing on yet other kinds of disasters, have yielded similar
patterns of findings (Van Emmerik et al., 2002). Obviously, these studies raise serious
questions about the effectiveness of psychological debriefing. Some clinicians believe
that the early intervention programs may encourage victims to dwell too long on the
traumatic events that they have experienced. And a number worry that early disaster
counseling may unintentionally “suggest” problems to victims, thus helping to produce
stress disorders in the first place (McNally, 2004; McClelland, 1998).

The current clinical climate continues to favor disaster counseling. However, the
concerns that have been raised merit serious consideration.We are reminded here, as else-
where, of the constant need for careful research in the field of abnormal psychology.

seeri:Samifiy

!.,

148 :it/CHAPTER 5

.psychophysiological disorders.
Illnesses that result from an interaction of
psychosocial and organic factors. Also
known as psychosomatic disorders.

.uicer.A lesion that forms in the wall of
the stomach or of the duodenum.

+asthma®A medical problem marked
by narrowing of the trachea and bron-
chi, which results in shortness of breath,
wheezing, coughing, and a choking
sensation.

•insomnia•Difficulty falling or staying
asleep.

. muscle contraction headache•A
headache caused by a narrowing of
muscles surrounding the skull. Also
known as tension headache.

°migraine headache•A very severe
headache that occurs on one side of the
head, often preceded by a warning sen-
sation and sometimes accompanied by
dizziness, nausea, or vomiting.

Stress and the Psychological Stress Disorders

When we view a stressor as threatening, we often experience a stress response
consisting of arousal and a sense of fear. The features of arousal and fear are set
in motion by the hypothalamus, a brain area that activates the autonomic nervous
system and the endocrine system. There are two pathways by which these sys-
tems produce arousal and fear—the sympathetic nervous system pathway and the
hypothalamic-pituitary-adrenal pathway.

People with acute stress disorder or posttraumatic stress disorder react with
anxiety and related symptoms after a traumatic event, including reexperiencing the
traumatic event and experiencing increased arousal, anxiety, and guilt. The symp-
toms of acute stress disorder begin soon after the trauma and last less than a month,
while those of posttraumatic stress disorder may begin of any time (even years) after
the trauma and may last for months or years.

In attempting to explain why some people develop a psychological stress
disorder, researchers have focused on biological factors, personality, childhood
experiences, social support, multicultural factors, and the severity of the traumatic
event. Treatments for the disorders include drug, exposure, insight, cognitive, family,
and group therapy. Rapidly mobilized community therapy, which often follows the
principles of critical incident stress debriefing, is frequently provided after large-
scale disasters.

The Physical Stress Disorders:
Psychophysiological Disorders
As you have seen, stress can greatly affect our psychological functioning (see Figure 5-3).
It can also have great impact on our physical fimctioning, contributing in some cases to
the development of medical problems.The idea that stress and related psychosocial factors
may contribute to physical illnesses has ancient roots, yet it had few supporters before the
twentieth century.The belief began to take hold about 80 years ago, when clinicians first
identified a group of physical illnesses that seemed to result from an interaction of biologi-
cal, psychological, and sociocultural factors (Dunbar, 1948; Bott, 1928). Early editions of
the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders,
but DSM-IV-TR labels them psythological _Actors affecting medical condition (see Table 5 -2).
The more familiar term “psychophysiological” will be used in this chapter.

It is important to recognize that psychophysiological disorders bring about actual
physical damage. They are different from “apparent” physical illnesses—factitious disorders
or somatofor• disorders—disorders that are accounted for entirely by psychological fac-
tors such as hidden needs, repression, or reinforcement. Those kinds of problems will
be examined in the next chapter.

Traditional Psychophysiological Disorders
Before the 1970s, clinicians believed that only a limited number of illnesses were psy-
chophysiological. The best known and most common of these disorders were ulcers,
asthma, insomnia, chronic headaches, high blood pressure, and coronary heart disease.
Recent research, however, has shown that many other physical illnesses—including
bacterial and viral infections—may also be caused by an interaction of psychosocial and
physical factors. Let’s look first at the traditional psychophysiological disorders and then
at the newer illnesses in this category.

Ulcers are lesions (holes) that form in the wall of the stomach or of the duodenum,
resulting in burning sensations or pain in the stomach, occasional vomiting, and stain-

Watch TV, read,
or listen to music

Talk to family
or friends

Prayer or meditation

Exercise

Eat

Smoke, drink,
or take drugs

Take medication 12%

‘1

Hurt self .. 1 1%

Percentage Who Perform Activity When Stressed

82%

71%

62%

55%

37%

26%

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Stress Disorders :1/ 1 49

ach bleeding.This disorder is experienced by 20 million people in the United States at
some point during their lives and is responsible for more than 6,000 deaths each year.
Ulcers are often caused by an interaction of stress factors, such as environmental pressure
or intense feelings of anger or anxiety, and physiological factors, such as the bacteria
H. pylori (Carr, 2001).

Asthma causes the body’s airways (the trachea and bronchi) to narrow periodically,
making it hard for air to pass to and from the luugs.The resulting symptoms are short-
ness of breath, wheezing, coughing, and a terrifying choking sensation. Some 20 million
people in the United States currently suffer from asthma, twice as many as 25 years ago
(AAAAI, 2005). Most victims are children or young teenagers at the time of the first
attack (Melamed et al, 2001). Seventy percent of all cases appear to be caused by an
interaction of stress factors, such as environmental pressures or anxiety, and physiological
factors, such as allergies to specific substances, a slow-acting sympathetic nervous system,
or a weakened respiratory system (NCHS, 2005; Melamed et al., 2001).

Insomnia, difficulty falling asleep or maintaining sleep, plagues 35 percent of the
population each year (Taylor, 2006). Although many of us have temporary bouts of in-
somnia that last a few nights or so, a large number of people experience insomnia that
lasts months or years. They feel as though they are almost constantly awake. Chronic
insomniacs are often very sleepy during the day and may have difficulty functioning.
Their problem may be caused by a combination of psychosocial factors, such as high
levels of anxiety or depression, and physiological problems, such as an overactive arousal
system or certain medical ailments (Thase, 2005;VandeCreek, 2005).

Chronic headaches are frequent intense aches of the head or neck that are not caused
by another physical disorder. There are two major types. Muscle contraction, or
tension, headaches are marked by pain at the back or front of the head or the back
of the neck. These occur when the muscles surrounding the skull tighten, narrowing
the blood vessels. Approximately 40 million Americans suffer from such headaches.
Migraine headaches are extremely severe, often near-paralyzing headaches that are
located on one side of the head and are sometimes accompanied by dizziness, nausea,
or vomiting. Migraine headaches are thought by some medical theorists to develop in
two phases: (1) Blood vessels in the brain narrow, so that the flow of blood to parts of
the brain is reduced, and (2) the same blood vessels later expand, so that blood flows

I

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00 pressure, a PsYc ‘op :

!cal disorder with few outwar
s tons_of thousands of people
•mptin health professionals to

blood., pressure checks in the
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January 1994

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1 50 ://CHAPTER 5

through them rapidly, stimulating many neuron endings and causing pain. Migraines are
suffered by about 23 million people in the United States.

Research suggests that chronic headaches are caused by an interaction of stress fac-
tors, such as environmental pressures or general feelings of helplessness, anger, anxiety,
or depression, and physiological factors, such as abnormal activity of the neurotransmit-
ter serotonin, vascular problems, or muscle weakness (Engel, 2009; Andrasik & Walch,
2003).

Hypertension is a state of chronic high blood pressure. That is, the blood pumped
through the body’s arteries by the heart produces too much pressure against the artery
walls. Hypertension has few outward signs, but it interferes with the proper function-
ing of the entire cardiovascular system, greatly increasing the likelihood of stroke, heart
disease, and kidney problems. It is estimated that 65 million people in the United States
have hypertension, 14,000 die directly from it annually, and millions more perish be-
cause of illnesses caused by it (Kalb, 2004; Kluger, 2004). Around 10 percent of all cases
are caused by physiological abnormalities alone; the rest result from a combination of
psychosocial and physiological factors and are called essential hypertension (Sperry, 2009).
Some of the leading psychosocial causes of essential hypertension are constant stress,
environmental danger, and general feelings of anger or depression. Physiological factors
include obesity, smoking, poor kidney function, and an unusually high proportion of the
gluey protein collagen in an individual’s blood vessels (Taylor, 2006; Kluger, 2004).

Coronary heart disease is caused by a blocking of the coronary arteries, the blood
vessels that surround the heart and are responsible for carrying oxygen to the heart muscle.
The term actually refers to several problems, including blockage of the coronary arteries
and myocardial it farction (a “heart attack”). Nearly 14 million people in the United States
suffer from some form of coronary heart disease (AHA, 2005). It is the leading cause of
death in men over the age of 35 and of women over 40 in the United States, accounting
for close to 1 million deaths each year, around 40 percent of all deaths in the nation (Travis
& Meltzer, 2008; AHA, 2005, 2003).The majority of all cases of coronary heart disease are
related to an interaction of psychosocial factors, such as job stress or high levels of anger or
depression, and physiological factors, such as a high level of cholesterol, obesity, hyperten-
sion, smoking, or lack of exercise (Travis & Meltzer, 2008; Wang et al., 2004).

Over the years, clinicians have identified a number of variables that may generally
contribute to the development of psychophysiological disorders (see Figure 5-4). It should
not surprise us that several of these variables are the same as those that contribute to the
onset of the psychological stress disorders—acute and posttraumatic stress disorders. The
variables may be grouped as biological, psychological, and sociocultural factors.

Biological Factors You saw earlier that one way the brain activates body organs is
through the operation of the autonomic nervous system (ANS), the network of nerve fibers
that connect the central nervous system to the body’s organs. Defects in this system are

Siress Disorders :If 1 51

believed to contribute to the development of psychophysiological disorders (Hugdahl,
1995). If one’s ANS is stimulated too easily, for example, it may overreact to situations
that most people find only mildly stressful, eventually damaging certain organs and caus-
ing a psychophysiological disorder (Boyce et al., 1995). Other more specific biological
problems may also contribute to psychophysiological disorders. A person with a weak
gastrointestinal system, for example, may be a prime candidate for an ulcer, whereas
someone with a weak respiratory system may develop asthma readily.

In a related vein, people may display favored biological reactions that raise their
chances of developing psychophysiological disorders. Some individuals perspire in
response to stress, others develop stomachaches, and still others experience a rise in
blood pressure (Fahrenberg et al., 1995). Research has indicated, for example, that some
individuals are particularly likely to experience temporary rises in blood pressure when
stressed (Gianaros et al., 2005). It may be that they are prone to develop hypertension.

Consistent with these notions, a team of cardiologists at Johns Hopkins Medical In-
stitutes offered an interesting report a few years ago on 19 patients who had symptoms
of a severe heart attack (Wittstein et al., 2005). In fact, none of the patients had heart-
tissue damage or clogged coronary arteries—that is, none had suffered a heart attack—
but all had recently had a highly stressful experience and all displayed extraordinarily
abnormal ANS and hormonal activity. Although such brain and bodily activity did not
lead to an actual heart attack during that hospitalization, some of their cardiologists
believed that repeated episodes could indeed contribute to coronary heart disease in
the future (Akashi et al., 2004).

Psycholo2ical Factors According to many theorists, certain needs, attitudes, emo-
tions, or coping styles may cause people to overreact repeatedly to stressors, and so in-
crease their chances of developing psychophysiological disorders (Chung et al., 2005).
Researchers have found, for example, that men with a repressive coping style (a reluctance
to express discomfort, anger, or hostility) tend to experience a particularly sharp rise in
blood pressure and heart rate when they are stressed (Pawls & Stemmler, 2003).

Another personality style that may contribute to psychophysiological disorders is the
Type A personality style, an idea introduced by two cardiologists, Meyer Friedman
and Raymond Rosenman (1959). People with this style are said to be consistently angry,
cynical, driven, impatient, competitive, and ambitious. They interact with the world in
a way that, according to Friedman and Rosenman, produces continual stress and often
leads to coronary heart disease. People with a Type B personality style, by contrast,
are thought to be more relaxed, less aggressive, and less concerned about time and thus,
in turn, are less likely to experience cardiovascular deterioration.

The link between the Type A personality style and coronary heart disease has been
supported by many studies. In one well-known investigation of more than 3,000 people,
Friedman and Rosenman (1974) separated healthy men in their forties and fifties into
Type A and Type B categories and then followed their health over the next eight years.
More than twice as many Type A men developed coronary heart disease. Later studies
found that Type A functioning correlates similarly with heart disease in women (Haynes
et al., 1980) .

Recent studies indicate that the link between the Type A personality style and heart
disease may not be as strong as the earlier studies suggested. These studies do suggest,
however, that several of the characteristics that supposedly make up the Type A style,
particularly hostility and time urgency, may indeed be strongly related to heart disease
(Myrtek, 2007; Taylor, 2006).

Sociocultural Factors: The Multicultural Perspective Adverse social con-
ditions may set the stage for psychophysiological disorders. Such conditions produce
ongoing stressors that trigger and interact with the biological and personality factors
just discussed. One of society’s most negative social conditions, for example, is poverty.
In study after study, it has been found that relatively wealthy people have fewer psy-
chophysiological disorders, better health, and better health outcomes than poor people
(Matsumoto & Juang, 2008; Adler et al., 1994). One obvious reason for this relationship

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1 52 :A/CHAPTER 5

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is that poorer people typically experience higher rates of crime, unemployment, over-
crowding, and other negative stressors than wealthier people. In addition, they typically
receive inferior medical care.

Research also reveals that belonging to ethnic and cultural minority groups increases
the risk of developing psychophysiological disorders and other health problems (Travis
& Meltzer, 2008).A major factor in this relationship may, once again, be economic.That
is, many members of minority groups live in poverty and, in turn, experience the high
rates of crime and unemployment and the inferior medical care that often result in poor
health outcomes. Census data reveal, for example, that 70 percent of all people who have
no health care insurance are Hispanic, African, or Asian American (U.S. Census Bureau,
2006). Moreover, women in these minority groups are particularly disadvantaged in the
health care arena. Hispanic American women, for example, have the worst access to
health care in the United States (Travis & Meltzer, 2008). Indeed, almost half of Hispanic
American women who live in poverty have no health care insurance (Travis & Meltzer,
2008; Pamuk et al., 1998).

Research further suggests that the link between minority group status and psy-
chophysiological disorders extends beyond economic factors. Consider, for example, the
repeated finding that high blood pressure is 43 percent more common among African
Americans than among white Americans (Kluger, 2004). Although this difference may
be explained, in part, by the dangerous environments in which so many African Ameri-
cans live and the unsatisfying jobs at which so many must work (Cozier-D’Amico,
2004), other factors may also be operating.A physiological predisposition among African
Americans may, for example, increase their risk of developing high blood pressure. Or it
may be that repeated experiences of racial discrimination constitute special stressors that
help raise the blood pressure of African Americans (Matsumoto & Juang, 2008).

In one study, African American and white American women were instructed to
talk about three hypothetical scenarios (Lepore et al., 2006). For one scenario, consid-
ered a racial stressor, the research participants had to describe being unjustly accused of
shoplifting. For another scenario, considered a nonracial stressor, they discussed being
caught in airport delays. And, for the third scenario, which involved little or no stres-
sors of any kind, the participants had to describe giving a campus tour. The African
American participants displayed significantly greater rises in blood pressure than the
white American participants when discussing the racial stressor scenario. Based on this
finding, the experimenters concluded that perceptions of racism produce greater physi-
ological stress for African American women, setting the stage for high blood pressure,
other psychophysiological disorders, and generally poorer health.

New Psychophysiologica usorders
Clearly, biological, psychological, and sociocultural factors combine to produce psy-
chophysiological disorders. In fact, the interaction of such factors is now considered the
rule of bodily functioning, not the exception, and, as the years have passed, more and
more illnesses have been added to the list of traditional psychophysiological disorders
and researchers have found many links between psychosocial stress and a wide range of
physical illnesses. Let’s look first at how these links were established and then at psyclzoneu-
roimmunology, the area of study that ties stress and illness to the body’s immune system.

Are Physical Illnesses Related o Stress? In 1967 two researchers, Thomas
Holmes and Richard Rahe, developed the Social Adjustment Rating Scale, which as-
signs numerical values to the stresses that most people experience at some time in their
lives (see Table 5-3). Answers given by a large sample of participants indicated that the
most stressful event on the scale is the death of a spouse, which receives a score of 100
life change units (LCUs). Lower on the scale is retirement (45 LCUs), and still lower is a
minor violation of the law (11 LCUs).This scale gave researchers a yardstick for mea-
suring the total amount of stress a person faces over a period of time. If, for example,
in the course of a year a woman started a new business (39 LCUs), sent her son off to
college (29 LCUs), moved to a new house (20 LCUs), and experienced the death of a

Stress Disorders :1/ 153

Most Stressful Life Events

Adults: Social Adjustment Rating Scale*

1. Death of spouse

2. Divorce

14. Gain of new family member

15. Business readjustment

16. Change in financial state

17. Death of close friend

18. Change to different line of work

19. Change in number of arguments with spouse

20. Mortgage over $10,000

21. Foreclosure of mortgage or loan

22. Change in responsibilities at work

3. Marital separation

4. Jail term

5. Death of close family member

6. Personal injury or illness

7. Marriage

8. Fired at work

9. Marital reconciliation

10. Retirement

11. Change in health of family member

12. Pregnancy

13. Sex d ifficulties

*Full scale has 43 items.
Source: Holmes & Rabe, 1967.

Students: Undergraduate Stress Questionnaire

1. Death (family member or friend)

2. Had a lot of tests

3. It’s finals week

4. Applying to graduate school

5. Victim of a crime

6. Assignments in all classes due the same day

7. Breaking up with boy-/girlfriend

8. Found out boy-/girlfriend cheated on you

9. Lots of deadlines to meet

10. Property stolen

11. You have a hard upcoming week

12. Went into a test unprepared

13. Lost something (especially wallet)

14. Death of a pet

15. Did worse than expected on test

17. Had projects, research papers due

18. Did badly on a test

19. Parents getting divorce

20. Dependent on other people

21. Having roommate conflicts

22. Car/bike broke down, flat tire, etc.

Tull scale has 83 items.
Source: Crandall et al., 1992.

close friend (37 LCUs), her stress score for the year would be 125 LCUs, a considerable
amount of stress for such a period of time.

With this scale in hand, Holmes and Rahe (1989, 1967) were able to examine the
relationship between life stress and the onset of illness.They found that the LCU scores
of sick people during the year before they fell ill were much higher than those of healthy
people. If a person’s life changes totaled more than 300 LCUs over the course of a year,
that person was particularly likely to develop a serious health problem.

Using the Social Adjustment Rating Scale or similar scales, studies have since linked
stresses of various kinds to a wide range of physical conditions, from trench mouth and
upper respiratory infection to cancer (Cohen, 2005; Taylor, 2004). Overall, the greater
the amount of life stress, the greater the likelihood of illness (see Figure 5-5 on the next
page). Researchers even have found a relationship between traumatic stress and death.
Widows and widowers, for example, display an increased risk of death during their
period of bereavement (Rees & Lutkin, 1967;Young et al., 1963).

One shortcoming of Holmes and Rahe’s Social Adjustment Rating Scale is that it
does not take into consideration the particular life stress reactions of specific popula-
tions. For example, in their development of the scale, the researchers sampled white

16. Had an interview

3-4 5-6 7-8 9-10 11-12

Psychological Stress Index

1 54 :figNARTER 5

Americans predominantly. Few of the respondents were African Americans. But
since their ongoing life experiences often differ in key ways, might not African
Americans and white Americans differ in their stress reactions to various kinds of
life events? One study indicates that indeed they do (Komaroff et al., 1989, 1986).
Although both white Americans and African Americans rank death of a spouse
as the single most stressful life event, African Americans experience greater stress
than white Americans in response to a major personal injury or illness, a major
change in work responsibilities, or a major change in living conditions. Similarly,
studies have shown that women and men differ in their reactions to certain life
changes (Miller & Rahe, 1997).

Finally, college students may face stressors that are different from those listed
in the Social Adjustment Rating Scale. Instead of having marital difficulties, being
fired, or applying for a job, a college student may have trouble with a roommate,
fail a course, or apply to graduate school. When researchers developed special
scales to measure life events more accurately in this population (see Table 5-3
again), they found the expected relationships between stressful events and illness
(Crandall et al., 1992).

Psychoneuroimmunology How do stressful events result in a viral or bac-
terial infection? An area of study called psychoneuroimmunology seeks to
answer this question by uncovering the links between psychosocial stress, the im-
mune system, and health.

The immune system is the body’s network of activities and cells that identify and
destroy antigens—foreign invaders, such as bacteria, viruses, fungi, and parasites—and
cancer cells. Among the most important cells in this system are billions of lympho-
cytes, white blood cells that circulate through the lymph system and the bloodstream.
When stimulated by antigens, lymphocytes spring into action to help the body over-
come the invaders.

One group of lymphocytes, called helper T-cells, identifies antigens and then multi-
plies and triggers the production of other kinds of immune cells. Another group, natural
hillerT-cells, seeks out and destroys body cells that have already been infected by viruses,
thus helping to stop the spread of a viral infection.A third group of lymphocytes, B -cells,
produces antibodies, protein molecules that recognize and bind to antigens, mark them
for destruction, and prevent them from causing infection.

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•psyclrioneuroimmunology•The study
of the connections between stress, the
body’s immune system, and illness.

•immune system•The body’s network
of activities and cells that identify and
destroy antigens and cancer cells.

•antigen•A foreign invader of the body,
such as a bacterium or virus.

•Iymphocytes•White blood cells that
circulate through the lymph system and
bloodstream, helping the body identify
and destroy antigens and cancer cells.

Stress Disorders :1/ 1 55

Researchers now believe that stress can interfere with the activity of lymphocytes,
slowing them down and thus increasing a person’s susceptibility to viral and bacterial
infections (Lutgendorf et al., 2005). In a landmark study, investigator Roger Bartrop and
his colleagues (1977) in New South Wales, Australia, compared the immune systems of
26 people whose spouses had died eight weeks earlier with those of 26 matched control
group participants whose spouses had not died. Blood samples revealed that lymphocyte
functioning was much lower in the bereaved people than in the controls. Still other
studies have shown slow immune functioning in persons who are exposed to long-term
stress. For example, researchers have found poorer immune functioning among people
who face the challenge of providing ongoing care for a relative with Alzheimer’s disease
(Vitaliano et al., 2005; Kiecolt-Glaser et al., 2002, 1996).

These studies seem to be telling a remarkable story. During periods when healthy
individuals happened to experience unusual levels of stress, they remained healthy on
the surface, but their experiences apparently slowed their immune systems so that they
became susceptible to illness. If stress affects our capacity to fight off illness, it is no won-
der that researchers have repeatedly found a relationship between life stress and illnesses
of various kinds. But why and when does stress interfere with the immune system? Sev-
eral factors influence whether stress will result in a slowdown of the system, including
biochemical activity, behavioral changes, personality style, and degree of social support.

BIOCHEMICAL ACTIVITY Excessive activity of the neurotransmitter norepinephrine apparently
contributes to slowdowns of the immune system. Remember that stress leads to increased
activity by the sympathetic nervous system, including an increase in the release of nor-
epinephrine throughout the brain and body. Research indicates that if stress continues for
an extended time, norepinephrine eventually travels to receptors on certain lymphocytes
and gives them an inhibitory message to stop their activity, thus slowing down immune
functioning (Carlson, 2008; Lekander, 2002).

In a similar manner, corticosteroids— cortisol and other so-called stress hormones–
apparently contribute to poorer immune system functioning. Remember that when a
person is under stress, the adrenal glands release corticosteroids. As in the case of nor-
epinephrine, if stress continues for an extended time, the stress hormones eventually
travel to receptor sites located on certain lymphocytes and give an inhibitory message,
again causing a slowdown of the activity of the lymphocytes (Bauer, 2005; Bellinger
et al., 1994) .

Recent research has further indicated that another action of the corticosteroids is
to trigger an increase in the production of cytokines, proteins that bind to receptors
throughout the body. At moderate levels of stress, the cytokines, another key player
in the immune system, help combat infection. But as stress continues and more corti-
costeroids are released, the growing production and spread of cytokines lead to chronic
inflammation throughout the body, contributing at times to heart disease, stroke, and
other illnesses (Travis & Meltzer, 2008; Suarez, 2004).

BEHAVIORAL CHANGES Stress may set in motion a series of behavioral changes that indi-
rectly affect the immune system. Some people under stress may, for example, become
anxious or depressed, perhaps even develop an anxiety or mood disorder.As a result, they
may sleep badly, eat poorly, exercise less, or smoke or drink more—behaviors known to
slow down the immune system (Irwin & Cole, 2005).

PERSONALITY STYLE According to research, people who generally respond to life stress
with optimism, constructive coping, and resilience—that is, people who welcome
challenges and are willing to take control in their daily encounters—experience better
immune system functioning and are better prepared to fight off illness (Taylor, 2006,
2004). Some studies find, for example, that people with “hardy” or resilient personalities
remain healthy after stressful events, while those whose personalities are less hardy seem
more susceptible to illness (Bonanno, 2004; Ouellette & DiPlacido, 2001). One study
even discovered that men with a general sense of hopelessness die at above-average rates
from heart disease and other causes (Everson et al., 1996). Similarly, a growing body
of research suggests that people who are spiritual tend to be healthier than individuals

156 :IICHAPTER 5

without spiritual beliefs, and a few studies have linked spirituality to better im-
mune system functioning (Thoresen & Plante, 2005; Lutgendorf et al., 2004).

In related work, certain studies have noted a relationship between certain
personality characteristics and recovery from cancer (Hjerl et al., 2003). They
have found that patients with certain forms of cancer who display a helpless
coping style and who cannot easily express their feelings, particularly anger,
tend to have less successful recoveries than patients who do express their emo-
tions. Other studies, however, have found no relationship between personality
and cancer outcome (Urcuyo et al., 2005; Garssen & Goodkin, 1999).

SOCIAL SUPPORT Finally, people who have few social supports and feel lonely seem
to display poorer immune functioning in the face of stress than people who do
not feel lonely (Curtis et al., 2004; Cohen, 2002). In a pioneering study, medical
students were given the UCLA Loneliness Scale and then divided into “high” and
“low” loneliness groups (Kiecolt-Glaser et al., 1984).The high-loneliness group
showed lower lymphocyte responses during a final exam period.

Other studies have found that social support and affiliation may actually
help protect people from stress, poor immune system functioning, and subse-
quent illness or help speed up recovery from illness or surgery (Matsumoto &
juang, 2008; Taylor, 2006). Similarly, some studies have suggested that patients
with certain forms of cancer who receive social support in their personal lives
or supportive therapy often have better immune system functioning and, in
turn, more successful recoveries than patients without such supports (Taylor,
2006; Spiegel & Fawzy, 2002).

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‘behavioral medicine’ A field that
combines psychological and physical
interventions to treat or prevent medical
problems.

Psychological Treatments for Physical Disorders
As clinicians have discovered that stress and related psychosocial factors may
contribute to physical disorders, they have applied psychological treatments to
more and more medical problems. The most common of these interventions
are relaxation training, biofeedback, meditation, hypnosis, cognitive interven-
tions, insight therapy, and support groups.The field of treatment that combines
psychological and physical approaches to treat or prevent medical problems is

known as behavioral medicine.

Relaxation Training As you saw in Chapter 4, people can be taught to relax their
muscles at will, a process that sometimes reduces feelings of anxiety. Given the positive
effects of relaxation on anxiety and the nervous system, clinicians believe that relaxation
training can help prevent or treat medical illnesses that are related to stress.

Relaxation training, often in combination with medication, has been widely used
in the treatment of high blood pressure (Stetter & Kupper, 2002). It has also been of
some help in treating headaches, insomnia, asthma, diabetes, pain after surgery, certain
vascular diseases, and the undesirable effects of certain cancer treatments (Devineni &
Blanchard, 2005; Carmichael, 2004).

iofeedback. As you also saw in Chapter 4, patients given biofeedback training are con-
nected to machinery that gives them continuous readings about their involuntary body
activities. This information enables them gradually to gain control over those activities.
Somewhat helpful in the treatment of anxiety disorders, the procedure has also been ap-
plied to a growing number of physical disorders.

In a classic study, electromyograph (EMG) feedback was used to treat 16 patients who
were experiencing facial pain caused in part by tension in their jaw muscles (Dohrmann &
Laskin, 1978). In an EMG procedure, electrodes are attached to a person’s muscles so that the
muscle contractions are detected and converted into a tone for the individual to hear (see
pages 105-106). Changes in the pitch and volume of the tone indicate changes in muscle
tension. After “listening” to EMG feedback repeatedly, the 16 patients in this study learned
how to relax their jaw muscles at will and later reported a reduction in facial pain.

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Stress Disorders :1/ 157

EMG feedback has also been used successfully in the
treatment of headaches and muscular disabilities caused by
strokes or accidents. Still other forms of biofeedback training
have been of some help in the treatment of heartbeat irregu-
larities, asthma, migraine headaches, high blood pressure, stut-
tering, and pain (Martin, 2002; Moss, 2002; Gatchel, 2001).

MeditatiOri Although meditation has been practiced since
ancient times,Western health care professionals have only re-
cently become aware of its effectiveness in relieving physical
distress. Meditation is a technique of turning one’s concen-
tration inward, achieving a slightly changed state of con-
sciousness, and temporarily ignoring all stressors. In the most
common approach, meditators go to a quiet place, assume a
comfortable posture, utter or think a particular sound (called
a mantra) to help focus their attention, and allow their minds
to turn away from all outside thoughts and concerns (Dass &
Levine, 2002). Many people who meditate regularly report
feeling more peaceful, engaged, and creative. Meditation has
been used to help manage pain and to treat high blood pres-
sure, heart problems, asthma, skin disorders, diabetes, insomnia, and even viral infections
(Stein, 2003 ;Andresen, 2000).

One form of meditation that has been applied in particular to patients suffering from
severe pain is mindfulness meditation (Carey, 2008; Kabat-Zinn, 2005). Here meditators
pay attention to the feelings, thoughts, and sensations that are flowing through their
minds during meditation, but they do so with detachment and objectivity and, most
importantly, without judgment. By just being mindful but not judgmental of their feel-
ings and thoughts, including feelings of pain, they are less inclined to label them, fixate
on them, or react negatively to them.

Hyp110515 As you saw in Chapter 1, individuals who undergo hypnosis are guided by a
hypnotist into a sleeplike, suggestible state during which they can be directed to act in
unusual ways, experience unusual sensations, remember seemingly forgotten events, or
forget remembered events.With training some people are even able to induce their own
hypnotic state (self-hypnosis). Hypnosis is now used as an aid to psychotherapy and to help
treat many physical conditions (Shenefelt, 2003).

Hypnosis seems to be particularly helpful in the control of pain (Kiecolt-Glaser et al.,
1998). One case study describes a patient who underwent dental surgery under hypnotic
suggestion: After a hypnotic state was induced, the dentist suggested to the patient that
he was in a pleasant and relaxed setting listening to a friend describe his own success at
undergoing similar dental surgery under hypnosis. The dentist then proceeded to per-
form a successful 25-minute operation (Gheorghiu & Orleanu, 1982). Although only
some people are able to undergo surgery while anesthetized by hypnosis alone, hypnosis
combined with chemical forms of anesthesia is apparently helpful to many patients
(Fredericks, 2001). Beyond its use in the control of pain, hypnosis has been used success-
fully to help treat such problems as skin diseases, asthma, insomnia, high blood pressure,
warts, and other forms of infection (Modlin, 2002; Hornyak & Green, 2000).

Cognitive interventions People with physical ailments have sometimes been taught
new attitudes or cognitive responses toward their ailments as part of treatment (Kyrios,
2009; Devineni & Blanchard, 2005). For example, an approach called self- instruction train-
ing has helped patients cope with severe pain (Allison & Friedman, 2004; Meichenbaum,
1997, 1993, 1977, 1975). In self-instruction training therapists teach people to identify
and eventually rid themselves of unpleasant thoughts that keep emerging during pain
episodes (so -called negative selfLstatements, such as “Oh, no, I can’t take this pain”) and
to replace them with coping self-statements instead (for example, “When pain comes, just
pause; keep focusing on what you have to do”).

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158 //CHAPTER 5

insight Therapy and Support Groups If anxiety, depression, anger,
and the like contribute to a person’s physical ills, therapy to reduce these nega-
tive emotions should help reduce the ills. In such cases, physicians may rec-
ommend insight therapy, support groups, or both to help patients overcome
their medical difficulties (Antoni, 2005). Research suggests that the discus-
sion of past and present upsets may indeed help improve a person’s health,
just as it may help one’s psychological functioning (Leibowitz, 2007; Smyth
& Pennebaker, 2001). In one study, asthma and arthritis patients who simply
wrote down their thoughts and feelings about stressful events for a handful of
days showed lasting improvements in their conditions. Similarly, stress-related
writing was found to be beneficial for patients with HIV infections (Petrie
et al., 2004). In addition, as we have seen, recovery from cancer and certain
other illnesses is sometimes improved by participation in support groups
(Antoni, 2005; Spiegel & Fawzy, 2002).

Combination Approaches Studies have found that the various psy-
chological interventions for physical problems tend to be equal in effective-
ness (Devineni & Blanchard, 2005). Relaxation and biofeedback training, for

example, are equally helpful (and more helpful than placebos) in the treatment of high
blood pressure, headaches, and asthma. Psychological interventions are, in fact, often of
greatest help when they are combined with other psychological interventions and with
medical treatments (Suinn, 2001). In one study, ulcer patients who were given relax-
ation, self-instruction, and assertiveness training along with medication were found to be
less anxious and more comfortable, have fewer symptoms, and have a better long-term
outcome than patients who received medication only (Brooks & Richardson, 1980).
Combination interventions have also been helpful in changing Type A patterns and
in reducing the risk of coronary heart disease among Type A people (Williams, 2001;
Cohen et al., 1997).

Clearly, the treatment picture for physical illnesses has been changing dramatically.
While medical treatments continue to dominate, today’s medical practitioners are travel-
ing a course far removed from that of their counterparts in centuries past.

• JM i LP
The Physical Stress Disorders

Psychophysiological disorders are those in which psychosocial and physiological
factors interact to cause a physical problem. Variables linked to these disorders are
biological factors, such as defects in the autonomic nervous system; psychological
factors, such as particular needs, attitudes, or personality styles; and sociocultural
factors, such as negative social conditions and cultural pressures.

For years clinical researchers singled out a limited number of physical illnesses
as psychophysiological, such as ulcers, asthma, and coronary heart disease. Re-
cently many other psychophysiological disorders have been identified. Scientists
hove developed an area of study called psychoneuroimmunology, which links many
physical illnesses to stress and immune system functioning. Stress can slow lympho-
cyte and other immune system activity, thereby interfering with the system’s ability
to protect against illness. Factors that seem to affect immune functioning include
norepinephrine and corticosteroid activity, behavioral changes, personality style,
and social support.

Behavioral medicine combines psychological and physical interventions to treat
or prevent medical problems. Psychological approaches such as relaxation training,
biofeedback training, meditation, hypnosis, cognitive techniques, insight therapy,
and support groups are increasingly being included in the treatment of various
medical problems.

Stress Disorders :1/ 1 59

Media HOME SEND EXPLORE

Empathy Goes a Long Way

BY DENISE GRADY, NEW YORK TIMES, JANUARY 8, 2008

our years ago, my sister found out she had two types
of cancer at the same time. It was like being hit by

lightning —twice.
She needed chemotherapy and radiation, a huge operation,

more chemotherapy and then a smaller operation. All in all, the
treatment took about a year. Thin to
begin with, she lost 30 pounds. The
chemo caused cracks in her fingers,
dry eyes, anemia and mouth sores so
painful they kept her awake at night.
A lot of her hair fell out. The radiation
burned her skin. . . .

She saw two doctors quite often.
The radiation oncologist would sling
her arm around my sister’s frail shoul-
ders and walk her down the corridor
as if they were old friends. The medi-
cal oncologist kept a close watch on
the side effects, suggested remedies,
reminded my sister she had good odds of beating the cancer
and reassured her that the hair would grow back. (It did.)

People in my family aren’t huggy-kissy types, but my sister
greatly appreciated the warmth and concern of those two
women. She trusted them completely, and their advice. Now
healthy, she says their compassion played a big part in helping
her get through a difficult and frightening time.

Research supports the idea that a few kind words from an
oncologist—what used to be called bedside manner—can go a
long way toward helping people with cancer understand their
treatment, stick with it, cope better and maybe even fare better
medically. “It is absolutely the role of the oncologist” to provide
a bit of emotional support, said Dr. James A. Tulsky, director of
the Center for Palliative Care at Duke University Medical Center.

‘y -V- [1- , ,,,• ,,,,, •,,•.,”,., ,

But in a study published last month in the Journal of Clinical
Oncology, Dr. Tulsky and other researchers found that doctors
and patients weren’t communicating all that well about emo-
tions. The researchers recorded 398 conversations between
51 oncologists and 270 patients with advanced cancer. They
listened for moments when patients expressed negative emotions
like fear, anger or sadness, and for the doctors’ replies.

A response like “I can imagine
how scary this must be for you”
was considered empathetic—a
“continuer” that would allow patients
to keep expressing their emotions.
But a comment like “Give us time;
we are getting there” was labeled
a “terminator” that could shut the
patient down. The team found that
doctors used continuers only 22 per-
cent of the time. Male doctors were
worse at it than female ones: 48
percent of the men never used con-
tinuers, as opposed to 20 percent

of the women…. Dr. Tulsky said, “There were a number of
times when patients brought up emotional content and it went
right by the doctors.” For instance, a patient would say, “I’m
scared,” and the doctor would go off on a “scientific riff” about
the disease. . . .

The good news … is that most doctors can be taught to re-
spond in more helpful ways. Brief, empathetic responses will suf-
fice, the researchers said; they are not recommending extensive
counseling or endless dialogue. Patients may benefit from some
coaching, too. It’s perfectly reasonable, Dr. Tulsky said, to talk
to an oncologist about sadness or fears about treatment, and to
ask for help.

Copyright (0 2008 New York Times.
All rights reserved. Used by permission. !:

PUTTING T. together
Expanding the Boundaries of Abnormal Psychology

The concept of stress is familiar to everyone, yet only in recent decades have clinical
scientists and practitioners had much success in understanding and treating it and recog-
nizing its powerful impact on our functioning. Now that the impact of stress has been
identified, however, research efforts in this area are moving forward at near-lightning
speed.What researchers once saw as a vague connection between stress and psychologi-
cal dysfunctioning or between stress and physical illness is now understood as a complex
interaction of many variables. Such factors as life changes, individual psychological states,

– • –

ti
f4illr CZj.11DI1 111E,r-‘- A511-’41;1

E11C1iittA’ 1L! 1 1-51,111, ,T.1 1 1111 12) -11::1) ‘711■1
1 41

\\\ KEY l’EPqIS/// •
stressor, p. 133

hypothalamus, p. 134

autonomic nervous system (ANS), p. 135

160 ://CHAPTER 5

social support, biochemical activity, and slowing of the immune system are all recog-
nized as contributors to psychological and physical stress disorders.

Insights into the treatment of the various stress disorders have been accumulating
just as rapidly. In recent years clinicians have learned that a combination of approaches—
from drug therapy to behavioral techniques to community interventions—may be of
help to people with acute and posttraumatic stress disorders. Similarly, psychological
approaches such as relaxation training and cognitive therapy are being applied to various
physical ills, usually in combination with traditional medical treatments. Small wonder
that many practitioners are convinced that such treatment combinations will eventually
be the norm in treating the majority of physical ailments.

One of the most exciting aspects of these recent developments is the field’s grow-
ing emphasis on the interrelationship of the social environment, the brain, and the rest
of the body. Researchers have observed repeatedly that mental disorders are often best
understood and treated when sociocultural, psychological, and biological factors are all
taken into consideration.They now know that this interaction also helps explain medi-
cal problems. We are reminded that the brain is part of the body and that both are part
of a social context. For better and for worse, the three are closely linked.

Another exciting aspect of this work on stress and its wide-ranging impact is the
interest it has sparked in illness prevention and health promotion (Compas & Gotlib, 2002;
Kaplan, 2000). If stress is indeed key to the development of both psychological and
physical disorders, perhaps such disorders can be prevented by eliminating or reducing
stress—for example, by helping people to cope better generally or by better preparing
their bodies for stress’s impact. With this notion in mind, illness prevention and health
promotion programs are now being developed around the world. Clinical theorists have,
for example, designed school-curriculum programs to help promote social competence in
children (Weissberg, 2000) and to teach children more optimistic ways of thinking (Gillham
et al., 2000, 1995).And in the realm of acute and posttraumatic stress disorders, one team of
clinical researchers has developed a program that immediately offers rape victims a combi-
nation of relaxation training, exposure techniques, cognitive interventions, and education
about rape’s impact, all before the onset of psychological or physical symptoms (Muran,
2007; Foa et al., 2005, 1995). Research indicates that women who receive such preventive
measures do indeed develop fewer stress symptoms than do other rape victims.

\\\ THOUrTHTS///
What types of events in modern
society might trigger acute and post-
traumatic stress disorders? What
kinds of factors might serve to relieve
the stresses of modern society?
pp. 137- 148

Do you think the vivid images seen
daily on the Web, on television, in
movies, in rock videos, and the like
would make people more vulnerable

•ft

to developing psychological stress
disorders or less vulnerable? Why?
pp. 137-144

3. How might physicians, police, the
courts, and other agents better meet
the psychological needs of rape
victims? pp. 138- 140

4. To help fend off terrorism attacks,
the United States and other countries

)57;”%77.,,77′.9 * .-:17 )>Z7.;-;07 • “.9.

have instituted various procedures,
such as color-coded (threat-level)
warning systems. How might such
warning systems affect the psycholog-
ical and physical health of citizens?
pp. 140, 141

5. What jobs in our society might be
particularly stressful and traumatiz-
ing? pp. 148-150, 152-154

• • •

endocrine system, p. 135

epinephrine, p. 135

norepinephrine, p. 135

hypothalamic-pituitary-adrenal (HPA)
pathway, p. 136

corticosteroids, p. 136

1

;1.11 ••

/4,

• • • • • !,•,1

Stress Disorders :1/ 161

el; acute stress disorder, p. 136
rape, p. 138

44 eye movement desensitization and
reprocessing, p. 145

O psychological debriefing, p. 146
• psychophysiological disorders, p. 148

ulcer, p. 148

10.). asthma, p. 149

*7/72.7/”W/7/7.1.7.7/1/74 07/27/ a 1M’

posttrctumatic stress disorder (PTSD), p. 136

insomnia, p. 149

headaches, p. 149

hypertension, p. 1

50

coronary heart disease, p. 150
Type A personality style, p. 151

Social Adjustment Rating Scale, p. 152

psychoneuroimmuology, p. 154

immune system, p. 154

antigen, p. 154

/ 77/717747//774,7//i.7477/X 7.7

lymphocyte, p. 154

cytokines, p. 155

behavioral medicine, p. 156

relaxation training, p. 156

biofeedback training, p. 156

meditation, p. 157

hypnosis, p. 157

self-instruction training, p. 157

\\\r)uriK ‘)U12///
,A; yzi 1. What factors determine how

people react to stressors in life?
pp. 134-136

V::: 2. What factors seem to help influence
whether a person will develop a
psychological stress disorder after
experiencing a traumatic event?
pp. 142-144

3.

aches, hypertension, and coronary
heart disease? pp. 148- 150

5. What kinds of biological, psycho.
logical, and sociocultural factors
appear to contribute to psychophys-
iological disorders? pp. 151 – 152

6. What kinds of links have been
found between life stress and
physical illnesses? What scale has
helped researchers investigate this
relationship? pp. 152- 154

7. Describe the relationship among
stress, the immune system, and
physical illness. pp. 154-156

8. Explain the specific roles played
by various types of lymphocytes.
pp. 154- 155

9. Discuss how immune system func-
tioning at times of stress may be
affected by a person’s biochemical
activity, behavioral changes, per-
sonality style, and social support.
pp. 155- 156

1 O. What psychological treatments
have been used to help treat physi-
cal illnesses? To which specific
illnesses has each been applied?
pp. 156-158

What treatment approaches have
been used with people suffering
from acute or posttraumatic stress
disorders? pp. 144- 147

4. What are the specific causes of
0•

:
ulcers, asthma, insomnia, head-

M.7073′”./.:=7;74272,M=5:;’,arfor.,9,0747,717,71227/r”

Search the Fundamentals of Abnormal Psychology Video Tool Kit
www.worthpublishers.com/apvtk

A Chapter 5 Video Cases
Fight-or-Flight: How Stress Affects Psychological and Bodily Functioning
One Man’s Return from Combat
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SOMATOFORM
AND DISSOCIATIVE
DISORDERS CHAPTER

rian was spending Saturday sailing with his wife, Helen. The water was rough but well
within what they considered safe limits. They were having a wonderful time and really
didn’t notice that the sky was getting darker, the wind blowing harder, and the sailboat
becoming more difficult to control. After a few hours of sailing, they found themselves

far from shore in the middle of a powerful and dangerous storm.

The storm intensified very quickly. Brian had trouble controlling the sailboat amidst the high
winds and wild waves. He and Helen tried to put on the safety jackets they had neglected to
wear earlier, but the boat turned over before they were finished. Brian, the better swimmer
of the two, was able to swim back to the overturned sailboat, grab the side, and hold on for
dear life, but Helen simply could not overcome the rough waves and reach the boat. As Brian
watched in horror and disbelief, his wife disappeared from view.

After a time, the storm began to lose its strength. Brian managed to right the sailboat and sail
back to shore. Finally he reached safety, but the personal consequences of this storm were
just beginning. The next days were filled with pain and further horror: the Coast Guard finding
Helen’s body … conversations with friends . . . self-blame . grief . and more.

Compounding this horror, the accident had left Brian with a severe physical impairment—he
could not walk properly. He first noticed this terrible impairment when he sailed the boat back
to shore, right after the accident. As he tried to run from the sailboat to get help, he could hardly
make his legs work. By the time he reached the nearby beach restaurant, all he could do was
crawl. Two patrons had to lift him to a chair, and after he told his story and the authorities were
alerted, he had to be taken to a hospital.

At first Brian and the hospital physician assumed that he must have been hurt during the ac-
cident. One by one, however, the hospital tests revealed nothing—no broken bones, no spinal
damage, nothing. Nothing that could explain such severe impairment.

By the following morning, the weakness in his legs had become near paralysis. Because the
physicians could not pin down the nature of his injuries, they decided to keep his activities
to a minimum. He was not allowed to talk long with the police. Someone else had to inform
Helen’s parents or her death. To his deep regret, he was not even permitted to attend Helen’s
funeral.

The mystery deepened over the following days and weeks. As Brian’s paralysis continued, he became
more and more withdrawn, unable to see more than a few friends and family members and unable
to take care of the many unpleasant tasks attached to Helen’s death. He could not bring himself
to return to work or get on with his fife. Almost from the beginning, Brian’s paralysis had left him
self-absorbed and drained of emotion, unable to look back and unable to move forward.

In the previous two chapters you saw how stress and anxiety can negatively affect
functioning. Indeed, anxiety is the key feature of disorders such as generalized
anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder. And
stress can produce the lingering reactions seen in acute stress disorder, posttrau-
matic stress disorder, and psychophysiological disorders.

Two other kinds of disorders are commonly linked to stress and anxiety-
somatofor -m disorders and dissociative disorders. Somatoform disorders are problems
that appear to be medical but are actually caused by psychosocial factors. Unlike

TOPIC OVERVIEW

Somatoform Disorders

Conversion Disorder
Somatization Disorder

Pain Disorder Associated with
Psychological Factors

Hypochondriasis

Body Dysmorphic Disorder

What Causes Somatoform
Disorders?

How Are Somatoform Disorders
Treated?

Dissociative Disorders

Dissociative Amnesia

Dissociative Fugue

Dissociative Identity Disorder
(Multiple Personality Disorder)

How Do Theorists Explain
Dissociative Disorders?

How Are Dissociative Disorders
Treated?

Putting It Together:
Disorders Rediscovered

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164 //CHAPTER 6

psychophysiological disorders, in which psychosocial factors
interact with genuine physical ailments, the somatoform dis-
orders are psychological disorders masquerading as physical
problems. Similarly, dissociative disorders are patterns of memory
loss and identity change that are caused almost entirely by
psychosocial factors rather than physical ones.

The somatoform and dissociative disorders have much in
common. Both, for example, may occur in response to severe
stress, and both have traditionally been viewed as forms of es-
cape from that stress. In addition, a number of individuals suffer
from both a somatoform and a dissociative disorder (Brown
et al., 2007). Indeed, theorists and clinicians often explain and
treat the two groups of disorders in similar ways.

•Somatoform Disorders
Think back to Brian, the young man whose tragic boating ac-
cident left him unable to walk. As medical test after test failed
to explain his paralysis, physicians became convinced that the
cause of his problem lay elsewhere.

When a physical ailment has no apparent medical cause, doctors may suspect a
somatoform disorder, a pattern of physical complaints with largely psychosocial
causes. People with such disorders do not consciously want or purposely produce their
symptoms; like Brian, they almost always believe that their problems are genuinely
medical (Phillips, Fallon, & King, 2008). In some somatoform disorders, known as
hysterical somatoform disorders, there is an actual change in physical functioning. In others,
the preoccupation somatoform disorders, people who are healthy mistakenly worry that there
is something physically wrong with them.

What Are Hysterical Somatoform Disorders?
People with hysterical somatoform disorders suffer actual changes in their physical
functioning. These somatoform disorders are often hard to distinguish from genuine
medical problems (Phillips et al., 2008). In fact, it is always possible that a diagnosis of
hysterical disorder is a mistake and that the patient’s problem has an undetected organic
cause (Aybek et al., 2008; Merskey, 2004). DSM-IV-TR lists three hysterical somato-
form disorders: conversion disordel; somatization disorder; and pain disorder associated with
psychological factors.

Conversion Disorder In conversion disorder, a psychosocial conflict or need is
converted into dramatic physical symptoms that affect voluntary motor or sensory func-
tioning (see Table 6-1). Brian, the man with the unexplained paralysis, would probably
receive this particular diagnosis.The symptoms often seem neurological, such as paralysis,
blindness, or loss of feeling (APA, 2000). One woman developed dizziness in apparent
response to her unhappy marriage:

A 46-year-old married housewife . . . described being overcome with feelings of ex-
treme dizziness, accompanied by slight nausea, four or five nights a week. During
these attacks, the room around her would take on a “shimmering” appearance, and
she would have the feeling that she was “floating” and unable to keep her balance.
Inexplicably, the attacks almost always occurred at about 4:00 P.M. She usually had
to fie down on the couch and often did not feel better until 7:00 or 8:00 P.M. After
recovering, she generally spent the rest of the evening watching TV; and more often
than not, she would fall asleep in the living room, not going to bed in the bedroom
until 2:00 or 3:00 in the morning.

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Somatoform and Dissociative Disorders :1/ 1 65

The patient had been pronounced physically fit by her internist, a neurologist, and an
ear, nose, and throat specialist on more than one occasion. Hypoglycemia had been ruled
out by glucose tolerance tests.

When asked about her marriage, the patient described her husband as a tyrant, fre-
quently demanding and verbally abusive of her and their four children. She admitted that
she dreaded his arrival home from work each day, knowing that he would comment that
the house was a mess and the dinner, if prepared, not to his liking. Recently, since the
onset of her attacks, when she was unable to make dinner he and the four kids would go
to McDona Id’s or the local pizza parlor. After that, he would settle in to watch a ballgame
in the bedroom, and their conversation was minimal. In spite of their troubles, the patient
claimed that she loved her husband and needed him very much.

(Spitzer et al., 1981, pp. 92-93)

Most conversion disorders begin between late childhood and young adulthood; they

are diagnosed at least twice as often in women as in men (Abbey, 2005; APA, 2000).
They usually appear suddenly, at times of extreme stress, and last a matter of weeks. Some
research suggests that people who develop this disorder tend to be generally suggestible;
many are highly susceptible to hypnotic procedures, for example (Roelofs et al., 2002).
Conversion disorders are thought to be quite rare, occurring in at most 5 of every 1,000
persons.

osomatoform disorderoA physical ill-
ness or ailment that is explained largely
by psychosocial causes, in which the
patient experiences no sense of wanting
or guiding the symptoms.

°hysterical somatoform disorders°
Somatoform disorders in which people
suffer actual changes in their physical
functioning.

°conversion disorderoA somatoform
disorder in which a psychosocial need
or conflict is converted into dramatic
physical symptoms that affect voluntary
motor or sensory function.

osomatization disorder®A somatoform
disorder marked by numerous recurring
physical ailments without an organic
basis. Also known as Briquet’s syndrome.

*pain disorder associated with
psychological factors°A sornatoform
disorder marked by pain, with psycho-
social factors playing a central role in
the onset, severity, or continuation of the
pain.

°factitious disorderoAn illness with
no identifiable physical cause, in which
the patient is believed to be intentionally
producing or faking symptoms in order
to assume a sick role.

Somatization Disorder Sheila baffled medical specialists with the wide range of
her symptoms:

Sheila reported having abdominal pain since age I 7, necessitating exploratory surgery that

yielded no specific diagnosis. She had several pregnancies, each with severe nausea, vomit-

ing, and abdominal pain; she ultimately had a hysterectomy for a “tipped uterus.” Since
age 40 she had experienced dizziness and “blackouts,” which she eventually was told

might be multiple sclerosis or a brain tumor. She continued to be bedridden for extended

periods of time, with weakness, blurred vision, and difficulty urinating. At age 43 she

was worked up for a Hotel hernia because of complaints of bloating and intolerance of
a variety of foods. She also had additional hospitalizations for neurological, hypertensive,
and renal workups, all of which failed to reveal a definitive diagnosis.

(Spitzer et al., 1981, pp. 185, 260)

1 66 ://CHAPTER 6

Like Sheila, people with somatization disorder have many long-lasting physical
ailments that have little or no organic basis (see again Table 6-1). This hysterical pat-
tern, first described by Pierre Briquet in 1859, is also known as Briquet’s syndrome.
To receive this diagnosis, a person must have a range of ailments, including several
pain symptoms (such as headaches and chest pain), gastrointestinal symptoms (such as
nausea and diarrhea), a sexual symptom (such as erectile or menstrual difficulties), and
a neurological symptom (such as double vision or paralysis) (APA, 2000). People with
somatization disorder usually go from doctor to doctor in search of relief. They often
describe their many symptoms in dramatic and exaggerated terms. Most also feel anx-
ious and depressed (Creed, 2009; Fink et al., 2004; APA, 2000).

Between 0.2 and 2.0 percent of all women in the United States may experience
a somatization disorder in any given year, compared to less than 0.2 percent of men
(North, 2005;APA, 2000).The disorder often runs in families; as many as 20 percent of
the close female relatives of women with the disorder also develop it. It usually begins
between adolescence and young adulthood.

A somatization disorder lasts much longer than a conversion disorder, typically for
many years (Yutzy, 2007). The symptoms may fluctuate over time but rarely disappear

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Somatoform and Dissociative Disorders :1,/ 167

completely -without therapy (Abbey, 2005). Two-thirds of individuals with this disorder
in the United States receive treatment for their physical ailments from a medical or
mental health professional in any given year (Regier et al., 1993).

Pain Disorder Associated with Psychological Factors When psychosocial
factors play a central role in the onset, severity, or continuation of pain, patients may re-
ceive a diagnosis of pain disorder associated with psychological factors (see again
Table 6-1). Patients with a conversion or somatization disorder may also experience pain,
but it is the key symptom in this disorder.

Although the precise prevalence has not been determined, pain disorder associated
with psychological factors appears to be fairly common (Creed, 2009).The disorder may
begin at any age, and women seem more likely than men to experience it (APA, 2000).
Often it develops after an accident or during an illness that has caused genuine pain,
which then takes on a life of its own. Laura, a 36-year-old woman, reported pains that
went far beyond the usual symptoms of her tubercular disease, called sarcoidosis:

Before the operation I would have little joint pains, nothing that really bothered me that
much. After the operation I was having severe pains in my chest and in my ribs, and
those were the type of problems I’d been having after the operation, that I didn’t have
before. . . . I’d go to an emergency room at night, 11:00, 12:00, 1:00 or so. I’d take the
medicine, and the next day it stopped hurting, and I’d go back again. In the meantime
this is when I went to the other doctors, to complain about the same thing, to find out
what was wrong; and they could never find out what was wrong with me either… .

. . . At certain points when I go out or my husband and I go out we have to leave early
because I start hurting. . . . A lot of times I just won’t do things because my chest is hurting for
one reason or another.. .. Two months ago when the doctor checked me and another doctor
looked at the x-rays, he said he didn’t see any signs of the sarcoid then and that they were
doing a study now, on blood and various things, to see if it was connected to sarcoid. . . .

(Green, 1985, pp. 60-63)

Hysterical vs. Medical Symptoms Because hysterical somatoform disorders are so
similar to “genuine” medical ailments, physicians sometimes rely on oddities in the patient’s
medical picture to help distinguish the two (Phillips et al., 2008; Kirmayer & Looper, 2007).
The symptoms of a hysterical disorder may, for example, be at odds with the way the ner-
vous system is known to work (APA, 2000). In a conversion symptom called glove anesthesia,
numbness begins sharply at the wrist and extends evenly right to the fingertips. As Figure
6-1 shows, real neurological damage is rarely as abrupt or evenly spread out.

The physical effects of a hysterical disorder may also differ from those of the cor-
responding medical problem. For example, when paralysis from the waist down, or
paraplegia, is caused by damage to the spinal cord, a person’s leg muscles may atrophy,
or waste away, unless physical therapy is applied. People whose paralysis is the result of a
conversion disorder, in contrast, do not usually experience atrophy. Perhaps they exercise
their muscles without being aware that they are doing so. Similarly, people with conver-
sion blindness have fewer accidents than people who are organically blind, an indication
that they have at least some vision even if they are unaware of it.

Hysterical VS, Factitious Symptoms Hysterical somatoform disorders are dif-
ferent from patterns in which individuals are purposefully producing or faking medical
symptoms.A patient may, for example,inatinget—intentionally fake illness to achieve some
external gain, such as financial compensation (Phillips et al., 2008). Or a patient may in-
tentionally produce or fake physical symptoms simply out of a wish to be a patient; that
is, the motivation for assuming the sick role may be the role itself. Physicians would then
decide that the patient is displaying a factitious disorder.

168 I/CHAPTER 6

People with a factitious disorder often go to extremes to create the appearance of ill-
ness (Phillips et al., 2008). Many give themselves medications secretly. Some inject drugs
to cause bleeding. High fevers are especially easy to create. In one study of patients with
long-standing mysterious fever, more than 9 percent were eventually diagnosed with facti-
tious disorder (Feldman, Ford, & Reinhold, 1994). People with a factitious disorder often
research their supposed ailments and are impressively knowledgeable about medicine.

Psychotherapists and medical practitioners often become angry at people with a
factitious disorder, feeling that these individuals are, among other issues, wasting their
time.Yet people with this disorder, like most persons with psychological disorders, feel
they have no control over their problem, and they often experience great distress.

Munchausen syndrome is the extreme and long-term form of factitious disor-
der. It is named after Baron Munchausen, an eighteenth-century cavalry officer who

A CLO$ER LOOK

Munchausen Syndrome by Proxy

[Jennifer] had been hospitalized 200 times and under-
gone 40 operations. Physicians removed her gallbladder,
her appendix and part of her intestines, and inserted
tubes into her chest stomach and intestines. [The
9-year-old from Florida] was befriended by the Florida
Marlins and served as a poster child for health care
reform, posing with Hillary Rodham Clinton at a White
Rouse rally. Then police notified her mother that she was
under investigation for child abuse. Suddenly, Jennifer’s
condition improved dramatically In the next nine months,
she was hospitalized only once, for a viral infection. . . .
Experts said Jennifer’s numerous baffling infections were
“consistent with someone smearing fecal matter” into her
feeding line and urinary catheter.

(KATEL& BECK, 1996)

ases like Jennifer’s have horrified
i the public and called attention to

Munchausen syndrome by proxy. This dis-
order is caused by a caregiver who uses
various techniques to induce symptoms in
a child—giving the child drugs, tampering
with medications, contaminating a feed-
ing tube, or even smothering the child, for
example. The illness can take almost any
form, but the most common symptoms are

bleeding, seizures, asthma, comas, diar-
rhea, vomiting, “accidental” poisonings,
infections, fevers, and sudden infant death
syndrome (Leamon et al., 2007; Feldman,

2004).
Between 6 and 30 percent of the vic-

tims of Munchausen syndrome by proxy
die as a result of their symptoms, and
8 percent of those who survive are
permanently disfigured or physically im-
paired (Ayoub, 2006; Mitchell, 2001).
Psychological, educational, and physical

• • 1■ • • •

development are also affected (Libow &
Schreier, 1998; Libow, 1995).

The syndrome is very hard to diagnose
and may be more common than clinicians
once thought (Feldman, 2004; Rogers,
2004). The parent (usually the mother)
seems to be so devoted and caring that
others sympathize with and admire her.
Yet the physical problems disappear when
child and parent are separated. In many
cases siblings of the sick child have also
been victimized {Ayoub, 2006).

What kind of parent carefully inflicts
pain and illness on her own child? The
typical Munchausen mother is emotionally
needy: She craves the attention and praise
she receives for her devoted care of her
sick child (Noeker, 2004). She may have
little social support outside the medical

system. Often the mothers have a medical
background of some kind—perhaps hav-
ing worked formerly in a doctor’s office.
Typically they deny their actions, even in
the face of clear evidence, and refuse to
undergo therapy (Bluglass, 2001).

Law enforcement authorities approach
Munchausen syndrome by proxy as a
crime—a carefully planned form of child
abuse (Slovenko, 2006; Mart, 2004). They
almost always require that the child be
separated from the mother (Ayoub, 2006).
At the same time, a parent who resorts
to such actions is seriously disturbed and
greatly in need of clinical help. Thus clini-
cal researchers and practitioners must now
work to develop clearer insights and more
effective treatments for such parents and
their young victims.

table:

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Somatoform and Dissociative Disorders 1 69

journeyed from tavern to tavern in Europe telling fantastical tales about his supposed
military adventures (Ford, 2005; Feldman, 2004). In a related disorder, Munchausen
syndrome by proxy, or factitious disorder by proxy, parents make up or produce
physical illnesses in their children, leading in some cases to repeated painful diagnostic
tests, medication, and surgery.

What Are Preoccupation Somatoform Disorders?
Hypochondriasis and body dysmorphic disorder are preoccupation somatoform disor-
ders. People with these problems misinterpret and overreact to bodily symptoms or
features no matter what friends, relatives, and physicians may say. Although preoccupa-
tion disorders also cause great distress, their impact on one’s life differs from that of
hysterical disorders.

Hypochondriasis People who suffer from hypochondriasis unrealistically interpret
bodily symp toms as signs ofa serious illness (seeTable 6-2). Often their symptoms are merely
normal bodily changes, such as occasional coughing, sores, or sweating. Although sonic
patients recognize that their concerns are excessive, many do not.

Although hypochondriasis can begin at any age, it starts most often in early adult-
hood, among men and women in equal numbers. Between 1 and 5 percent of all people
experience the disorder (Bouman, 2008; APA, 2000). As with pain disorder associated
with psychological factors, physicians report seeing many cases (Mitchell, 2004). As
many as 7 percent of all patients seen by primary care physicians may display hypo-
chondriasis (Asmundson & Taylor, 2008). For most patients, the symptoms rise and fall
over the years.

Body Dysmorphic Disorder People who experience body dysmorphic disor-
der, also known as dysmorphophobia, become deeply concerned about some imag-
ined or minor defect in their appearance (see again Table 6-2). Most often they focus
on wrinkles; spots on the skin; excessive facial hair; swelling of the face; or a misshapen
nose, mouth, jaw, or eyebrow (McKay, Gosselin, & Gupta, 2008; Veale, 2004). Some
worry about the appearance of their feet, hands, breasts, penis, or other body parts. Still
others are concerned about bad odors coming from sweat, breath, genitals, or the rectum
(Phillips & Castle, 2002). Here we see such a case:

A woman of 35 had for 16 years been worried that her sweat smelled terrible. The fear
began just before her marriage when she was sharing a bed with a close friend who said
that someone at work smelled badly, and the patient felt that the remark was directed at
her. For fear that she smelled, for 5 years she had not gone out anywhere except when ac-
companied by her husband or mother. She had not spoken to her neighbors for 3 years be-
cause she thought she had overheard them speak about her to some friends. She avoided
cinemas, dances, shops, cafes, and private homes. . . . Her husband was not allowed to
invite any friends home; she constantly sought reassurance from him about her smell… .
Her husband bought all her new clothes as she was afraid to try on clothes in front of
shop assistants. She used vast quantities of deodorant and always bathed and changed
her clothes before going out, up to 4 times daily.

(Marks, 1987, p. 371)

It is corrunon in our society to worry about appearance (see Figure 6-2 on the next
page). Many teenagers and young adults worry about acne, for instance. The concerns of
people with body dysmorphic disorder, however, are extreme. Sufferers may severely limit
contact with other people, be unable to look others in the eye, or go to great lengths to
conceal their “defects”—say, always wearing sunglasses to cover their supposedly misshapen
eyes (Phillips, 2005). As many as half of people with this disorder seek plastic surgery or

oMunchausen syndromeoThe extreme
and chronic form of factitious disorder.

°Munchausen syndrome by proxy°.
A factitious disorder in which parents
make up or produce illnesses in their
children. Also known as factitious disor-
der by proxy.

°preoccupation somatoform
drsorders.Disorders in which people
misinterpret and overreact to minor, even
normal, bodily symptoms or features.

ehypochondriasisoA disorder in
which people mistakenly fear that minor
changes in their physical functioning
indicate a serious disease.

°body dysmorphic disorderoA
disorder marked by excessive worry
that some aspect of one’s physical
appearance is defective. Also known as
dysmorphophobia.

People who would change
something about their appearance

if they could

People who daydream about being
beautiful or handsome

People who think that the
cosmetics industry is very important

or essential to our country

People who wear uncomfortable
shoes because they look good

People who have brushed their
teeth twice in the last 24 hours

People who have flossed their
teeth in the last 24 hours

People who have stuffed their
bras (women) or shorts (men)

170 :/JCHAPTER 6

dermatology treatment, and often they feel worse rather than better afterward (McKay et
al., 2008). One study found that 30 percent of participants with body dysmorphic disorder
were housebound and 17 percent had attempted suicide (Phillips et al., 1993).

Most cases of body dysmorphic disorder begin during adolescence. Often, however,
people don’t reveal their concerns for many years (McKay et al., 2008). Up to 5 percent
of people in the United States—including many college students—suffer from the
disorder (Ovsiew, 2006; Miller, 2005). Clinical reports suggest that it may be equally
common among women and men (APA, 2000).

tidritliTil” )J
fr)

=ri

What Causes Somatoform Disorders?
Theorists typically explain the preoccupation somatoform disorders much as they
explain anxiety disorders (Bouman, 2008; Noyes, 2008, 2003, 2001). Behaviorists, for
example, believe that the fears found in hypochondriasis and body dysmorphic disorder

are acquired through classical conditioning or modeling (Marshall
et al., 2007). Cognitive theorists suggest that people with the dis-
orders are so sensitive to and threatened by bodily cues that they
come to misinterpret them (Williams, 2004).

In contrast, the hysterical somatoform disorders—conversion,
somatization, and pain disorders—are widely considered unique
and in need of special explanations. The ancient Greeks believed
that only women had hysterical disorders. The uterus of a sexually
ungratified woman was supposed to wander throughout her body
in search of fulfillment, producing a physical symptom wherever
it lodged. Thus Hippocrates suggested marriage as the most effec-
tive treatment for such disorders. Today’s leading explanations for
hysterical somatoform disorders come from the psychodynamic,
behavioral, cognitive, and multicultural models. None has received
much research support, however, and the disorders are still poorly
understood (Kirmayer & Looper, 2007;Yutzy, 2007).

WrOl
Expectant ::Fri cers ::

I.

f3;

Somataform and Dissociative Disorders :1/ 1 71

eauty is in the Eye of the Beholder

eople almost everywhere want to be
attractive, and they tend to worry

about how they appear in the eyes of oth-
ers. At the same time, these concerns take
different forms in different cultures.

Whereas people in Western society
worry in particular about their body size
and facial features, women of the Padaung
tribe in Myanmar focus on the length of
their neck and wear heavy stacks of brass
rings to try to extend it. Many of them seek
desperately to achieve what their culture
has taught them is the perfect neck size.
Said one, “It is most beautiful when the
neck is really long. . . . I will never take
off my rings. . . I’ll be buried in them”
(Mydans, 1996).

Similarly, for centuries women of China,
in response to the preferences of men in
that country, worried greatly about the size
and appearance of their feet and practiced
foot binding to stop the growth of these
extremities (Wang Ping, 2000). In this
procedure, which began in the year 900

and was widely practiced until it
was outlawed in 1911, young girls
were instructed to wrap a long ban-
dage tightly around their feet each
day, forcing the four toes under
the sole of the foot. The procedure,
which was carried out for about two
years, caused the feet to become
narrower and smaller. Typically
the practice led to serious medical
problems and poor mobility, but it
did produce the small feet that were
considered attractive.

Western society also falls victim
to such cultural influences. Recent
decades have witnessed staggering
increases in such procedures as
rhinoplasty (reshaping of the nose),
breast augmentation, and body
piercing-all reminders that cul-
tural values greatly influence each
person’s ideas and concerns about
beauty, and in some cases may set
the stage for body dysmorphic disorder.

The Psychodynamic View As you read in Chapter 1, Freud’s theory of psycho-
analysis began with his efforts to explain hysterical symptoms. Indeed, he was one of the
few clinicians of his day to treat patients with these symptoms seriously, as people with
genuine pro blems.After studying hypnosis in Paris, Freud became interested in the work
of an older physician, Josef Breuer (1842-1925). Breuer had successfully used hypnosis
to treat a woman he called Anna 0., who suffered from hysterical deafness, disorga-
nized speech, and paralysis. Critics have since questioned whether Anna’s ailments were
entirely hysterical and whether Breuer’s treatment helped her as much as he claimed
(Ellenberger, 1972). But on the basis of this and similar cases, Freud (1894) came to be-
lieve that hysterical disorders represented a conversion of underlying emotional conflicts
into physical symptoms.

Observing that most of his patients with hysterical disorders were women, Freud
centered his explanation of hysterical disorders on the needs of girls during their phallic
stage (ages 3 through 5). At that time in life, he believed, all girls develop a pattern of
desires called the Electra complex: Each girl experiences sexual feelings for her father and
at the same time recognizes that she must compete with her mother for his affection.
However, aware of her mother’s more powerful position and of cultural taboos, the
child typically represses her sexual feelings and rejects these early desires for her father.

Freud believed that if a child’s parents overreact to her sexual feelings—with strong
punishments, for example—the Electra conflict will be unresolved and the child may
reexperience sexual anxiety throughout her life.Whenever events trigger sexual feelings,
she may experience an unconscious need to hide them from both herself and others.
Freud concluded that some women hide their sexual feelings by unconsciously convert-
ing them into physical symptoms.

172 :it/CHAPTER 6

L.+

En

ectra complex goes awry
eudued-that a h -anj hysterical disorder
y result when parents overreact to the • aughter’s early cliSplays -of affection 6

er father, The child ma –
xual repression in a •

[Feeling

Most of today’s psychodynamic theorists take issue with Freud’s expla-
nation of hysterical disorders, particularly his notion that the disorders can
always be traced to an unresolved Electra conflict (Verhaeghe,Vanheule, &
de Rick, 2007; Hess, 1995).They continue to believe, however, that sufferers
of these disorders have unconscious conflicts carried forth from childhood,
which arouse anxiety, and that the individuals convert this anxiety into
“more tolerable” physical symptoms (Brown et al., 2005).

Psychodynamic theorists propose that two mechanisms are at work in
hysterical somatoform disorders—primary gain and secondary gain (van
Egmond, 2003). People achieve primary gain when their hysterical symptoms
keep their internal conflicts out of awareness. During an argument, for ex-
ample, a man who has underlying fears about expressing anger may develop
a conversion paralysis of the arm, thus preventing his feelings of rage from
reaching consciousness. People achieve secondary gain when their hysterical
symptoms further enable them to avoid unpleasant activities or to receive
sympathy from others. When, for example, a conversion paralysis allows a
soldier to avoid combat duty or conversion blindness prevents the breakup
of a relationship, secondary gain may be at work. Similarly, the conversion
paralysis of Brian, the man who lost his wife in the boating accident, seemed
to help him avoid many painful duties after the accident, from telling his

wife’s parents of her death to attending her funeral and returning to work.

The Behavioral View Behavioral theorists propose that the physical symptoms
of hysterical disorders bring rewards to sufferers (see Table 6-3). Perhaps the symptoms
remove the individuals from an unpleasant relationship or bring attention from other
people (Whitehead et al., 1994). In response to such rewards, the sufferers learn to dis-
play the symptoms more and more prominently. Behaviorists also hold that people who
are familiar with an illness will more readily adopt its physical symptoms (Garralda,
1996). In fact, studies find that many sufferers develop their hysterical symptoms after
they or their close relatives or friends have had similar medical problems (Marshall et al.,
2007). Clearly, the behavioral focus on rewards is similar to the psychodynamic idea of
secondary gains.

Like the psychodynamic explanation, the behavioral view of hysterical disorders has
received little research support. Even clinical case reports only occasionally support this
position. In many cases the pain and upset that surround the disorders seem to outweigh
any rewards the symptoms may bring.

The Cognitive View Some cognitive theorists propose that hysterical disorders are
forms of communication, providing a means for people to express emotions that would
otherwise be difficult to convey (Mitchell, 2004). Like their psychodynamic colleagues,
these theorists hold that the emotions of patients with hysterical disorders are being con-
verted into physical symptoms. They suggest, however, that the purpose of the conver-
sion is not to defend against anxiety but to communicate extreme feelings—anger, fear,
depression, guilt, jealousy—in a “physical language” that is familiar and comfortable for
the patient (Koh et al., 2005).

According to this view, people who find it particularly hard to recognize or express
their emotions are candidates for a hysterical disorder. So are those who “know” the
language of physical symptoms through firsthand experience with a genuine physical
ailment. Because children are less able to express their emotions verbally, they are par-
ticularly likely to develop physical symptoms as a form of communication (Dhossche
et al., 2002). Like the other explanations, this cognitive view has not been widely tested
or supported by research.

The Multicultural View Clinicians often use the term somatization when referring
generally to the development of somatic symptoms in response to personal distress, the
key feature of hysterical somatoform disorders. Somatization of any kind is considered
inappropriate in Western countries (So, 2008; Escobar, 2004). Some theorists believe,

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table:

Disorders That Have Physical Symptoms

Disorder

Voluntary
Control of
Symptoms?

Symptoms
Linked to
Psychosocial
Factor?

An
Apparent
Goal?

Malingering Yes Maybe Yes

Factitious disorder Yes Yes No*

Somatoform disorder No Yes Maybe

Psychophysiological disorder No Yes No

Physical illness No Maybe No

*Except for medical attention.

however, that this position reflects a bias held by Western clinicians—a bias that sees so-
matic symptoms as an inferior way of dealing with emotions (Moldaysky, 2004; FAbrega,
1990).

In fact, the transformation of personal distress into somatic complaints is the norm
in many non-Western cultures (Draguns, 2006; Kleinman, 1987). In such cultures,
somatization is viewed as a socially and medically correct—and less stigmatizing—
reaction to life’s stressors.

Studies have found very high rates of somatization in non-Western medical settings
throughout the world, including those in China, Japan, and Arab countries (Matsumoto

Juang, 2008). Individuals in Latin countries seem to display the greatest number of
somatic symptoms (Escobar, 2004, 1995; Escobar et al., 1998, 1992). Even within the
United States, people from Hispanic cultures display more somatic symptoms in the face
of stress than do other populations.

In Chapter 5 you saw that posttraumatic stress disorder may be more common
among Hispanic Americans than among other ethnic groups in the United States (see
page 143). Interestingly, however, research clarifies that this trend exists only among
Hispanic Americans who were born in the United States or have lived in the United
States for a number of years (Escobar, 2004, 1998). Indeed, recent Latin immigrants
display a lower rate of posttraumatic stress disorder than do other individuals throughout
the country. It may be that recent immigrants, not yet influenced by the Western bias
against somatization, react to traumatic events with familiar somatic symptoms and that
those symptoms help prevent the onset of a full-blown posttraumatic stress disorder.

The lesson to be learned from such multicultural findings is not that somatic reac-
tions to stress are superior to psychological ones or vice versa, but rather, once again,
that reactions to life’s stressors are often influenced by one’s culture. Overlooking this
point can lead to knee-jerk mislabels or misdiagnoses.

I E., r
A Possim e Kole for Biology Although hysterical somatoform disorders are, by
definition, thought to result largely from psychological and sociocultural factors, the im-
pact of biological processes should not be overlooked (Ovsiew, 2006).To understand this
point, consider first what researchers have learned about placebos and the placebo effect.

For centuries physicians have observed that patients suffering from many kinds of
illnesses, fro m seasickness to angina, often find relief from placebos, substances that
have no known medicinal value (Price, Finniss, & Benedetti, 2008; Brody, 2000). Some
studies have raised questions about the actual number of patients helped by placebos
(Hrobjartsson & Gotzsche, 2006, 2001), but it is generally agreed that such “pretend”
treatments do bring help to many people.

Why do placebos have a medicinal effect? Theorists used to believe that they operated
in purely psychological ways—that the power of suggestion worked almost magically

oplacebooA sham treatment that a
patient believes to be genuine.

Somatoform and Dissociative Disorders :1/ 173

174 ://CHAPTER 6

“If this doesn’t help you don’t worry, it’s a placebo.”

upon the body. More recently, however, researchers have found that a belief or expecta-
tion can trigger certain chemicals throughout the body into action, and these chemicals
then may produce a medicinal effect (Price et al., 2008). The body chemicals most often
mentioned are hormones and lymphocytes, chemicals that you observed at work in Chap-
ter 5, and endorphins, natural opioid substances that you will read about in Chapter 10.
Howard Brody, a leading theorist on the subject, compares the placebo effect to visiting
a pharmacy:

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Our bodies are capable of producing many substances that can heal a wide variety of ill-
nesses, and make us feel generally healthier and more energized. When the body simply
secretes these substances on its own, we have what is often termed “spontaneous healing.”
Some of the time, our bodies seem slow to react, and a message from outside can serve
as a wake-up call to our inner pharmacy.The placebo response can thus be seen as the
reaction of our inner pharmacies to that wake-up call.

(Brody, 2000, p. 61)

If placebos can “wake up” our inner pharmacies in this way,
perhaps traumatic events and related concerns or needs are doing
the same thing (although in a negative way) in cases of conversion
disorder, somatization disorder, or pain disorder associated with
psychological factors. That is, such events and reactions may, in
fact, be triggering our inner pharmacies and setting in motion the
bodily symptoms of hysterical somatoform disorders.

How Are Somatoform Disorders Treated?
People with somatoform disorders usually seek psychotherapy
only as a last resort. They fully believe that their problems
are medical and at first reject all suggestions to the contrary
(Asmundson & Taylor, 2008). When a physician tells them that
their problems have no physical basis, they often go to another
physician. Eventually, however, many patients with these disor-

Somata form and Dissociative Disorders :1/ 175

ders do consent to psychotherapy, psychotropic drug therapy,
or both.

Individuals with preoccupation somatoform disorders-
hypochondriasis and body dysmorphic disorder—typically
receive the kinds of treatment that are applied to anxiety disor-
ders, particularly obsessive-compulsive disorder. Studies reveal,
for example, that patients with either of the preoccupation
disorders often improve considerably when treated with the
same antidepressant drugs that are helpful in cases of obsessive-
compulsive disorder (Bouman, 2008; McKay et al., 2008).

Similarly, in one study, 17 patients with body dysmorphic
disorder were treated with exposure and response prevention—the
behavioral approach that often helps persons with obsessive-
compulsive disorder. Over the course of four weeks, the clients
were repeatedly reminded of their perceived physical defects
and, at the same time, prevented from doing anything to help
reduce their discomfort (for example, checking their appear-
ance) (Neziroglu et al., 2004, 1996). By the end of treatment, these individuals were
less concerned with their “defects” and spent less time checking their body parts and
avoiding social interactions. Increasingly, this behavioral approach is being successfully
combined with a cognitive approach that also helps clients with body dysmorphic
disorder identify, test, and change their distorted thoughts about their appearance and
social impact (Sarwer et al., 2004; Geremia & Neziroglu, 2001).

Cognitive-behavioral therapies of this kind are also being applied to cases of hypo-
chondriasis . Here, therapists repeatedly point out bodily variations to clients while, at
the same time, preventing them from seeking their usual medical attention. In addition,
the therapists guide the clients to identify and change the illness-related beliefs that are
helping to maintain their disorder. Once again, such approaches are receiving promising
research support (Bouman, 2008; Greeven et al., 2007).

Treatments for hysterical somatoform disorders—conversion, somatization, and pain
disorders—often focus on the cause of the disorder (the trauma or anxiety behind the
physical symptoms) and apply the same kinds of techniques used in cases of posttrau-
matic stress disorder, particularly insight, exposure, and drug therapies. Psychodynamic
therapists, for example, try to help individuals with hysterical disorders become con-
scious of and resolve their underlying fears, thus eliminating the need to convert anxiety
into physical symptoms (Hawkins, 2004). Alternatively, behavioral therapists use expo-
sure treatments:They expose clients to features of the horrific events that first triggered
their physical symptoms, expecting that the individuals will become less anxious over
the course of repeated exposures and, in turn, more able to face those upsetting events
directly rather than through physical channels (Stuart et al., 2008).And biological thera-
pists use antianxiety drugs or certain antidepressant drugs to help reduce the anxiety of
clients with hysterical disorders (Eifert et al., 2008; Han et al., 2008).

Other therapists try to address the physical symptoms of the hysterical disorders rather
than the causes, applying techniques such as suggestion, reinforcement, or confrontation
(Yutzy, 2007).Those who employ suggestion offer emotional support to patients and tell
them persuasively (or hypnotically) that their physical symptoms will soon disappear
(Elkins & Perfect, 2007; Moene et al., 2002).Therapists who take a reinforcement approach
arrange the removal of rewards for a client’s “sick” behaviors and an increase of rewards
for healthy behaviors (North, 2005). And therapists who take a confrontational approach
try to force patients out of the sick role by straightforwardly telling them that their
symptoms are without medical basis (Sjolie, 2002).

Researc hers have not fully evaluated the effects of these particular approaches on
hysterical disorders (Ciano-Federoff & Sperry, 2005). Case studies suggest, however,
that conversion disorder and pain disorder respond better than somatization disorder to
therapy and that approaches using a confrontational strategy are less helpful than sug-
gestion and reinforcement interventions (Miller, 2004).

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eading Cosmetic Procedures in the
United States Annually

Nonsurgical procedures

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1 76 :I/CHAPTER 6

ememoryoThe faculty for recalling past
events and past learning.

*dissociative disordersoDisorders
marked by major changes in memory
that do not have clear physical causes.

Somatoform Disorders

Patients with somatoform disorders have physical complaints whose causes are
largely psychosocial. Nevertheless, the individuals genuinely believe that their ill-
nesses are medical in origin.

Hysterical somatoform disorders involve an actual loss or change of physical
functioning. They include conversion disorder, somatization disorder (or Briquet’s
syndrome), and pain disorder associated with psychological factors. Freud devel-
oped the initial psychodynamic view of hysterical somatoform disorders, proposing
that the disorders represent a conversion of underlying emotional conflicts into physi-
cal symptoms. According to behaviorists, the physical symptoms of these disorders
bring rewards to the sufferer, Some cognitive theorists propose that the disorders are
forms of communication. Biological factors may also help explain these disorders, as
we ore reminded by recent studies of placebos. Treatments for hysterical disorders
emphasize either insight, suggestion, reinforcement, or confrontation.

People with preoccupation somatoform disorders are preoccupied with the
notion that something is wrong with them physically. In this category are hypocho-
driasis and body dysmorphic disorder. Theorists explain preoccupation somatoform
disorders much as they do anxiety disorders. Treatment for the disorders includes
medications, exposure and response prevention, and other treatments originally
developed for anxiety disorders, particularly obsessive-compulsive disorder.

Dissociative Disorders
Most of us experience a sense of wholeness and continuity as we interact with the world.
We perceive ourselves as being more than a collection of isolated sensory experiences,
feelings, and behaviors. In other words, we have an identity, a sense of who we are and
where we fit in our environment. Others recognize us and expect certain things of us.
But more important, we recognize ourselves and have our own expectations, values,
and goals.

Memory is a key to this sense of identity, the link between our past, present, and fu-
ture. Our recall of past experiences, although not always precisely accurate, helps us react
to present events and guides us in making decisions about the future.We recognize our
friends and relatives, teachers and employers, and respond to them in appropriate ways.
Without a memory, we would always be starting over; with it, life moves forward.

People sometimes experience a major disruption of their memory. They may, for
example, lose their ability to remember new information they just learned or old in-
formation they once knew well. When such changes in memory lack a clear physical
cause, they are called dissociative disorders. In such disorders, one part of the person’s
memory typically seems to be dissociated, or separated, from the rest.

There are several kinds of dissociative disorders.The primary symptom of dissociative
amnesia is an inability to recall important personal events and information. A person
with dissociative fiegue not only forgets the past but also travels to a new location and may
assume a new identity. Individuals with dissociative identity disorder; also known as multiple
personality disorder, have two or more separate identities that may not always be aware of
each other’s thoughts, feelings, and behavior.

Several memorable books and movies have portrayed dissociative disorders.Two of
the best known are The Three Faces of Eve and Sybil, each about a woman with mul-
tiple personalities. The topic is so fascinating that most television drama series seem to
include at least one case of dissociation every season, creating the impression that the
disorders are very common (Pope et al., 2007). Many clinicians, however, believe that
they are rare.

Somatoforrn and Dissociative Disorders :1/ 1 77

DSM-IV-TR also lists depersonalization disorder as a disso-
ciative disorder. People with this problem feel as though they
have become detached from their own mental processes or
body and are observing themselves from the outside. Because
memory problems are not a central feature of this disorder, it
will not be discussed here.

As you read through the remainder of this chapter, keep
in mind that dissociative symptoms are often found in cases
of acute or posttraumatic stress disorder. Recall from Chap-
ter 5 that sufferers of those disorders may feel dazed or have
trouble remembering things. When such symptoms occur
as part of a stress disorder, they do not necessarily indicate
a dissociative disorder, in which the dissociative symptoms
dominate. On the other hand, research suggests that a num-
ber of people with one of these disorders also develop the
other as well (Bremner, 2002).

Dissociative Amnesia
At the beginning of this chapter you met the unfortunate man named Brian. As you
will recall, Brian developed a conversion disorder after a traumatic boating accident in
which his wife was killed. To help examine dissociative amnesia, let us now revisit that
case, changing the reactions and symptoms that Brian develops in the aftermath of the
traumatic event.

Brian was spending Saturday sailing with his wife, Helen. The water was rough but well
within what they considered safe limits. They were having a wonderful time and really
didn’t notice that the sky was getting darker, the wind blowing harder, and the sailboat
becoming more difficult to control. After a few hours of sailing, they found themselves far
from shore in the middle of a powerful and dangerous storm.

The storm intensified very quickly. Brian had trouble controlling the sailboat amidst
the high winds and wild waves. He and Helen tried to put on the safety jackets they had
neglected to wear earlier, but the boat turned over before they were finished. Brian, the
better swimmer of the two, was able to swim back to the overturned sailboat, grab the
side, and hold on for dear life, but Helen simply could not overcome the rough waves and
reach the boat. As Brian watched in horror and disbelief, his wife disappeared from view.

After a time, the storm began to lose its strength. Brian managed to right the sailboat
and sail back to shore. Finally he reached safety, but the personal consequences of this
storm were just beginning. The next days were filled with pain and further horror: the
Coast Guard finding Helen’s body … discussions with authorities . . . breaking the news
to Helen’s parents . conversations with friends . . . self-blame . . . grief . . . and more.
On Wednesday, four days after that fateful afternoon, Brian collected himself and at-
tended Helen’s funeral and burial. It was the longest and most difficult day of his life.
Most of the time, he felt as though he were in a trance.

Soon after awakening on Thursday morning, Brian realized that something was terribly
wrong with him. Try though he might, he couldn’t remember the events of the past few
days. He remembered the occident, Helen’s death, and the call from the Coast Guard
after they had found her body. But just about everything else was gone, right up through
the funeral. At first he had even thought that it was now Sunday, and that his discussions
with family and friends and the funeral were all ahead of him. But the newspaper, the
funeral guestbook, and a phone conversation with his brother soon convinced him that he
had lost the post four days of his life.

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Repressed Childhood Memories or False Memory Syndrome?

hroughout the 1990s, reports of re-
_ pressed childhood memory of abuse
attracted much public attention. Adults with
this type of dissociative amnesia seemed
to recover buried memories of sexual and
physical abuse from their childhood. A
woman might claim, for example, that her
father hod sexually molested her repeat.
edly between the ages of 5 and 7. Or a
young man might remember that a family
friend had made sexual advances on sev-
eral occasions when he was very young.
Often the repressed memories surfaced
during therapy for another problem.

Although the number of such claims has
declined in recent years, experts remain
split on this issue (Loftus & Cahill, 2007;
McNally et al., 2005). Some believe that
recovered memories are just what they ap-
pear to be—horrible memories of abuse
that have been buried for years in the
person’s mind. Other experts believe that
the memories are actually illusions—false
images created by a mind that is confused.
Opponents of the repressed memory

concept hold that the details of childhood
sexual abuse are often remembered all too
well, not completely wiped from memory
(Loftus & Cahill, 2007; McNally et al.,
2004). They also point out that memory
in general is often flawed (Lindsay et al.,
2004). Moreover, false memories of vari-
ous kinds can be created in the laboratory
by tapping into research participants’
imaginations (Brainerd, Reyna, & Ceci,
2008; Loftus & Cahill, 2007).

If the alleged recovery of childhood
memories is not what it appears to be,
what is it? According to opponents of the
concept, it may be a powerful case of sug-
gestibility (Loftus & Cahill, 2007; Loftus,
2003, 2001, 1997). These theorists hold
that the attention paid to the phenomenon
by both clinicians and the public has led
some therapists to make the diagnosis
without sufficient evidence (Frankel, 1993).
The therapists may actively search for signs
of early abuse in clients and even encour-
age clients to produce repressed memories
(Gardner, 2004). Certain therapists in fact

use special memory recovery techniques,
including hypnosis, regression therapy,
journal writing, dream interpretation, and
interpretation of bodily symptoms (Madill
& Holch, 2004; Lindsay, 1996, 1994).
Perhaps some clients respond to the tech-
niques by unknowingly forming false mem-
ories of abuse (Hyman & Loftus, 2002).
The apparent memories may then become
increasingly familiar to them as a result of
repeated therapy discussions of the alleged
incidents.

Of course, repressed memories of child-
hood sexual abuse do not emerge only in
clinical settings (Loftus & Cahill, 2007).
Many individuals come forward on their
own. Opponents of the repressed memory
concept explain these cases by pointing
to various books, articles, websites, and
television shows that seem to validate
repressed memories of childhood abuse
(Loftus, 1993). Still other opponents of the
repressed memory concept believe that, for
biological or other reasons, some individu-
als are more prone than others to experi-
ence false memories—either of childhood
abuse or of other kinds of events (McNally
et al., 2005).

It is important to recognize that the
experts who question the recovery of
repressed childhood memories do not in
any way deny the problem of child sexual
abuse. In fact, proponents and opponents
alike are greatly concerned that the public
may take this debate to mean that clini-
cians have doubts about the scope of the
problem of child sexual abuse. Whatever
may be the final outcome of the repressed
memory debate, the problem of childhood
sexual abuse is all too real and all too
common.

178 ://CHAPTER 6

*dissociative amnesia®A disorder
marked by an inability to recall important
personal events and information.

In this revised scenario, Brian is reacting to his traumatic experience with symptoms
of dissociative amnesia. People with this disorder are unable to recall important
information, usually of an upsetting nature, about their lives (APA, 2000). The loss of
memory is much more extensive than normal forgetting and is not caused by physical
factors (see Table 6-4). Often an episode of amnesia is directly triggered by a specific
upsetting event (McLeod et al., 2004).

Dissociative amnesia may be localized, selective, generalized, or continuous. Any of these
kinds of amnesia can be triggered by a traumatic experience such as Brian’s, but each
represents a particular pattern of forgetting. Brian was suffering from localized amnesia,

the most common type of dissociative amnesia, in which a person loses all memory of
events that took place within a limited period of time, almost always beginning with
some very disturbing occurrence. Recall that Brian awakened on the day after the
funeral and could not recall any of the events of the past difficult days, beginning after
the boating tragedy. He remembered everything that happened up to and including the
accident. He could also recall everything from the morning after the funeral onward, but
the days in between remained a total blank. The forgotten period is called the amnestic
episode. During an amnestic episode, people may appear confused; in some cases they
wander about aimlessly. They are already experiencing memory difficulties but seem
unaware of them. In the revised case, for example, Brian felt as though he were in a
trance on the day of Helen’s funeral.

People with selective amnesia, the second most common form of dissociative amnesia,
remember some, but not all, events that occurred during a period of time. If Brian had
selective amnesia, he might remember certain conversations with friends but perhaps
not the funeral itself.

In some cases the loss of memory extends back to times long before the upsetting pe-
riod. Brian might awaken after the funeral and find that, in addition to forgetting events
of the past few days, he could not remember events that occurred earlier in his life. In
this case, he would be experiencing generalized amnesia. In extreme cases, Brian might not
even remember who he was and might fail to recognize relatives and friends.

In the forms of dissociative amnesia discussed so far, the period affected by the amne-
sia has an end. In continuous amnesia, however, forgetting continues into the present. Brian
might forget new and ongoing experiences as well as what happened before and during
the tragedy. Continuous forgetting of this kind is actually quite rare in cases of dissociative
amnesia but not, as you will see in Chapter 15, in cases of organic amnesia.

All of these forms of dissociative amnesia are similar in that the amnesia interferes
mostly with a person’s memory of personal material. Memory for abstract or ency-
clopedic information usually remains. People with dissociative amnesia are as likely as
anyone else to know the name of the president of the United States and how to write,
read, or drive a car.

Clinicians do not know how common dissociative amnesia is (Pope et al., 2007), but
they do know that many cases seem to begin during serious threats to health and safety,
as in wartime and natural disasters (Cardena & Gleaves, 2007). Combat veterans often
report memory gaps of hours or days, and some forget personal information, such as

Somatoform and Dissociative Disorders :1/ 1 79

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180 ://CHAPTER 6

their names and addresses (Bremner, 2002). It appears that childhood abuse, particularly
child sexual abuse, can also sometimes trigger dissociative amnesia; indeed, the 1990s
witnessed many reports in which adults claimed to recall long-forgotten experiences
of childhood abuse. In addition, dissociative amnesia may occur tinder more ordinary
circumstances, such as the sudden loss of a loved one through rejection or death or guilt
over certain actions (for example, an extramarital affair) (Koh et al., 2000).

The personal impact of dissociative amnesia depends on
how much is forgotten. Obviously, an amnestic episode of two
years is more of a problem than one of two hours. Similarly, an
amnestic episode during which a person’s life changes in major
ways causes more difficulties than one that is quiet.

Dissociative Fugue
People with a dissociative fugue not only forget their per-
sonal identities and details of their past lives but also flee to an
entirely different location (see again Table 6-4). Some individu-
als travel a short distance and make few social contacts in the
new setting (APA, 2000).Their fugue may be brief—a matter of
hours or days—and end suddenly. In other cases, however, the
person may travel far from home, take a new name, and establish
a new identity, new relationships, and even a new line of work.
Such people may also display new personality characteristics;
often they are more outgoing (APA, 2000). This pattern is seen
in the century-old case of the Reverend Ansel Bourne:

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°dissociative fugueoA disorder in
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and may assume a new identity, simulta-
neously forgetting his or her past.

On January 17, 1887, [the Reverend Ansel Bourne, of Greene, RI.] drew 551 dollars from
a bank in Providence with which to pay for a certain lot of land in Greene, paid certain
bills, and got into a Pawtucket horsecar. This is the last incident which he remembers. He
did not return home that day, and nothing was heard of him for two months. He was
published in the papers as missing, and foul play being suspected, the police sought in vain
his whereabouts. On the morning of March 14th, however, at Norristown, Pennsylvania, a
man calling himself A. 1. Brown who had rented a small shop six weeks previously, stocked
it with stationery, confectionery, fruit and small articles, and carried on his quiet trade with-
out seeming to any one unnatural or eccentric, woke up in a fright and called in the people
of the house to tell him where he was. He said that his name was Ansel Bourne, that
he was entirely ignorant of Norristown, that he knew nothing of shop-keeping, and that
the last thing he remembered—it seemed only yesterday—was drawing the money from
the bank, etc. in Providence.. . . He was very weak, having lost apparently over twenty
pounds of flesh during his escapade, and had such a horror of the idea of the candy-store
that he refused to set foot in it again.

(James, 1890, pp. 391-393)

Approximately 0.2 percent of the population experience dissociative fugue. Like dis-
sociative amnesia, a fugue usually follows a severely stressful event (Cardena & Gleaves,
2007; APA, 2000). Some adolescent runaways may be in a state of fugue (Loewenstein,
1991). Like cases of dissociative amnesia, fugues usually affect personal memories rather
than encyclopedic or abstract knowledge (Maldonado & Spiegel, 2007).

Fugues tend to end abruptly. In some cases, as with Reverend Bourne, the person
“awakens” in a strange place, surrounded by unfamiliar faces, and wonders how he or
she got there. In other cases, the lack of personal history may arouse suspicion. Perhaps
a traffic accident or legal problem leads police to discover the false identity; at other
times friends search for and find the missing person.When people are found before their
state of fugue has ended, therapists may find it necessary to ask them many questions

Sornatoform and Dissociative Disorders :1/ 181

Homeward Hound: A Case of Dog Fugue?

BY SHERRY MORSE, ANIMAL NEWS, DECEMBER 13, 2003

he Flores family of Wichita, Kansas received an early

Christmas present this year when their beloved dog Bear,

who had disappeared in November of 1997, made it back

home in time for Thanksgiving in 2003.

Jeanie Flores looked out the window of her house two days

before Thanksgiving to see a dog that looked exactly like Bear

standing outside. She recalls thinking, “Oh my God. I think

that’s my dogl” She called the dog; and he responded.

Jeanie burst into tears, then called her husband Frank and

told him she thought Bear was really home. Frank Flores rushed

home and, after seeing the dog, agreed with his wife that the

brindle lab-chow mix was indeed their Bear. One of the family’s

neighbors told them she had spotted Bear a little earlier, walking

around and carefully scrutinizing the houses.

A veterinarian who examined Bear said that although his

paws were red and sore in spots, probably from pounding the

pavement, he only weighed one pound less than when he disap-

peared. It appeared that someone had been taking care of him.

Bear had disappeared in 1997 about one month after the

Flores family had moved to a new neighborhood. Jeanie let him

out for exercise one night, and he never came back. “I waited

up all night for him, and he never came home,” she said.

At the time, Bear’s ID tag had not yet been updated with his

new address. The desperate family put up signs, canvassed their

old neighborhood, ran ads in the paper, and visited shelters,

but, tragically, the dog that Mr. Flores had brought home as a

puppy in 1990 seemed to have disappeared without a trace.

Since his extraordinary return home six years later, Bear has

been catching up on his sleep and getting re-acquainted with

his family, which includes a son who was not yet born when the
dog disappeared.

The Flores family said they just wish that Bear could tell them

where he’s been all this time. “Where was he? We don’t know

how rough a life he’s had,” Frank Flores said.

about the details of their lives, repeatedly remind them who they are, and even begin
psychotherapy before they recover their memories. As these people recover their past,
some forget the events of the fugue period (APA, 2000).

The majority of people who experience dissociative fugue regain most or all of
their memories and never have a recurrence. Since fugues are usually brief and totally
reversible, individuals tend to experience few aftereffects. People who have been away
for months or years, however, often do have trouble adjusting to the changes that have
occurred during their flights. In addition, some people commit illegal or violent acts in
their fugue state and later must face the consequences.

Dissociative Identity Disorder (Multiple Personality Disorder)
Dissociative identity disorder is both dramatic and disabling, as we see in the case of Eric:

Dazed and bruised from a beating, Eric, 29, was discovered wandering around a Day-
tona Beach shopping mall on Feb. 9. . . . Transferred six weeks later to Daytona Beach’s
Human Resources Center, Eric began talking to doctors in two voices: the infantile rhythms
of “young Eric,” a dim and frightened child, and the measured tones of “older Eric,”
who told a tale of terror and child abuse. According to “older Eric,” after his immigrant
German parents died, a harsh stepfather and his mistress took Eric from his native South

182 ://CHAPTER 6

°dissociative identity disorder-0A dis-
order in which a person develops two or
more distinct personalities. Also known
as multiple personality disorder.

osubpersonalitiesoThe two or more
distinct personalities found in individuals
suffering with dissociative identity
disorder. Also known as alternate
personalities.

Carolina to a drug dealers’ hideout in a Florida swamp. Eric said he was raped by several
gang members and watched his stepfather murder two men.

One day in late March an alarmed counselor watched Eric’s face twist into a violent
snarl. Eric let loose an unearthly growl and spat out a stream of obscenities. “It sounded
like something out of The Exorcist,” says Malcolm Graham, the psychologist who directs
the case at the center. “it was the most intense thing rye ever seen in a patient.” That
disclosure of a new personality, who insolently demanded to be called Mark, was the first
indication that Graham had been dealing with a rare and serious emotional disorder: true
multiple personality… .

Eric’s other manifestations emerged over the next weeks: quiet, middle-aged Dwight; the
hysterically blind and mute Jeffrey; Michael, an arrogant jock; the coquettish Tian, whom
Eric considered a whore; and argumentative Phillip, the lawyer. “Phillip was always asking
about Eric’s rights,” says Graham. “He was kind of obnoxious. Actually, Phillip was a pain.”

To Graham’s astonishment, Eric gradually unfurled 27 different personalities, including
three females. . . They ranged in age from a fetus to a sordid old man who kept trying to
persuade Eric to fight as a mercenary in Haiti. In one therapy session, reports Graham, Eric
shifted personality nine times in an hour. “I felt i was losing control of the sessions,” says
the psychologist, who has eleven years of clinical experience. “Some personalities would not
talk to me, and some of them were very insightful into my behavior as well as Eric’s.”

(Time, October 25, 1982, p. 70)

A person with dissociative identity disorder, or multiple personality disorder,
develops two or more distinct personalities, often called subpersonalities or alternate
personalities, each with a unique set of memories, behaviors, thoughts, and emotions
(see Table 6-5). At any given time, one of the subpersonalities takes center stage and
dominates the person’s functioning. Usually one subpersonality, called the primary, or host,
personality, appears more often than the others.

The transition from one subpersonality to another, called switching, is usually sud-
den and may be dramatic (APA, 2000). Eric, for example, twisted his face, growled,
and yelled obscenities while changing personalities. Switching is usually triggered by a
stressful event, although clinicians can also bring about the change with hypnotic sug-
gestion (APA, 2000).

Cases of dissociative identity disorder were first reported almost three centuries ago
(Bieber, 2002). Many clinicians consider the disorder to be rare, but some reports sug-
gest that it may be more common than was once thought (Sar et al., 2007; APA, 2000).
Most cases are first diagnosed in late adolescence or early adulthood, but, more often than
not, the symptoms actually began in early childhood after episodes of abuse (often sexual
abuse), perhaps even before the age of 5 (Maldonado Sc Spiegel, 2007; Roe-Sepowitz et
al., 2007).Women receive this diagnosis at least three times as often as men (APA, 2000).

How Do Subpersonalities nieraet? How subpersonalities relate to or recall one
another varies from case to case. Generally, however, there are three kinds of relationships.
In mutually amnesic relationships, the subpersonalities have no awareness of one another
(Ellenberger, 1970). Conversely, in mutually cognizant patterns, each subpersonality is well
aware of the rest. They may hear one another’s voices and even talk among themselves.
Some are on good terms, while others do not get along at all.

In one-way amnesic relationships, the most common relationship pattern, some subper-
sonalities are aware of others, but the awareness is not mutual (Huntjens et al., 2005).
Those who are aware, called co-conscious subpersonalities, are “quiet observers” who watch
the actions and thoughts of the other subpersonalities but do not interact with them.
Sometimes while another subpersonality is present, the co-conscious personality makes
itself known through indirect means, such as auditory hallucinations (perhaps a voice
giving commands) or “automatic writing” (the current personality may find itself writ-
ing down words over which it has no control).

Profit Distributions

Somatoform and Dissociative. Disorders 1 83

Investigators used to believe that most cases of dissociative identity disorder involved
two or three subpersonalities. Studies now suggest, however, that the average number of
subpersonalities per patient is much higher-15 for women and 8 for men (APA, 2000).
In fact, there have been cases in which 100 or more subpersonalities were observed.
Often the subpersonalities emerge in groups of two or three at a time.

In the case of “Eve White,” made famous in the book and movie The Three Faces of
Eve, a woman had three subpersonalities—Eve White, Eve Black, and Jane (Thigpen &
Cleckley, 1957). Eve White, the primary personality, was quiet and serious; Eve Black
was carefree and mischievous; and Jane was mature and intelligent. According to the
book, these three subpersonalities eventually merged into Evelyn, a stable personality
who was really an integration of the other three.

The book was mistaken, however; this was not to be the end of Eve’s dissociation.
In an autobiography 20 years later, she revealed that altogether 22 subpersonalities had
come forth during her life, including 9 subpersonalities after Evelyn. Usually they ap-
peared in groups of three, and so the authors of The Three Faces of Eve apparently never
knew about her previous or subsequent subpersonalities. She has now overcome her
disorder, achieving a single, stable identity, and has been known as Chris Sizemore for
over 30 years (Sizemore, 1991).

How Do Subpersonalities Differ? As in Chris Sizemore’s case, subpersonalities
often exhibit dramatically different characteristics.They may also have their own names
and different identifying features, abilities and preferences, and even physiological responses.

IDENTIFYING FEATURES The subpersonalities may differ in features as basic as age, gender,
race, and family history, as in the famous case of Sybil Dorsett. Sybil’s dissociative identity
disorder has been described in fictional form (in the novel Sybil) but is based on the real
case of a patient named Shirley Ardell Mason, from the practice of psychiatrist Cornelia
Wilbur (Schreiber, 1973). Sybil displayed 17 subpersonalities, all with different identify-
ing features. They included adults, a teenager, and a baby named Ruthie; two were male,
named Mike and Sid. Sybil’s subpersonalities each had particular images of themselves
and of each other.The subpersonality named Vicky, for example, saw herself as an attrac-
tive blonde, while another, Peggy Lou, was described as a pixie with a pug nose. Mary
was plump with dark hair, and Vanessa was a tall redhead with a willowy figure.

ABILITIES AND PREFERENCES Although memories of abstract or encyclopedic information
are not usually affected in dissociative amnesia or fugue, they are often disturbed in dis-
sociative identity disorder. It is not uncommon for the different subpersonalities to have
different abilities: One may be able to drive, speak a foreign language, or play a musical
instrument, while the others cannot (Coons & Bowman, 2001; Coons et al., 1988).
Their handwriting can also differ. In addition, the subpersonalities usually have different
tastes in food, friends, music, and literature. Chris Sizemore (“Eve”) later pointed out,
“If I had learned to sew as one personality and then tried to sew as another, I couldn’t
do it. Driving a car was the same. Some of my personalities couldn’t drive” (Sizemore
& Pitillo, 1977, p. 4).

PHYSIOLOGICAL RESPONSES Researchers have discovered that subpersonalities may have
physiological differences, such as differences in autonomic nervous system activity, blood
pressure levels, and allergies (Putnam, Zahn, & Post, 1990). One study looked at the
brain activities of different subpersonalities by measuring their evoked potentials—that
is, brain-response patterns recorded on an electroencephalograph (Putnam, 1984). The
brain pattern a person produces in response to a specific stimulus (such as a flashing
light) is usually unique and consistent. However, when an evoked potential test was
administered to four subpersonalities of each of 10 people with dissociative identity
disorder, the results were dramatic. The brain-activity pattern of each subpersonality was
unique, showing the kinds of variations usually found in totally different people.

How Common Is Dissociative Identity Disorder? As you have seen, dissocia-
tive identity disorder has traditionally been thought ofas rare. Some researchers even argue

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Cultural Ties

that many or all cases are iatrogenic— that is, unintentionally produced by
practitioners (Loewenstein, 2007; Piper & Merskey, 2005, 2004). They
believe that therapists create this disorder by subtly suggesting the exis-
tence of other personalities during therapy or by explicitly asking a pa-
tient to produce different personalities while under hypnosis. In addition,
they believe, a therapist who is looking for multiple personalities may
reinforce these patterns by displaying greater interest when a patient dis-
plays symptoms of dissociation.

These arguments seem to be supported by the fact that many cases
of dissociative identity disorder first come to attention while the person
is already in treatment for a less serious problem. But such is not true
of all cases; many people seek treatment because they have noticed
time lapses throughout their lives or because relatives and friends have
observed their subpersonalities (Putnam, 2000, 1988, 1985).

The number of people diagnosed with dissociative identity disorder
has been increasing (Sar et al., 2007; Casey, 2001).Although the disorder

is still uncommon, thousands of cases have now been diagnosed in the United States
and Canada alone. Two factors may account for this increase. First, a growing number
of today’s clinicians believe that the disorder does exist and are willing to diagnose it
(Merenda, 2008; Lalonde et al., 2002, 2001). Second, diagnostic procedures tend to be
more accurate today than in past years. For much of the twentieth century, schizophrenia
was one of the clinical field’s most commonly applied diagnoses. It was applied, often
incorrectly, to a wide range of unusual behavioral patterns, perhaps including dissociative
identity disorder (Turkington & Harris, 2009, 2001). Under the stricter criteria of recent
editions of the DSM, clinicians are now more accurate in diagnosing schizophrenia,
allowing more cases of dissociative identity disorder to be recognized (Welborn et al.,
2003). In addition, several diagnostic tests have been developed to help detect dissocia-
tive identity disorder (Cardena, 2008). Despite such changes, however, many clinicians
continue to question the legitimacy of this category (Lalonde et al., 2002, 2001).

How Do Theorists Explain Dissociative Disorders?
A variety of theories have been proposed to explain dissociative disorders. Older
explanations, such as those offered by psychodynamic and behavioral theorists, have
not received much investigation (Merenda, 2008). However, newer viewpoints, which
combine cognitive, behavioral, and biological principles and highlight such factors as
state- dependent learning and self- hypnosis, have captured the interest of clinical scientists.

The Psychodynamic View Psychodynamic theorists believe that dissociative
disorders are caused by repression, the most basic ego defense mechanism: People fight
off anxiety by unconsciously preventing painful memories, thoughts, or impulses from
reaching awareness. Everyone uses repression to a degree, but people with dissociative
disorders are thought to repress their memories excessively (Fayek, 2002).

In the psychodynamic view, dissociative amnesia and fugue are single episodes of mas-
sive repression. In each of these disorders, a person unconsciously blocks the memory of
an extremely upsetting event to avoid the pain of facing it (Turkington & Harris, 2009,
2001). Repressing may be their only protection from overwhelming anxiety.

In contrast, dissociative identity disorder is thought to result from a lifetime of ex-
cessive repression (Brenner, 2009, 1999; Wang & Jiang, 2007). Psychodynamic theorists
believe that continuous use of repression is motivated by traumatic childhood events,
particularly abusive parenting. Children who experience such traumas may come to fear
the dangerous world they live in and take flight from it by pretending to be another
person who is looking on safely from afar. Abused children may also come to fear the
impulses that they believe are the reasons for their excessive punishments. Whenever
they experience “bad” thoughts or impulses, they unconsciously try to disown and deny
them by assigning them to other personalities.

Peculiarities of Memory

sually memory problems must interfere
greatly with a person’s functioning

before they are considered a sign of a
disorder. Peculiarities of memory, on the
other hand, fill our daily lives. Memory
investigators have identified a number
of these peculiarities—some familiar,
some useful, some problematic, but none
abnormal {Turkington & Harris, 2009,
2001; Mathews & Wang, 2007; Brown,
2004, 2003).

Absentmindedness Often we fail
to register information because our
thoughts are focusing on other things.
If we haven’t absorbed the information
in the first place, it is no surprise that
later we can’t recall it.

Déjà vu Almost all of us have at
some time had the strange sensation
of recognizing a scene that we hap-
pen upon for the first time. We feel
sure we have been there before.

Jamais vu Sometimes we have the
opposite experience: A situation or
scene that is part of our daily life
seems suddenly unfamiliar. “I knew it
was my car, but I felt as if I’d never
seen it before.”

The tip-of-the-tongue phenom-
enon To have something on the tip
of the tongue is an acute “feeling of
knowing”: We are unable to recall

20
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kinds of information: They easily can
bring to their mind the appearance of
places, objects, faces, or the pages
of a book. They almost never forget
a face, yet they may well forget the
name attached to it. Other people
have stronger verbal memories: They
remember sounds or words particularly
well, and the memories that come to
their minds are often puns or rhymes.

some piece of informa-
tion, but we know that we
know it.

Eidetic images Some
people experience visual af-
terimages so vividly that they
can describe a picture in
detail after looking at it just
once. The images may be
memories of pictures, events,
fantasies, or dreams.

Memory while under
anesthesia As many as 2 of
every 1,000 anesthetized pa-
tients process enough of what
is said in their presence during
surgery to affect their recovery.
In many such cases, the ability
to understand language has
continued under anesthesia,
even though the patient cannot
explicitly recall it.

Memory for music Even as
a small child, Mozart could memorize
and reproduce a piece of music after
having heard it only once. While no
one yet has matched the genius of
Mozart, many musicians can mentally
hear whole pieces of music, so that
they can rehearse anywhere, far from
their instruments.

Visual memory Most people recall
visual information better than other

“Did you ever start to do something and then
forget what the heck it was?”

Somotoform and Dissociative Disorders 185

Most of the support for the psychodynamic position is drawn from case histories,
which report such brutal childhood experiences as beatings, cuttings, burnings with
cigarettes, imprisonment in closets, rape, and extensive verbal abuse.Yet some individu-
als with dissociative identity disorder do not seem to have experiences of abuse in their
background (Bliss, 1980). Moreover, child abuse appears to be far more common than
dissociative identity disorder. Why might only a small fraction of abused children de-
velop this disorder?

The Behavioral View Behaviorists believe that dissociation is a response learned
through operant conditioning (Casey, 2001). People who experience a horrifying event
may later find temporary relief when their minds drift to other subjects. For some, this
momentary forgetting, leading to a drop in anxiety, increases the likelihood of future
forgetting. In short, they are reinforced for the act of forgetting and learn—without
being aware that they are learning—that such acts help them escape anxiety. Thus, like
psychodynamic theorists, behaviorists see dissociation as escape behavior. But behavior-
ists believe that a reinforcement process rather than a hardworking unconscious is keep-
ing the individuals unaware that they are using dissociation as a means of escape. Like

186 .110-1APTER 6

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State during Recall Testing

0state-dependent learningoLearning
that becomes associated with the condi-
tions under which it occurred, so that
it is best remembered under the some
conditions.

oseif-hypnosiseThe process of hypnotiz-
ing oneself, sometimes for the purpose of
forgetting unpleasant events.

hypnotic therapy®A treatment in
which the patient undergoes hypnosis
and is then guided to recall forgotten
events or perform other therapeutic activ-
ities. Also known as hypnotherapy.

psychodynarnic theorists, behaviorists have relied largely on case histories to support
their view of dissociative disorders. Moreover, the behavioral explanation fails to explain
precisely how temporary and normal escapes from painful memories grow into a com-
plex disorder or why more people do not develop dissociative disorders.

State-Dependent Learning If people learn something when
they are in a particular situation or state of mind, they are likely to
remember it best when they are again in that same condition. If they
are given a learning task while under the influence of alcohol, for
example, their later recall of the information may be strongest under
the influence of alcohol (Overton, 1966). Similarly, if they smoke
cigarettes while learning, they may later have better recall when they
are again smoking.

This link between state and recall is called state -dependent
learning. It was initially observed in experimental animals who
learned things while under the influence of certain drugs (Rezayof
et al., 2008; Overton, 1966, 1964). Research with human partici-
pants later showed that state-dependent learning can be associated
with mood states as well: Material learned during a happy mood
is recalled best when the participant is again happy, and sad-state
learning is recalled best during sad states (de l’Etoile, 2002; Bower,
1981) (see Figure 6-3).

What causes state-dependent learning? One possibility is that
arousal levels are an important part of learning and memory.That is, a particular level of
arousal will have a set of remembered events, thoughts, and skills attached to it. When
a situation produces that particular level of arousal, the person is more likely to recall
the memories linked to it.

Although people may remember certain events better in some arousal states than
in others, most can recall events under a variety of states. However, perhaps people
who are prone to develop dissociative disorders have state-to-memory links that are
unusually rigid and narrow. Maybe each of their thoughts, memories, and skills is tied
exclusively to a particular state of arousal, so that they recall a given event only when
they experience an arousal state almost identical to the state in which the memory was
first acquired.When such people are calm, for example, they may forget what occurred
during stressful times, thus laying the groundwork for dissociative amnesia or fugue.
Similarly, in dissociative identity disorder, different arousal levels may produce entirely
different groups of memories, thoughts, and abilities—that is, different subpersonalities
(Dorahy & Huntjens, 2007; Putnam, 1992). This could explain why personality transi-
tions in dissociative identity disorder tend to be sudden and stress-related.

Self-Hypnosis As you first saw in Chapter 1, people who are hypnotized enter a sleep-
like state in which they become very suggestible.While in this state, they can behave, per-
ceive, and think in ways that would ordinarily seem impossible. They may, for example,
become temporarily blind, deaf, or insensitive to pain. Hypnosis can also help people
remember events that occurred and were forgotten years ago, a capability used by many
psychotherapists. Conversely, it can make people forget facts, events, and even their per-
sonal identities—an effect called hypnotic amnesia.

The parallels between hypnotic amnesia and dissociative disorders are striking. Both
are conditions in which people forget certain material for a period of time yet later
remember it. And in both, the people forget without any insight into why they are
forgetting or any awareness that something is being forgotten. These parallels have led
some theorists to conclude that dissociative disorders may be a form of self-hypnosis in
which people hypnotize themselves to forget unpleasant events (Maldonado & Spiegel,
2007, 2003). Dissociative amnesia may occur, for example, in people who, consciously
or unconsciously, hypnotize themselves into forgetting horrifying experiences that have
recently occurred in their lives. If the self-induced amnesia covers all memories of a
person’s past and identity, that person may undergo a dissociative fugue.

Participants who learned words in a sad mood

Participants who learned words in a happy mood

Happy

SAyob it ior and thechtl

Somatoform and Dissociative Disorders :11 1 87

Self-hypnosis might also be used to explain dissociative identity disorder. On the
basis of several investigations, some theorists believe that this disorder often begins
between the ages of 4 and 6, a time when children are generally very suggestible and
excellent hypnotic subjects (Kluft, 2001, 1987; Bliss, 1985, 1980).These theorists argue
that some children who experience abuse or other horrifying events manage to escape
their threatening world by self-hypnosis, mentally separating themselves from their bod-
ies and fulfilling their wish to become some other person or persons. One patient with
multiple personalities observed, “I was in a trance often [during my childhood]. There
was a little place where I could sit, close my eyes and imagine, until I felt very relaxed
just like hypnosis” (Bliss, 1980, p. 1392).

How Are Dissociative Disorders Treated?
As you have seen, people with dissociative amnesia and fugue often recover on their
own. Only sometimes do their memory problems linger and require treatment. In con-
trast, people with dissociative identity disorder usually require treatment to regain their
lost memories and develop an integrated personality.Treatments for dissociative amnesia
and fugue tend to be more successful than those for dissociative identity disorder, prob-
ably because the former disorders are less complex.

How Do Ther pists Help People with Dissociative Amnesia and
Fugue? The leading treatments for dissociative amnesia and fugue are psychodynamic
therapy, hypnotic therapy, and drug therapy, although support for these interventions comes
largely from. case studies rather than controlled investigations (Maldonado & Spiegel,
2003). Psychodynamic therapists guide patients with these disorders to search their
unconscious in the hope of bringing forgotten experiences back to consciousness
(Bartholomew, 2000; Loewenstein, 1991). The focus of psychodynamic therapy seems
particularly well suited to the needs of people with these disorders. After all, the patients
need to recover lost memories, and the general approach of psychodynamic therapists is
to try to uncover memories—as well as other psychological processes—that have been
repressed.Thus many theorists, including some who do not ordinarily favor psychody-
namic approaches, believe that psychodynamic therapy may be the most appropriate
treatment for these disorders.

Another common treatment for dissociative amnesia and fugue is hypnotic therapy,
or hypnotherapy (see Table 6-6 on the next page). Therapists hypnotize patients and
then guide them to recall forgotten events (Degun-Mather, 2002). Given the possibility
that dissociative amnesia and fugue may each be a form of self-hypnosis, hypnotherapy

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People remember more accurately under hypnosis. Hypnosis can help create false memories.

Hypnotized people can be led to do immoral acts. Hypnotized subjects fully adhere to their usual values.

1

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Some Myths about Hypnosis

Myth

Reality

Hypnosis relies on having a good imagination. Vivid imaginations are unrelated to hypnotizability.

Hypnosis is dangerous. Hypnosis is no more distressing than a lecture.

It has something to do with a sleeplike state. Hypnotized subjects are fully awake.

1 88 :// CHAPTER 6

may be a particularly useful intervention. It has been applied both alone and in com-
bination with other approaches.

Sometimes intravenous injections of barbiturates such as sodium amobarbital (Amytal)
or sodium pentobarbital (Pentothal) are used to help patients with dissociative amnesia and
fugue regain lost memories. These drugs are often called “truth serums,” but the key to
their success is their ability to calm people and free their inhibitions, thus helping them
to recall anxiety-producing events (Fraser, 1993; Kluft, 1988).These drugs do not always
work, however, and if used at all, they are likely to be combined with other treatment
approaches (Spiegel, 1994).

How Do Therapists Help Individuals with Dissociative Identity Disorder?
Unlike victims of amnesia and fugue, people with dissociative identity disorder do not
typically recover without treatment (Maldonado & Spiegel, 2003; Spiegel, 1994).Treat-
ment for this pattern is complex and difficult, much like the disorder itself. Therapists
usually try to help the clients (1) recognize fully the nature of their disorder, (2) recover
the gaps in their memory, and (3) integrate their subpersonalities into one functional
personality (North &Yutzy, 2005; Kihlstrom, 2001).

RECOGNIZING THE DISORDER Once a diagnosis of dissociative identity disorder is made,
therapists typically try to bond with the primary personality and with each of the sub-
personalities (Kluft, 1999, 1992).As bonds are formed, therapists try to educate patients
and help them to recognize fully the nature of their disorder (Krakauer, 2001; Allen,
1993). Some therapists actually introduce the subpersonalities to one another under

hypnosis, and some have patients look at video-
tapes of their other personalities (Ross & Gahan,
1988; Sakheim et al., 1988). Many therapists have
also found that group therapy helps to educate pa-
tients (Fine & Madden, 2000). In addition, family
therapy may be used to help educate spouses and
children about the disorder and to gather helpful
information about the patient (Kluft, 2001, 2000).

RECOVERING MEMORIES To help patients recover the
missing pieces of their past, therapists use many of
the approaches applied in other dissociative disor-
ders, including psychodynamic therapy, hypnother-
apy, and drug treatment (Kluft, 2001, 1991, 1985).
These techniques work slowly for patients with
dissociative identity disorder, as some subpersonali-
ties may keep denying experiences that the others
recall (Lyon, 1992). One of the subpersonalities

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Dissociative Disorders

People with dissociative disorders experience major changes in memory and iden-
tity that are not caused by clear physical factors. People with dissociative amnesia
are suddenly unable to recall important personal information or post events in their
lives. Those with dissociative fugue not only fail to remember their personal identities
but also flee to a different location and may establish a new identity. In dissociative
identity disorder (multiple personality disorder), people display two or more distinct
subpersonalities. The number of people diagnosed with dissociative identity disor-
der has increased in recent years.

The dissociative disorders are not well understood. Among the processes that
have been cited to explain them are extreme repression, operant conditioning, state-
dependent learning, and self-hypnosis. The latter two phenomena, in particular,
have excited the interest of clinical scientists.

Dissociative amnesia and fugue may end on their own or may require treat-
ment. Dissociative identity disorder typically requires treatment. Approaches com-
monly used to help people with dissociative amnesia and fugue recover their lost
memories are psychodynamic therapy, hypnotic therapy, and sodium amoborbital
or sodium pentobarbital. Therapists who treat people with dissociative identity disor-
der use the same approaches but further focus on trying to help the clients recognize
the scope of their disorder, recover the gaps in their memory, and integrate their
subpersonalities into one functional personality.

Sornotoform and Dissociative Disorders :1/ 1 89

may even assume a “protector” role to prevent the primary personality from suffering
the pain of recollecting traumatic experiences.

INTEGRATING THE SUBPERSONALITIES The final goal of therapy is to merge the different
subpersonalities into a single, integrated identity. Integration is a continuous process
that occurs throughout treatment until patients “own” all of their behaviors, emotions,
sensations, and knowledge. Fusion is the final merging of two or more subpersonali-
ties. Many patients distrust this final treatment goal, and their subpersonalities may see
integration as a form of death (Kluft, 2001, 1999, 1991).Therapists have used a range of
approaches to help merge subpersonalities, including psychodynamic, supportive, cogni-
tive, and drug therapies (Goldman, 1995; Fichtner et al., 1990).

Once the subpersonalities are integrated, further therapy is typically needed to main-
tain the complete personality and to teach social and coping skills that may help prevent
later dissociations. In case reports, some therapists note high success rates (Rothschild,
2009; Coons & Bowman, 2001), but others find that patients continue to resist full in-
tegration. A few therapists have in fact questioned the need for full integration.

PUTTING IT… together
Disorders Rediscovered
Somatoform and dissociative disorders are among the clinical field’s earliest identified
psychological disorders. Indeed, as you read in Chapter 1, they were key to the develop-
ment of the psychogenic perspective. Despite this early impact, the clinical field stopped
paying much attention to these disorders during the middle part of the twentieth cen-
tury. The feeling among many clinical theorists was that the number of such cases was
shrinking. And more than a few questioned the legitimacy of the diagnoses.

Much of that thinking has changed in the past two decades.The field’s keen interest
in the impact of stress upon health and physical illness has, by association, reawakened
interest in sornatoform disorders. Similarly, as you will see in Chapter 15, the field has

efusionoThe final merging of two or
more subpersonalities in multiple person-
ality disorder.

THOUPTHTS///
1. Why do the terms “hysteria” and

“hysterical” currently have such nega-
tive connotations in our society, as in
“mass hysteria” and “hysterical per-
sonality”? pp. 164- 169

2. If parents who harm their chil-
dren are clearly disturbed, as in
cases of Munchausen syndrome
by proxy, how should society
react to them? Which is more

190 ://CHAPTER 6

1:1=1,1 r

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os to l?iilii;c^s

greatly intensified its efforts to understand and treat Alzheimer’s disease in recent years,
and that work has sparked a broad interest in the operation of -memory, including an
interest in dissociative disorders.

Over the past 25 years there has been an explosion of research seeking to help cli-
nicians recognize, understand, and treat unexplained physical and memory disorders.
Although this research has yet to produce clear insights or highly effective treatments, it
has already suggested that the disorders may be more common than clinical theorists had
come to believe. Moreover, there isgrowing evidence that the disorders may be rooted
in processes that are already well known from other areas of study, such as overattentive-
ness to bodily processes, cognitive misinterpretations, state-dependent learning, and self-
hypnosis. Given this new wave of research enthusiasm, we may witness significant growth
in our understanding and treatment of these disorders in the coming years.

At the same time, many of today’s clinicians worry that the focus on somatoform and
dissociative disorders is swinging back too far—that the high degree of interest in them
may be creating a false impression of their prevalence or importance (Pope et al., 2007;
Piper & Merskey, 2004). Some clinicians note, for example, that physicians are often quick
to assign the label “somatoform” to elusive medical problems such as chronic fatigue
syndrome and lupus—clearly a disservice to patients with such severe problems and to
the progress of medical science. Similarly, a number of clinicians worry that at least some
of the many legal defenses based on dissociative identity disorder or other dissociative
disorders are contrived or inaccurate. Of course, such possibilities serve to highlight even
further the importance of continued investigations into all aspects of the disorders.

appropriate — treatment or punish- and fugue are listed in DSM-IV-TR,
ment? p. 168

many people greet such explanations

3. How might a culture help create
with skepticism. Why? pp. 176- 181

cases of body dysmorphic disorder?

5 Some accused criminals claim that
pp. 169- 173

they have dissociative identity dis-

4. Periodically we hear in the news
about missing individuals who show
up suddenly, claiming to have lost
their memories while away. Although
disorders such as dissociative amnesia

what would be an appropriate
verdict? pp. 181-187

order and that their crimes were
committed by one of their subperson-
alities. If such claims are accurate,

• • .00. • ,?•.,.••••

:\\■ KEY TEPIS/w:
off-: s matoform disorder, p. 164

1:1 hysterical somatoform disorders, p. 164
conversion disorder, p. 164

somatization disorder, p. 166

pain disorder associated with
psychological factors, p. 167

.4, malingering, p. 167

factitious disorder, p. 167

Munchausen syndrome, p. 168

Munchausen syndrome by proxy, p. 169

74777
•••••173,,,,

preoccupation somatoform disorders,
p. 169

hypochondriasis, p. 169

body dysmorphic disorder, p. 169

Electra complex, p. 171

primary gain, p. 172

secondary gain, p. 172

placebo, p. 173

memory, p. 176

dissociative disorders, p. 176

dissociative amnesia, p. 178
%tett ,.

amnestic episode, p. 179

dissociative fugue, p. 180

dissociative identity disorder, p. 182

subpersonalities, p. 182

iatrogenic disorder, p. 184

repression, p. 184

state -dependent learning, p. 186

self-hypnosis, p. 186

hypnotic therapy, p. 187

fusion, p. 189

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ememoryoThe faculty for recalling past
events and past learning.
*dissociative disordersoDisorders
marked by major changes in memory
that do not have clear physical causes.
Somatoform Disorders
Patients with somatoform disorders have physical complaints whose causes are
largely psychosocial. Nevertheless, the individuals genuinely believe that their ill-
nesses are medical in origin.
Hysterical somatoform disorders involve an actual loss or change of physical
functioning. They include conversion disorder, somatization disorder (or Briquet’s
syndrome), and pain disorder associated with psychological factors. Freud devel-
oped the initial psychodynamic view of hysterical somatoform disorders, proposing
that the disorders represent a conversion of underlying emotional conflicts into physi-
cal symptoms. According to behaviorists, the physical symptoms of these disorders
bring rewards to the sufferer, Some cognitive theorists propose that the disorders are
forms of communication. Biological factors may also help explain these disorders, as
we ore reminded by recent studies of placebos. Treatments for hysterical disorders
emphasize either insight, suggestion, reinforcement, or confrontation.
People with preoccupation somatoform disorders are preoccupied with the
notion that something is wrong with them physically. In this category are hypocho-
driasis and body dysmorphic disorder. Theorists explain preoccupation somatoform
disorders much as they do anxiety disorders. Treatment for the disorders includes
medications, exposure and response prevention, and other treatments originally
developed for anxiety disorders, particularly obsessive-compulsive disorder.
Dissociative Disorders
Most of us experience a sense of wholeness and continuity as we interact with the world.
We perceive ourselves as being more than a collection of isolated sensory experiences,
feelings, and behaviors. In other words, we have an identity, a sense of who we are and
where we fit in our environment. Others recognize us and expect certain things of us.
But more important, we recognize ourselves and have our own expectations, values,
and goals.
Memory is a key to this sense of identity, the link between our past, present, and fu-
ture. Our recall of past experiences, although not always precisely accurate, helps us react
to present events and guides us in making decisions about the future.We recognize our
friends and relatives, teachers and employers, and respond to them in appropriate ways.
Without a memory, we would always be starting over; with it, life moves forward.
People sometimes experience a major disruption of their memory. They may, for
example, lose their ability to remember new information they just learned or old in-
formation they once knew well. When such changes in memory lack a clear physical
cause, they are called dissociative disorders. In such disorders, one part of the person’s
memory typically seems to be dissociated, or separated, from the rest.
There are several kinds of dissociative disorders.The primary symptom of dissociative
amnesia is an inability to recall important personal events and information. A person
with dissociative fiegue not only forgets the past but also travels to a new location and may
assume a new identity. Individuals with dissociative identity disorder; also known as multiple
personality disorder, have two or more separate identities that may not always be aware of
each other’s thoughts, feelings, and behavior.
Several memorable books and movies have portrayed dissociative disorders.Two of
the best known are The Three Faces of Eve and Sybil, each about a woman with mul-
tiple personalities. The topic is so fascinating that most television drama series seem to
include at least one case of dissociation every season, creating the impression that the
disorders are very common (Pope et al., 2007). Many clinicians, however, believe that
they are rare.

Somatoforrn and Dissociative Disorders :1/ 1 77
DSM-IV-TR also lists depersonalization disorder as a disso-
ciative disorder. People with this problem feel as though they
have become detached from their own mental processes or
body and are observing themselves from the outside. Because
memory problems are not a central feature of this disorder, it
will not be discussed here.
As you read through the remainder of this chapter, keep
in mind that dissociative symptoms are often found in cases
of acute or posttraumatic stress disorder. Recall from Chap-
ter 5 that sufferers of those disorders may feel dazed or have
trouble remembering things. When such symptoms occur
as part of a stress disorder, they do not necessarily indicate
a dissociative disorder, in which the dissociative symptoms
dominate. On the other hand, research suggests that a num-
ber of people with one of these disorders also develop the
other as well (Bremner, 2002).
Dissociative Amnesia
At the beginning of this chapter you met the unfortunate man named Brian. As you
will recall, Brian developed a conversion disorder after a traumatic boating accident in
which his wife was killed. To help examine dissociative amnesia, let us now revisit that
case, changing the reactions and symptoms that Brian develops in the aftermath of the
traumatic event.
Brian was spending Saturday sailing with his wife, Helen. The water was rough but well
within what they considered safe limits. They were having a wonderful time and really
didn’t notice that the sky was getting darker, the wind blowing harder, and the sailboat
becoming more difficult to control. After a few hours of sailing, they found themselves far
from shore in the middle of a powerful and dangerous storm.
The storm intensified very quickly. Brian had trouble controlling the sailboat amidst
the high winds and wild waves. He and Helen tried to put on the safety jackets they had
neglected to wear earlier, but the boat turned over before they were finished. Brian, the
better swimmer of the two, was able to swim back to the overturned sailboat, grab the
side, and hold on for dear life, but Helen simply could not overcome the rough waves and
reach the boat. As Brian watched in horror and disbelief, his wife disappeared from view.
After a time, the storm began to lose its strength. Brian managed to right the sailboat
and sail back to shore. Finally he reached safety, but the personal consequences of this
storm were just beginning. The next days were filled with pain and further horror: the
Coast Guard finding Helen’s body … discussions with authorities . . . breaking the news
to Helen’s parents . conversations with friends . . . self-blame . . . grief . . . and more.
On Wednesday, four days after that fateful afternoon, Brian collected himself and at-
tended Helen’s funeral and burial. It was the longest and most difficult day of his life.
Most of the time, he felt as though he were in a trance.
Soon after awakening on Thursday morning, Brian realized that something was terribly
wrong with him. Try though he might, he couldn’t remember the events of the past few
days. He remembered the occident, Helen’s death, and the call from the Coast Guard
after they had found her body. But just about everything else was gone, right up through
the funeral. At first he had even thought that it was now Sunday, and that his discussions
with family and friends and the funeral were all ahead of him. But the newspaper, the
funeral guestbook, and a phone conversation with his brother soon convinced him that he
had lost the post four days of his life.
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Repressed Childhood Memories or False Memory Syndrome?
hroughout the 1990s, reports of re-
_ pressed childhood memory of abuse
attracted much public attention. Adults with
this type of dissociative amnesia seemed
to recover buried memories of sexual and
physical abuse from their childhood. A
woman might claim, for example, that her
father hod sexually molested her repeat.
edly between the ages of 5 and 7. Or a
young man might remember that a family
friend had made sexual advances on sev-
eral occasions when he was very young.
Often the repressed memories surfaced
during therapy for another problem.
Although the number of such claims has
declined in recent years, experts remain
split on this issue (Loftus & Cahill, 2007;
McNally et al., 2005). Some believe that
recovered memories are just what they ap-
pear to be—horrible memories of abuse
that have been buried for years in the
person’s mind. Other experts believe that
the memories are actually illusions—false
images created by a mind that is confused.
Opponents of the repressed memory
concept hold that the details of childhood
sexual abuse are often remembered all too
well, not completely wiped from memory
(Loftus & Cahill, 2007; McNally et al.,
2004). They also point out that memory
in general is often flawed (Lindsay et al.,
2004). Moreover, false memories of vari-
ous kinds can be created in the laboratory
by tapping into research participants’
imaginations (Brainerd, Reyna, & Ceci,
2008; Loftus & Cahill, 2007).
If the alleged recovery of childhood
memories is not what it appears to be,
what is it? According to opponents of the
concept, it may be a powerful case of sug-
gestibility (Loftus & Cahill, 2007; Loftus,
2003, 2001, 1997). These theorists hold
that the attention paid to the phenomenon
by both clinicians and the public has led
some therapists to make the diagnosis
without sufficient evidence (Frankel, 1993).
The therapists may actively search for signs
of early abuse in clients and even encour-
age clients to produce repressed memories
(Gardner, 2004). Certain therapists in fact
use special memory recovery techniques,
including hypnosis, regression therapy,
journal writing, dream interpretation, and
interpretation of bodily symptoms (Madill
& Holch, 2004; Lindsay, 1996, 1994).
Perhaps some clients respond to the tech-
niques by unknowingly forming false mem-
ories of abuse (Hyman & Loftus, 2002).
The apparent memories may then become
increasingly familiar to them as a result of
repeated therapy discussions of the alleged
incidents.
Of course, repressed memories of child-
hood sexual abuse do not emerge only in
clinical settings (Loftus & Cahill, 2007).
Many individuals come forward on their
own. Opponents of the repressed memory
concept explain these cases by pointing
to various books, articles, websites, and
television shows that seem to validate
repressed memories of childhood abuse
(Loftus, 1993). Still other opponents of the
repressed memory concept believe that, for
biological or other reasons, some individu-
als are more prone than others to experi-
ence false memories—either of childhood
abuse or of other kinds of events (McNally
et al., 2005).
It is important to recognize that the
experts who question the recovery of
repressed childhood memories do not in
any way deny the problem of child sexual
abuse. In fact, proponents and opponents
alike are greatly concerned that the public
may take this debate to mean that clini-
cians have doubts about the scope of the
problem of child sexual abuse. Whatever
may be the final outcome of the repressed
memory debate, the problem of childhood
sexual abuse is all too real and all too
common.
178 ://CHAPTER 6
*dissociative amnesia®A disorder
marked by an inability to recall important
personal events and information.
In this revised scenario, Brian is reacting to his traumatic experience with symptoms
of dissociative amnesia. People with this disorder are unable to recall important
information, usually of an upsetting nature, about their lives (APA, 2000). The loss of
memory is much more extensive than normal forgetting and is not caused by physical
factors (see Table 6-4). Often an episode of amnesia is directly triggered by a specific
upsetting event (McLeod et al., 2004).
Dissociative amnesia may be localized, selective, generalized, or continuous. Any of these
kinds of amnesia can be triggered by a traumatic experience such as Brian’s, but each
represents a particular pattern of forgetting. Brian was suffering from localized amnesia,

the most common type of dissociative amnesia, in which a person loses all memory of
events that took place within a limited period of time, almost always beginning with
some very disturbing occurrence. Recall that Brian awakened on the day after the
funeral and could not recall any of the events of the past difficult days, beginning after
the boating tragedy. He remembered everything that happened up to and including the
accident. He could also recall everything from the morning after the funeral onward, but
the days in between remained a total blank. The forgotten period is called the amnestic
episode. During an amnestic episode, people may appear confused; in some cases they
wander about aimlessly. They are already experiencing memory difficulties but seem
unaware of them. In the revised case, for example, Brian felt as though he were in a
trance on the day of Helen’s funeral.
People with selective amnesia, the second most common form of dissociative amnesia,
remember some, but not all, events that occurred during a period of time. If Brian had
selective amnesia, he might remember certain conversations with friends but perhaps
not the funeral itself.
In some cases the loss of memory extends back to times long before the upsetting pe-
riod. Brian might awaken after the funeral and find that, in addition to forgetting events
of the past few days, he could not remember events that occurred earlier in his life. In
this case, he would be experiencing generalized amnesia. In extreme cases, Brian might not
even remember who he was and might fail to recognize relatives and friends.
In the forms of dissociative amnesia discussed so far, the period affected by the amne-
sia has an end. In continuous amnesia, however, forgetting continues into the present. Brian
might forget new and ongoing experiences as well as what happened before and during
the tragedy. Continuous forgetting of this kind is actually quite rare in cases of dissociative
amnesia but not, as you will see in Chapter 15, in cases of organic amnesia.
All of these forms of dissociative amnesia are similar in that the amnesia interferes
mostly with a person’s memory of personal material. Memory for abstract or ency-
clopedic information usually remains. People with dissociative amnesia are as likely as
anyone else to know the name of the president of the United States and how to write,
read, or drive a car.
Clinicians do not know how common dissociative amnesia is (Pope et al., 2007), but
they do know that many cases seem to begin during serious threats to health and safety,
as in wartime and natural disasters (Cardena & Gleaves, 2007). Combat veterans often
report memory gaps of hours or days, and some forget personal information, such as
Somatoform and Dissociative Disorders :1/ 1 79
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180 ://CHAPTER 6
their names and addresses (Bremner, 2002). It appears that childhood abuse, particularly
child sexual abuse, can also sometimes trigger dissociative amnesia; indeed, the 1990s
witnessed many reports in which adults claimed to recall long-forgotten experiences
of childhood abuse. In addition, dissociative amnesia may occur tinder more ordinary
circumstances, such as the sudden loss of a loved one through rejection or death or guilt
over certain actions (for example, an extramarital affair) (Koh et al., 2000).
The personal impact of dissociative amnesia depends on
how much is forgotten. Obviously, an amnestic episode of two
years is more of a problem than one of two hours. Similarly, an
amnestic episode during which a person’s life changes in major
ways causes more difficulties than one that is quiet.
Dissociative Fugue
People with a dissociative fugue not only forget their per-
sonal identities and details of their past lives but also flee to an
entirely different location (see again Table 6-4). Some individu-
als travel a short distance and make few social contacts in the
new setting (APA, 2000).Their fugue may be brief—a matter of
hours or days—and end suddenly. In other cases, however, the
person may travel far from home, take a new name, and establish
a new identity, new relationships, and even a new line of work.
Such people may also display new personality characteristics;
often they are more outgoing (APA, 2000). This pattern is seen
in the century-old case of the Reverend Ansel Bourne:
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On January 17, 1887, [the Reverend Ansel Bourne, of Greene, RI.] drew 551 dollars from
a bank in Providence with which to pay for a certain lot of land in Greene, paid certain
bills, and got into a Pawtucket horsecar. This is the last incident which he remembers. He
did not return home that day, and nothing was heard of him for two months. He was
published in the papers as missing, and foul play being suspected, the police sought in vain
his whereabouts. On the morning of March 14th, however, at Norristown, Pennsylvania, a
man calling himself A. 1. Brown who had rented a small shop six weeks previously, stocked
it with stationery, confectionery, fruit and small articles, and carried on his quiet trade with-
out seeming to any one unnatural or eccentric, woke up in a fright and called in the people
of the house to tell him where he was. He said that his name was Ansel Bourne, that
he was entirely ignorant of Norristown, that he knew nothing of shop-keeping, and that
the last thing he remembered—it seemed only yesterday—was drawing the money from
the bank, etc. in Providence.. . . He was very weak, having lost apparently over twenty
pounds of flesh during his escapade, and had such a horror of the idea of the candy-store
that he refused to set foot in it again.
(James, 1890, pp. 391-393)
Approximately 0.2 percent of the population experience dissociative fugue. Like dis-
sociative amnesia, a fugue usually follows a severely stressful event (Cardena & Gleaves,
2007; APA, 2000). Some adolescent runaways may be in a state of fugue (Loewenstein,
1991). Like cases of dissociative amnesia, fugues usually affect personal memories rather
than encyclopedic or abstract knowledge (Maldonado & Spiegel, 2007).
Fugues tend to end abruptly. In some cases, as with Reverend Bourne, the person
“awakens” in a strange place, surrounded by unfamiliar faces, and wonders how he or
she got there. In other cases, the lack of personal history may arouse suspicion. Perhaps
a traffic accident or legal problem leads police to discover the false identity; at other
times friends search for and find the missing person.When people are found before their
state of fugue has ended, therapists may find it necessary to ask them many questions

Sornatoform and Dissociative Disorders :1/ 181
Homeward Hound: A Case of Dog Fugue?
BY SHERRY MORSE, ANIMAL NEWS, DECEMBER 13, 2003
he Flores family of Wichita, Kansas received an early
Christmas present this year when their beloved dog Bear,
who had disappeared in November of 1997, made it back
home in time for Thanksgiving in 2003.
Jeanie Flores looked out the window of her house two days
before Thanksgiving to see a dog that looked exactly like Bear
standing outside. She recalls thinking, “Oh my God. I think
that’s my dogl” She called the dog; and he responded.
Jeanie burst into tears, then called her husband Frank and
told him she thought Bear was really home. Frank Flores rushed
home and, after seeing the dog, agreed with his wife that the
brindle lab-chow mix was indeed their Bear. One of the family’s
neighbors told them she had spotted Bear a little earlier, walking
around and carefully scrutinizing the houses.
A veterinarian who examined Bear said that although his
paws were red and sore in spots, probably from pounding the
pavement, he only weighed one pound less than when he disap-
peared. It appeared that someone had been taking care of him.
Bear had disappeared in 1997 about one month after the
Flores family had moved to a new neighborhood. Jeanie let him
out for exercise one night, and he never came back. “I waited
up all night for him, and he never came home,” she said.
At the time, Bear’s ID tag had not yet been updated with his
new address. The desperate family put up signs, canvassed their
old neighborhood, ran ads in the paper, and visited shelters,
but, tragically, the dog that Mr. Flores had brought home as a
puppy in 1990 seemed to have disappeared without a trace.
Since his extraordinary return home six years later, Bear has
been catching up on his sleep and getting re-acquainted with
his family, which includes a son who was not yet born when the
dog disappeared.
The Flores family said they just wish that Bear could tell them
where he’s been all this time. “Where was he? We don’t know
how rough a life he’s had,” Frank Flores said.
about the details of their lives, repeatedly remind them who they are, and even begin
psychotherapy before they recover their memories. As these people recover their past,
some forget the events of the fugue period (APA, 2000).
The majority of people who experience dissociative fugue regain most or all of
their memories and never have a recurrence. Since fugues are usually brief and totally
reversible, individuals tend to experience few aftereffects. People who have been away
for months or years, however, often do have trouble adjusting to the changes that have
occurred during their flights. In addition, some people commit illegal or violent acts in
their fugue state and later must face the consequences.
Dissociative Identity Disorder (Multiple Personality Disorder)
Dissociative identity disorder is both dramatic and disabling, as we see in the case of Eric:
Dazed and bruised from a beating, Eric, 29, was discovered wandering around a Day-
tona Beach shopping mall on Feb. 9. . . . Transferred six weeks later to Daytona Beach’s
Human Resources Center, Eric began talking to doctors in two voices: the infantile rhythms
of “young Eric,” a dim and frightened child, and the measured tones of “older Eric,”
who told a tale of terror and child abuse. According to “older Eric,” after his immigrant
German parents died, a harsh stepfather and his mistress took Eric from his native South

182 ://CHAPTER 6
°dissociative identity disorder-0A dis-
order in which a person develops two or
more distinct personalities. Also known
as multiple personality disorder.
osubpersonalitiesoThe two or more
distinct personalities found in individuals
suffering with dissociative identity
disorder. Also known as alternate
personalities.
Carolina to a drug dealers’ hideout in a Florida swamp. Eric said he was raped by several
gang members and watched his stepfather murder two men.
One day in late March an alarmed counselor watched Eric’s face twist into a violent
snarl. Eric let loose an unearthly growl and spat out a stream of obscenities. “It sounded
like something out of The Exorcist,” says Malcolm Graham, the psychologist who directs
the case at the center. “it was the most intense thing rye ever seen in a patient.” That
disclosure of a new personality, who insolently demanded to be called Mark, was the first
indication that Graham had been dealing with a rare and serious emotional disorder: true
multiple personality… .
Eric’s other manifestations emerged over the next weeks: quiet, middle-aged Dwight; the
hysterically blind and mute Jeffrey; Michael, an arrogant jock; the coquettish Tian, whom
Eric considered a whore; and argumentative Phillip, the lawyer. “Phillip was always asking
about Eric’s rights,” says Graham. “He was kind of obnoxious. Actually, Phillip was a pain.”
To Graham’s astonishment, Eric gradually unfurled 27 different personalities, including
three females. . . They ranged in age from a fetus to a sordid old man who kept trying to
persuade Eric to fight as a mercenary in Haiti. In one therapy session, reports Graham, Eric
shifted personality nine times in an hour. “I felt i was losing control of the sessions,” says
the psychologist, who has eleven years of clinical experience. “Some personalities would not
talk to me, and some of them were very insightful into my behavior as well as Eric’s.”
(Time, October 25, 1982, p. 70)
A person with dissociative identity disorder, or multiple personality disorder,
develops two or more distinct personalities, often called subpersonalities or alternate
personalities, each with a unique set of memories, behaviors, thoughts, and emotions
(see Table 6-5). At any given time, one of the subpersonalities takes center stage and
dominates the person’s functioning. Usually one subpersonality, called the primary, or host,
personality, appears more often than the others.
The transition from one subpersonality to another, called switching, is usually sud-
den and may be dramatic (APA, 2000). Eric, for example, twisted his face, growled,
and yelled obscenities while changing personalities. Switching is usually triggered by a
stressful event, although clinicians can also bring about the change with hypnotic sug-
gestion (APA, 2000).
Cases of dissociative identity disorder were first reported almost three centuries ago
(Bieber, 2002). Many clinicians consider the disorder to be rare, but some reports sug-
gest that it may be more common than was once thought (Sar et al., 2007; APA, 2000).
Most cases are first diagnosed in late adolescence or early adulthood, but, more often than
not, the symptoms actually began in early childhood after episodes of abuse (often sexual
abuse), perhaps even before the age of 5 (Maldonado Sc Spiegel, 2007; Roe-Sepowitz et
al., 2007).Women receive this diagnosis at least three times as often as men (APA, 2000).
How Do Subpersonalities nieraet? How subpersonalities relate to or recall one
another varies from case to case. Generally, however, there are three kinds of relationships.
In mutually amnesic relationships, the subpersonalities have no awareness of one another
(Ellenberger, 1970). Conversely, in mutually cognizant patterns, each subpersonality is well
aware of the rest. They may hear one another’s voices and even talk among themselves.
Some are on good terms, while others do not get along at all.
In one-way amnesic relationships, the most common relationship pattern, some subper-
sonalities are aware of others, but the awareness is not mutual (Huntjens et al., 2005).
Those who are aware, called co-conscious subpersonalities, are “quiet observers” who watch
the actions and thoughts of the other subpersonalities but do not interact with them.
Sometimes while another subpersonality is present, the co-conscious personality makes
itself known through indirect means, such as auditory hallucinations (perhaps a voice
giving commands) or “automatic writing” (the current personality may find itself writ-
ing down words over which it has no control).

Profit Distributions
Somatoform and Dissociative. Disorders 1 83
Investigators used to believe that most cases of dissociative identity disorder involved
two or three subpersonalities. Studies now suggest, however, that the average number of
subpersonalities per patient is much higher-15 for women and 8 for men (APA, 2000).
In fact, there have been cases in which 100 or more subpersonalities were observed.
Often the subpersonalities emerge in groups of two or three at a time.
In the case of “Eve White,” made famous in the book and movie The Three Faces of
Eve, a woman had three subpersonalities—Eve White, Eve Black, and Jane (Thigpen &
Cleckley, 1957). Eve White, the primary personality, was quiet and serious; Eve Black
was carefree and mischievous; and Jane was mature and intelligent. According to the
book, these three subpersonalities eventually merged into Evelyn, a stable personality
who was really an integration of the other three.
The book was mistaken, however; this was not to be the end of Eve’s dissociation.
In an autobiography 20 years later, she revealed that altogether 22 subpersonalities had
come forth during her life, including 9 subpersonalities after Evelyn. Usually they ap-
peared in groups of three, and so the authors of The Three Faces of Eve apparently never
knew about her previous or subsequent subpersonalities. She has now overcome her
disorder, achieving a single, stable identity, and has been known as Chris Sizemore for
over 30 years (Sizemore, 1991).
How Do Subpersonalities Differ? As in Chris Sizemore’s case, subpersonalities
often exhibit dramatically different characteristics.They may also have their own names
and different identifying features, abilities and preferences, and even physiological responses.
IDENTIFYING FEATURES The subpersonalities may differ in features as basic as age, gender,
race, and family history, as in the famous case of Sybil Dorsett. Sybil’s dissociative identity
disorder has been described in fictional form (in the novel Sybil) but is based on the real
case of a patient named Shirley Ardell Mason, from the practice of psychiatrist Cornelia
Wilbur (Schreiber, 1973). Sybil displayed 17 subpersonalities, all with different identify-
ing features. They included adults, a teenager, and a baby named Ruthie; two were male,
named Mike and Sid. Sybil’s subpersonalities each had particular images of themselves
and of each other.The subpersonality named Vicky, for example, saw herself as an attrac-
tive blonde, while another, Peggy Lou, was described as a pixie with a pug nose. Mary
was plump with dark hair, and Vanessa was a tall redhead with a willowy figure.
ABILITIES AND PREFERENCES Although memories of abstract or encyclopedic information
are not usually affected in dissociative amnesia or fugue, they are often disturbed in dis-
sociative identity disorder. It is not uncommon for the different subpersonalities to have
different abilities: One may be able to drive, speak a foreign language, or play a musical
instrument, while the others cannot (Coons & Bowman, 2001; Coons et al., 1988).
Their handwriting can also differ. In addition, the subpersonalities usually have different
tastes in food, friends, music, and literature. Chris Sizemore (“Eve”) later pointed out,
“If I had learned to sew as one personality and then tried to sew as another, I couldn’t
do it. Driving a car was the same. Some of my personalities couldn’t drive” (Sizemore
& Pitillo, 1977, p. 4).
PHYSIOLOGICAL RESPONSES Researchers have discovered that subpersonalities may have
physiological differences, such as differences in autonomic nervous system activity, blood
pressure levels, and allergies (Putnam, Zahn, & Post, 1990). One study looked at the
brain activities of different subpersonalities by measuring their evoked potentials—that
is, brain-response patterns recorded on an electroencephalograph (Putnam, 1984). The
brain pattern a person produces in response to a specific stimulus (such as a flashing
light) is usually unique and consistent. However, when an evoked potential test was
administered to four subpersonalities of each of 10 people with dissociative identity
disorder, the results were dramatic. The brain-activity pattern of each subpersonality was
unique, showing the kinds of variations usually found in totally different people.
How Common Is Dissociative Identity Disorder? As you have seen, dissocia-
tive identity disorder has traditionally been thought ofas rare. Some researchers even argue
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Cultural Ties
that many or all cases are iatrogenic— that is, unintentionally produced by
practitioners (Loewenstein, 2007; Piper & Merskey, 2005, 2004). They
believe that therapists create this disorder by subtly suggesting the exis-
tence of other personalities during therapy or by explicitly asking a pa-
tient to produce different personalities while under hypnosis. In addition,
they believe, a therapist who is looking for multiple personalities may
reinforce these patterns by displaying greater interest when a patient dis-
plays symptoms of dissociation.
These arguments seem to be supported by the fact that many cases
of dissociative identity disorder first come to attention while the person
is already in treatment for a less serious problem. But such is not true
of all cases; many people seek treatment because they have noticed
time lapses throughout their lives or because relatives and friends have
observed their subpersonalities (Putnam, 2000, 1988, 1985).
The number of people diagnosed with dissociative identity disorder
has been increasing (Sar et al., 2007; Casey, 2001).Although the disorder
is still uncommon, thousands of cases have now been diagnosed in the United States
and Canada alone. Two factors may account for this increase. First, a growing number
of today’s clinicians believe that the disorder does exist and are willing to diagnose it
(Merenda, 2008; Lalonde et al., 2002, 2001). Second, diagnostic procedures tend to be
more accurate today than in past years. For much of the twentieth century, schizophrenia
was one of the clinical field’s most commonly applied diagnoses. It was applied, often
incorrectly, to a wide range of unusual behavioral patterns, perhaps including dissociative
identity disorder (Turkington & Harris, 2009, 2001). Under the stricter criteria of recent
editions of the DSM, clinicians are now more accurate in diagnosing schizophrenia,
allowing more cases of dissociative identity disorder to be recognized (Welborn et al.,
2003). In addition, several diagnostic tests have been developed to help detect dissocia-
tive identity disorder (Cardena, 2008). Despite such changes, however, many clinicians
continue to question the legitimacy of this category (Lalonde et al., 2002, 2001).
How Do Theorists Explain Dissociative Disorders?
A variety of theories have been proposed to explain dissociative disorders. Older
explanations, such as those offered by psychodynamic and behavioral theorists, have
not received much investigation (Merenda, 2008). However, newer viewpoints, which
combine cognitive, behavioral, and biological principles and highlight such factors as
state- dependent learning and self- hypnosis, have captured the interest of clinical scientists.
The Psychodynamic View Psychodynamic theorists believe that dissociative
disorders are caused by repression, the most basic ego defense mechanism: People fight
off anxiety by unconsciously preventing painful memories, thoughts, or impulses from
reaching awareness. Everyone uses repression to a degree, but people with dissociative
disorders are thought to repress their memories excessively (Fayek, 2002).
In the psychodynamic view, dissociative amnesia and fugue are single episodes of mas-
sive repression. In each of these disorders, a person unconsciously blocks the memory of
an extremely upsetting event to avoid the pain of facing it (Turkington & Harris, 2009,
2001). Repressing may be their only protection from overwhelming anxiety.
In contrast, dissociative identity disorder is thought to result from a lifetime of ex-
cessive repression (Brenner, 2009, 1999; Wang & Jiang, 2007). Psychodynamic theorists
believe that continuous use of repression is motivated by traumatic childhood events,
particularly abusive parenting. Children who experience such traumas may come to fear
the dangerous world they live in and take flight from it by pretending to be another
person who is looking on safely from afar. Abused children may also come to fear the
impulses that they believe are the reasons for their excessive punishments. Whenever
they experience “bad” thoughts or impulses, they unconsciously try to disown and deny
them by assigning them to other personalities.

Peculiarities of Memory
sually memory problems must interfere
greatly with a person’s functioning
before they are considered a sign of a
disorder. Peculiarities of memory, on the
other hand, fill our daily lives. Memory
investigators have identified a number
of these peculiarities—some familiar,
some useful, some problematic, but none
abnormal {Turkington & Harris, 2009,
2001; Mathews & Wang, 2007; Brown,
2004, 2003).
Absentmindedness Often we fail
to register information because our
thoughts are focusing on other things.
If we haven’t absorbed the information
in the first place, it is no surprise that
later we can’t recall it.
Déjà vu Almost all of us have at
some time had the strange sensation
of recognizing a scene that we hap-
pen upon for the first time. We feel
sure we have been there before.
Jamais vu Sometimes we have the
opposite experience: A situation or
scene that is part of our daily life
seems suddenly unfamiliar. “I knew it
was my car, but I felt as if I’d never
seen it before.”
The tip-of-the-tongue phenom-
enon To have something on the tip
of the tongue is an acute “feeling of
knowing”: We are unable to recall
20
07
il
er
sc
iti
h
am
C
ar
loo
siS
on
k.
ro
n.
A
ll
rig
ht
s r
es
ty
le
d
a
kinds of information: They easily can
bring to their mind the appearance of
places, objects, faces, or the pages
of a book. They almost never forget
a face, yet they may well forget the
name attached to it. Other people
have stronger verbal memories: They
remember sounds or words particularly
well, and the memories that come to
their minds are often puns or rhymes.
some piece of informa-
tion, but we know that we
know it.
Eidetic images Some
people experience visual af-
terimages so vividly that they
can describe a picture in
detail after looking at it just
once. The images may be
memories of pictures, events,
fantasies, or dreams.
Memory while under
anesthesia As many as 2 of
every 1,000 anesthetized pa-
tients process enough of what
is said in their presence during
surgery to affect their recovery.
In many such cases, the ability
to understand language has
continued under anesthesia,
even though the patient cannot
explicitly recall it.
Memory for music Even as
a small child, Mozart could memorize
and reproduce a piece of music after
having heard it only once. While no
one yet has matched the genius of
Mozart, many musicians can mentally
hear whole pieces of music, so that
they can rehearse anywhere, far from
their instruments.
Visual memory Most people recall
visual information better than other
“Did you ever start to do something and then
forget what the heck it was?”
Somotoform and Dissociative Disorders 185
Most of the support for the psychodynamic position is drawn from case histories,
which report such brutal childhood experiences as beatings, cuttings, burnings with
cigarettes, imprisonment in closets, rape, and extensive verbal abuse.Yet some individu-
als with dissociative identity disorder do not seem to have experiences of abuse in their
background (Bliss, 1980). Moreover, child abuse appears to be far more common than
dissociative identity disorder. Why might only a small fraction of abused children de-
velop this disorder?
The Behavioral View Behaviorists believe that dissociation is a response learned
through operant conditioning (Casey, 2001). People who experience a horrifying event
may later find temporary relief when their minds drift to other subjects. For some, this
momentary forgetting, leading to a drop in anxiety, increases the likelihood of future
forgetting. In short, they are reinforced for the act of forgetting and learn—without
being aware that they are learning—that such acts help them escape anxiety. Thus, like
psychodynamic theorists, behaviorists see dissociation as escape behavior. But behavior-
ists believe that a reinforcement process rather than a hardworking unconscious is keep-
ing the individuals unaware that they are using dissociation as a means of escape. Like

186 .110-1APTER 6
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c
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• on 0 w
70 • bo
O C
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cl
60
s-
e ) 0_
100
80
50
40
90
Sad
State during Recall Testing
0state-dependent learningoLearning
that becomes associated with the condi-
tions under which it occurred, so that
it is best remembered under the some
conditions.
oseif-hypnosiseThe process of hypnotiz-
ing oneself, sometimes for the purpose of
forgetting unpleasant events.
hypnotic therapy®A treatment in
which the patient undergoes hypnosis
and is then guided to recall forgotten
events or perform other therapeutic activ-
ities. Also known as hypnotherapy.
psychodynarnic theorists, behaviorists have relied largely on case histories to support
their view of dissociative disorders. Moreover, the behavioral explanation fails to explain
precisely how temporary and normal escapes from painful memories grow into a com-
plex disorder or why more people do not develop dissociative disorders.
State-Dependent Learning If people learn something when
they are in a particular situation or state of mind, they are likely to
remember it best when they are again in that same condition. If they
are given a learning task while under the influence of alcohol, for
example, their later recall of the information may be strongest under
the influence of alcohol (Overton, 1966). Similarly, if they smoke
cigarettes while learning, they may later have better recall when they
are again smoking.
This link between state and recall is called state -dependent
learning. It was initially observed in experimental animals who
learned things while under the influence of certain drugs (Rezayof
et al., 2008; Overton, 1966, 1964). Research with human partici-
pants later showed that state-dependent learning can be associated
with mood states as well: Material learned during a happy mood
is recalled best when the participant is again happy, and sad-state
learning is recalled best during sad states (de l’Etoile, 2002; Bower,
1981) (see Figure 6-3).
What causes state-dependent learning? One possibility is that
arousal levels are an important part of learning and memory.That is, a particular level of
arousal will have a set of remembered events, thoughts, and skills attached to it. When
a situation produces that particular level of arousal, the person is more likely to recall
the memories linked to it.
Although people may remember certain events better in some arousal states than
in others, most can recall events under a variety of states. However, perhaps people
who are prone to develop dissociative disorders have state-to-memory links that are
unusually rigid and narrow. Maybe each of their thoughts, memories, and skills is tied
exclusively to a particular state of arousal, so that they recall a given event only when
they experience an arousal state almost identical to the state in which the memory was
first acquired.When such people are calm, for example, they may forget what occurred
during stressful times, thus laying the groundwork for dissociative amnesia or fugue.
Similarly, in dissociative identity disorder, different arousal levels may produce entirely
different groups of memories, thoughts, and abilities—that is, different subpersonalities
(Dorahy & Huntjens, 2007; Putnam, 1992). This could explain why personality transi-
tions in dissociative identity disorder tend to be sudden and stress-related.
Self-Hypnosis As you first saw in Chapter 1, people who are hypnotized enter a sleep-
like state in which they become very suggestible.While in this state, they can behave, per-
ceive, and think in ways that would ordinarily seem impossible. They may, for example,
become temporarily blind, deaf, or insensitive to pain. Hypnosis can also help people
remember events that occurred and were forgotten years ago, a capability used by many
psychotherapists. Conversely, it can make people forget facts, events, and even their per-
sonal identities—an effect called hypnotic amnesia.
The parallels between hypnotic amnesia and dissociative disorders are striking. Both
are conditions in which people forget certain material for a period of time yet later
remember it. And in both, the people forget without any insight into why they are
forgetting or any awareness that something is being forgotten. These parallels have led
some theorists to conclude that dissociative disorders may be a form of self-hypnosis in
which people hypnotize themselves to forget unpleasant events (Maldonado & Spiegel,
2007, 2003). Dissociative amnesia may occur, for example, in people who, consciously
or unconsciously, hypnotize themselves into forgetting horrifying experiences that have
recently occurred in their lives. If the self-induced amnesia covers all memories of a
person’s past and identity, that person may undergo a dissociative fugue.
Participants who learned words in a sad mood
Participants who learned words in a happy mood
Happy

SAyob it ior and thechtl
Somatoform and Dissociative Disorders :11 1 87
Self-hypnosis might also be used to explain dissociative identity disorder. On the
basis of several investigations, some theorists believe that this disorder often begins
between the ages of 4 and 6, a time when children are generally very suggestible and
excellent hypnotic subjects (Kluft, 2001, 1987; Bliss, 1985, 1980).These theorists argue
that some children who experience abuse or other horrifying events manage to escape
their threatening world by self-hypnosis, mentally separating themselves from their bod-
ies and fulfilling their wish to become some other person or persons. One patient with
multiple personalities observed, “I was in a trance often [during my childhood]. There
was a little place where I could sit, close my eyes and imagine, until I felt very relaxed
just like hypnosis” (Bliss, 1980, p. 1392).
How Are Dissociative Disorders Treated?
As you have seen, people with dissociative amnesia and fugue often recover on their
own. Only sometimes do their memory problems linger and require treatment. In con-
trast, people with dissociative identity disorder usually require treatment to regain their
lost memories and develop an integrated personality.Treatments for dissociative amnesia
and fugue tend to be more successful than those for dissociative identity disorder, prob-
ably because the former disorders are less complex.
How Do Ther pists Help People with Dissociative Amnesia and
Fugue? The leading treatments for dissociative amnesia and fugue are psychodynamic
therapy, hypnotic therapy, and drug therapy, although support for these interventions comes
largely from. case studies rather than controlled investigations (Maldonado & Spiegel,
2003). Psychodynamic therapists guide patients with these disorders to search their
unconscious in the hope of bringing forgotten experiences back to consciousness
(Bartholomew, 2000; Loewenstein, 1991). The focus of psychodynamic therapy seems
particularly well suited to the needs of people with these disorders. After all, the patients
need to recover lost memories, and the general approach of psychodynamic therapists is
to try to uncover memories—as well as other psychological processes—that have been
repressed.Thus many theorists, including some who do not ordinarily favor psychody-
namic approaches, believe that psychodynamic therapy may be the most appropriate
treatment for these disorders.
Another common treatment for dissociative amnesia and fugue is hypnotic therapy,
or hypnotherapy (see Table 6-6 on the next page). Therapists hypnotize patients and
then guide them to recall forgotten events (Degun-Mather, 2002). Given the possibility
that dissociative amnesia and fugue may each be a form of self-hypnosis, hypnotherapy
.Y.-4,4fai i Tr-,,-
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Hypnotized people lose control of themselves. Hypnotized people are perfectly capable of saying no.
People remember more accurately under hypnosis. Hypnosis can help create false memories.
Hypnotized people can be led to do immoral acts. Hypnotized subjects fully adhere to their usual values.
1
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Source: Nash, 2006, 2005, 2004, 2001.
Some Myths about Hypnosis
Myth

Reality
Hypnosis relies on having a good imagination. Vivid imaginations are unrelated to hypnotizability.
Hypnosis is dangerous. Hypnosis is no more distressing than a lecture.
It has something to do with a sleeplike state. Hypnotized subjects are fully awake.
1 88 :// CHAPTER 6
may be a particularly useful intervention. It has been applied both alone and in com-
bination with other approaches.
Sometimes intravenous injections of barbiturates such as sodium amobarbital (Amytal)
or sodium pentobarbital (Pentothal) are used to help patients with dissociative amnesia and
fugue regain lost memories. These drugs are often called “truth serums,” but the key to
their success is their ability to calm people and free their inhibitions, thus helping them
to recall anxiety-producing events (Fraser, 1993; Kluft, 1988).These drugs do not always
work, however, and if used at all, they are likely to be combined with other treatment
approaches (Spiegel, 1994).
How Do Therapists Help Individuals with Dissociative Identity Disorder?
Unlike victims of amnesia and fugue, people with dissociative identity disorder do not
typically recover without treatment (Maldonado & Spiegel, 2003; Spiegel, 1994).Treat-
ment for this pattern is complex and difficult, much like the disorder itself. Therapists
usually try to help the clients (1) recognize fully the nature of their disorder, (2) recover
the gaps in their memory, and (3) integrate their subpersonalities into one functional
personality (North &Yutzy, 2005; Kihlstrom, 2001).
RECOGNIZING THE DISORDER Once a diagnosis of dissociative identity disorder is made,
therapists typically try to bond with the primary personality and with each of the sub-
personalities (Kluft, 1999, 1992).As bonds are formed, therapists try to educate patients
and help them to recognize fully the nature of their disorder (Krakauer, 2001; Allen,
1993). Some therapists actually introduce the subpersonalities to one another under
hypnosis, and some have patients look at video-
tapes of their other personalities (Ross & Gahan,
1988; Sakheim et al., 1988). Many therapists have
also found that group therapy helps to educate pa-
tients (Fine & Madden, 2000). In addition, family
therapy may be used to help educate spouses and
children about the disorder and to gather helpful
information about the patient (Kluft, 2001, 2000).
RECOVERING MEMORIES To help patients recover the
missing pieces of their past, therapists use many of
the approaches applied in other dissociative disor-
ders, including psychodynamic therapy, hypnother-
apy, and drug treatment (Kluft, 2001, 1991, 1985).
These techniques work slowly for patients with
dissociative identity disorder, as some subpersonali-
ties may keep denying experiences that the others
recall (Lyon, 1992). One of the subpersonalities

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Dissociative Disorders
People with dissociative disorders experience major changes in memory and iden-
tity that are not caused by clear physical factors. People with dissociative amnesia
are suddenly unable to recall important personal information or post events in their
lives. Those with dissociative fugue not only fail to remember their personal identities
but also flee to a different location and may establish a new identity. In dissociative
identity disorder (multiple personality disorder), people display two or more distinct
subpersonalities. The number of people diagnosed with dissociative identity disor-
der has increased in recent years.
The dissociative disorders are not well understood. Among the processes that
have been cited to explain them are extreme repression, operant conditioning, state-
dependent learning, and self-hypnosis. The latter two phenomena, in particular,
have excited the interest of clinical scientists.
Dissociative amnesia and fugue may end on their own or may require treat-
ment. Dissociative identity disorder typically requires treatment. Approaches com-
monly used to help people with dissociative amnesia and fugue recover their lost
memories are psychodynamic therapy, hypnotic therapy, and sodium amoborbital
or sodium pentobarbital. Therapists who treat people with dissociative identity disor-
der use the same approaches but further focus on trying to help the clients recognize
the scope of their disorder, recover the gaps in their memory, and integrate their
subpersonalities into one functional personality.
Sornotoform and Dissociative Disorders :1/ 1 89
may even assume a “protector” role to prevent the primary personality from suffering
the pain of recollecting traumatic experiences.
INTEGRATING THE SUBPERSONALITIES The final goal of therapy is to merge the different
subpersonalities into a single, integrated identity. Integration is a continuous process
that occurs throughout treatment until patients “own” all of their behaviors, emotions,
sensations, and knowledge. Fusion is the final merging of two or more subpersonali-
ties. Many patients distrust this final treatment goal, and their subpersonalities may see
integration as a form of death (Kluft, 2001, 1999, 1991).Therapists have used a range of
approaches to help merge subpersonalities, including psychodynamic, supportive, cogni-
tive, and drug therapies (Goldman, 1995; Fichtner et al., 1990).
Once the subpersonalities are integrated, further therapy is typically needed to main-
tain the complete personality and to teach social and coping skills that may help prevent
later dissociations. In case reports, some therapists note high success rates (Rothschild,
2009; Coons & Bowman, 2001), but others find that patients continue to resist full in-
tegration. A few therapists have in fact questioned the need for full integration.
PUTTING IT… together
Disorders Rediscovered
Somatoform and dissociative disorders are among the clinical field’s earliest identified
psychological disorders. Indeed, as you read in Chapter 1, they were key to the develop-
ment of the psychogenic perspective. Despite this early impact, the clinical field stopped
paying much attention to these disorders during the middle part of the twentieth cen-
tury. The feeling among many clinical theorists was that the number of such cases was
shrinking. And more than a few questioned the legitimacy of the diagnoses.
Much of that thinking has changed in the past two decades.The field’s keen interest
in the impact of stress upon health and physical illness has, by association, reawakened
interest in sornatoform disorders. Similarly, as you will see in Chapter 15, the field has
efusionoThe final merging of two or
more subpersonalities in multiple person-
ality disorder.

THOUPTHTS///
1. Why do the terms “hysteria” and
“hysterical” currently have such nega-
tive connotations in our society, as in
“mass hysteria” and “hysterical per-
sonality”? pp. 164- 169
2. If parents who harm their chil-
dren are clearly disturbed, as in
cases of Munchausen syndrome
by proxy, how should society
react to them? Which is more
190 ://CHAPTER 6
1:1=1,1 r
Iri Their Words
(…
,•.?
os to l?iilii;c^s
greatly intensified its efforts to understand and treat Alzheimer’s disease in recent years,
and that work has sparked a broad interest in the operation of -memory, including an
interest in dissociative disorders.
Over the past 25 years there has been an explosion of research seeking to help cli-
nicians recognize, understand, and treat unexplained physical and memory disorders.
Although this research has yet to produce clear insights or highly effective treatments, it
has already suggested that the disorders may be more common than clinical theorists had
come to believe. Moreover, there isgrowing evidence that the disorders may be rooted
in processes that are already well known from other areas of study, such as overattentive-
ness to bodily processes, cognitive misinterpretations, state-dependent learning, and self-
hypnosis. Given this new wave of research enthusiasm, we may witness significant growth
in our understanding and treatment of these disorders in the coming years.
At the same time, many of today’s clinicians worry that the focus on somatoform and
dissociative disorders is swinging back too far—that the high degree of interest in them
may be creating a false impression of their prevalence or importance (Pope et al., 2007;
Piper & Merskey, 2004). Some clinicians note, for example, that physicians are often quick
to assign the label “somatoform” to elusive medical problems such as chronic fatigue
syndrome and lupus—clearly a disservice to patients with such severe problems and to
the progress of medical science. Similarly, a number of clinicians worry that at least some
of the many legal defenses based on dissociative identity disorder or other dissociative
disorders are contrived or inaccurate. Of course, such possibilities serve to highlight even
further the importance of continued investigations into all aspects of the disorders.
appropriate — treatment or punish- and fugue are listed in DSM-IV-TR,
ment? p. 168

many people greet such explanations
3. How might a culture help create
with skepticism. Why? pp. 176- 181
cases of body dysmorphic disorder?

5 Some accused criminals claim that
pp. 169- 173

they have dissociative identity dis-
4. Periodically we hear in the news
about missing individuals who show
up suddenly, claiming to have lost
their memories while away. Although
disorders such as dissociative amnesia
what would be an appropriate
verdict? pp. 181-187
order and that their crimes were
committed by one of their subperson-
alities. If such claims are accurate,
• • .00. • ,?•.,.••••

:\\■ KEY TEPIS/w:
off-: s matoform disorder, p. 164
1:1 hysterical somatoform disorders, p. 164
conversion disorder, p. 164
somatization disorder, p. 166
pain disorder associated with
psychological factors, p. 167
.4, malingering, p. 167
factitious disorder, p. 167
Munchausen syndrome, p. 168
Munchausen syndrome by proxy, p. 169
74777
•••••173,,,,
preoccupation somatoform disorders,
p. 169
hypochondriasis, p. 169
body dysmorphic disorder, p. 169
Electra complex, p. 171
primary gain, p. 172
secondary gain, p. 172
placebo, p. 173
memory, p. 176
dissociative disorders, p. 176
dissociative amnesia, p. 178
%tett ,.
amnestic episode, p. 179
dissociative fugue, p. 180
dissociative identity disorder, p. 182
subpersonalities, p. 182
iatrogenic disorder, p. 184
repression, p. 184
state -dependent learning, p. 186
self-hypnosis, p. 186
hypnotic therapy, p. 187
fusion, p. 189
• • • •*•,…• ‘,AV? t 1!. Sot.

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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