PSCY Essay
Write an 6-8-page term paper (double-spaced) using APA format. In this paper choose any DSM disorder, whether it has been covered in class or the text, and discuss what treatment may look like within a particular population. Claims should be supported by existing literature on psychopathology, with sources being properly cited.
DSM Paper Guidelines and Rubric
Students will write a 6-8 page research paper that will critically evaluate the treatment(s) available for a specific disorder, within a specified population.
Include: (a) DSM-5 disorder with relevant diagnostic criteria, (b) prevalence of the disorder in the general population and a discussion of how that disorder is relevant to a particular population of your choosing (this could be individuals of a certain age group, gender, sexual orientation, racial/ethnic background, etc.), and (c) detail of what treatment may look like for individuals with this disorder in the population selected. The paper should be between 6-8 pages, double spaced (not including title page or reference page). The DSM-5 and a minimum of two additional sources used (ideally peer-reviewed journal articles, though textbooks are also acceptable) should be cited. Use the current APA 7th formatting throughout the paper.
Grading Rubric:
Unsatisfactory
Fair
Good
Excellent
Disorder and Diagnostic Criteria
– Very few or no diagnostic criteria are identified.
– The student does not display an understanding of the relationship between criteria and diagnoses.
– Some criteria are included, with few examples.
– Diagnostic ideas are present, but not well supported by symptoms or evidence.
– The diagnostic criteria are given and supported with some examples.
– The student displays a general understanding of how the disorder presents.
– Diagnostic criteria are stated and clearly backed with ample examples.
– Clear connection is made between specific criteria and overall presentation of individuals with the given disorder
Prevalence & Chosen Population
– Prevalence of the disorder in the general population is not identified
– Population is discussed but no correlation is made between the disorder prevalence and the population chosen
– Prevalence of the disorder in the general population is identified, but may not be supported by peer-reviewed sources
– Basic description of population is given with some detail clarifying why population was chosen/prevalence of the disorder among the population
– Prevalence of the disorder in the general population is identified
– Description of the chosen population and the prevalence of the disorder among that population is given, though no support is given by peer-reviewed sources.
– Prevalence of the disorder in the general population is identified
– Thorough description of the chosen population and the prevalence of the disorder among that population is given, with ample support by peer-reviewed sources.
Treatment
-Lacking in the description of treatment options and nuance of treatment within the population are discussed
-Little to no support or supporting citations are not peer-reviewed.
-Basic description of treatment options are discussed
-Information presented may not be supported by peer-reviewed research or fewer than 2 references.
-Adequate description treatment options and nuances of treatment population are discussed
-Information presented is fully supported by at least 2 peer-reviewed references
-Complete description of treatment options and nuances of treatment population are discussed
-Information presented is fully supported by at least 2 peer-reviewed references
Grammar, Spelling, & Punctuation
– Paper contains numerous grammatical, punctuation, and spelling errors.
– Language uses jargon, slang or conversational tone.
– Uses “I” or “me” throughout the paper.
– There are some errors throughout the paper in punctuation, spelling, and/or language.
– Language is somewhat professional; some conversational tone or “I”/”me” is occasionally used.
– Rules of grammar, and punctuation are followed with minor errors. Spelling is correct.
– Language is mostly professional
– Overall, the paper is comprehensive and easy to read.
– Rules of grammar, usage, and punctuation are followed; spelling is correct.
– Language is clear and precise; sentences display consistently strong, varied structure.
– Professional language is used throughout the paper
Format
– Paper lacks many elements of correct formatting.
– Page requirement is inadequate or excessive
– Paper is not in APA format.
– Format and/or flow make it difficult to follow the writing.
– Paper is about 6-8 pages.
– APA format has flaws, however, the general idea of how to format a paper in this structure comes across.
– Format and flow neither add to nor subtract from the readability of the paper.
– Paper follows designated guidelines.
– Paper is 6-8 pages long.
– APA format is good, with few errors.
– Format and flow are good and deliberate.
– Paper meets the 6-8 page requirement.
– Paper is in APA format, following all guidelines for structure, format, font, margins, and spacing.
-Format and flow between paragraphs enhances readability of paper.
RunningHead: PARAPHILLIC DISORDERS 1
Paraphilic Disorders Within the Sex Offender Population
Student Name
College Name
PARAPHILLIC DISORDERS 2
Abstract
This paper discusses the diagnostic criteria for the subset of paraphilic disorder known as
courtship disorders, and addresses what is both known and assumed regarding their
prevalence in the general population. A number of treatment methods for paraphilic
disorders among the sex offender population are explored, as well as the current support, or
lack of support, for their success in reducing recidivism. It is noted that treatment is
typically geared towards those who may cause the most harm, such as pedophiles or sexual
sadists. As such, there is a dearth of research specific to managing courtship disorders, or
more specifically; exhibitionism, voyeurism, and frotteurism. The impact of the therapeutic
alliance and counselor characteristics is stressed, as it is shown to be more relevant to the
success of treatment than the specific method used. Finally, this text highlights the
optimism relayed in the literature regarding the use of treatment methods, developed to
reduce recidivism, to help those living with all types of paraphilic disorders manage their
symptoms.
Keywords: paraphilic disorder, sex offender, treatment
PARAPHILLIC DISORDERS 3
Paraphilic Disorders Within the Sex Offender Population
Paraphilic disorders have two predominant classifications; anomalous activity
preferences and anomalous target preferences. The anomalous activity preferences
classification is further subdivided into courtship disorders, featuring distorted
components of human courtship behavior, and algolagnic disorders, which involve pain
and suffering (APA, 2013). Algolagnic disorders include sexual masochism disorder
and sexual sadism disorder, while the courtship disorders include voyeuristic disorder,
exhibitionistic disorder, and frotteuristic disorder. Courtship disorders will be the focus
of this manuscript. As defined by the DSM-5 (American Psychiatric Association, 2013),
voyeuristic disorder can be defined as “spying on others in private activities,”
exhibitionistic disorder is known as “exposing the genitals,” and frotteuristic disorder
involves “touching or rubbing against a nonconsenting individual” (p.685). It is
important to note that due to the inherent potential harm to others, these behaviors are
classified as criminal offenses. The term paraphilia in and of itself “denotes any intense
and persistent sexual interest other than sexual interest in genital stimulation or
prepatory fondling with phenotypically normal, physically mature, consenting human
partners” (APA, 2013, p.685).
Diagnosis
For a paraphilia to rise to the level of being a diagnosable paraphilic disorder it
must be causing the individual distress or impairment, or entail personal harm, or risk of
harm, to others. It is important to keep in mind that a paraphilia by itself does not
necessarily warrant clinical intervention. In order to be diagnosed with a paraphilic
disorder, an individual must meet diagnostic Criterion A and B. Criterion A specifies
PARAPHILLIC DISORDERS 4
“the qualitative nature of the paraphilia”, while Criterion B specifies its negative
consequences (APA, 2013, p.686). It is not uncommon for an individual to have a
number of paraphilias, and comorbid diagnoses of individual paraphilic disorders may
be warranted if more than one paraphilia is causing distress to the individual or harm to
others (APA, 2013). Moreover, it is important to consider the likelihood of other co-
occurring disorders. The most prevalent disorders among the sex offender population
are mood and anxiety disorders, as well as ADHD and substance abuse (Kafka &
Hennen, 2002). As such, treatment providers should be on the look-out for signs and
symptoms that suggest comorbidity, and always be open to differential diagnoses.
Prevalence
Of potentially law-breaking sexual behaviors, voyeuristic acts are the most
common (APA, 2013, p.687). Based on voyeuristic sexual acts in nonclinical samples,
the highest possible lifetime prevalence for voyeuristic disorder is approximately 12%
in males and 4% in females. The specific population prevalence of voyeuristic disorder
is unknown. Similarly, the prevalence of exhibitionistic disorder is unknown, though
based on sexual acts in nonclinical or general populations, the highest possible
prevalence is thought to be between 2% and 4% in the male population (APA, 2013,
p.690). The prevalence of exhibitionistic disorder in females is even more uncertain but
is largely assumed to be significantly lower than in males. Finally, about 10%-14% of
adult males seen for paraphilic disorders and hypersexuality in outpatient settings meet
the diagnostic criteria for frotteuristic disorder (APA, 2013, p.692-693). As such, while
the population prevalence of the disorder in the general population is not known, it is
unlikely to exceed the rate found in clinical settings. As with both voyeuristic and
PARAPHILLIC DISORDERS 5
exhibitionistic disorders, the prevalence of frotteuristic disorder in women is unknown
but commonly believed to be notably lower in females. It is important to note that the
vast majority of information quoted in studies of paraphilic disorders is derived from
research done with the sexual offender population. Moreover, given the rate of
comorbidity in paraphilias, there is some overlap in the statistics as well as the
recommendations for treatment (APA, 2013).
Treatment
In the history of sex offender treatment, a number of methods have been
explored; including surgical, hormonal, and chemical castration (Mpofu et al., 2018).
Such methods are more common with high-risk or violent offenders, such as pedophiles
and rapists, and are not considered effective treatment methods for offenders who
engage in less serious criminal sexual behaviors such as exhibitionism, voyeurism, or
frotteurism. Overall, psychosocial interventions are perceived to be more humane and
more promising than medical castration, and with an augmented understanding of an
offender’s criminogenic needs, there is value to tailoring interventions in accordance
with individual offender profiles (Mpofu et al., 2018). A specific treatment method that
has received significant attention in the literature in relation to sexual offending is
Cognitive Behavioral Therapy (CBT). CBT is “a cluster of interventions to address
presumed dysfunctional thought processes that mediate a precipitating event and otherwise
harmful behavioral responses to the event. The aim of CBT is to correct the cognitive
distortions or decisional lapses believed to be behind maladaptive behaviors, including
criminal behavior” (Mpofu et al., 2018, p.172). When working with the sex offender
population, increasing decisional choice when faced with criminogenic impulses can be key
PARAPHILLIC DISORDERS 6
to minimizing the risk of recidivism. As such, the techniques and strategies promoted in
CBT can be a fundamental part of therapy aimed at preventing relapse (Schmucker & Losel,
2015). A number of studies have explored the effectiveness of CBT on recidivism within
this population, with many showing the use of CBT leading to a significant reduction in re-
offending. Examples include an integrative study by Craig, Browne, and Stringer (2003)
which compared a recidivism rate of 8% for CBT studies with 17% for those in
comparative treatments, and a meta-analysis published by Hall (1995) that reported a
median rate of re-offense of 10.5% for those treated with CBT, compared to a rate of
19.96% among those who received other treatments. These studies suggest that CBT is a
promising intervention to reduce the risk of recidivism among sex offenders. However, it is
important to note that when sex offenders do re-offend, it tends not to be sexual or violent
nature (Craig et al., 2003), yet the focus of many studies is on all criminal offending
(sexual, violent, and general), not specifically sexual offending. As such, one should not
generalize and interpret these results to mean that CBT is successful, at the rates mentioned
above, in preventing relapse of disordered sexual behaviors.
Moreover, given the range of harmfulness among paraphilic disorders, it should
not come as a shock that the vast majority of research focuses on those that directly
involve the infliction of harm upon others. As a result, there is more information
available regarding effective treatment methods for those disorders, such as pedophilic
disorder, for example. Interestingly, it has been found that when treatment has been
implemented for paraphilias that receive less attention in the research literature, the
treatment programs were typically based on those developed for the more problematic
disorders (Marshall & Marshall, 2015). Luckily, there does not appear to be
PARAPHILLIC DISORDERS 7
significantly different results as a consequence of treatment when the same treatment is
applied to different types of offenders. A particular challenge in treatment of paraphilic
disorders is that those with sexually deviant interests and behaviors typically have no
motivation for treatment (Prescott, 2014). Accordingly, Motivational Interviewing (MI)
was identified as a tool to build clients’ interest and commitment to treatment. MI
instructs treatment providers to utilize a more therapeutic style (i.e., empathic, genuine,
collaborative) that will create an alliance between clients and their counselors and
positively influence the client’s commitment to treatment (Miller & Rollnick, 2002).
Further, the Good Lives Model proposes that sex offenders (i.e., those with diagnosable
paraphilic disorders) seek to satisfy the same needs as others, but as a result of a deficit
of skills they look to meet these needs in inappropriate ways. As such, treatment should
focus on skill building and instilling attitudes that enable the realization of life-fulfilling
goals, as opposed to focusing solely on the deficits of paraphilics (Ward, 2002). This
model is in line with positive psychology, where the focus is on strengthening a client’s
positive features as a method of surmounting problems. The two approaches discussed
here, MI and GLM are in contrast with the earlier thought that sex offenders ought to be
confronted forcefully about their distorted perceptions and problematic
behaviors.
Subsequently, the focus of sex offender treatment has turned to risk assessment.
While risk assessments initially focused on identifying risk of recidivism based on past
behavior, the historical features considered were unchangeable and therefore not useful
targets for treatment. Researches then began to examine features that could be amenable
to change while still being viable predictors of future risk, developing what are now
known as static and dynamic risk factors in the field of sexual offending (Hanson &
PARAPHILLIC DISORDERS 8
Thornton, 1999). Static risk factors that predict reoffending are derived from features of
the offender’s history that are not modifiable, and as such do not come into play in
treatment. Conversely, the dynamic risk factors identified give treatment providers
something to focus on changing, and by reducing these issues and developing strengths
to counter these dangers the risk of re-offense can go down. There are two forms of
dynamic risk factors, those that are stable and reflect lasting issues, and those that are
acute which surface in the life of the offender preceding the onset of offending. While
treatment may target both sets of factors, the priority is addressing stable factors, while
acute factors may become a focus of post-treatment support. Stable factors include
“insecure attachments, lack of intimacy, emotional loneliness, poor self-regulation, sexual
preoccupation, deviant sexual interests, emotional congruence with children, lack of
concern for others, attitudes supportive of sexual offending, and hostility toward women”
(Marshall & Marshall, 2015, p.3). However, it is important to note that these factors are
predominantly relevant to child molesters, rapists, etc., there is a dearth of research on the
dynamic factors specific to those who commit exhibitionism, voyeurism, and frotteurism.
As a result, it is often assumed that the treatment for these disorders are the same as those
relevant to more violent or target-focused offenders, though this assumption is largely
unfounded. This treatment does not have strong evidence in support of its effectiveness.
Rather, it has been found that the way in which treatment is delivered has a greater impact
on reducing recidivism than does the actual implementation of practices (Marshall &
Marshall, 2012).
Consequently, there has been an emphasis on the role of the counselor in
treatment delivery, with three preeminent facets of the research; “features of the
PARAPHILLIC DISORDERS 9
therapist’s style, the therapeutic alliance, and the climate of treatment groups” (Marshall &
Marshall, 2015, p.4). In an extensive review of the literature, Norcross (2002) summed
up the research and revealed that the therapeutic alliance is responsible for somewhere
between 25 and 30% of the positive outcomes of treatment. Sex offenders report gaining
the most from therapists who are empathic, nonjudgmental, warm, and supportive
(Drapeau, 2005). Marshall and his colleagues executed an extensive review of therapist
features that predicted success in treatment programs oriented towards the sex offender
population, and they found that more than 30% of the positive changes were rooted in
the counselors’ characteristics (Marshall, et al., 2013). While treatment providers who
had a confrontational or aggressive style negatively impacted their clients, those who
were warm, empathic, and offered guidance produced positive transformations. One
study examined specifically the group counseling dynamic in a number of sex offender
treatment programs and found that those that were characterized by cohesiveness and
expressiveness were the most effective by far (Beech & Hamilton-Giachritsis, 2005).
Overall, the research seems to support the idea that as long as the appropriate issues,
namely dynamic risk factors, are targeted, and treatment delivery itself is effective, the
theoretical orientation used has minimal influence on treatment effectiveness (Marshall
& Marshall, 2012).
In this vein, it is important to take a step back and acknowledge that, given the
shame and stigma surrounding paraphilias and sexual offending, it is vital to cultivate a
strong therapeutic alliance with the client to increase the likelihood of disclosure of
behaviors at the start of treatment. In a forensic setting a therapist may have access to
official documents with objective information such as police reports, victim statements,
PARAPHILLIC DISORDERS 10
criminal records including prior sexual and nonsexual offenses, etc., however
information provided by the client can be an extremely useful addition, and in non-
forensic settings may be the only way to properly diagnose the client and move forward
with treatment. In working with clients with paraphilic disorders, mental health
practitioners have been found to assess factors such as offense patterns and victim
preferences, frequency of behavior, duration of behavior, compulsivity, and more,
(Morin & Levenson, 2008). This information is used to determine the diagnosis and
develop a treatment plan, and can come only from the offender, which further
emphasizes the importance of the counselor-client relationship and the trust needed to
encourage the client’s self-report.
Conclusion
Overall, research has shown us that regardless of the method used, if a sex offender
treatment program follows established principles, the effects will be overarchingly positive.
The benefits of attending treatment, compared to offender groups who do not receive
treatment, is indisputable. There is a significant reduction in recidivism among those who
have received treatment, irrespective to the treatment type. Though programs that focus on
the effective features delineated earlier, namely targeting dynamic risk factors, using
appropriate techniques to modify these risks, and provide treatment in a warm and empathic
fashion, seem to maximize success. While there is no clear evidence that individuals with
paraphilic disorders in the general population will respond similarly to the treatment
programs currently in place, the results with sex offenders inspires optimism about the
potential to help them manage the symptoms of their disorders and live more fulfilling
lives.
PARAPHILLIC DISORDERS 11
References
American Psychiatric Association. (2013). Paraphilic Disorders. In Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Beech, A.R., & Hamilton-Giachritsis, C.E. (2005). Relationship between therapeutic
climate and treatment outcome in group-based sexual offender treatment programs.
Sexual Abuse: A Journal of Research and Treatment, 17, 127–140.
Craig, L. A., Browne, K. D., & Stringer, I. (2003). Treatment and sexual offence
recidivism. Trauma, Violence & Abuse, 4, 70-89.
Drapeau, M. (2005). Research on the processes involved in treating sexual offenders.
Sexual Abuse: A Journal of Research and Treatment, 17, 117–125.
Hall, G.C.N. (1995). Sexual offender recidivism revisited. A meta-analysis of recent
treatment studies. Journal of Consulting and Clinical Psychology, 63, 802-809.
Hanson, R.K., & Thornton D. (1999). Static 99: Improving actuarial risk assessments for
sex offenders (User Report 99–02). Ottawa: Department of the Solicitor General of
Canada.
Kafka, M.P., & Hennen, L. (2002). A DSM-IV Axis I comorbidity study of males (n=120)
with paraphilias and paraphilia-related disorders. Sexual Abuse: A Journal of
Research and Treatment, 14(4), 349-366.
PARAPHILLIC DISORDERS 12
Marshall, W.L., Boer, D., & Marshall, L.E. (2014). Assessing and treating sex offenders.
In: I.B. Weiner & R.K. Otto (Eds.), The handbook of forensic psychology (pp. 839–
866). Hoboken: Wiley.
Marshall, W.L. & Marshall, L.E. (2015). Psychological Treatment of the Paraphilias: A
Review and an Appraisal of Effectiveness. Current Psychiatry Reports, 17(14), 1-6.
doi:10.1007/s11920-015-0580-2.
Marshall, W.L., & Marshall, L.E. (2012). Treatment of sexual offenders: Effective elements
and appropriate outcome evaluations. In: E. Bowen & S. Brown (Eds.), Perspectives
on evaluating criminal justice and corrections (pp. 71– 94). Bingley: Emerald
Publishing.
Marshall, W.L., Marshall, L.E., & Burton, D.L. (2013) Features of treatment delivery and
group processes that maximize the effects of offender programs. In: J.L. Wood,
& T.A. Gannon (Eds.), Crime and crime reduction: The importance of group
processes (pp. 160-176). London: Routledge.
Marshall, W.L., Fernandez, Y.M., Serran, G.A., Mulloy, R., Thornton, D., & Mann, R.E.
(2003). Process variables in the treatment of sexual offenders: A review of the
relevant literature. Aggressive and Violent Behavior: A Review Journal, 8, 205–234.
Miller, W.R., & Rollnick, S. (Eds). (2002). Motivational Interviewing: Preparing people
for change (2nd ed.). New York: Guilford Press.
PARAPHILLIC DISORDERS 13
Morin, J.W., & Levenson, J.S. (2008). Exhibitionism: Assessment and treatment. In D.R.
Laws, & W. O’Donohue (Eds.), Sexual deviance (2nd ed., pp. 76-107). New York,
NY: Guilford.
Mpofu, E., Athanasou, J.A., Rafe, C., & Belshaw, S.H. (2018). Cognitive-behavioral
therapy efficacy for reducing recidivism rates of moderate- and high-risk sexual
offenders: A scoping systematic literature review. International Journal of Offender
Therapy and Comparative Criminology, 62(1), 170-186.
doi:10.177/0306624X164501.
Norcross, C. (2002). Empirically supported therapy relationships. In: J.C., Norcross (Ed.),
Psychotherapy relationships that work: Therapist contributions and responsiveness
to patient needs (pp.3-10). New York: Oxford University Press.
Prescott, D.S. (2014). Motivating clients to change. In: M.S. Carrich, & S.E. Mussack
(Eds.), Handbook of sexual abuser assessment and treatment (pp.103-124).
Brandon: Safer Society Press.
Schmucker, M., & Losel, F. (2015). The effects of sexual offender treatment on recidivism:
An international meta-analysis of sound quality evaluations. Journal of
Experimental Criminology, 11, 597-630. doi:10.1007/s11292-015-924-z.
Ward, T. (2002). Good lives and the rehabilitation of offenders: Promises and problems.
Aggression and Violent Behavior: A Review Journal, 7(5), 13–28.
PARAPHILLIC DISORDERS 14
Appendix A
Diagnostic Criteria for Voyeuristic, Exhibitionistic, and Frotteuristic Disorders
Voyeuristic Disorder
A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing
an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual
activity, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of
age.
Exhibitionistic Disorder
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the
exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or
behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Frotteuristic Disorder
PARAPHILLIC DISORDERS 15
A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or
rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Anxiety, Obsessive-Compulsive, and Trauma- and Stressor-Related Disorders SSY 230: Lecture 7
Anxiety Disorders
The central defining feature of anxiety disorders is the experience of a chronic and intense feeling of anxiety in which people feel a sense of dread about what might happen to them in the future. The anxiety experienced by people with anxiety disorders causes them to have great difficulty functioning on a day-to-day basis. This feeling goes beyond the typical worries people have from time to time about performing their everyday activities at work or home, or in their interactions with other people.
People with anxiety disorders also experience fear, which is the emotional response to real or perceived imminent threat. Again, like the experience of anxiety, the sense of fear that people with these disorders have goes beyond ordinary or even rational concern over the possible dangers of the situations in which they find themselves.
People with anxiety disorders go to great lengths to avoid situations that provoke the emotional responses of anxiety and fear. When they are unable to do so, they will have difficulty performing jobs, enjoying leisure pursuits, or engaging in social activities with friends and families.
Anxiety Disorder Prevalence
Across all categories, anxiety disorders have a lifetime prevalence rate in the United States of 28.8 percent.
The percent of people reporting lifetime prevalence across all anxiety disorders peaks between the ages of 30 and 44, with a sharp drop off to 15.3 percent among people 60 years and older
The average age of onset across all anxiety disorders is
21.3 years of age, with ranges from 15 years and younger
to up to 39 years, depending on the nature of the
disorder.
Note the gender differences in the chart.
Separation Anxiety Disorder
Individuals with separation anxiety disorder have intense and inappropriate anxiety about leaving home or being left by their attachment figures, the people close to them in their lives. Children with this disorder may cling so closely to a parent they will not let the parent out of their sight. Adults who meet the criteria for this disorder have intense anxiety about being separated from the person to whom they are most emotionally attached.
Prior to the DSM-5, the condition of separation anxiety disorder was considered specific to children. However, recognizing that there are a significant number of adult-onset cases, DSM-5 lifted the disorder’s age restriction to make it diagnosis applicable to adults as well as children. Although the key features of the disorder can vary according to the individual’s age, always included is being excessively distressed when separated from the home or the attachment figure or even at the thought of such separation occurring.
Part of the anxiety people with the disorder experience is worry about harm befalling their attachment figure, such as him or her being kidnapped, a fear that can become extreme and irrational. This worry leads them to try to avoid spending any time apart or away from home, interfering with their ability to work or go to school. They need to sleep near their attachment figures and may have nightmares about separation. The prospect of separation may lead them to develop physical complaints such as headaches, stomachaches, or even nausea and vomiting.
Regardless of when the symptoms first become evident, people with this disorder were more likely to have suffered adversities during their childhood or traumatic events at some point in their lives. Females are more likely than males to experience separation anxiety disorder. People who develop this disorder are at greater risk of subsequently developing other anxiety disorders and depressive disorder (“internalizing” disorders) as well as ADHD and conduct disorder.
Theories of Separation Anxiety Disorder
Although twin studies supported the role of genetic contributions to this disorder, a novel children-of-twins study conducted by Swedish researchers suggested that anxiety is passed down from parents to children through environmental, rather than genetic, mechanisms. In other words, children with anxious parents learn to develop anxiety through modeling.
Sociocultural factors also play a role in predisposing certain individuals to developing separation anxiety disorder. The symptoms of the disorder seem to be more severe in countries that promote an individualistic, independent culture than in those with a more collectivist set of cultural norms. Remaining with attachment figures may seem more acceptable in collectivist cultures, so the behavior of individuals with separation anxiety disorder may not appear so out of the ordinary.
Trauma may also play a role in the development of separation anxiety disorder.
In the aftermath of the September 11 terrorist attacks in 2001, nearly 13
percent of New York City schoolchildren had a probable diagnosis of separation
anxiety disorder. It is possible that temperamental differences rooted in
biology cause some children to experience heightened reactivity in these kinds
of situations.
Treatment of Separation Anxiety Disorder
At present, the treatment literature does not include studies of adults, given that the condition was considered specific to childhood until DSM-5’s publication. For children, both behavioral and cognitive-behavioral therapies (CBT) seem to have the greatest promise. Behavioral techniques include systematic desensitization, prolonged exposure, and modeling. Contingency management and self-management are also useful in teaching the child to react more positively and competently to a fear-provoking situation.
Researchers investigating the effectiveness of this approach have developed a form of CBT that clinicians can administer in an intensive and time-limited manner, so children do not have to commit to weeks or months of therapy. In one version, girls with separation anxiety disorder attended a 1-week camp where they received intensive CBT in a group setting. The treatment included working with parents and their children in a combination of psychoeducation, cognitive restructuring, and relaxation training. Craft activities without the parents present took place at regularly scheduled times. At the end of the week, the children and their parents attended an awards ceremony. At that time, parents were also given training for follow-up during the weeks subsequent to camp. Relapse prevention training was also built into the final day’s activities to ensure that, should a bout of separation anxiety reoccur, parents and children did not revert completely to their pretreatment behavior.
Selective Mutism
Refusing to talk in specific situations is the core feature of selective mutism. Children with this disorder are capable of using normal language, but they become almost completely silent under certain circumstances, most commonly the classroom. Anxiety may be at the root of selective mutism given that children most typically show this behavior in school rather than at home.
Children with selective mutism seem to respond well to behavioral therapy. The clinician devises a hierarchy of desired responses, beginning by rewarding the child for making any utterances and then progressing through words and sentences, perhaps moving from the home to the clinic and eventually to the school. Another behavioral approach uses contingency management, in which children receive rewards if they engage in the desired behavior of speaking. Contingency management seems particularly well suited for use in the home by parents. Of the two methods, shaping plus exposure therapy seems to be more effective, but contingency management in the home can nevertheless serve as an important adjunct.
CBT is another method that produces improvement in children with selective mutism. An investigation of CBT’s effectiveness among children age 3 to 9 years showed high rates of improvement for children younger than 5 (78 percent) and less improvement for children 6 and older. The treatment, which was adapted for school settings, progressed through six levels, from speaking to the therapist with the parent present to ultimately speaking to other children with neither the therapist nor the parent present. Parents and teachers were instructed to use “defocused communication,” in which they minimize the direct pressure placed on the child to speak. CBT can have lasting benefits, as indicated in a follow-up showing the gains in these children persisting 5 years post-treatment.
Specific Phobias
A phobia is an irrational fear associated with a particular object or situation. It is common to have some fear of or at least a desire to avoid such objects as spiders or situations with enclosed spaces or heights. In a specific phobia, however, the fear or anxiety is so intense that it becomes incapacitating.
People with specific phobia go to great lengths to avoid the feared object or situation. If they can’t get away, they endure the situation but only with marked anxiety and discomfort. Like all anxiety disorders, a specific phobia induces significant distress. Moreover, it is not a fleeting condition but must be present for at least 6 months to justify a diagnosis.
Almost any object or situation, from the act of driving to syringes, can form the target of a phobia. However endless the list of possible specific phobias may be, they fall into four major categories: insects and animals, the natural environment (storms or fires), blood-injection-injury (seeing blood, having an invasive medical procedure), and engaging in activities in particular situations (riding an escalator, flying). A fifth category includes a variety of miscellaneous stimuli or situations such as fear of vomiting.
The two most common forms of specific phobia are fear of natural situations (particularly heights), and animal phobias.
Phobia Types
Insects and Animals
● Snakes
● Spiders
● Birds
● Dogs
The Natural
Environment
● Heights ● Water
● Storms
● Earthquakes
Blood-Injection-Injury
● Seeing blood ● Getting blood drawn
● Having an
invasive medical procedure
Situational
● Being in an enclosed space
● Driving
● Riding an escalator
Miscellaneous
● Vomiting ● Clowns
● Loud noises
Specific Phobias
Biological Theory and Treatment of Specific Phobias
There are many types of specific phobias, ranging from the common to the relatively obscure. However, the fact that they are grouped together suggests an underlying theme or element at the root of their cause and, potentially, their treatment.
Within the biological perspective, researchers believe the anxiety associated with specific phobias may relate to abnormalities in the anterior insular cortex. This area of the brain lies between the temporal and frontal lobes and is associated with emotion and self-awareness. The amygdala, which moderates the fear response, also seems to play a role in specific phobias, particularly those acquired through learning in which people associate a given stimulus with the emotion of fear.
Treatment of specific phobias following from the biological perspective focuses on symptom management. Clinicians operating from this perspective prescribe medications, primarily benzodiazepines, but only if their clients do not respond to other treatments. Unlike other forms of anxiety disorder, specific phobias are more circumscribed in nature and the situations are generally more easily avoided. Thus, clinicians would prescribe medications only when the specific phobia interferes with the individual’s ability to carry out ordinary activities to such a degree that he or she cannot function on a daily basis.
Behavioral Theory and Treatment of Specific Phobias
The behavioral approach to specific phobias emphasizes the conditioning that occurs when the individual learns to associate unpleasant physical sensations with a certain kind of stimulus or situation. Behaviorists assume there may be some adaptive value to having such reactions, because the situations may truly be ones we should fear, such as poisonous snakes. The symptoms become maladaptive, according to this view, as individuals begin to generalize an appropriate fear reaction to all stimuli in that category, including harmless ones.
According to the cognitive-behavioral view, individuals with specific phobias have overactive alarm systems for danger, and they perceive things as dangerous because they misinterpret harmless stimuli. For example, the mistaken perception of an object or a situation as uncontrollable, unpredictable, dangerous, or disgusting is correlated with feelings of vulnerability. These attributions might explain the common phobia of spiders, an insect about which people have many misconceptions and apprehensions. In blood-injection-injury phobia, in contrast, disgust and fear of contamination play a prominent role. People with phobias also tend to overestimate the likelihood of a dangerous outcome after becoming exposed to the feared stimulus.
Cognitive-behavioral treatment for specific phobia focuses on helping the client learn more adaptive ways of thinking about previously threatening situations and objects by challenging their irrational beliefs about the feared stimuli. For example, a therapist may show a young man with an elevator phobia that the disastrous consequences he believes will result from riding in an elevator are unrealistic and exaggerated. The client can also learn the technique of “talking to himself” while in this situation, telling himself that his fears are ridiculous, that nothing bad will really happen, and that he will soon reach his destination.
As illustrated in the following table, behavioral treatments vary according to the nature of the client’s exposure to the phobic stimulus (live or imaginal) and the degree of intensity with which the stimulus is confronted (immediate full
Graduated
Exposure
Imagery Systematic Desensitization
Immediate Full Exposure
Imaginal Flooding
exposure or exposure in graduated steps).
Live Graded in vivo In vivo flooding
Exposure Therapy
In exposure therapy, positive reinforcement is used to lead clients to substitute adaptive responses (relaxation) for maladaptive ones (fear or anxiety). The four methods of exposure therapy vary in the way this basic procedure is carried out
Systematic desensitization presents the client with progressively more anxiety-provoking images while at the same time the client is being trained to relax. The idea is that the client cannot feel both anxious and relaxed at the same time, and that over the course of treatment, anxiety will be completely replaced with relaxation.
In the behavioral technique called flooding, clients are totally immersed in the feared situation, where they feel the anxiety with full force. ● In vivo flooding exposes the client to the actual feared situation, such as the top floor of a tall building for a client who fears heights (In vivo flooding is probably the most stressful of any of the treatments described and therefore has a high dropout rate). ● Another variant of flooding is imaginal flooding, in which the clinician exposes the client virtually to the feared situation. ● An alternative is the graded in vivo method in which clients initially confront situations that cause only minor anxiety and then gradually progress toward those that cause greater anxiety. Often the therapist tries to be encouraging and to model the desired nonanxious response. (In treating a client who has a fear of enclosed spaces, the therapist could go with the client into smaller and smaller rooms. Seeing the therapist showing no signs of fear could lead the client to model the therapist’s response).
Virtual Reality Exposure Therapy
The most recently tested variant of exposure therapy uses virtual reality exposure therapy (VRET), in which clients become immersed in computer-generated environments that resemble the situations they fear.
Safer than in vivo therapy for obvious reasons and more realistic than imaginal methods, VRET would seem to be an ideal way to provide clients with experiences that can allow them to unlearn their fears.
It is quite likely that VRET will become increasingly used to treat specific phobias given the rapid growth in the availability of this form of technology.
Please create a discussion board thread giving an example of a specific phobia. Include what type of phobia it is (insect-animal,situational, etc.), and suggest a potential course of treatment.
Social Anxiety Disorder
The primary feature of social anxiety disorder is a fear of becoming humiliated or embarrassed in front of other people.
Extending beyond the ordinary concerns people may have about
looking foolish or making a mistake during a performance, this
disorder makes people anxious even at the prospect of eating or
drinking in front of others.
Thus, the fear is not of other people (it is not a phobia), but rather of
what other people may think of the individual. In DSM-IV-TR, the
disorder was referred to as social phobia; it was renamed in DSM-5
with “social phobia” in parentheses.
Social Anxiety Disorder
Biological Theory and Treatment of Social Anxiety Disorder
The biological underpinnings of social anxiety disorder may, some researchers believe, be related to partly heritable mechanisms. The intense anxiety experienced by an individual with social anxiety disorder, from this perspective, is essentially a form of intense shyness combined with the personality trait of neuroticism. These qualities in turn either cause or are caused by alterations in areas of the brain responsible for attention. Individuals with social anxiety disorder, according to this view, become excessively self-focused and therefore exaggerate the extent to which others look critically upon them.
Of the possible medications that can be used to treat social anxiety disorder, the selective serotonin or norepinephrine reuptake inhibitors (SSRIs and SNRIs) are regarded as having the greatest effectiveness. Other medications that may work as well have considerable drawbacks. Benzodiazepines have significant potential for abuse; moreover, they may actually interfere with treatment that includes psychological methods such as exposure to feared situations. MAOIs, which can also effectively manage social anxiety symptoms, have potentially dangerous side effects.
Cognitive Behavioral Theory and Treatment of Social Anxiety Disorder
Among psychological approaches, the cognitive-behavioral perspective regards people with social anxiety disorder as unable to gain a realistic view of how others really perceive them. As in other forms of cognitive-behavioral therapy, the clinician working from this perspective attempts to reframe the client’s thoughts in combination with real or imagined exposure.
Related to the cognitive-behavioral approach is the view of social anxiety disorder as reflecting a core fear of interacting with new people in new situations. Rather than viewing the various symptoms of the disorder as having independent origins, researchers working within this network model believe the specific fears (such as being unable to look new people in the eye or to take a test in front of others) may all be interrelated via a central connection to that core fear of strangers. Following this approach, therapy would attempt to treat the core set of fears, which would then have a cascade effect on the more peripheral symptoms.
Nevertheless, treatment of social anxiety disorder can be particularly challenging, because clients may tend to isolate themselves socially and therefore have fewer opportunities to expose themselves to challenging situations in the course of their daily lives. Their impaired social skills may then lead them to experience negative reactions from others, thus confirming their fears. Unfortunately, researchers attempting to use VRET find virtual scenarios less effective than in the treatment of specific phobias. Although virtual exposure may evoke similar responses as in vivo exposure to social situations, when it comes to reenacting those social situations in therapy, individuals need to be exposed to an actual audience.
For clients who do not respond to psychotherapy or medication, there are promising signs about the benefits of alternate methods, including motivational interviewing, acceptance and commitment therapy, and mindfulness/meditation. Their common element, also present in CBT, is the practice of stepping back from situations to identify and challenge automatic thoughts.
Panic Disorder
People with panic disorder experience periods of intense physical discomfort known as panic attacks.
During a panic attack, the individual feels overwhelmed by a range of highly unpleasant physical sensations. These can include respiratory distress (shortness of breath, hyperventilation, feeling of choking), autonomic disturbances (sweating, stomach distress, shaking or trembling, heart palpitations), and sensory abnormalities (dizziness, numbness, or tingling). During a panic attack, people may also feel that they are “going crazy” or losing control.
Having an occasional panic attack is not enough to justify a diagnosis of panic disorder. To meet the diagnostic criteria, the panic attacks have to occur on a repeated basis and be accompanied by fear of having another.
People with this disorder also might engage in avoidance behaviors, staying away from situations in which another panic attack might occur.
Panic attacks are somewhat common in that they are estimated to occur in 20 percent or more of adults; panic disorder has a much lower lifetime prevalence of between 3 and 5 percent.
Agoraphobia
In agoraphobia, the individual feels intense fear or anxiety triggered by real or anticipated exposure to situations such as using public transportation, being in an enclosed space such as a theater or an open space such as a parking lot, and being outside the home alone.
People with agoraphobia are fearful not of the situations themselves but of the possibility that they can’t get help or escape if they have panic-like symptoms or other embarrassing or incapacitating symptoms when in those situations.
Their fear or anxiety is out of proportion to the actual danger they might face. If they cannot avoid the situation, they become highly anxious and fearful, and to cope, they might require the presence of a companion.
As in other psychological disorders, these symptoms must persist over time (in this case, at least 6 months), cause considerable distress, and not be due to another psychological or medical disorder.
Theories and Treatment of Panic Disorder and Agoraphobia
Researchers studying biological contributions to panic disorder focus on norepinephrine, the neurotransmitter that helps prepare the body to react to stressful situations. Higher levels of norepinephrine can make the individual more likely to experience fear, anxiety, and panic. Serotonin may also play a role in increasing a person’s likelihood of developing panic disorder, as deficits in serotonin are linked to anxiety.
Furthermore, according to anxiety sensitivity theory, people who develop panic disorder have heightened responsiveness to the presence of carbon dioxide in the blood. Hence, they are more likely to panic due to the sensation that they are suffocating.
The most effective anti-anxiety medications for panic disorder and agoraphobia are benzodiazepines, which increase the availability of the inhibitory neurotransmitter GABA. However, because benzodiazepines can lead clients to become dependent on them or to abuse them, clinicians may prefer to prescribe SSRIs or SNRIs.
Theories and Treatment of Panic Disorder and Agoraphobia
From a classical conditioning perspective, panic disorder results from conditioned fear reactions in which the individual associates bodily sensations such as difficulty breathing with memories of the last panic attack, causing a full-blown panic attack to develop. The cognitive-behavioral model proposes that people with panic disorder, upon feeling the unpleasant sensations of the panic attack begin (loss of breath), believe it is unpredictable and uncontrollable and that they will not be able to stop it.
Adding to their desire to avoid the unpleasant emotions associated with these experiences, people with panic disorder and agoraphobia may also have personality traits that exacerbate their symptoms, including high levels of neuroticism and low levels of extraversion. Their tendency to ruminate, to prefer not to experience strong emotions, and to keep to themselves may serve to maintain their symptoms above and beyond whatever was their prior exposure to anxiety-provoking situations.
Relaxation training is one behavioral technique used to help clients gain control over the bodily reactions that occur in panic attacks. After training, the client should be able to relax the entire body when confronting a feared situation. Another approach focuses on breathing. The client is instructed to hyperventilate intentionally and then to begin slow breathing, a response that is incompatible with hyperventilation. Following this training, the client can begin the slow breathing at the first signs of hyperventilation. In addition to changing the response itself, this method allows clients to feel that they can exert voluntary control over the development of a panic attack. In the method known as panic-control therapy (PCT), the therapist combines breathing retraining, psychoeducation, and cognitive restructuring to help individuals recognize and ultimately control the bodily cues associated with panic attacks.
Generalized Anxiety Disorder
The key feature of generalized anxiety disorder is that, unlike the disorders you have learned about so far, it does not have a particular focus. People with generalized anxiety disorder feel anxious for much of the time, even though they may not be able to say exactly why they feel this way. In addition, they worry a great deal, apprehensively expecting the worst to happen to them.
Their symptoms span a range of physical and psychological experiences
including general restlessness, sleep disturbances, feelings of fatigue,
irritability, muscle tension, and trouble concentrating, to the point where
their mind goes blank.
There is no particular situation they can identify as lying at the root of
their anxiety, and they find it difficult to control their worrying.
There are differences between older and younger adults in the nature of
generalized anxiety disorder. Older individuals worry more about their
own health and family well-being, and young adults worry more about
their own future and the health of other people. Older adults also show
more sleep disturbances, are less likely to seek reassurance, and show
higher rates and severity of depression accompanying their anxiety.
Generalized Anxiety Disorder
Theories and Treatment of Generalized Anxiety Disorder
Biologically based theories of generalized anxiety disorder focus on disturbances in GABA, serotonergic, and noradrenergic systems. Support for the notion that there is a biological component to generalized anxiety disorder is the finding of an overlap in genetic vulnerability with the personality trait of neuroticism. In other words, people who are prone to developing this disorder have inherited an underlying neurotic personality style.
Cognitive-behavioral therapy builds on the assumption that the anxiety people with this disorder experience results from cognitive distortions in their interpretation of the minor inconveniences of life. Clinicians using this approach attempt to break the cycle of negative thoughts and worries by helping clients learn how to recognize anxious thoughts, to seek more rational alternatives to worrying, and to take action to test these alternatives. Once the cycle of worry has been broken, the individual can develop a sense of control over the worrying behavior and become better able to manage and reduce anxious thoughts when they threaten to become overwhelming.
Another compounding factor in generalized anxiety disorder may be the individual’s inability to tolerate uncertainty or ambiguity. The outcomes of many common situations in life are indeed ambiguous. People with this disorder seek to reduce uncertainty by trying to know exactly what will happen when, without taking into account the fact that it is not always possible to know the outcome of every situation. Cognitive-behavioral therapy can be of benefit in helping individuals with the disorder come to accept such ambiguities.
Cognitive-behavioral therapy is therefore considered the method of choice in treating individuals with generalized anxiety disorder, particularly because it avoids the potentially negative side effects of antianxiety medications. Researchers are continuing to explore variations in the basic cognitive-behavioral approach to give individuals a broader set of options. Acceptance and commitment therapy (ACT) is thought to have similar mechanisms to CBT and is gaining evidence as a stand-alone treatment for various anxiety disorders.
Obsessive Compulsive Disorder
An obsession is a recurrent and persistent thought, urge, or image that the individual experiences as intrusive and unwanted. Individuals try to ignore or suppress the obsession or to neutralize it by engaging in some other thought or action. The thought or action the person uses to try to neutralize the obsession is known as a compulsion, a repetitive behavior or mental act the person feels driven to carry out according to rigid rules. Compulsions need not, however, be paired with obsessions.
In obsessive-compulsive disorder (OCD), individuals experience either obsessions or compulsions to such an extent that they find it difficult to conduct their daily activities. As part of the disorder, they may experience significant distress or impairment in their ability to work and have a satisfying family or social life.
Obsessive Compulsive Disorder
The most common compulsions experienced by people with OCD are repeated behaviors such as washing and cleaning, counting items, putting items in order, checking, or requesting assurance. These compulsions may also take the form of mental rituals, such as counting up to a certain number every time the individual has an unwanted thought. Some individuals with OCD experience tics, which are uncontrollable motor movements such as twitches, vocalizations, and facial grimaces.
In general, there appear to be four major dimensions of the
symptoms of OCD. These are the needs for:
● Symmetry
● Order
● Cleanliness
● The saving of apparently useless items
Yale-Brown Obsessive-Compulsive Symptom Checklist Items
|
Aggressive obsessions |
|
Contamination obsessions |
Fear might harm self
Fear of blurting out obscenities
Fear will be responsible for something else terrible happening (e.g., fire, burglary)
Concerns or disgust with bodily waste or secretions (e.g., urine, feces, saliva)
Bothered by sticky substances or residues
Miscellaneous obsessions Fear of saying certain things
Lucky/unlucky numbers
Superstitious fears
Cleaning/washing compulsions Excessive or ritualized hand-washing
Excessive or ritualized showering, bathing, toothbrushing, grooming, or toilet
routine
Checking compulsions Checking locks, stove, appliances, etc.
Sexual obsessions Forbidden or perverse sexual thoughts, images, or impulses Sexual behavior toward others (aggressive)
Hoarding/saving obsessions Distinguish from hobbies and concern with objects of monetary or sentimental value
Checking that did not make mistake completing a task
Repeating rituals Rereading or rewriting
Need to repeat routine activities (e.g., in/out door, up/down from chair)
Religious obsessions Concerned with sacrilege and blasphemy Excess concern with right/wrong, morality
Counting compulsions +
Ordering/arranging compulsions
(Check for presence)
Obsession with need for symmetry or exactness Accompanied by magical thinking (e.g., concerned that another will have an accident unless things are in the right place)
Somatic obsessions Concern with illness or disease Excessive concern with body part or aspect of appearance (e.g.,
dysmorphophobia)
Hoarding/collecting compulsions Distinguish from hobbies and concern with objects of monetary or sentimental value
(e.g., carefully reads junk mail, sorts through garbage)
Miscellaneous compulsions Excessive list making
Need to tell, ask, or confess
Need to touch, tap, or rub
Rituals involving blinking or staring
Theories and Treatment of OCD
Given the prominent role in OCD of motor movements such as cleaning and ordering, the biological basis for the disorder has long been thought to originate in abnormalities in the basal ganglia, which are subcortical areas of the brain active in motor control. Further contributing to the motor symptoms was thought to be failure of the prefrontal cortex to inhibit unwanted thoughts, images, or urges. Brain scan evidence now supports these explanations, showing heightened levels of activity in the brain’s motor control centers of the basal ganglia and frontal lobes.
The most effective biological treatment for OCD is clomipramine (a tricyclic antidepressant) or an SSRI such as fluoxetine or sertraline. In extreme cases in which no other treatments provide symptom relief, people with OCD may be treated with psychosurgery. For example, deep-brain stimulation to areas active in motor control can help relieve symptoms by reducing the activity of the prefrontal cortex, which in turn may help reduce the frequency of obsessive-compulsive thoughts.
The cognitive-behavioral perspective on OCD proposes that maladaptive thought patterns contribute to the development and maintenance of OCD symptoms. Individuals with OCD may be primed to overreact to anxiety-producing events in their environment. Such priming may place OCD in a spectrum of so-called internalizing disorders that include other anxiety and mood disorders invoking a similar pattern of startle reactivity. For people with OCD, these experiences become transformed to disturbing images, which they then try to suppress or counteract by engaging in compulsive rituals. Complicating their symptoms are beliefs in the danger and meaning of their thoughts, or their
“metacognitions,” which lead people with OCD to worry, ruminate, and feel they must monitor their every thought. Additionally, people with OCD may be high in the personality trait of perfectionism, a component of neuroticism, that can be thought of as a cognitive vulnerability unique to this disorder.
Cognitive-behavioral therapy is currently regarded as the most effective treatment for OCD. In addition to reducing target symptoms, cognitive-behavioral therapy had beneficial effects on the individual’s everyday quality of life
Body Dysmorphic Disorder
People with body dysmorphic disorder (BDD) are preoccupied with the idea that a part of their body is ugly or defective. Their preoccupation goes far beyond the ordinary dissatisfaction many people feel about the size and shape of their body or appearance of a particular body part. People with BDD may check themselves constantly, groom themselves to an excessive degree, or constantly seek reassurance from others about how they look. They don’t necessarily see themselves as fat or excessively heavy, both of which are common concerns in Western cultures, but they may believe that their body build is too small or not muscular enough.
The DSM-5 reclassified BDD from its prior placement in the anxiety disorders to its current inclusion with obsessive-compulsive and related disorders. The main change was to include repetitive behaviors, such as checking the mirror or seeking reassurance, as part of the criteria, changes that seem to have improved diagnostic accuracy.
This modification of the Yale–Brown Obsessive-Compulsive Scale uses the following criteria to determine the severity of the client’s symptoms regarding the presumed body defect or defects:
1. Time occupied by thoughts about body defect
2. Interference due to thoughts about body defect
3. Distress associated with thoughts about body defect 4. Resistance against thoughts about body defect
5. Degree of control over thoughts about body defect
6. Time spent in activities related to body defect such as mirror checking, grooming, excessive exercise, camouflaging, picking at skin, asking others about defect
7. Interference due to activities related to body defect 8. Distress associated with activities related to body defect 9. Resistance against compulsions
10. Degree of control over compulsive behavior 11. Insight into the nature of excessive concern over defect 12. Avoidance of activities due to concern over defect
Body Dysmorphic Disorder
As many as 87 percent of women are dissatisfied with some aspect of their body’s appearance. Overall, however, at any one point in time, the prevalence of BDD is a much lower 2.5 percent of women and 2.2 percent of men. The most common areas that concern people with BDD differ by gender, with men more likely to be concerned with their body build and thinning hair, and women with their weight and hip size.
BDD is frequently accompanied by major depressive disorder, social anxiety disorder, obsessive-compulsive disorder, and eating disorders. Clients’ distress clearly can become intense. Completed suicides are 45 times more common among people with this disorder than in the
general U.S. population.
Treatment of Body Dysmorphic Disorder
Treatment of BDD from a biological perspective includes medications, particularly SSRIs, that can reduce the associated symptoms of depression and anxiety as well as the more obsessive symptoms of distress, bodily preoccupations, and compulsions. Once on SSRIs, people with BDD can experience improved quality of life and overall functioning and perhaps gain insight into their disorder.
From a psychosocial perspective, people with BDD may have experienced being teased about their appearance or made to feel sensitive in some other way during a time when their identities were in a critical period of formation. Once they start to believe that their bodily appearance is defective or deviates from the ideal to which they aspire, they become preoccupied with this belief, setting off a series of dysfunctional thoughts and repetitive behaviors. For example, they may look at an ordinary feature of their appearance, such as their waist size, and see only their “too large” waist when they view themselves. Their selective attention to this body part is accompanied by the belief
that no one could possibly like them, which in turn can lead them to avoid social situations and engage in rituals such as looking in the mirror and frequently studying their waist.
Clinicians treating clients with BDD from a cognitive-behavioral perspective focus on helping them to understand that appearance is only one aspect of their total identity, while at the same time challenging them to question their assumptions that their appearance is, in fact, defective. The clinician may also help these individuals realize that other people looking at them may not even be thinking about their appearance at all, or if so, not critically.
In one hands-on cognitive technique, clinicians encourage clients to look at themselves in a mirror and change their negative thoughts about what they see. Interpersonal therapy can also help people with BDD develop improved strategies for dealing with the distress they feel in their relationships with others, as well as addressing their low self-esteem and depressed mood.
Hoarding Disorder
In the compulsion known as hoarding, people have persistent difficulties discarding or parting with their possessions, even if they are not of much value. These difficulties include any form of discarding, including putting items into the garbage. People with hoarding disorder believe these items have utility or aesthetic or sentimental value, but in reality they often consist of old newspapers, bags, or leftover food.
When faced with the prospect of discarding the items, these individuals become
distressed, while their homes can become unlivable due to the clutter that
accumulates over the years. The rooms fill up with a mixture of objects that actually
are of value and items that ordinarily would be thrown away, such as old magazines.
Unlike ordinary collectors, who organize their items in a systematic way, people with
hoarding disorder accumulate items without any form of organization.
A substantial percentage of adults with hoarding disorder also have comorbid
depressive symptoms. Older adults who develop hoarding disorder are likely to
become physically and cognitively impaired, experiencing significant effects on their
daily functioning.
Hoarding Disorder
Treatment of Hoarding Disorder
Treatment of hoarding disorder that follows a biopsychosocial approach appears to be the most effective. Biological treatments have traditionally included SSRIs, but researchers believe the disorder may also have a neurocognitive component that would warrant treatment through addressing cognitive function. For example, people with hoarding disorder may have a form of ADHD in which they lack the ability to focus their attention on specific details. Hoarding disorder is also becoming understood from a developmental perspective as reflecting attachment difficulties and growing up in a household that lacked warmth.
Home visits in which the therapist uses cognitive-behavioral methods seem to hold the most promise, particularly in encouraging clients to discard their hoarded items. Practical assistance from movers or professional organizers may also be useful in supplementing medications and cognitive-behavioral treatment. Friends, family members, and local officials may also be consulted to assist in clearing the individual’s living space.
Trichotillomania (Hair-Pulling Disorder)
A diagnosis of trichotillomania (hair-pulling disorder) is given to individuals who pull out their hair in response to an increasing sense of tension or urge. After they pull their hair, they feel
temporary relief, pleasure, or gratification. People with trichotillomania are upset by their
uncontrollable behavior and may find that their social, occupational, or other areas of functioning are impaired because of the disorder. They feel unable to stop the behavior, even when it results in bald patches and lost eyebrows, eyelashes, armpit hair, and pubic hair. As they get older, they
increase the number of bodily sites from which they pull hair.
People with this disorder experience significant impairment in areas of life ranging from sexual intimacy to social activities, medical examinations, and haircuts. They can also develop skin
infections, scalp pain or bleeding, and carpal tunnel syndrome. Psychologically, they may suffer low self-esteem, shame and embarrassment, depressed mood, irritability, and argumentativeness. Their impairments appear early in life and continue through to middle and late adulthood. Those who also eat the hair they pull can develop hairballs, which settle in their gastrointestinal tract and cause abdominal pain, nausea and vomiting, weakness, and weight loss.
Trichotillomania
Diagnosable trichotillomania is relatively rare, with an estimated current prevalence rate of 0.6 percent. However, trichotillomania may be underreported because people with this disorder are secretive about the behavior and tend to engage in hair pulling only when alone.
In DSM-IV-TR trichotillomania was included in the category of impulse-control disorders, but in DSM-5 it moved to the category that includes obsessive-compulsive and related disorders. In addition, the name changed to hair pulling, which the DSM-5 authors concur is a better description of the disorder than “mania.”
There may be two types of hair pulling:
● In the “focused” type, which may account for one-quarter of cases, the individual is aware of having the urge to pull and may develop compulsive behaviors or rituals to avoid doing so. For people in the focused category, depression and disability are likely to occur along with stress and anxiety.
● In “automatic” hair pulling, the individual is engaged in another task or is absorbed in thought while pulling hair. Individuals who fall into the automatic category experience pronounced stress and anxiety.
Theories Behind Trichotillomania
Genetics seems to play an important role in trichotillomania, with an estimate of 80 percent heritability of the disorder. Abnormalities in a gene on chromosome 1 known as SLTRK1 may play a role in the disorder; this gene is also linked to Tourette’s disorder. Researchers have also identified abnormalities in SAPAP3, a gene related to glutamate, which in turn is implicated in obsessive-compulsive disorder. The neurotransmitters serotonin, dopamine, and glutamate are, in turn, thought to play a role in the development of trichotillomania. Brain imaging studies of individuals with trichotillomania suggest that they may also have abnormalities in brain regions active in attentional control, memory, and the ability to suppress automatic motor reactions.
Taking account of these abnormalities in neurotransmitter and brain functioning, the regulation model of trichotillomania suggests that individuals with this disorder seek an optimal state of emotional arousal, providing them with greater stimulation when they are understimulated and calming them when they are overstimulated. At the same time, hair pulling may bring them from a negative to a positive affective state.
Using the Trichotillomania Symptoms Questionnaire, researchers conducting an online survey found that individuals who engaged in hair pulling experienced more difficulty controlling their emotions than those who did not. There were subgroups in the sample, which varied in whether the subjects were more likely to experience boredom or anxiety and tension, and in the overall intensity of emotions they felt that seemed to drive them toward hair pulling. The researchers suggested that these subgroups on the questionnaire seemed to correspond to the automatic and focused subtypes of the disorder.
Trichotillomania Symptoms
Questionnaire
1. Do you currently pull your hair out?
2. At any point in your life, including now, have you had periods of uncontrollable hair-pulling?
3. Do you (or did you in the past) experience urges to pull your hair out?
4. Do you (or did you in the past) try to resist pulling your hair out?
5. Do you (or did you in the past) feel relief when pulling your hair out?
6. Do you (or did you in the past) wish that the urge to pull your hair out would go away?
7. Have you been diagnosed with trichotillomania by a professional?
8. Do you, or did you in the past, feel shame, secrecy, or distress about your hair-pulling?
Trichotillomania Treatment
Pharmacological treatments for trichotillomania include antidepressants, atypical antipsychotics, lithium, and naltrexone. Of these, naltrexone seems to have shown the most promising results. However, the results of controlled studies are not compelling and do not seem to justify the use of medications when weighed against the side effects, which can include obesity, diabetes, neurotoxicity, delirium, encephalopathy, tremors, and hyperthyroidism, among others.
The behavioral treatment of habit reversal training (HRT) is regarded as the most effective approach to treating trichotillomania. Not only does this method prevent the side effects of medication, but it is more successful in reducing the symptoms of hair pulling; however, for treatment-resistant individuals, a combination of medication and HRT may be required. In HRT, the individual learns a new response to compete with the habit of hair pulling, such as fist clenching. The key feature is that the new response is incompatible with the undesirable habit. Dialectical behavior therapy (DBT) may add to these methods a combination of mindfulness training, in which clients learn to identify the cues that trigger their hair pulling, and imagery training, in which they visualize themselves in a tranquil state.
Combining acceptance and commitment therapy (ACT) with HRT is also shown to produce relief from hair-pulling symptoms. Cognitive-behavioral therapy can help in treating children and adolescents with trichotillomania, with very little alteration from the basic protocol used for adults. In one study, 77 percent of those who received treatment remained symptom-free after 6 months. An advantage of ACT for this disorder is that it can be administered along with cognitive-behavioral treatment in a group format with results as effective as those obtained with individual therapy.
Although trichotillomania can be a highly disabling condition, there is promise in the range of therapies based on behavior therapy, cognitive-behavior therapy, and the newer approaches that help individuals identify and cope with the feelings associated with the behavior. Newer therapies are also including psychoeducation to provide clients with the opportunity to gain insight into their disorder.
Excoriation (Skin-Picking) Disorder
In a new diagnosis in DSM-5, individuals are regarded as having excoriation (skin-picking) disorder if they repeatedly pick at their own skin, perhaps as much as several hours a day. The skin picking may be of healthy skin, skin with mild irregularities (such as moles), pimples, calluses, or scabs. People with this disorder pick at these bodily areas either with their own fingernails or with instruments such as tweezers. When they are not picking their skin, they think about picking it and try to resist their urges to do so. They may attempt to cover the evidence of their skin picking with clothing or bandages, and they feel ashamed of and embarrassed about their behavior.
Because this is a new diagnosis, epidemiological data are limited,
but DSM-5 estimates the prevalence as at least 1.4 percent of
adults, three-quarters of whom are female. Researchers believe skin
picking is valid as a distinct diagnosis from trichotillomania.
However, the two disorders share causes and effective treatment
approaches. For some individuals with excoriation disorder, high
levels of impulsivity also appear to play an important role.
Trauma and Stressor-Related Disorders
Individuals who are exposed to trauma or a stressful event may be at risk for developing a psychological disorder. The category of trauma- and stressor-related disorders have as a diagnostic criterion the condition of an actual event that acts as a precipitant.
DSM-5 includes disorders in this group that were originally in their own category within the anxiety disorders. The DSM-5 also places into this category a set of disorders in childhood that can be traced to exposure to stress or trauma.
Reactive Attachment and Disinhibited Social Engagement Disorder
In this first of the trauma- and stressor-related disorders we find reactive attachment disorder (RAD), a diagnosis given to children who literally “react against” attachment to others.
Their symptoms include becoming withdrawn and inhibited. They tend not to show positive affect, but they also lack the ability to control their emotions. Unlike normal children, when they become distressed, they do not seek comfort from adults.
The diagnosis of disinhibited social engagement disorder describes an opposite situation in which a child with a history of trauma engages in culturally inappropriate, overly familiar behavior with people who are relative strangers.
These disorders are placed among the trauma- and stressor-related disorders because they are found in children who have experienced an abuse pattern of social neglect, repeated changes of primary caregivers, or rearing in institutions with high child-to-caregiver ratios. Consequently, such children are significantly impaired in their ability to interact with other children and adults.
Acute Stress Disorder
A trauma is said to occur when an individual is exposed, either once or repeatedly, to circumstances that are harmful or life threatening and that have lasting adverse effects on the individual’s functioning and mental health. When people are exposed to the threat of death, or to actual or threatened serious injury, or sexual violation, they risk developing acute stress disorder. Being exposed to the death of others, or to any of these events, real or threatened, to others can also lead to the development of this disorder.
The symptoms of acute stress disorder fall into four categories: intrusion of distressing reminders of the event, dissociative symptoms such as feeling numb or detached from others, avoidance of situations that might serve as reminders of the event, and hyperarousal including sleep disturbances or irritability. The symptoms may persist for a few days to a month after the traumatic event.
Post Traumatic Stress Disorder
The events that can cause acute stress disorder may lead to the longer-lasting disorder known as post-traumatic stress disorder (PTSD).
If the individual experiences acute stress disorder symptoms for more than a month, the clinician assigns the PTSD diagnosis.
The intrusions, dissociation, and avoidance seen in acute stress disorder are also present in PTSD.
Symptoms also include loss of memory of the event, excessive self-blame, distancing from others, and inability to experience positive emotions.
Post Traumatic Stress Disorder
The diagnosis of PTSD has a long history. The Vietnam War was perhaps the most publicized war to produce psychological casualties, but reports of psychological dysfunction following exposure to combat emerged after the Civil War. In World Wars I and II, the condition was referred to with such terms as shell shock, traumatic neurosis, combat stress, and combat fatigue. Survivors of European concentration camps in the 1930s and 1940s also were reported to suffer long-term psychological effects, including chronic depression, anxiety, and difficulties in interpersonal relationships due to guilt over having survived when so many others were killed.
Although PTSD is often studied among male combat veterans, researchers are beginning to examine the phenomenon in women exposed to trauma during their military service. A traumatic experience more likely to affect women than men is sexual assault. Women exposed to combat-related trauma and sexual assault show a cumulatively higher risk of developing both PTSD and substance use disorders
Theories and Treatment of PTSD
A traumatic experience is an external event that impinges on the individual and hence does not have biological “causality.” However, researchers propose that traumatic experiences have their impact in part because they do lead to changes in the brain that make certain regions primed or hypersensitive to possible danger in the future. Individuals with PTSD experience alterations in the hippocampus, the structure in the brain responsible for consolidating short-term memory. As a result, these individuals become unable to distinguish relatively harmless situations (such as fireworks) from the ones in which real trauma occurred (such as combat). They continue to re-experience the event with heightened arousal and therefore avoid situations that resemble those in which they were traumatized.
SSRI antidepressants are the only FDA-approved medications for people with PTSD. However, the response rates of patients with PTSD to these medications are rarely more than 60 percent, and fewer than 20 to 30 percent achieve full remission of their symptoms. Research does not support the use of benzodiazepines in treatment of PTSD, although these medications may relieve insomnia or anxiety. Although researchers believed the antipsychotic medication risperidone might benefit individuals with PTSD, findings from a large-scale study of nearly 300 veterans did not provide empirical support for its use in reducing symptoms.
From a psychological perspective, people with PTSD have a biased information-processing style that, due to the trauma they experienced, causes their attention to be highly attuned toward potentially threatening cues. Therefore they are more likely to feel that they are in danger, and also are more likely to avoid situations they perceive as potentially threatening. Personality and coping style also predict responses to trauma, including high levels of neuroticism and extreme sensitivity to internal cues of anxiety.
Theories and Treatment of PTSD
Generally considered the most effective psychological treatment for PTSD, cognitive-behavioral therapy combines some type of exposure (in vivo or imaginal) with relaxation and cognitive restructuring. Specific trauma-focused psychotherapy that focuses on memory of the traumatic event or its meaning is gaining support as a first-line treatment. Trauma-focused therapy produces longer-lasting results without the side effects associated with psychotropic interventions. The American Psychological Association’s Clinical Practice Guidelines for the Treatment of PTSD in Adults also strongly recommended cognitive-behavioral and exposure therapy and, if medication is indicated, the use of SSRIs but not antipsychotics.
Because trauma is so often a component of other disorders, including substance use disorders, the U.S. government’s Substance Abuse and Mental Health Services Administration (SAMHSA) has compiled a treatment manual for clinicians working in behavioral health. This manual is based on the principles of trauma informed care, a model that promotes trauma awareness and understanding to professionals treating individuals with a history of trauma. The idea of resilience is central to this philosophy of treatment, helping individuals foster their own inner strengths as they develop a greater sense of competence. Furthermore, according to the principles of trauma informed care, clinicians must avoid retraumatizing clients who already have histories of trauma.
Couples therapy is another method that can prove beneficial in reducing symptoms as well as reducing distress both in the individual and in the individual’s partner. Such an approach can help lower reintegration stress in both partners, improving their communication and expression of intimacy and reducing the number of disagreements about parenting.
Post-Traumatic
Growth An alternative view to PTSD comes from the
field of positive psychology, which proposes
that people can grow through the experience
of trauma, a phenomenon known as
post-traumatic growth.
According to this approach, trauma can allow
clients to cope by developing positive
interpretations of their experiences.
Anxiety,
Obsessive-Compulsive, and Trauma- and
Stressor-Related Disorders: The Biopsychosocial
Perspective
The disorders we covered in this lecture span a broad spectrum of problems, ranging from specific and seemingly idiosyncratic responses to diffuse and undifferentiated feelings of dread. There are differences among the disorders in symptoms and causes, but there do seem to be important similarities in that they all involve regions of the brain active in responding to fearful or threatening situations. Perhaps what determines whether an individual with a propensity toward developing an anxiety disorder does so are the combined effects of genetics, brain functioning, life experiences, and social context. Across these disorders, there also appear to be similarities in treatment approach, with cognitive-behavioral methods showing perhaps the greatest effectiveness.
Sources
Image 1: https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml
Image 2: https://www.therecoveryvillage.com/mental-health/separation-anxiety/
Image 3: https://www.wsj.com/articles/virtual-reality-as-a-therapy-tool-1443260202
Image 4: https://www.verywellmind.com/social-anxiety-disorder-symptoms-and-diagnosis-4157219
Image 5: https://www.verywellmind.com/social-anxiety-disorder-causes-3024749
Image 6: https://www.verywellmind.com/top-symptoms-of-panic-attacks-2584270
Image 7: https://www.findatopdoc.com/Top-Videos-and-Slideshows/Agoraphobia
Image 8: https://www.verywellmind.com/dsm-5-criteria-for-generalized-anxiety-disorder-1393147
Image 9: https://www.verywellmind.com/gad-causes-risk-factors-1392982
Image 10: https://www.helpguide.org/articles/anxiety/obssessive-compulsive-disorder-ocd.htm
Image 11: https://www.wikihow.com/Cope-With-Obsessive-Compulsive-Disorder
Image 12: https://metro.co.uk/2018/03/02/three-people-reveal-what-its-like-to-live-with-body-dysmorphic-disorder-7355573/ Image 13: https://coard.psychiatry.ufl.edu/hoarding-2/
Image 14: https://www.trichstop.com/info
Image 15: http://coard.psychiatry.ufl.edu/research/participate-in-research/
Images 16-18: https://mindcology.com/mental-health/anxiety/statistics-acute-stress-disorder-infographic/
Image 19: https://synapse.koreamed.org/ViewImage.php?Type=F&aid=17747&id=F1&afn=55_JKNA_54_1_32&fn=jkna-54-32-g001_0055JKNA
Video 1: https://www.youtube.com/watch?v=PCOg2G797ek
Video 2: https://www.youtube.com/watch?v=PnV6KqJ0OfU
Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education. Kindle Edition.
Dissociative and Somatic Symptom Disorders SSY 230: Lecture 8
Dissociative Disorders
The human mind seems almost endlessly capable of dissociating, or separating attentional focus. You can think intensively about a problem while jogging, perhaps not even realizing that you ran a mile without being aware of your surroundings. In dissociative disorders, this separation of a person’s mental functions occurs to a far more extreme degree than what many people experience in daily life.
Dissociative disorders raise intriguing questions about the ways in which people’s sense of self evolves over time, and the way memory and sense of reality can become fragmented and distinct within the same individual. In contrast, somatic symptom disorders, discussed later in this lecture, raise equally fascinating questions about mind-body relationships.
Dissociative Identity Disorder
DID
In dissociative identity disorder (DID), separate personalities and identities can develop within the same individual. The separate personalities seem to have their own unique characteristic ways of perceiving, thinking, and relating to others.
By definition, people with DID have at least two distinct identities and, when inhabiting the identity of one, are not aware that they also inhabit the other.
As a result, their experiences lack continuity. They have large gaps in important memories about themselves and their lives, often memories of a traumatic nature such as being victimized or abused.
Dissociative
Amnesia
People with dissociative amnesia are unable to remember information about an event or set of events in their lives.
This type of memory loss is different from the everyday slips that cause us to misplace objects or forget people’s names. People with dissociative amnesia forget a specific event in their lives, most likely one of a traumatic or stressful nature.
Their amnesia may even invoke a fugue state, an episode of amnesia that leaves them unable to recall some or all of their past and identity, along with either bewildered wandering or travel that seems focused on a particular purpose.
Depersonalization/Derealization Disorder
Your ordinary perception of who you are includes
knowing that you live within your own body.
Depersonalization is the condition in which people
feel their identities have become detached from their
bodies. They may have experiences of unreality, of
being an outside observer, and of emotional or
physical numbing. Derealization is a condition in
which people feel a sense of unreality or detachment
from their surroundings.
Depersonalization/derealization disorder is a
condition in which people have the experience of
depersonalization, derealization, or both.
Theories of Dissociative Disorders
In normal development, people integrate the perceptions and memories they have of themselves and their experiences. You can remember many of the events from your past, which give you a sense of continuity over time. In a dissociative disorder, the individual loses this continuity, trying to block out or separate from conscious awareness events that caused extreme psychological, if not physical, pain.
Clinicians face a daunting task in both diagnosing and treating an individual’s dissociative symptoms. In the first place, they must determine whether the condition is real or fabricated. People may deliberately feign a dissociative disorder to gain attention or avoid punishment. As a result of the potential fabrication of dissociative disorder by people who appear to have its symptoms, DID remains one of the most controversial of psychological disorders .
In true cases of a dissociative disorder, when the symptoms do not appear feigned, the current consensus is that the dissociation is a response to early emotional or physical trauma. One large psychiatric outpatient study demonstrated that people with dissociative symptoms in fact had high prevalence rates of both physical and sexual abuse in childhood. However, many people without a dissociative disorder have been subjected to traumatic events early in life that they do remember. Along similar lines, traumatic experiences in childhood can lead to other types of disorders.
The question remains why some individuals exposed to trauma develop a dissociative disorder, but others do not.
Treatment of Dissociative Disorders
Assuming that people with dissociative disorders are reacting to trauma by developing dissociative symptoms, the treatment goal becomes primarily one of integrating the disparate parts of self, memory, and time within the person’s consciousness. Treatment guidelines for dissociative identity disorder emphasize best practices such as establishing and maintaining a strong therapeutic alliance, not playing favorites with any of the alters, and, from a positive psychology perspective, helping clients see themselves and their worlds in a more favorable manner by restoring their shattered assumptions.
As a specific technique, cognitive-behavioral therapy is well suited to helping clients with dissociative identity disorder develop a coherent sense of themselves and their experiences. To help clients view themselves more favorably, clinicians can stimulate them to question long-held core assumptions about themselves that are contributing to their symptoms. For example, they may believe they are responsible for their abuse, or that it is wrong for them to show anger toward their abusers, or that they can’t cope with their painful memories. By confronting and then changing these cognitions, clients can gain a sense of control that will allow them to incorporate those memories into their sense of self.
Clinicians should also attend to the comorbidity of a dissociative disorder with other symptoms, including post-traumatic stress disorder. Treatment of dissociative disorders often addresses not only these disorders themselves but also associated disorders of mood, anxiety, and post-traumatic stress.
SCID-D-R Items
The Structured
Clinical Interview for DSM–IV
Dissociative
Disorders–Revised (SCID-D-R) includes a careful
structuring,
presentation, and scoring of questions to aid expert
clinicians in
determining an accurate diagnosis.
Scale Items
Amnesia Have you ever felt as if there were large gaps in your memory?
Depersonalization Have you ever felt that you were watching yourself from a point outside of your body, as if you were seeing yourself from a distance (or watching a movie
of yourself)?
Have you ever felt as if a part of your body or your whole being was foreign
to you?
Have you ever felt as if you were two different people, one going through the
motions of life and the other part observing quietly?
Derealization Have you ever felt as if familiar surroundings or people you knew seemed unfamiliar or unreal?
Have you ever felt puzzled as to what is real and what’s unreal in your
surroundings?
Have you ever felt as if your surroundings or other people were fading away?
Identity confusion Have you ever felt as if there was a struggle going on inside of you? Have you ever felt confused as to who you are?
Identity alteration Have you ever acted as if you were a completely different person? Have you ever been told by others that you seem like a different person?
Have you ever found things in your possession (for instance, shoes) that
belong to you, but you could not remember how you got them?
Somatic Symptom and Related Disorders
In the group of disorders in which somatic symptoms are prominent, people experience physical problems and/or concerns about medical symptoms.
The term somatic comes from the Greek word soma, meaning “body.” Somatic symptom disorders are psychological in nature, because although people with these disorders may or may not have a diagnosed medical condition, they seek treatment for their physical symptoms and associated distressing behaviors, thoughts, and feelings.
Somatic Symptom Disorder
People with somatic symptom disorder have physical symptoms that may or may not be accounted for by a medical condition; they also have maladaptive thoughts, feelings, and behaviors. These symptoms disrupt their everyday lives.
People with this disorder think to a disproportionate degree about the seriousness of their symptoms, feel extremely anxious about them, and spend a great deal of time and energy on the symptoms or their concerns about their health. Although it may appear that people with this diagnosis are intentionally manufacturing symptoms, they actually are not consciously attuned to the ways in which they express these psychological problems physically.
The somatic symptoms individuals experience may include pain as the primary focus. A diagnosable medical condition may exist, but it cannot account for the amount and nature of the pain clients report. There are also clients with pain disorder for whom no diagnosable medical condition exists.
Further complicating the picture in the diagnosis and treatment of somatic symptom disorder is the fact that often people with this disorder also have other psychological disorders, including major depressive disorder, panic disorder, and agoraphobia. Researchers are also attempting to rule out the role of diagnosable medical conditions that may be associated with somatic symptom disorder and its comorbid anxiety and depressive disorders.
Illness Anxiety Disorder
People with illness anxiety disorder fear or mistakenly believe that normal bodily reactions represent the symptoms of a serious illness. They easily become alarmed about their health and seek unnecessary medical tests and procedures to rule out or treat their exaggerated or imagined illnesses.
Their worry is not about the symptoms themselves but about the possibility that they have a serious disease. They also are preoccupied with their mistaken beliefs about the seriousness of their symptoms.
They may turn to non-medical abuse of prescription drugs, which in turn can expose them to harmful side effects as well as to dependence on the medications themselves.
Conversion Disorder
The essential feature of conversion disorder (functional neurological symptom disorder) is that the individual experiences a change in a bodily function that is not due to an underlying medical condition. The forms the disorder can take range from movement abnormalities such as paralysis or difficulty walking to sensory abnormalities such as inability to hear or see.
The term conversion in the name of this disorder refers to the transformation of psychological conflict to physical symptoms presumed to underlie the disorder. The term functional neurological symptom disorder in parentheses represents an alternate way of referring to the disorder that some clinicians may prefer. In some ways it is more descriptive than “conversion,” which has historic roots in Freudian psychoanalysis in which the assumption was made that psychological conflicts “convert” or transfer into what look like neurological symptoms, such as paralysis. Functional in this context refers to abnormal functioning of the central nervous system. It is somewhat awkward to use the complete form of the disorder’s name, so we will refer here to “conversion disorder” with the understanding that its formal title includes the parenthetical addition.
Conversion Disorder
Clients with conversion disorder may show a wide range of physical ailments, including “pseudoseizures” (not real seizures, but appearing as such), disorders of movement, paralysis, weakness, disturbances of speech, blindness and other sensory disorders, and cognitive impairment. The symptoms can be so severe that they make it impossible for clients to perform their work duties. Over half are bedridden or require assistive devices. Even though virtually all clients with conversion disorder do not have a medical diagnosis, clinicians must nevertheless rule out medical diagnoses before assigning the diagnosis.
A large review of brain imaging studies on patients with motor
conversion disorder (movement abnormalities) identified alterations
in areas of the frontal and prefrontal regions active in planning and
executing movements, as well as altered activities in brain regions
responsible for emotion. Individuals with this form of conversion
disorder may, then, be unaware of what their bodies are doing and
therefore unable to control their actions.
Malingering
Malingering consists of deliberately feigning the symptoms of physical illness or psychological disorder for an ulterior motive such as receiving disability or insurance benefits. Though a diagnosis in DSM-IV-TR, malingering is not one in DSM-5. It nevertheless remains a concern when diagnoses must be made in a forensic, occupational, or military setting and the possibility that clients are feigning symptoms must at least be ruled out.
Clinicians assume that clients engage in malingering in order to get a direct benefit, such as paid time off from work, insurance payments, or some other tangible reward. Some of these situations can yield what we call primary gain—namely the direct benefits of occupying the sick role. Structured malingering assessments are becoming more widely used, both to improve the evaluation of suspected malingerers and to protect the practitioners who are faced with making the determination.
Factitious Disorder
In factitious disorder imposed on self, people show a pattern of falsifying symptoms that are either physical, psychological, or a combination of the two. The individual falsifies these symptoms not to achieve economic gain but for the purpose of adopting the sick role. In extreme cases, known informally as instances of Munchausen’s syndrome, the individual’s entire existence becomesconsumed with the pursuit of medical care.
The individual may also feign the illness of someone else in cases of factitious disorder imposed on another or Munchausen’s syndrome by proxy. Interestingly, one epidemiological study of individuals with factitious disorder as a diagnosis showed the most frequent occupations to be those in the health professions.
Unlike people with conversion disorder, people with factitious disorder are consciously producing their symptoms, but their motives are internally rather than externally driven. They may be motivated by secondary gain, which is the sympathy and attention they receive from other people when they are ill. They know they are producing their symptoms, but they don’t know why. People with conversion disorder, in other words, believe they are ill and rightfully assume the sick role. People who are malingering know that they are not ill, and therefore, any rewards they receive from sickness are illegally obtained
Breakdown of Somatic Symptom Disorders
Theories and Treatment of Somatic Symptom Disorders
Early psychodynamic theorists were the first to attempt to understand and treat this group of disorders from what they regarded as a scientific perspective. Lacking sophisticated diagnostic tools and basing their work on the concept of unconscious conflict, they referred to conversion disorder as “hysteria”. They could not find a physiological basis for the symptoms, which tended to disappear after the individual received treatment through hypnosis or psychoanalysis, reinforcing the notion that the symptoms were psychologically based. In keeping with Freud’s general formulation of hysteria, clinicians working from a psychodynamic approach today aim to identify and bring into conscious awareness the underlying conflicts that we associate with the individual’s symptoms. Through this process, the client gains insight and self-awareness and becomes able to express emotion directly, rather than through physical manifestation.
From the cognitive-behavioral perspective, the dissociative, somatic symptom, and related disorders are viewed in terms of the thoughts linked to their physical symptoms. The underlying model is based on the premise that people with these disorders are subject to cognitive distortions that lead them to misinterpret normal bodily sensations. Once they start to exaggerate the importance of their symptoms, they become even more sensitized to internal bodily cues, which in turn leads them to conclude that they are truly ill. In applying cognitive-behavioral therapy to clients with somatic symptom and related disorders, clinicians help their clients gain a more realistic appraisal of their body’s reactions. For example, in one study, clients who had no cardiac illness but complained of palpitations or chest pain were exposed to exercise on a treadmill while being taught to interpret their raised heartbeat not as a sign of disease but as a normal reaction to exertion.
Hypnotherapy
Hypnotherapy is an additional approach that clinicians use specifically for treating conversion disorder. In hypnotherapy, the therapist instructs the hypnotized client to move the paralyzed limb. The therapist then makes the posthypnotic suggestion to enable the client to sustain the movement after the therapist brings him or her out of the hypnotic trance.
Psychological Factors Affecting Other Medical Conditions
So far we have looked at disorders in which individuals are experiencing physical symptoms that do not have a physiological cause. The diagnostic category called psychological factors affecting other medical conditions includes conditions in which a client’s physical illness is adversely affected by one or more psychological states. These can include depression, stress, denial of a diagnosis, or engaging in poor or even dangerous health-related behaviors.
The following table outlines several examples of medical conditions that can be affected by psychological factors. Specifying the interaction of psychological factors with medical conditions provides health professionals with a clearer understanding of how the two interact. Once this interaction has been identified, the clinician can address the issues and work to help the client’s medical condition improve.
Medical Condition Possible Psychological Factor
Hypertension (high blood pressure) Chronic occupational stress increasing the risk of high blood pressure. Asthma Anxiety exacerbating the individual’s respiratory symptoms. Cancer Denying the need for surgical interventions.
Diabetes Being unwilling to alter lifestyle to monitor glucose levels or reduce intake. Chronic tension headache Continuing family-related stresses that contribute to worsening of symptoms. Cardiovascular disease Refusing to visit a cardiac specialist for evaluation despite chest discomfort.
Stress and Coping
Within psychology, the term stress refers to the unpleasant emotional reaction experienced when a person perceives an event to be threatening. This emotional reaction may include heightened physiological arousal, reflecting increased reactivity of the sympathetic nervous system. A stressful life event is a stressor that disrupts the individual’s life. A person’s efforts to reduce stress is called coping.
It is when coping is unsuccessful, and the stress does not subside, that the individual may seek clinical attention for medical or psychological problems that have developed as a consequence of the constant physiological arousal caused by the experience of chronic negative emotions.
Stressful Life Events Scales
What types of events qualify as stressors? The most common way to describe stressors is through stressful life event rating scales, which are intended to quantify the degree to which individuals were exposed to experiences that could threaten their health. One of the best known of these is the Social Readjustment Rating Scale (SRRS), which assesses life stress in terms of life change units (LCUs). In developing the LCU index, researchers calculated how strongly each type of event was associated with physical illness. The rationale behind this measure is that the more an event causes you to adjust your life circumstances, the more deleterious it is to your health.
The College Undergraduate Stress Scale (CUSS) is a good example of a stressful life events scale. Unlike the SRRS, which is used with adults of all ages, the CUSS assesses the kinds of stressors most familiar to traditional-age college students (90 percent of the people in the sample were under age 22). The most stressful event in the CUSS is rape, which has an LCU score of 100. Talking in front of class has a score of 72, however, which is also relatively high. Getting straight As has a moderately high score of 51. The least stressful event on the CUSS is attending an athletic event (LCU score = 20).
Life events scales have merit because they are relatively easy to complete and present a set of objective criteria against which we can compare people. However, it is not always easy to quantify stress. You and your best friend may each experience the same potentially stressful event, such as being late for class, but you may be far more perturbed by this situation than your friend. Your day will thus be far less pleasant than your friend’s, and if you are repeatedly late, you might be at risk for a stress-related illness.
Cognitive Model of Stress
The cognitive model of stress places greater emphasis on the way you interpret events than on whether you experienced a given event. Like the cognitive approach in general, the cognitive model of stress proposes that the appraisal of an event as stressful determines whether it will have a negative impact on your emotional state. Not only do people differ in the way they interpret events, the circumstances surrounding the event also affect them. If your friend’s professor doesn’t take class attendance but yours does, this would help explain why you feel more stressed about being late than your friend.
As this example shows, stress is in the eye of the beholder. Even a relatively minor event can lead you to experience stress if you interpret it negatively. The cognitive model assumes, furthermore, that these “little” events can have a big impact, especially when they build up in a short period of time. Events called hassles can have significant effects on health when there are enough of them and you interpret them negatively. If you are not only late for class but get into an argument with your friend, stub your toe, spill your coffee, and miss your bus home, you will have as many potentially stress-causing events in one afternoon as someone experiencing a “bigger” life event such as going out on a first date.
On the positive side, you can balance your hassles with what researchers call uplifts, which are events on a small scale that boost your feelings of well-being. Perhaps you open up your Facebook page and find a pleasant greeting from a former high school acquaintance. The smile this greeting brings to your face can help make up for some of the stress of the hassles you just experienced. Uplifts are especially important within the positive psychology movement, which views them as contributing to people’s feelings of day-to-day happiness.
Cognitive Model of Coping
It’s wonderful when life sends a few uplifts your way, but when it doesn’t, you need to find other ways to reduce stress through coping if you are to maintain your mental health. The two basic ways of coping are problem-focused coping and emotion-focused coping.
In problem-focused coping, you attempt to reduce stress by acting to change whatever it is that makes the situation stressful. If you’re constantly late for class because the bus is overcrowded and tends to arrive 5 or 10 minutes after it’s supposed to, then you can cope by getting an earlier bus, even if it means you have to wake up 10 minutes ahead of schedule.
In contrast, in emotion-focused coping, you don’t change the situation but instead change the way you feel about it. Maybe your professor doesn’t care if you’re a little bit late, so you needn’t be so hard on yourself. Avoidance is another emotion-focused strategy. This coping method is similar to the defense mechanism of denial. Rather than think about a stressful experience, you just put it out of your mind.
Cognitive Model of Coping
Which is the better of the two ways of coping? The answer is, it depends. People cope with some situations more effectively through problem-focused coping. In changeable situations, you are most likely better off if you use problem-focused coping. If you’re stressed because your grades are in a slump, rather than not think about the problem, you would be well advised to try to change the situation by studying harder. If you’re stressed because you lost your cell phone and you truly cannot find it, then you may be better off by using emotion-focused coping such as telling yourself you needed a newer model anyhow (and taking some problem-focused steps as well, such as closing down that lost phone).
Activity prompt:
Come up with an example of a stressor and describe what coping skills someone can use when faced with that stressor (give examples of both emotion-focused and problem-focused coping strategies).
Age and Coping
As people get older, they are able to use coping strategies that more effectively alleviate their stress, perhaps because they are better able to tolerate the mixed emotions that come with experiencing life’s highs and lows.
In comparing samples of community-dwelling older adults and college undergraduates, for example, one study found that younger adults received higher scores on the dysfunctional coping strategies of focusing on and venting emotions, mentally disengaging, and using alcohol and drugs. Older adults, in contrast, were more likely to use impulse control and turn to their religion as coping strategies.
It may in fact be their better use of coping strategies that accounts for the resilience older adults show in the face of the stresses associated with caregiving for an ill spouse or other relative.
Theories of Stress
Personality also plays a role in affecting how much stress individuals experience as a result of exposure to potential stressors. In general, people with high levels of optimism are more resilient to stress.
Sociocultural factors also play a role in causing and aggravating an individual’s level of stress. For example, living in a harsh social environment that threatens a person’s safety, interferes with the establishment of social relationships, and includes high levels of conflict, abuse, and violence is a condition related to lower socioeconomic status. Chronic exposure to the stresses of such an environment can lead to a number of changes in hormones that ultimately have deleterious effects on cardiovascular health, interacting with an individual’s genetic and physiological risk. Both cardiovascular health and immune system functioning seem to be sensitive to the degree of stress a person experiences as a function of being lower in socioeconomic status. The limbic system, which mediates a person’s responses to stress, appears to play a large role in accounting for
these connections between social class and health.
Ample evidence supports the role of stress in a variety of medical conditions through its interaction with immune status and function. A stressful event can initiate a set of reactions within the body that lowers its resistance to disease. These reactions can also aggravate the symptoms of a chronic, stress-related physical disorder. Personality also interacts with stress in influencing health. Studies of workplace stress show that people high in the tendency to overcommit themselves tend to put more effort into their job than is rewarded and, in turn, have poorer cardiovascular health.
Emotional Expression
Coping with stress by controlling your negative emotions is one way to reduce your levels of perceived stress. However, there are times when expressing your emotions, even if they are negative, can improve your physical and mental well-being.
In one classic study, researchers instructed a group of first-year college students to write about the experience of coming to college, a highly stressful one, as noted above. A control group wrote about superficial topics. Those who wrote about coming to college reported being more homesick than the control subjects. Even though they experienced more negative emotions, however, they made fewer visits to physicians and, by the end of
the year, were doing as well as or better than the control subjects in terms of grade point average and the experience of positive moods. The researchers concluded that confronting feelings and thoughts about a stressful experience can have long-lasting positive effects, even though the initial impact of such a confrontation may be disruptive.
Keep in mind, however, that although the person expressing these feelings may feel better, the person who listens to the retelling of a sad or difficult story may suffer negative emotional consequences. This is one of the reasons individuals who work in the helping professions may experience burnout, otherwise known as “compassion fatigue”.
Personality Style Type A
One of the most thoroughly researched connections between personality and health is the type A behavior pattern, a set of behaviors that include being hard-driving, competitive, impatient, cynical, suspicious of and hostile toward others, and easily irritated.
People with a type A behavior pattern experience high levels of emotional arousal that keep their blood pressure and sympathetic nervous system on overdrive, placing them at risk for developing heart disease and at greater risk for heart attacks and stroke. Not only are they at high risk because their bodies are placed under stress, but their hard-driving and competitive lifestyles often include high-risk behaviors including smoking, drinking alcohol to excess, and failing to exercise.
Personality Style Type D
Another significant personality risk factor for heart disease occurs among people who experience strong depressive affect but keep their feelings hidden—the so-called type D personality. Unlike the “A” in type A, which is not an acronym, the “D” in type D stands for “distressed.”
Type D personalities experience emotions that include anxiety, irritation, and depressed mood. These individuals are at increased risk for heart disease due to their tendency to experience negative emotions while inhibiting the expression of these emotions when they are in social situations.
In addition to being at higher risk of becoming ill or dying from heart disease, these individuals have reduced quality of daily life and benefit less from medical treatments. Psychologists think the link between personality and heart disease for these people is due in part to an impaired immune response to stress.
Applications to Behavioral Medicine
Because psychological factors that contribute to a medical condition have such a wide range, clinicians must conduct a careful assessment of the way each particular client’s health is affected by behavior. The field of behavioral medicine applies the growing field in the health sciences regarding mind-body relationships to helping improve people’s physical health by addressing the psychological factors of stress, emotions, behavior patterns, and personality. In addition, clinicians working in behavioral medicine often team up with psychologists and other mental health professionals to help clients learn and maintain behaviors that will maximize their physical functioning. By improving patients’ compliance with medical treatment, clinicians can help them achieve better health and avoid further complications.
Psychoeducation is an important component of behavioral medicine. Clients need to understand how their behavior influences the development or worsening of the symptoms of chronic illness. Then the clinician can work with them to develop specific ways to improve their health habits. For example, diet control and exercise are key to preventing and reducing the serious complications of cardiovascular disease. Time spent outdoors, even if not in active exercise, can also reduce stress levels.. The clinician can teach clients ways to build these new health habits into their daily regimens and train people with sleep disorders to improve their sleep habits. People can manage chronic pain, which contributes to depressive symptoms, through strategies such as biofeedback.
Applications to Behavioral Medicine
Behavioral medicine is also moving increasingly toward interventions the profession once considered alternative, including mindfulness training, relaxation, and meditation. In these approaches, clinicians teach clients to monitor their internal bodily states (such as heart rate and breathing), as well as their perceptions, affective states, thoughts, and imagery, without judging. By observing their bodily reactions in this objective fashion, clients gain a more differentiated understanding of which aspects of their experiences illness affects and which it does not. Thus they can gain self-control over their body’s reactions and see their ailments as having natural roles, not as impeding their ability to enjoy life in general.
For example, people with a type A behavior pattern can benefit from training aimed at improving awareness of their reactions to stress, methods of coping with stressful situations, and behavioral interventions intended to improve their compliance with medical advice aimed at reducing their cardiovascular risk. Particularly important is a sense of mastery—namely, the belief that you have the ability to cope with or control the problems you encounter in life. People who feel they are in greater control over their life circumstances have a reduced risk of developing cardiovascular and related health problems. Increasingly, clinicians are finding that efforts to improve people’s health by addressing only their medical needs do not have the long-term desired effects unless the clinicians also incorporate these psychological issues into treatment.
Dissociative and Somatic Symptom Disorders: The Biopsychosocial Perspective
Although distinct, the disorders we’ve covered in this lecture all reveal the complex interactions between mind and body and call for distinctions between “real” and “fake” psychological symptoms. They also all raise questions about the nature of the self. We’ve also examined the role of stress in psychological disorders and its relationship to medical illnesses and physical symptoms.
Biology clearly plays a role in making some individuals more vulnerable to psychological disorders, and particularly these disorders. A person may have a known or undiagnosed physical condition that certain stressors particularly affect, which then trigger the symptoms for a somatic symptom or related disorder. However, whatever the role of biology,
cognitive-behavioral explanations provide useful approaches for treatment. Even people whose medical condition is clearly documented, as in chronic pain disorder, can benefit from learning how to reframe their thoughts about their disorder, if not also their actual health-related behaviors. At the same time, we are learning more about how stress affects physical functioning, including the impact of social discrimination on chronic conditions such as heart disease and diabetes.
Sources
Image 1: https://www.seattletimes.com/life/wellness/hypochondria-gets-a-new-treatment-and-a-new-name/ Image 2: https://www.therecoveryvillage.com/mental-health/conversion-disorder/related/conversion-disorder-statistics/ Image 3: https://www.youtube.com/watch?v=gaAdSGVgd3Y
Image 4: https://hypnotc.com/how-does-hypnotherapy-work/
Image 5: https://www.verywellmind.com/forty-healthy-coping-skills-4586742
Image 6: https://www.verywellmind.com/type-a-personality-traits-3145240
Image 7: https://www.verywellmind.com/what-does-it-mean-to-have-type-d-personality-4175368 Video: https://www.youtube.com/watch?v=_1GCjggflEU
Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education. Kindle Edition.
Feeding and Eating Disorders, Elimination Disorders, and Sleep-Wake Disorders
SSY 230: Lecture 9
Eating Disorders
People who have eating disorders experience persistent disturbances of eating or eating-related behavior that change the way they eat or retain their food. These disorders go beyond dieting or occasional overeating, significantly impairing the individual’s physical and psychosocial functioning.
Anorexia Nervosa
Clinicians diagnose an individual as having anorexia nervosa (AN) when he or she shows three basic types of symptoms:
-Severely restricted eating, which leads to an abnormally low body weight
-Intense and unrealistic fear of getting fat or gaining weight
-Disturbed self-perception of body shape or weight In other words, people with AN restrict their food intake, become preoccupied with gaining weight, and feel that they are already overweight even though they may be seriously underweight.
Anorexia Nervosa
In addition to the psychological consequences of AN, the depletion of nutrients in people who merit the diagnosis leads them to develop a series of serious health changes that can, in the extreme, become life threatening.
Constant undereating causes cardiac and respiratory problems, thinning bones, changes in gastrointestinal functioning, and loss of energy. Not only does their appearance change in terms of becoming abnormally thin and gaunt, but they can also suffer hair loss, and their nails become weak and brittle. Changes in their hormones caused by constant food deprivation can also lead them to become infertile. Their sexual functioning becomes disturbed.
Anorexia Nervosa
The higher risk of mortality in people with AN has been firmly established. The longer individuals have the disorder, the greater their risk. Although the majority of deaths from AN occur in young adults, a Norwegian study found that 43 percent of AN-related deaths occurred in women age 65 and older. Women with AN die not only from the complications of their disorder but from suicide, particularly if they have comorbid depression and the form of the disorder in which they alternate overeating with severe food restriction.
At the heart of the experience of AN is a core disturbance in the individual’s body image. People with AN believe their bodies are larger than they really are, which, in turn, they believe makes them unattractive. Women with the restrictive form of AN appear not to value thinness so much as to be repelled by the idea of being overweight.
The lifetime prevalence of AN is 0.9 percent for women and 0.3 percent for men. In addition, people with anorexia nervosa have higher rates of mood, anxiety, impulse-control, and substance use disorders.
Bulimia Nervosa
People with the eating disorder bulimia nervosa engage in binge eating, during which they rapidly eat an inordinately excessive amount of food, perhaps amounting to several thousand calories in a sitting. During these episodes, they experience a lack of control, which makes them feel they cannot stop eating or regulate how much they eat.
Following the binge, they then engage in purging, during
which they try to rid themselves of their excess caloric
consumption by engaging in self-induced vomiting, taking
laxatives or diuretics, and fasting or exercising
excessively. For a bulimia nervosa diagnosis, these
episodes must not occur exclusively during episodes of
anorexia nervosa.
The lifetime prevalence of bulimia nervosa is 1.5 percent
among women and 0.5 percent among men.
Bulimia Nervosa
Like those who have AN, people with bulimia nervosa develop a number of medical problems. The most serious occur with purging. For example, ipecac syrup, the medication that people use to induce vomiting, has severe toxic effects when taken regularly and in large doses. People who induce vomiting frequently also suffer from dental decay because the regurgitated material is highly acidic.
The laxatives, diuretics, and diet pills that people with bulimia use can also have toxic effects. Other health problems stem from behaviors they use to try to lose weight, such as giving themselves frequent enemas, regurgitating and then rechewing their food, and spending too much time in saunas. Related to being in a state of constant dehydration, the bulimic individual runs the risk of permanent gastrointestinal damage, fluid retention in the hands and feet, and heart muscle destruction or heart valve collapse.
Binge-Eating Disorder
Binge-eating disorder is a new diagnosis added to DSM-5 that covers individuals who lack control over their eating and engage in binges at least twice a week for 6 months. For binge-eating disorder to be diagnosed, the binges must occur with the intake of large amounts of food, go past the point of feeling full or hungry, occur while the person is alone, and be followed by self-disgust or guilt. Because the binge eating does not occur in association with compensatory behaviors, it is possible that individuals with this disorder gain a significant amount of weight.
Gender Differences in Eating Disorder Prevalence
Activity prompt: Consider the graphic on gender differences in eating disorder prevalence on the previous slide. Why do you think anorexia and bulimia are more prevalent among women, but binge-eating disorder is split evenly between men and women?
Biological Perspective of Eating Disorders
Eating disorders reflect a complex set of interactions among an individual’s experiences with eating, body image, and exposure to sociocultural influences. The attitudes people develop throughout life toward food, eating, and body size can all play a role in influencing the risk of developing an eating disorder.
Researchers working within the biological perspective are increasingly focusing on altered brain activity in individuals with eating disorders. In one innovative study, women with AN and women who had recovered from AN were compared on their fMRI responses to food-related cues with healthy controls after a night of fasting. Even those who were no longer symptomatic still showed lowered activation in the food reward centers and higher activation of inhibitory control areas of the brain, suggesting that the disorder creates lingering effects in the ways that individuals process food-related cues. Further research supports the effect of AN in altered brain activity in areas responsible for processing emotions, body-related stimuli, and self-perception
From the biological perspective, binge-eating disorder is understood as a form of addiction, in that individuals with this disorder engage in repetitive behaviors that persist despite the negative consequences. Because of its efficacy in treatment and the similarity of the disorder to other addictive disorders, researchers propose that lower levels of serotonin could be operating in this case. The fact that people with binge-eating disorder also experience mood and anxiety disorders further supports the role of serotonin. Researchers investigating altered serotonin activity in the brains of individuals with binge-eating disorder have indeed found evidence of its role. Compared to both healthy controls and people with gambling disorder, people with binge-eating disorder had effectively
lower serotonin in brain regions active in addictive behaviors.
Clinicians working from the biological perspective base their treatment of people with eating disorders on administering psychotropic medications, particularly SSRIs. However, despite their continued use, these are no longer considered advisable from an evidence-based perspective.
Cognitive Behavioral Approach to Eating Disorders
Psychological perspectives are now considered the treatment of choice for eating disorders. These approaches focus
on the core psychological components of disturbances in body image. The cognitive-affective component of body
image includes evaluation of one’s own appearance (satisfaction or dissatisfaction) and the importance of weight
and shape for an individual’s self-esteem. The perceptual component of body image includes the way individuals
mentally represent their bodies. Individuals with eating disorders typically overestimate their own body size. The
behavioral component includes body checking, such as frequent weighing or measuring body parts, and avoidance,
which is the wearing of baggy clothing or avoiding of social situations that expose the individual’s body to viewing
by others.
The primary aim of treatment is identifying and changing the individual’s maladaptive assumptions about his or her
body shape and weight. In addition, clinicians attempt to reduce the frequency of such maladaptive behaviors as
body checking and avoidance.
In cognitive-behavioral therapy, clinicians first attempt to change selective biases in people with eating disorders that lead them to focus on the parts of their bodies they dislike. Second, by using exposure therapy in which clients view their own bodies (“mirror confrontation”), clinicians attempt to reduce the negative emotions they ordinarily experience. Behavioral interventions focus on reducing the frequency of body checking. Third, clinicians can address size overestimation by helping clients view their bodies more holistically in front of a mirror, by teaching them mindfulness techniques to reduce their negative cognitions and affect about their bodies, and by giving them psychoeducation about the ways their beliefs reinforce their negative body image.
Avoidant/Restrictive Food Intake Disorder
In avoidant/restrictive food intake disorder, individuals show an apparent lack of interest in eating or food. They do so because they are concerned about the aversive consequences. In addition, they may avoid food based on its sensory characteristics (color, smell, texture, temperature, or taste). People may develop this disorder as the result of a conditioned negative response to having an aversive experience while eating, such as choking.
Previously included as a feeding disorder of infancy or early childhood in the DSM-IV-TR and regarded as an extreme version of “picky eating”, this diagnosis is now applicable to individuals of any age who do not have another eating disorder or concurrent medical condition, or who are following culturally prescribed eating restrictions. As a result of their disorder, they lose a significant amount of weight (or fail to achieve expected weight gain), show a significant nutritional deficiency, become dependent on feeding through a stomach tube or oral nutritional supplements, and show marked interference with their psychosocial functioning.
Eating Disorders Associated with Childhood
Pica
Children with pica eat inedible substances, such as paint, string, hair, animal droppings, and paper.
This is a serious disorder because even one incident can cause the child to experience significant medical consequences due to lead poisoning or injury to the gastrointestinal tract.
Pica is the most serious cause of self-injury to occur in people with intellectual developmental disabilities.
Clinicians treating pica must not only use a behavioral treatment strategy to reduce the individual’s injurious behaviors, but also institute prevention by ridding the home of potentially dangerous substances.
Eating Disorders Associated with Childhood
Rumination Disorder
In rumination disorder, the infant or child regurgitates and rechews food after swallowing it. Researchers have identified five common disturbances in these children:
(1) delayed or absent development of feeding and eating skills
(2) difficulty managing or tolerating food or drink (3) reluctance to eat food based on taste, texture, and other sensory factors
(4) lack of appetite or interest in food
(5) the use of feeding behaviors to comfort, self-soothe, or self-stimulate.
Of note: 25 to 45 percent of developmentally normal children have some type of problem with food and feeding, but 80 percent of those who are intellectually disabled do.
Elimination Disorders
Elimination disorders are characterized by age-inappropriate incontinence and are generally diagnosed in childhood.
Individuals with enuresis wet the bed or urinate in their clothing after they have reached the age of 5 years, at which point it is expected that they should be completely toilet trained. To receive this diagnosis, the child must show symptoms of enuresis for three consecutive months. In encopresis, a child who is at least 4 years old repeatedly has bowel movements either in his or her clothes or in another inappropriate place.
There are subtypes of enuresis based on the time of day the child inappropriately passes urine (daytime only, night only, or both). The subtypes of encopresis distinguish between children who have constipation and then become incontinent due to overflow of feces, and those who do not have constipation and overflow. Researchers believe these distinctions are important because they can differentiate which children do and do not have a medical condition that underlies their symptoms.
Of note: Boys are more likely than girls to experience these conditions.
Treatment for Elimination Disorders
Evidence-based treatment for childhood elimination disorders focuses on biobehavioral methods to establish continence. Enuresis can be treated through use of a “urine alarm,” a device attached to a child’s underwear or pajamas that emits an auditory and/or tactile sensation in response to moisture. The child then develops a conditioned avoidance response that can trigger muscular contractions in the external sphincter of the bladder prior to the leakage of urine. Encopresis treatments supported by empirical studies include enhanced toilet training and biofeedback. In enhanced toilet training, the child is rewarded for continence, given training about appropriate defecation dynamics, and taught breathing techniques and muscle training exercises to gain control over the anal sphincters.
If children have the retentive form of encopresis, they can benefit from behavioral training that rewards them for increasing their intake of fiber and fluid and ensures that they include time on the toilet as part of their daily schedules. Another more psychologically oriented approach focuses on unresolved anger that a child may be expressing in response to family issues. Such issues can include conflict between the parents, the arrival of a newborn sibling, or the behavior of an older sibling who torments the child. Treatment that addresses these family system issues can help to reduce the child’s symptoms.
Sleep-Wake Disorders
The science of sleep and treatment of sleep-wake disturbances is rapidly gaining attention, so much so that sleep medicine is now a field in its own right. Researchers and clinicians in sleep medicine typically take a biopsychosocial approach, examining genetic and neurophysiological contributions, psychological interactions, and social and cultural factors that impinge on the individual’s sleep quality and amount.
In the next slides, we will cover the major categories of sleep-wake disorders. They fall into the categories of insomnia disorder, narcolepsy, hypersomnolence disorder, breathing sleep-related disorders, circadian rhythm disorders, and parasomnias. To be diagnosable, symptoms must be present for a significant period of time, occur relatively frequently, and cause the individual to experience distress.
Insomnia Disorder
Difficulty initiating or maintaining sleep, along with early-morning awakening.
Narcolepsy Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or
napping within the same day.
Diagnosis also requires either
episodes of jaw-opening or losing
facial muscle tone while laughing or
showing abnormal cerebral spinal
fluid (CSF) or sleep disturbances on
polysomnography.
Polysomography
The DSM-5 diagnostic criteria for sleep-wake disorders reflect progress in the availability of technology in assessment and differential diagnosis. Many of these diagnoses now use polysomnography, which is a sleep study that records brain waves, blood oxygen levels, heart rate, breathing, eye movements, and leg movements.
Hypersomnolence Disorder
Recurrent periods of sleep or lapses into sleep during the day, prolonged main sleep episodes, or difficulty being fully awake after abruptly awakening.
Breathing
Sleep-Related Disorders
Obstructive sleep apnea separate specific disorder: Frequent episodes of apnea and hypopnea while sleeping as indicated on polysomnography along with either snoring, snorting/gasping, or breathing pauses during sleep and daytime sleepiness, fatigue, or unrefreshing sleep.
Central sleep apnea: Frequent episodes of apnea while asleep.
Sleep-related hypoventilation: Episodes of decreased breathing (ventilation) while asleep.
Circadian Rhythm Sleep-Wake
Disorders
Persistent patterns of sleep disruption due primarily to altered circadian rhythm or misalignment between the individual’s internal circadian rhythm and the sleep-wake schedule required by the person’s
environment, or work or social schedule.
Includes delayed sleep phase type (delay in timing of major sleep period), advanced sleep phase type (sleep-wake cycles that are several hours earlier than conventional), irregular sleep-wake type, non-24-hour sleep-wake type, and shift work type.
Parasomnias
Non-rapid eye movement sleep arousal disorder: Recurrent episodes of incomplete awakening from sleep accompanied by either sleepwalking or sleepwalking not associated with rapid eye movements (REMs).
Nightmare disorder: Repeated occurrences of extended, dysphoric, and well-remembered dreams that typically involve threats to one’s life.
Rapid eye movement sleep behavior disorder: Frequent episodes of arousal during sleep associated with speaking and/or motor behaviors occurring during REM sleep.
Restless legs syndrome (RLS): An urge to move the legs along with uncomfortable and unpleasant sensations in the legs, urges that begin or worsen during periods of rest or inactivity that are partially or totally relieved by movement, and are worse or only occur in the evening or night.
Sleep-Wake Disorders
Sleeping disorders affect a large number of individuals, with perhaps as many as 30 percent of adults in the general population in the case of insomnia alone. If you are like many undergraduates, you most likely have already been affected by one or more of these disorders, given the typical environment of the college dormitory or student-populated apartment building in which noise in the night hours interferes with both sleep quality and quantity.
The availability of wearable technology that records length of time asleep, time awake, and even sleep stages is making it increasingly possible for individuals to gain an understanding of their own sleep patterns. As a result, more individuals may seek sleep therapy than was true in the past, when the only signal people received of a possible sleep disorder was feeling tired.
Treatments for sleep-wake disorders vary considerably depending on the nature of the disorder. Cognitive-behavioral therapy is regarded as highly efficacious for insomnia and, along with relaxation and sleep hygiene training, for improving sleep in college student populations.
New technologies are making it increasingly possible for individuals not only to detect but also to manage their own treatment in the home. Continuous positive airway pressure (CPAP) machines are mechanical devices used for treating sleep apnea. They are becoming increasingly practical and affordable .
Disruptive, Impulse-Control, and Conduct Disorders SSY 230: Lecture 9 Part II
Disruptive, Impulse-Control, and Conduct Disorders
People with one of the disruptive, impulse-control, or
conduct disorders show extreme lack of inhibition
(“disinhibition”). They are unable to restrain themselves
from expressing what are often high levels of negative
emotions. Although people with a variety of other disorders
also experience difficulties in self-regulating their behavior,
these particular disorders bring the individuals who have
them into significant conflict with social norms or authority
figures
Oppositional Defiant Disorder
Most children go through periods of negativism and mild defiance, particularly in adolescence, and most parents complain of occasional hostility or argumentativeness in their children. But what if such behaviors are present most of the time and are not just a phase?
Children and adolescents with oppositional defiant disorder display angry or irritable mood, argumentative or defiant behavior, and vindictiveness that results in significant family or school problems. Youths with this disorder repeatedly lose their temper, argue, refuse to do what they are told, and deliberately annoy other people. They are touchy, resentful, belligerent, spiteful, and self-righteous. Rather than seeing themselves as the cause of their problems, they blame other people or insist they are victims of circumstances.
To the extent that their behavior interferes with their school performance and friendships, they risk jeopardizing their relationships with teachers and peers. These losses can, in turn, lead them to feel inadequate and depressed and perhaps cause them to act out even more.
Oppositional Defiant Disorder
Oppositional defiant disorder makes its first appearance during the preteen years between ages 8 and 12, with rates higher in boys. Many children with the disorder, particularly boys, will develop antisocial personality disorder in adulthood; a small percentage will engage in serious criminal behavior. Girls with oppositional defiant disorder are at higher risk of developing depression, particularly if they show inability to regulate their emotions and a tendency toward defiance.
The goal of treatment for oppositional-defiant disorder is to help the child learn to exhibit appropriate behaviors, such as cooperation and self-control, and to unlearn problem behaviors, such as aggression, stealing, and lying. Therapy focuses on reinforcement, behavioral contracting, modeling, and relaxation training and may take place in the context of peer therapy groups and parent training. One such approach, individualized social competence therapy, uses cognitive-behavioral methods specifically tailored to the situations in which the child has experienced difficulties
Intermittent Explosive Disorder
People with intermittent explosive disorder are unable to hold back their urges to express strong angry feelings and associated violent behaviors. They can have angry outbursts that are either verbal (temper tantrums, tirades, arguments) or physical outbursts in which they become assaultive or destructive in ways that are out of proportion to any stress or provocation. These physical outbursts, on at least three occasions in a 12-month period, may cause damage to the individual, other people, or property. However, even if individuals showing verbal or physical aggression do not cause harm, they may still receive this diagnosis.
The rage shown by people with this disorder is out of proportion to any particular provocation or stress, and their actions are not premeditated. Afterward, they feel significantly distressed, suffer interpersonal or occupational consequences, or experience financial or legal consequences.
People with this disorder are more vulnerable to a number of threats to their physical health, including coronary heart disease, hypertension, stroke, diabetes, arthritis, back/neck pain, ulcer, headaches, and other chronic pain. They also are likely to have co-occurring disorders, including bipolar disorder, personality disorders such as antisocial or borderline, substance use disorder (particularly alcohol), and cognitive disorders.
Intermittent explosive disorder appears to have a strong familial component not accounted for by any comorbid conditions associated with it. Researchers believe the disorder may result from abnormalities in the serotonin system causing a loss of the ability to inhibit movement.
Intermittent Explosive Disorder
Faulty cognitions further contribute to the development of intermittent explosive disorder. People with this disorder have a set of negative beliefs that other people wish to harm them, beliefs they may have acquired through harsh punishments they received as children from their parents or caregivers. They feel, therefore, that their violence is justified. In addition, they may have learned through modeling that aggression is the way to cope with conflict or frustration. Adding to these psychological processes is the sanctioning of violence associated with the masculine gender role, a view that may in part explain the greater prevalence of this disorder in men.
Given the possible role of serotonergic abnormalities in this disorder, researchers have investigated the utility of SSRIs in treatment. However, though effective in reducing aggressive behaviors, SSRIs result in full or partial remission in fewer than 50 percent of cases. Mood stabilizers used in the treatment of bipolar disorder (lithium, oxcarbazepine, carbamazepine) also have some effects in reducing aggressive behavior, but there are few well-controlled studies.
Cognitive-behavioral therapy can also be beneficial for individuals with this disorder. In one approach, a variant of anger management therapy uses relaxation training, cognitive restructuring, hierarchical imaginal exposure, and relapse prevention for a 12-week period in individual or group modalities. Cognitive-behavioral therapy focuses on reducing anger and aggression as well as improving the individual’s social skills. Particularly important is reducing the individual’s misperceptions of social threat, which can, in turn, reduce overt expression of relational aggression.
Conduct Disorder
Individuals with conduct disorder violate the rights of others and society’s norms or laws.
Their delinquent behaviors include aggression directed toward people and animals such
as bullying and acts of animal cruelty, destruction of property, deceitfulness or theft, and
serious violations of rules such as being truant from school or running away from home.
The DSM-5 also specifies childhood or adolescent onset (before or after 10 years of age);
the presence or absence of remorse, guilt, and empathy; and the severity of the behavior,
ranging from lying and truancy to physical cruelty, use of a weapon, and stealing in the
presence of the victim.
Predisposing conditions to the development of conduct disorder include being raised
in harsh environments involving trauma, abuse, and neglect. Genetic vulnerability
may further exacerbate the risk of growing up in such households.
Unfortunately, whatever the causes, we know that aggressive and antisocial children are likely to have serious problems as adults. Results of longitudinal studies indicate that at least 50 percent of children with conduct disorder develop antisocial personality disorder.
Impulse Control Disorders
People with impulse-control disorders engage in repetitive, often harmful, behaviors that they feel are beyond their control.
Before they act on their impulses, these individuals experience tension and anxiety that they can relieve only by following through on their impulses.
After acting on their impulses, they experience a sense of pleasure or gratification, although later they may regret that they engaged in the behavior.
Pyromania
People with pyromania deliberately set fires, feeling tension and arousal before they commit the act. They are fascinated with and curious about fire and its situational contexts, and they derive pleasure, gratification, or relief when setting or witnessing fires or participating in their aftermath.
For an individual to be diagnosed with pyromania, the firesetting must not be done for monetary reasons, and the individual must not have other medical or psychiatric conditions. Arson, by contrast, is deliberate firesetting intended to produce financial gain, and an arsonist does not experience the relief shown by people with pyromania.
Pyromania
The majority of people with pyromania are male. Pyromania appears to be rare, however, even among arsonists. Pyromania appears to be a chronic condition if the individual does not receive treatment. Some individuals with pyromania may discontinue firesetting and instead switch to another addictive or impulsive behavior such as kleptomania or gambling disorder. An intensive study of 21 participants with a lifetime history of pyromania described the most likely triggers for their behavior as stress, boredom, feelings of inadequacy, and interpersonal conflict.
Like the other impulse-control disorders, pyromania may reflect abnormalities in dopamine functioning in areas of the brain involving behavioral addictions. Nevertheless, treatment for pyromania that follows the cognitive-behavioral model seems to show the most promise. The techniques include imaginal exposure and response prevention, cognitive restructuring of response to urges, and relaxation training.
Kleptomania
People with the impulse-control disorder kleptomania are driven by a persistent urge to steal. Unlike shoplifters or thieves, they are not motivated by monetary gain but instead seek excitement from the act of stealing. Like people with other impulse-control disorders, they would rather not be driven to this behavior, and they feel their urge is unpleasant, unwanted, intrusive, and senseless. They steal in response to an urge or state of craving,and they experience gratification afterwards. Because their focus is not on the items but on the act of stealing, individuals with kleptomania may give or throw away the stolen goods.
Kleptomania
To make a diagnosis of kleptomania, clinicians must be unable to better account for the individual’s stealing with another diagnosis of antisocial personality disorder, conduct disorder, or bipolar disorder (in a manic episode). There is overlap among the symptoms of kleptomania and mood, anxiety, and other impulse-control disorders, making it particularly important that clinicians engage in a thorough process of differential diagnosis.
Kleptomania has a number of significant effects on the individual’s life, not the least of which is the fear of or reality of arrest. Studies have shown that people with kleptomania are likely to have high lifetime prevalence rates of co-occurring depressive disorders, anxiety disorders, other impulse-control disorders, and drug abuse or dependence. Suicide attempts are common among people with kleptomania.
Studies of the neurobiology of kleptomania suggest that, like substance use disorders, this diagnosis is associated with altered dopamine, serotonin, and opioid receptor functions as well as changes in brain structures similar to those in people with cocaine dependence.
Individuals with kleptomania may struggle with their symptoms for years before seeking treatment, perhaps because they fear prosecution or because they are ashamed of their illegal yet uncontrollable actions. Naltrexone, a therapeutic medication used to treat individuals with substance dependence, is one approach that appears to have had some effectiveness. Cognitive-behavioral treatments also are effective, although they may need to be used beyond the typical 12-session structure.
Activity prompt: How do you imagine impulse control disorders can lead to conflict with the criminal justice system? Also consider
malingering-For example, what if an arsonist or thief were to feign mental illness to avoid criminal culpability?
Biopsychosocial Perspective
The disorders we have covered in this lecture represent a wide range of symptoms with a combination of biological causes, emotional difficulties, and sociocultural influences. A biopsychosocial approach therefore seems appropriate in understanding each. Moreover, these disorders have a developmental course. Eating and oppositional/conduct disorders appear to originate early in life. Over the course of adulthood, individuals may develop impulse-control disorders, and late in life, physiological changes may predispose older adults to sleep-wake disorders.
In the case of each category of disorder, clients can benefit from a multifaceted approach in which clinicians take into account these developmental and biopsychosocial influences. Some disorders, such as those in the sleep-wake category, may best be diagnosed through physiological tests such as polysomnography, even though treatment may focus on behavioral control of sleep. Individuals with symptoms of eating disorders should also be evaluated medically, but effective treatment requires a multipronged and team approach among mental health and medical professionals. The psychological and sociocultural components of impulse-control disorders tend to be more prominent in both diagnosis and treatment, although there may be biological contributions to each of these as well.
This wide range of disorders provides an excellent example of why a broad-ranging and integrative approach that takes a life-span view can be so important in understanding and treating psychological disorders. As research in these areas progresses, it is likely that clients in the future will benefit increasingly from interventions that take advantage of this multifaceted view.
Sources
Image 1: https://www.verywellmind.com/pregnancy-and-eating-disorders-4179037
Image 2: https://kidshelpline.com.au/teens/issues/eating-disorders
Image 3: https://www.quora.com/What-are-the-health-risks-of-eating-disorders
Image 4: https://www.verywellmind.com/signs-and-symptoms-of-bulimia-in-teens-2609258
Images 5 and 6: https://www.quora.com/What-are-the-health-risks-of-eating-disorders
Image 7: https://www.therecoveryvillage.com/mental-health/eating-disorders/related/eating-disorder-statistics/#gref
Image 8: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education. Image 9: https://www.asrasleepcentre.com/2019/11/23/insomnia-symptoms-causes/
Image 10: https://www.verywellhealth.com/what-is-narcolepsy-3014795
Image 11: https://www.verywellhealth.com/what-to-expect-in-a-sleep-study-3015121
Image 12: https://www.verywellhealth.com/hypersomnia-overview-4582688
Image 13: https://www.bettersleepsimplified.com/sleep-disorders/
Image 14: https://www.facebook.com/illustratedpsych/photos/a.1436906373219284/1436906473219274/?type=3&theater
Image 15: https://www.liahonaacademy.com/oppositional-defiant-disorder-infographic-info.html
Image 16: https://socialecology.uci.edu/news/children-and-society-pay-high-price-failure-diagnose-treat-conduct-disorder
Images 17 and 18:
https://www.dk.com/uk/article/5-psychological-disorders-explained-in-eye-opening-infographics/?utm_source=Facebook&utm_medium=social&utm_campaign=250119_Psy chology_article_Facebook
Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education. Kindle Edition.
Substance-Related and Addictive Disorders SSY 230: Lecture 10
Key Features of Substance Disorders
A substance is a chemical that alters a person’s mood or behavior when the person smokes, injects, drinks, inhales, snorts, or swallows it. Substance-related disorders reflect patterns of abuse of these substances, the resulting intoxication, and the consequences of discontinuing use of the substance. A person in a state of substance withdrawal shows physiological and psychological changes that vary according to the actual substance involved. Tolerance occurs when an individual requires increasingly greater amounts of the substance in order to achieve its desired effects, or when the person feels less of an effect after using the same amount of the substance.
A substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using a substance even though it causes significant problems in his or her life. Clinicians diagnose substance use disorders by assessing the individual on four categories of symptoms: loss of control, social impairment, risky use, and pharmacological changes. Based on the number of symptoms the individual demonstrates, clinicians assign a severity rating from mild to severe.
Substance Use Disorders
People with substance use disorders suffer a range of significant effects on their daily life. They neglect obligations at work, and their commitments to home and family erode. They may begin to take risks that are personally dangerous and put others in jeopardy, such as driving or operating machinery while intoxicated.
It stands to reason that legal problems can arise for people who abuse substances. In addition to being arrested for driving while under the influence of a substance, they may face charges of disorderly conduct or assaultive behavior. The substance use disorders also frequently instigate interpersonal problems as well, due to the fact that excessive use of drugs or alcohol creates strains on relationships with family, friends, and co-workers. In extreme cases, these disorders can also lead to health problems and even premature death.
Substance-Induced Disorders
Substance-related disorders also include substance-induced disorders, which are disorders arising from the effects of the substance itself.
People receive a diagnosis of substance intoxication when they experience a drug’s effects on their physiological functioning and show signs of significant impairment. The extent of substance intoxication depends on the specific drug, the speed with which it acts, and the duration of its effects. Efficient absorption of intravenous or smokable drugs into the bloodstream can lead to a more intense kind of intoxication than occurs with drugs taken in pill form.
The second category of substance-induced disorders includes those that reflect the effects of withdrawal, in which individuals develop behavioral changes specific to the particular substance. These changes include physiological and cognitive alterations associated with the discontinuation of the substance in question. Other disorders can also occur as a function of substance use, including psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. People may also show comorbidity of the
substance-related disorder with another condition, such as an anxiety disorder or a mood disorder.
Drug Withdrawal
Disorders Associated with Specific Substances
According to the U.S. government’s Substance Abuse and Mental Health
Service (SAMHSA) National Survey on Drug Use and Health (NSDUH), in
2016 an estimated 11 percent of the population used illicit drugs at
least once in the preceding 30 days (that is, they were current users).
Marijuana is the most commonly used substance, with 28.6 million
people 12 and older reporting use of any illicit drug in the United States
within the past month.
Rates of current illicit drug use by individuals 12 years of age and older
vary considerably by demographic group. According to the NSDUH, the
three most significant grouping characteristics are race/ethnicity, age,
and gender.
The rate of past-month illicit drug use is 15.7 percent for American Indians or Alaska Natives, followed by 12.5 percent among people who identify as Black or African American, 10.8 percent for Whites, 9.2 percent for Hispanic or Latino, and 4.1 percent for Asian. The rates generally decline with age from the peak of 22.3 percent at ages 18 to 25 to 1.9 percent at ages 65 and older. Males have a higher rate of drug use (12.8 percent) than females (8.5 percent). Illicit drug use tends to be lower among college graduates, the employed, and Midwesterners and highest among people living in cities.
Disorders Associated with Specific Substances
Most drugs of abuse directly or indirectly target the reward center of the brain by flooding its circuits with dopamine. Overstimulation of the reward system produces the euphoric effects abusers seek and leads them to engage in the behavior that will allow them to repeat the experience. Drugs are more addictive than the natural “highs” produced by such activities as eating and sex because they release far more dopamine (2 to 10 times as much) than do natural rewards, and the effects last much longer.
Over time, the neurons in these dopamine pathways “down-regulate” in response to these surges in dopamine, meaning they produce less dopamine themselves or reduce the number of dopamine receptors. Users then need to take the drugs to raise their dopamine levels back to normal. In order to experience the effects they experienced initially from the drugs, they also need to take higher and higher levels; in other words, they develop tolerance.
In addition to dopamine, some drugs of abuse also influence glutamate, a neurotransmitter active in memory and learning. Long-term drug abuse can lower the individual’s level of glutamate and lead to memory impairments.
Because users learn to associate the pleasurable feelings of using the drug with the cues in the environment that were there when they took the drug, they develop classically conditioned responses that maintain their addiction.
Comorbidity
Individuals with mood and anxiety disorders are more likely to abuse substances. The most common comorbid conditions are mood disorders, anxiety disorders, borderline personality disorder, and antisocial personality disorder. People with schizophrenia are more likely to use alcohol and tobacco and to have drug use disorders.
There are three possible routes to the development of comorbid substance use and
other
psychological disorders.
● The first is the similarity of risk factors in substance use and other
psychological disorders.
● Second, individuals with psychological disorders or symptoms may use drugs
as a form of self-medication.
● Third, people who use substances may subsequently develop a psychological
disorder, due either to changes in brain activity produced by the substances or
to changes in lifestyle that precipitate stress, which, in turn, leads to
symptoms of depression and anxiety.
Risk Factors of Early Drug Use
Drug use typically begins in adolescence, which is also the time of heightened vulnerability to other psychological disorders. Early drug use is also a risk factor for later substance use disorder and possibly for the subsequent development of other disorders as well.
The risks are particularly likely to occur in individuals who have a high genetic vulnerability. In one study following adolescents into early adulthood, only those heavy marijuana users with a particular gene variant had significantly higher risk of developing schizophreniform disorder.
Substance Use and PTSD
Higher rates of substance use disorders also occur in physically or emotionally traumatized individuals. This is a matter of particular concern for the veterans returning from the Iraq and Afghanistan wars. As many as half of veterans who have a diagnosis of PTSD also have a comorbid substance use disorder.
In addition, researchers estimate that 45 percent of offenders in state and local prisons have a comorbid mental health and substance use disorder. People with a comorbid substance disorder and either PTSD or a criminal history may have difficulty receiving treatment.
Veterans with PTSD and substance disorders may not receive treatment for the PTSD until the substance use disorder has been treated; however, traditional substance disorder clinics may defer treating the PTSD. Incarcerated criminals may also have difficulty receiving appropriate treatment in the prison system.
Clearly, individuals with comorbid disorders face particular challenges in treating their substance use disorders.
Alcohol
Alcohol use is associated with several categories of disorders including use disorders, intoxication, and withdrawal. According to the World Health Organization (WHO), worldwide there are 3.3 million deaths every year due to alcohol, representing nearly 6 percent of all deaths.
Patterns of alcohol use are associated with age. Young adults 21 to 25 have the highest rates of binge drinking and the highest rates of heavy drinking. The rates of binge and heavy drinking decline sharply through adulthood.
Although the rates of alcohol use by age are lower in those 65 years of age and older, longitudinal studies provide a different picture. People are less likely to start drinking after the young adult years, but many persist in their previously established patterns of alcohol use disorder throughout adulthood. Adults going through certain life transitions may alter their alcohol use patterns, however.
For men, parenthood is associated with lower rates of alcohol use after the age of 38; women show the opposite pattern. Men who lose their jobs have the highest rates of alcohol use after age 38; for women, there is no relationship between job status and alcohol-use persistence. These findings suggest that the relationships among alcohol use, life transitions, and gender are complex and that aging alone is not sufficient for understanding age-related changes in alcohol use disorders.
Alcohol
To understand how alcohol affects behavior, consider that from a physiological standpoint alcohol is a nervous system depressant, and the way it affects the individual depends on how much the drinker ingests.
In small amounts, alcohol has sedating effects, and the drinker therefore feels more relaxed. With larger amounts, drinkers may begin to feel more outgoing, self-confident, and uninhibited. Beyond that point, the depressant effects become apparent, leading users to experience sleepiness, lack of physical coordination, dysphoria, and irritability. In even larger amounts, alcohol can be fatal, leading the individual’s vital functions to shut down.
More severe effects also occur when the individual mixes alcohol with other drugs; potentiation makes the effects of two drugs taken together greater than the effect of either substance alone. Combining alcohol with another depressant can have a fatal outcome, for example.
Alcohol
The rate at which alcohol absorption occurs in the bloodstream depends on a number of factors, including how much a person consumes and over what time period, and whether food is present in the digestive system. Another factor is the drinker’s metabolic rate (the rate at which the body converts food substances to energy). The average person metabolizes alcohol at a rate of one third of an ounce of 100 percent alcohol per hour, which is equivalent to an ounce of whiskey per hour.
Following a bout of extensive intake of alcohol, a person is likely to experience an abstinence syndrome, or the phenomenon commonly called a “hangover.” The symptoms of abstinence syndrome include a range of phenomena including nausea and vomiting, tremors, extreme thirst, headache, tiredness, irritability, depression, and dizziness. As with alcohol absorption, the extent of abstinence syndrome the person experiences reflects the amount and rate of alcohol consumption and the individual’s metabolic rate.
Directly or indirectly, alcohol affects almost every organ system in the body. Long-term use can lead to permanent brain damage, with symptoms of dementia, blackouts, seizures, hallucinations, and damage to the peripheral parts of the nervous system. Two forms of dementia are associated with long-term heavy alcohol use.
Wernicke’s Disease Wernicke’s disease is an acute and potentially reversible condition characterized by delirium,
eye-movement disturbances, difficulties in
movement and balance, and deterioration of the
peripheral nerves to the hands and feet.
It is not alcohol itself but the associated deficiency
of thiamine (vitamin B1) that causes Wernicke’s
disease. Long-term heavy use of alcohol damages
the body’s ability to metabolize nutrients, and
alcohol users often have an overall pattern of poor
nutrition. Adequate thiamine intake can reverse
Wernicke’s disease.
Korsakoff’s SyndromeKorsakoff’s syndrome is a permanent form of dementia in which the individual develops
retrograde amnesia, the inability to remember
past events, and anterograde amnesia, the
inability to remember new information.
The chances of recovering from Korsakoff’s
syndrome are fewer than one in four, and about
another one in four people who have this
disorder require permanent institutionalization.
Effects of Alcohol Abuse
Chronic heavy alcohol consumption also causes a number of harmful changes in the rest of the body outside the nervous system,
including to the liver,
gastrointestinal system, bones,
muscles, and immune system.
Alcohol Withdrawal
When people abruptly stop ingesting alcohol after periods of chronic usage, they can experience sleep disturbances, profound anxiety, tremors, hyperactivity of the sympathetic nervous system, psychosis, seizures, or death.
Delirium tremens is a severe form of alcohol withdrawal that involves sudden changes in the person’s mental state and/or nervous system. Most people refer to it as DTs.
DTs begin when alcoholics stop drinking after they have been consuming excessive amounts of alcohol for a period of time. It usually occurs in those who have a history of withdrawal. That means your risk for it is higher if you have been through alcohol withdrawals in the past. You are also more at risk for the condition if you have been drinking a lot over the course of several months, or have been an alcoholic for more than ten years.
Alcohol Use Disorders from a Biological Perspective
Twin, family, and adoption studies consistently point to the importance of genetic factors as contributors to alcohol-related disorders, with an estimated heritability of 50 to 60 percent. Pinpointing the genes responsible for alcohol-related disorders is a great challenge to researchers, however, because it is likely that multiple genes are active in their transmission. The greatest success has come from studies examining associations between genes that govern alcohol metabolism and neural transmission. Researchers are attempting to connect variations in some of these genes not only with patterns of alcohol use but also with comorbid disorders such as social anxiety disorder, personality traits, and early childhood predictors.
Sociocultural influences also appear to interact with genetic vulnerability. In a large nationwide study of midlife adults, researchers found differences between twins in the level of alcohol use, based on socioeconomic status. In families from lower socioeconomic levels, genetic factors seemed to play a larger role than the environment. In higher social status families, the amount of alcohol individuals use is affected by such factors as familial habits and traditions. These findings support the diathesis-stress model that relates genetic predisposition to environmental stressors.
Treatment Approaches from a Biological Perspective
In the biological perspective, treatment of individuals with alcohol use disorders relies on prescription medications, alone or in conjunction with psychologically based therapies. A large number of well-controlled studies support the use of naltrexone as an aid in preventing relapse. As an opioid receptor antagonist, it blocks the effects of the body’s production of alcohol-induced opioids, perhaps through involving dopamine. The individual who takes naltrexone is less likely to experience pleasurable effects of alcohol and even less likely to feel pleasure thinking about it. As a result, he or she will feel less of an urge to drink and therefore will be less likely to suffer a relapse of heavy drinking. A large number of studies provide supportive evidence about naltrexone’s effect on drinking, including its ability to lower the individual’s cravings and, hence, consumption.
Disulfiram is a medication that operates by the principles of aversion therapy. An individual taking disulfiram who consumes alcohol within a 2-week period will experience a variety of unpleasant physical reactions, including flushing, palpitations, increased heart rate, lowered blood pressure, nausea and vomiting, sweating, and dizziness. Although not as effective as naltrexone, it does work for highly motivated individuals, particularly those treated in supervised settings who are also older, have a longer drinking history, and participate in Alcoholics Anonymous meetings.
The third medication shown to be effective in treating alcohol use disorders is acamprosate, an amino acid derivative that appears to moderate glutamate receptors. Acamprosate reduces the risk of relapse by reducing the individual’s urge to drink and thereby reducing the drive to use alcohol as a way of reducing anxiety and other negative psychological states. The evidence on acamprosate is generally positive, though individuals who seem to benefit from it the most are those who are older when they become dependent on alcohol, have physiological signs of higher dependence, and have higher levels of anxiety. People who are more highly motivated to become fully abstinent at the start of treatment are more likely to remain on the medication and therefore more likely to improve. Individuals who have only recently stopped drinking and are of normal or close to normal body weight appear to derive greater benefit.
Dual-Process Theory
Psychological Perspective
Current psychological approaches to alcohol use disorders focus on the cognitive systems that guide people’s drinking behavior.
According to dual-process theory, one cognitive system generates fast, automatic processes that trigger an impulse to drink alcohol. These automatic processes are based on the conditioned positive associations with alcohol that people have formed.
The second, and slower, system consists of the controlled, laborious processing that would allow individuals to regulate and inhibit acting on those positive associations.
The dual-process theory posits that the more the individual can inhibit the automatic impulse, the less likely he or she is to consume excessive amounts of alcohol.
Personality may play a role in this process, because individuals who are lower in emotional control seem to find it more difficult to engage in the deliberate process of inhibiting their urges to drink.
Alcohol Use Disorders from a Psychological Perspective
Alcohol consumption is also guided by individuals’ expectations about what will happen to them after they consume alcohol. Individuals develop alcohol expectancies early in life, even before they first taste alcohol. These can include the potential for alcohol to reduce tension or help them cope with social challenges, feel better or sexier, or become more mentally alert. Expectancies about alcohol can also include people’s beliefs in their self-efficacy, or their ability to resist or control their drinking.
Cognitive factors also can influence what happens when a person consumes alcohol. According to alcohol myopia theory, individuals narrow their attentional focus the more alcohol they consume. This theory also predicts that when people drink alcohol, they also become more likely to engage in impulsive and potentially harmful behaviors, such as high-risk sexual activities. The high prevalence of binge drinking on college campuses presents a particular concern for this reason. As individuals consume greater amounts of alcohol, they are more likely to make risky choices because
the immediate temptation of the moment (such as engaging in risky sex) overcomes the long-term consequences of the behavior (such as developing a sexually transmitted disease).
Even individuals who engage in healthy lifestyle behaviors can be at risk for alcohol use disorders. In one large study examining alcohol use (beer) and engagement in physical activity, people who engaged in more activity were also more likely to drink beer the same day. College students who believe they are engaging in healthy activity may feel they have “earned” the right to drink, placing themselves at potential risk for developing regular habits in which they overuse alcohol.
Alcohol Use Identification Test
Clinicians who design interventions targeting individuals with alcohol use disorders begin by conducting an assessment of the alcohol use patterns of their clients. The AUDIT, or Alcohol Use Disorders Identification Test, is one such instrument.
The Alcohol Use Disorders Identification Test (AUDIT) provides a self-guided test that individuals can take to assess their alcohol consumption, drinking behaviors, and alcohol-related problems. Below is a summary of the questions found on the AUDIT, each of which is rated with a frequency scale:
1. How often do you drink alcohol?
2. How many alcoholic drinks do you typically have on a day you are drinking?
3. How often do you have 6 or more alcoholic drinks at one time?
4. How often have you found that you were not able to stop drinking daily once you had started?
5. How often during the past year has drinking alcohol kept you from doing something you were normally expected to do? 6. How often in the past year have you needed a first drink in the morning to get yourself going after a night of heavy drinking?
7. How often during the last year have you felt guilty or remorseful after drinking?
8. How often during the last year have you been unable to remember what happened the day before because of drinking too much alcohol?
9. Have you or someone else been hurt or harmed because of your drinking?
10. Has someone close to you or a health care professional spoken to you about your drinking or suggested that you cut down?
Treatment Approaches from a Psychological Perspective
There are several well-tested psychological approaches to treating alcohol use disorders. The most successful rely on cognitive-behavioral interventions, motivational approaches, and expectancy manipulation.
Part of effective treatment is relapse prevention, in which the clinician essentially builds “failure” into treatment. If the client recognizes that occasional slips from abstinence are bound to occur, then he or she will be less likely to give up on therapy altogether after suffering a temporary setback.
Mindfulness training may also be added to relapse prevention to help individuals gain greater insight into the factors that trigger their relapses as well as to recognize that substance use may be a way of avoiding the present moment.
Combined Behavioral Intervention
The COMBINE project (Combining Medications and Behavioral Interventions) developed the most comprehensive protocol for psychological treatment. In this treatment, known as Combined Behavioral Intervention (CBI), participants receive up to 20 sessions, according to their needs, beginning semiweekly and then eventually biweekly or less, for up to 16 weeks. The primary emphasis of CBI is on enhancing reinforcement and social support for abstinence. Clinicians assign motivational enhancement therapy at the outset, meaning they attempt to draw out the client’s own motivation to change. The clinical style used in CBI follows from the motivational interviewing perspective, in which the clinician uses a client-centered but directive style.
Clinicians expect and encourage families and significant others to participate throughout treatment, and they also encourage mutual help and involvement among clients, including participation in Alcoholics Anonymous (AA). CBI includes content modules focusing on coping skills (for coping with cravings and urges), ways to refuse drinks and avoid social pressure to drink, communication skills, assertiveness skills, management of moods, social and recreational counseling, social support for sobriety, and job-seeking skills. As
needed, clinicians may also monitor sobriety, provide telephone consultation, and provide crisis intervention. They also put procedures in place to work with clients who resume drinking during treatment. Toward the end of the treatment period, clients enter a maintenance phase and then complete treatment in a termination session.
Sociocultural Perspective
Researchers and theorists working within the sociocultural perspective regard stressors in the family, community, and culture as factors that, when combined with genetic vulnerability, lead the individual to develop alcohol use disorder. As indicated earlier, socioeconomic status seems to interact with genetic vulnerability as an influence on how much alcohol individuals consume.
Support of the sociocultural perspective first became apparent in a landmark longitudinal study in the early 1980s. Researchers followed individuals from childhood or adolescence to adulthood, the time when most individuals who become alcohol-dependent make the transition from social or occasional alcohol use to an alcohol use disorder.
Those most likely to develop alcohol use disorder in adulthood had a history of childhood antisocial behavior, including aggressive and sadistic behavior, trouble with the law, rebelliousness, lower achievement in school, completion of fewer years of school, and a higher truancy rate. These individuals also showed a variety of behaviors possibly indicative of early neural dysfunction, including nervousness and fretfulness as infants, hyperactivity as children, and poor physical coordination while growing up through the normal motor development milestones. Researchers concluded that these characteristics reflected a genetically based vulnerability, which, when combined with environmental stresses, led to the development of alcohol use disorder.
Sociocultural Perspective
Families can also provide social support in other ways that affect alcohol use by teenagers. In a 2-year study of more than 800 suburban adolescents, those who received high levels of social support from their families were less likely to consume alcohol. The effect seemed to be due primarily to the fact that these families were also more likely to strongly emphasize religion in the home.
Further, teens earning good grades in school were more likely to be receiving higher levels of social support from their families, which in turn was associated with lower rates of alcohol use. The teens who used alcohol were more likely to show poorer school performance over the course of the study.
Another approach within the sociocultural perspective takes into account the impact of socialization on patterns of alcohol use disorders. Researchers have demonstrated the benefits of cognitive-behavioral therapy designed specifically for women. Female-specific cognitive-behavioral therapy emphasizes the themes of self-care and self-confidence as well as addressing friendships, social support, and levels of assertiveness, using female models in relevant training vignettes and worksheets.
Stimulants The category of drugs called stimulants includes substances that have an activating
effect on the nervous system.
These differ in their chemical structure, their
specific physical and psychological effects, and
their potential danger to the user.
Stimulants are associated with disorders
related to use, intoxication, and withdrawal.
Amphetamines
Amphetamine is a stimulant that affects both the central nervous and the autonomic nervous systems. In addition to waking or speeding up the central nervous system, it also causes elevated blood pressure and heart rate, and decreased appetite and physical activity.
It may be used for medical purposes, such as to treat ADHD or as a diet pill. Even when used for medical purposes, however, amphetamine can cause dependence and have unpleasant or dangerous side effects.
Increasingly large doses can make users
hostile, violent, and paranoid. Users may also
experience a range of physiological effects
including fever, sweating, headache, blurred
vision, dizziness, chest pain, nausea, vomiting,
and diarrhea.
Methamphetamine is an addictive stimulant drug that is related to amphetamine but one that provokes more intense central nervous system effects. Whether taken orally, through the nose, intravenously, or by smoking, methamphetamine causes a rush or feeling of euphoria and becomes addictive very quickly.
Methamphetamine overdose can cause overheating of the body and convulsions, and if not treated immediately, it can result in death.
Long-term use of methamphetamine can lead users to develop mood disturbances, violent behavior, anxiety, confusion, insomnia, severe dental problems (“meth mouth”), and a heightened risk of infectious diseases including hepatitis and HIV/AIDS. The long-term effects of methamphetamines also include severe brain damage
Cocaine Cocaine is a highly addictive central nervous system
stimulant that an individual snorts, injects, or smokes. Users
can snort the powdered hydrochloride salt of cocaine or
dissolve it in water and then inject it.
Crack is the street name given to the form of cocaine that is
processed to form a rock crystal which, when heated,
produces vapors that the individual smokes.
The effects of cocaine include feelings of euphoria,
heightened mental alertness, reduced fatigue, and
heightened energy. The faster the bloodstream absorbs the
cocaine and delivers it to the brain, the more intense the
user’s high. Because this intense high is relatively short (5
to 10 minutes), the user may administer the drug again in a
binge-like pattern.
Cocaine
Like amphetamines, cocaine increases body temperature, blood pressure, and heart rate. Cocaine’s risks include heart attack, respiratory failure, stroke, seizures, abdominal pain, and nausea. In rare cases, the user can experience sudden death on the first use of cocaine or unexpectedly afterwards.
Other adverse effects on the body develop over time and include changes within the nose (loss of sense of smell, chronically runny nose, and nosebleeds), as well as problems with swallowing and hoarseness. Users may experience severe bowel gangrene due to a reduction of blood flow to the digestive system. Cocaine users may also have severe allergic reactions and increased risk of developing HIV/AIDS and other blood-borne diseases.
When people use cocaine in binges, they may develop chronic restlessness, irritability, and anxiety. Chronic users may experience severe paranoia in which they have auditory hallucinations and lose touch with reality.
Activity prompt:
Look at the graphics on the previous slide comparing the cost of powder cocaine and crack cocaine and showing a breakdown of
crack cocaine users by race/ethnicity. How do you think these realities interact and contribute to the overrepresentation of African Americans in the criminal justice system?
Cannabis
Cannabis is associated with disorders related to use, intoxication, and withdrawal. Marijuana is a mix of flowers, stems, and leaves from the hemp plant Cannabis sativa, a tall, leafy, green plant that thrives in warm climates. Although the plant contains more than 400 chemical constituents, the primary active ingredient in marijuana is delta-9-tetrahydrocannabinol (THC).
Hashish, containing a more concentrated form of THC, comes from the resins of the plant’s flowers. The marijuana and hashish that reach the street are never pure THC; other substances, such as tobacco, are always mixed in, too. Synthetic forms of THC serve some medicinal purposes, such as treating asthma and glaucoma and reducing nausea in cancer patients undergoing chemotherapy.
Most people who use marijuana smoke it as a cigarette or in a pipe. Users can also mix the drug in food or serve it as a tea. When smoked, marijuana reaches its peak blood level in about 10 minutes, but the subjective effect of intoxication does not become apparent for another 20 to 30 minutes. This effect may last 2 to 3 hours, but the metabolites of THC can remain in the body for 8 or more days.
Marijuana
Marijuana is the most commonly used illicit drug in the United States.
However, current prevalence statistics do not take into account the fact that both recreational and medical use of marijuana are now legal in a number of states, and federal regulation has eased in these states as well.
With these changes in legislation, the definition of an “illicit” drug will need to change in estimates of prevalence statistics. Furthermore, as marijuana use becomes decriminalized, it will be possible to examine the effects of its use on an individual’s daily life.
Marijuana
People take marijuana in order to alter their bodily sensations and perceptions of their environment. The effects they seek include euphoria, a heightened sense of sensuality and sexuality, and an increased awareness of internal and external stimuli.
However, marijuana use also carries a number of unpleasant effects including impaired short-term memory, slowed reaction time, impaired physical coordination, altered judgment, and poor decision making. Instead of feeling euphoric and relaxed, users may experience paranoia and anxiety, particularly when they ingest high doses.
Marijuana
THC produces its effects by acting upon specific sites in the brain, called cannabinoid receptors. The brain regions with the highest density of cannabinoid receptors are the areas that influence pleasure but also are active in memory, thinking and concentration, perception of time, sensory responses, and ability to carry out coordinated movement. Many of marijuana’s acute effects on cognitive functioning are reversible as long as the individual does not engage in chronic use.
Heavy and continued use of marijuana can produce a number
of deleterious effects on bodily functioning, including higher
risk of heart attack and impaired respiratory functioning. In
addition to developing psychological dependence on
marijuana, long-term users may experience lower educational
and occupational achievement, psychosis, and persistent
cognitive impairment. Particularly at risk are individuals who
begin using marijuana at an early age and continue to use it
throughout their lives.
Hallucinogens
Included in hallucinogen-related disorders are use and intoxication, but not withdrawal. Hallucinogens are drugs that cause people to experience profound distortions in their perception of reality. Under the influence of hallucinogens, people see images, hear sounds, and feel sensations that they believe to be real but are not. In some cases, users experience rapid, intense mood swings. Some develop a condition called hallucinogen persisting perception disorder, in which they experience flashbacks or spontaneous hallucinations, delusions, or disturbances in mood similar to the changes that took place while they were intoxicated with the drug. The specific effects and risks of each hallucinogen vary according to the particular substance.
LSD
People take lysergic acid diethylamide (LSD) in tablets, capsules, and
occasionally liquid form. Users show dramatic changes in their
sensations and emotions. They may feel several emotions at once or
swing rapidly from one emotion to another. With larger doses, users can
experience delusions and visual hallucinations. In addition, they may feel
an altered sense of time and self. They may also experience synesthesia,
in which they “hear” colors and “see” sounds. These perceptual and mood
alterations may be accompanied by severe, terrifying thoughts and
feelings of despair, panic, and fear of losing control, going insane, or
dying. Even after they stop taking LSD, users may experience flashbacks,
leading them to be significantly distressed and impaired in their social
and occupational functioning.
Unlike other substances, LSD does not seem to produce compulsive drug-seeking behavior, and most users choose to decrease or stop using it without withdrawal. However, it does produce tolerance, so users may need to take larger doses to achieve the effects they desire. Given the unpredictable nature of the drug’s effects, such increases in doses can be dangerous. LSD can also affect other bodily functions, with effects including sweating, loss of appetite, dry mouth, sleeplessness, tremors, and increased body temperature, blood pressure, and heart rate.
Peyote Peyote is a small, spineless cactus whose principal
active ingredient, mescaline, can also be produced
artificially. Users chew the mescaline-containing
crown of the cactus or soak it in water to produce a
liquid; some prepare a tea by boiling the cactus in
water to rid the drug of its bitter taste.
Used as part of religious ceremonies by native
peoples in northern Mexico and the southwestern
United States, mescaline has long-term effects on
these and recreational users that are not known.
However, its effects on the body are similar to those
of LSD, including increases in body temperature
and heart rate, uncoordinated movements, extreme
sweating, and flushing. In addition, mescaline may
cause flashbacks, much like those associated with
LSD.
Psilocybin AKA Magic Mushrooms
Psilocybin and its biologically active form, psilocin, are substances found in certain mushrooms. Users brew the mushrooms or add them to other foods to disguise their bitter taste.
The active compounds in psilocybin-containing mushrooms, like LSD, alter the individual’s autonomic functions, motor reflexes, behavior, and perception. Individuals may experience hallucinations, an altered sense of time, and an inability to differentiate between fantasy and reality. Large doses may cause flashbacks, memory impairments, and greater vulnerability to psychological disorders.
In addition to the risk of poisoning if the individual incorrectly identifies the mushroom, the bodily effects can include muscle weakness, loss of motor control, nausea, vomiting, and drowsiness.
PCP
Researchers developed phencyclidine (PCP) in the 1950s as an intravenous anesthetic, but it is no longer used medically because patients became agitated, delusional, and irrational while recovering from its effects. Users can easily mix the white crystalline powder with alcohol, water, or colored dye. PCP may also be available on the illegal drug market in pill, capsule, or colored powder forms that users can smoke, snort, or take orally. When individuals smoke PCP, they may apply the drug to mint, parsley, oregano, or marijuana.
PCP causes users to experience a sense of dissociation from their surroundings and their own sense of self. It has many adverse effects including symptoms that mimic schizophrenia, mood disturbance, memory loss, difficulties with speech and thinking, weight loss, and depression. Although these negative effects led to its diminished popularity as a street drug, PCP appeals to those who still use it because they feel that it makes them stronger, more powerful, and invulnerable. Despite its adverse effects, users can develop strong cravings and compulsive PCP-seeking behavior.
PCP
The physiological effects of PCP are extensive. Low to moderate doses produce increases in breathing rate, a rise in blood pressure and pulse, general numbness of the extremities, and loss of muscular coordination, as well as flushing and profuse sweating. At high doses, users experience a drop in blood pressure, pulse rate, and respiration, which may be accompanied by nausea, vomiting, blurred vision, abnormal eye movements, drooling, loss of balance, and dizziness. They may
become violent or suicidal. In addition, at high doses users may experience seizures, coma, and death. Those who combine PCP with other central nervous system depressants (such as alcohol) may become comatose.
MDMA
The chemical named MDMA and known on the street as ecstasy is a synthetic substance chemically similar to methamphetamine and mescaline. Users experience feelings of increased energy, euphoria, emotional warmth, distorted perceptions and sense of time, and unusual tactile experiences. Taken as a capsule or tablet, MDMA was once most popular among white teens and young adults at weekend-long dances known as raves.
Users of MDMA may experience a range of unpleasant psychological effects, including confusion, depression, sleep problems, cravings for the drug, and severe anxiety. The drug may be neurotoxic, which means that over time users may experience greater difficulty carrying out cognitive tasks. Like stimulants, MDMA can affect the sympathetic nervous system, leading to increased heart rate and blood pressure, muscle tension, nausea, blurred vision, fainting, chills or sweating, and involuntary teeth clenching. Individuals also risk severe spikes in body temperature, which in turn can lead to liver, kidney, or cardiovascular system failure. Repeated dosages over short periods of time may also interfere with MDMA metabolism, leading to significant and harmful buildup within the body.
MDMA
The main neurotransmitter involved with MDMA is serotonin. MDMA (labeled “ecstasy”) binds to the serotonin transporter responsible for removing serotonin from the synapse. As a result, MDMA extends the effects of serotonin. In addition, MDMA enters the neuron, where it stimulates excessive release of serotonin. MDMA has similar effects on norepinephrine, which leads to increases in autonomic nervous system activity. The drug also releases dopamine, but to a lesser extent.
Researchers find it difficult to investigate the long-term effects of MDMA use on cognitive functioning because users typically take it with other substances. However, significant negative effects on verbal memory do occur with MDMA use alone. MDMA’s effects on cognition appear to relate at least in part to the impact of the drug on the availability of an individual’s cognitive resources. Moreover, when combined with alcohol, MDMA produces a number of long-term adverse psychological effects including paranoia, poor physical health, irritability, confusion, and moodiness.
Opioids
Opioid-related disorders are connected to opioid use, intoxication, and withdrawal. An opioid is a substance that relieves pain.
Many legally prescribed medications fall within this category, including hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), codeine, and related drugs. Clinicians prescribe hydrocodone products most commonly for a variety of painful conditions, including dental procedures and injuries. Physicians often administer morphine before and after surgical procedures to alleviate severe pain. Codeine, on the other hand, is prescribed for mild pain. Some opioid drugs—codeine and diphenoxylate (Lomotil), for example—are used to relieve coughs and severe diarrhea, respectively.
When people take them as prescribed, these medications are effective for managing pain safely. However, because of their potential to produce euphoria as well as physical dependence, they are among the most frequently abused prescription drugs. People who abuse OxyContin may snort or inject it and suffer a serious overdose reaction as a result.
The opioids of abuse include prescription pain relievers, heroin, and synthetic opioids such as fentanyl. The so-called opioid crisis, the rise in the number of individuals addicted to prescription painkillers and resulting deaths, is now seen as a major public health crisis in the United States.
Heroin
Heroin is a form of opioid. It is a painkilling drug synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Users inject, snort, sniff, or smoke heroin. The body then converts it to morphine, which binds to the opioid receptors throughout the brain and body, particularly those active in reward and pain perception. Opioid receptors are also located in the brain stem, which contains structures that control breathing, blood pressure, and arousal.
Users experience a surge of euphoric feelings, along with dry mouth, warm flushing of the skin, heaviness in the arms and legs, and compromised mental functioning. Shortly afterward, they alternate between feeling wakeful and drowsy. If users do not inject the drug, they may not feel euphoria at all. With continued use of heroin, users develop tolerance, meaning they need larger amounts of the drug to feel the same effect. Heroin has a high potential for addiction; it is estimated that as many as 23 percent of all users develop dependence.
Heroin
There are many serious health consequences of heroin use, including fatal overdoses, infectious diseases (related to needle sharing), damage to the cardiovascular system, abscesses, and liver and kidney disease.
Users are often in poor general health and therefore are more susceptible to pneumonia and other pulmonary complications, as well as damage to the brain, liver, and kidneys resulting from the toxic contaminants often added to the drug.
Chronic heroin users experience severe withdrawal should they discontinue its use. Severe cravings can begin within 2 to 3 days and last for as long as a week, and they can recur years later if the individual experiences certain triggers or stress.
There are also dangers to sudden withdrawal, particularly in long-term users who are in poor health. Withdrawal symptoms can include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes, and kicking movements.
Effects of Opioid Use
Abuse of opiates, whether prescription painkillers or heroin, can have a serious impact on your health. In addition to the hazards of overusing opioid painkillers, sharing needles for the injection of heroin or injecting crushed pills poses its own dangers.
These substances and practices can affect almost every part of your body, potentially leading to permanent damage to your health. While a multitude of health consequences can accompany long-term opiate abuse, many of the dangers are seen more acutely. Even a first time user can experience respiratory arrest, for example.
Sedatives, Hypnotics, and Anxiolytics
The category of sedatives, hypnotics, and anxiolytics (antianxiety medications) includes prescription medications that act as central nervous system depressants. A sedative has a soothing or calming effect, a hypnotic induces sleep, and an anxiolytic is used to treat anxiety symptoms. The sedating effects of these central nervous system depressants are due to the fact that they increase the levels of the neurotransmitter GABA, which inhibits brain activity and therefore produces a calming effect. Disorders within this category include use disorder, intoxication, and withdrawal.
These medications are among the most commonly abused drugs in the United States. They include benzodiazepines, barbiturates, nonbenzodiazepine sleep medications such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon. Although safe when taken as prescribed, these medications have high potential for abuse and dependence. The longer a person uses them, the greater the amount needed to produce the sedating effects. In addition to the risk of dependence, these medications can also have harmful effects on individuals taking other prescription and over-the-counter drugs.
For older adults, the risk of abuse is also high, particularly given the potential for drug interactions with alcohol and other medications. Moreover, older adults with cognitive decline may take their medication incorrectly, which in turn can lead to further cognitive decline.
Caffeine
Caffeine is a stimulant found in coffee, tea, chocolate, energy drinks, diet pills, and headache remedies. By activating the sympathetic nervous system through increasing the production of adrenaline, caffeine increases an individual’s perceived level of energy and alertness. It also increases blood pressure and may lead to increases in the body’s production of cortisol, the stress hormone.
Because caffeine is such a common feature of everyday life, people tend not to be aware of its dangers. When consumed in large quantities, caffeine can lead to many adverse reactions, including the development of other forms of substance dependence.
Caffeine
Disorders included in the caffeine-related category are intoxication and withdrawal, but not caffeine use disorder. Support is growing for adding caffeine use disorder as a diagnosis similar to other substance use disorders.
The DSM-5 was the first psychiatric manual in the United States to include caffeine withdrawal as a diagnosis (it was already a diagnosis in ICD-10). The symptoms of caffeine withdrawal include headache, tiredness and fatigue, sleepiness and drowsiness, dysphoric mood, difficulty concentrating, depression, irritability, nausea, vomiting, muscle aches, and
stiffness.
Particularly dangerous is the combination of caffeine and alcohol, a problem that is most severe on college campuses where as many as 75 percent report lifetime prevalence of using a caffeinated beverage. When users combine alcohol and caffeine, they may not realize how intoxicated they are and as a result may have a higher prevalence of alcohol-related consequences. In one daily-diary study of undergraduates asked to record their daily consumption of caffeine and alcohol, those who consumed caffeine in energy drinks had more alcohol-related problems.
Tobacco Individuals can be diagnosed with tobacco use disorder or tobacco withdrawal, but not tobacco intoxication. Nicotine is the psychoactive
Effect of Nicotine on the Body
substance found in cigarettes. The health risks of tobacco are well known; these risks are primarily associated with smoking cigarettes which, in addition to nicotine, contain tar, carbon monoxide, and other additives. Readily absorbed into the bloodstream, nicotine is also present in chewing tobacco, pipe tobacco, and cigars.
When nicotine enters the bloodstream, it stimulates the release of adrenaline (norepinephrine), which activates the autonomic nervous system and increases blood pressure, heart rate, and respiration. Like other psychoactive substances, nicotine increases the level of dopamine, affecting the brain’s reward and pleasure centers. Substances found in tobacco smoke, such as acetaldehyde, may further enhance nicotine’s effects on the central nervous system. The withdrawal symptoms associated with quitting tobacco use include irritability, difficulties with concentration, and strong cravings for nicotine.
Inhalants
Inhalants are a diverse group of substances that cause psychoactive effects by producing chemical vapors. These products are not in and of themselves harmful; in fact, they are all products commonly found in the home and workplace.
There are four categories of inhalants:
● Volatile solvents (paint thinners or removers, dry-cleaning fluids, gasoline, glue, and lighter fluid) ● Aerosols (sprays that contain propellants and solvents)
● Gases (butane lighters and propane tanks, ether, and nitrous oxide)
● Nitrites (a special category of products that individuals use as sexual enhancers)
Young teens (ages 12 to 15) tend to inhale glue, shoe polish, spray paint, gasoline, and lighter fluid. Older teens (ages 16 to 17) inhale nitrous oxide, and adults (ages 18 and older) are most likely to inhale nitrites. Within the category of inhalant disorders, individuals can be diagnosed as having inhalant use disorder or intoxication, but not inhalant withdrawal.
Inhalants
The effects of an inhalant tend to be short-lived; consequently, users try to extend their high by inhaling repeatedly over a period of several hours.
Inhalants have effects similar to those of alcohol, including slurring of speech, loss of coordination, euphoria, dizziness, and, over time, loss of inhibition and control. Users may experience drowsiness and headaches, but depending on the substance, they may also feel confused and nauseated.
The vapors displace the air in the lungs, causing hypoxia (oxygen deprivation), which is particularly lethal to neurons in the central nervous system. Long-term use may also cause the myelin sheath around the axon to deteriorate, leading to tremors, muscle spasms, and perhaps permanent muscle damage. The chemicals in inhalants can also cause heart failure and sudden death.
Theories and Treatment of Substance Use Disorders
Since all psychoactive substances operate on the reward
and pleasure systems in the brain, similarities exist in the
mechanisms through which individuals develop dependence
on them.
However, important differences exist between alcohol and
other substances in the receptor pathways for the
substance, the psychosocial factors associated with the
users’ dependence, and, ultimately, the best treatment
methods.
Biological Perspectives
Except in the case of alcohol dependence, weak evidence exists for the efficacy of pharmacotherapies. There are no FDA-approved treatments for dependence on cocaine, methamphetamines, marijuana, hallucinogens, ecstasy, or prescription opioids. There are, however, several treatments for heroin dependence that are particularly effective when combined with behavioral interventions.
Medically assisted detoxification is the first step in treatment of heroin dependence. During detoxification, individuals may receive medications to minimize withdrawal symptoms. To prevent relapse, clinicians may use one or more of three different medications. Developed more than 30 years ago, methadone is a synthetic opioid that blocks the effects of heroin by binding to the same receptor sites in the central nervous system. Proper use requires specialized treatment including group and/or individual counseling along with referrals for other medical, psychological, or social services. Methadone is not considered an ideal treatment because of its potential for dependence, even when combined with psychosocial interventions.
Buprenorphine, approved by the FDA in 2002, produces less physical dependence, a lower risk of overdose, and fewer withdrawal effects. Originally developed as a pain medication, it is also approved for treatment of opiate dependence. The FDA has also approved naltrexone for heroin dependence, but it is not widely used because patients are less likely to comply with treatment due to such side effects as nausea and headaches.
For nicotine dependence, clinicians may use biologically based treatments. Nicotine replacement therapies (NRTs), including nicotine gum and the nicotine patch, were the first FDA-approved pharmacological treatments. These deliver controlled doses of nicotine to the individual to relieve symptoms of withdrawal. Other FDA-approved products include nasal sprays, inhalers, and lozenges. Other biological approaches to nicotine dependence are medications that do not deliver nicotine, including bupropion (Wellbutrin), an antidepressant, and varenicline tartrate (Chantix), which targets nicotine receptors in the brain.
Psychological Perspectives
Whether or not individuals with dependence on substances other than alcohol receive biologically based treatment, cognitive-behavioral therapy (CBT) is now widely understood to be a crucial component of successful treatment and an important counterpart to biological theories and treatments.
The principles applied in treating substance use disorders other than alcohol through CBT are similar to those in treating alcohol dependence. Well-controlled studies support the efficacy of CBT for populations dependent on a wide range of substances. Clinicians may combine CBT with motivational therapies, as well as with behavioral interventions that focus on contingency management. In addition, clinicians can readily adapt CBT to a range of clinical modalities, settings, and age
groups.
Given the limitations of medication-only treatment, CBT also provides an effective adjunct in both inpatient and outpatient clinics. The ability to help clients develop coping skills is useful in fostering compliance with pharmacotherapies such as methadone and naltrexone as well. Because these interventions are relatively brief and highly focused, they are adaptable to clients treated within managed care who may not have access to longer-term treatment.
Non-Substance Related Disorders
Gambling Disorder
People who have gambling disorder are unable to resist recurrent urges to gamble despite knowing that it will bring negative consequences to themselves or others.
The diagnosis in DSM-IV-TR included gambling disorder as an impulse-control disorder. In DSM-5, it is included with substance use disorders because it is now conceptualized as showing many of the same behaviors, such as cravings, increasing needs to engage in the behavior, and negative social consequences.
The unique features of gambling disorder include behaviors such as chasing a bad bet, lying about how much has been lost, searching for financial bailouts, and committing crimes to support gambling.
Gambling Disorder
Gambling disorder often co-occurs with other psychological disorders. The highest risk of developing gambling disorder occurs among people who engage in gambling on games involving mental skill (such as cards), followed by sports betting, use of gambling machines, and betting on horse races or cock and dog fights. People with gambling disorder who bet on sports tend to be young men who have substance use disorders. Those who bet on slot machines are more likely to be older women who have higher rates of other psychological disorders and begin gambling at a later age. In general, women are less likely than men to engage in the type of gambling that depends on strategy, such as poker.
People with gambling disorder also have high rates of other disorders, particularly nicotine dependence (60 percent), dependence on other substances (58 percent), mood disorder (38 percent), and anxiety disorder (37 percent). Mood and anxiety disorders are more likely to precede, rather than follow, the onset of gambling disorder . Older adults are less likely than younger adults to have gambling disorder, but they are nevertheless at risk because of limited incomes and lack of access to more physically engaging activities.
The repetitive behaviors characteristic of gambling disorder may be viewed as resulting from an imbalance between two competing and relatively separate neurobiological mechanisms—those responsible for urges and those responsible for cognitive control. There may also be genetic contributions, perhaps including abnormalities in dopamine receptor genes.
Theories of Gambling Disorder
From a behavioral perspective, gambling disorder may develop in part because gambling follows a variable-ratio reinforcement schedule in which rewards occur, on average, every X number of times. This pattern of reinforcement produces behaviors that are highly resistant to extinction. Slot machines, in particular, produce payoffs on this type of schedule, maintaining high rates of response by gamblers. Classical conditioning also operates to maintain this behavior, because gamblers learn to associate certain cues with gambling, including their internal states or moods and external stimuli such as advertisements for gambling.
Cognitive factors too play an important role in gambling
disorder. People with this disorder seem to engage in a
phenomenon known as discounting of probabilistic rewards,
in which they discount or devalue rewards they could obtain
in the future compared to rewards they can obtain right
away. They also engage in other cognitive distortions, many
of which spring from poor judgment of the probabilities that
their gambling will lead to successful outcomes, as shown in
the next slide.
|
Type of Distortion |
|
Representativeness |
Examples of Cognitive Distortions Example
Gambler’s fallacy When events generated by a random process have deviated from the population average in a short run, such as a roulette ball falling on red four times in a row, individuals may erroneously believe that the opposite deviation (e.g.,
ball falls on black) becomes more likely.
Overconfidence Individuals express a degree of confidence in their knowledge or ability that is not warranted by objective reality.
Trends in number picking Lottery players commonly try to apply long-run random patterns to short strings in their picks such as avoiding duplicate numbers and adjacent digits in number string
Availability Illusory correlations Individuals believe events that they expect to be correlated, due to previous experience or perceptions, have been correlated in previous experience even when they have not been, such as wearing a “lucky hat” they wore when they
won previously.
Availability of others’ wins When individuals see and hear other gamblers winning, they start to believe that winning is a regular occurrence, which reinforces their belief that they will win if they continue to play.
Inherent memory bias Individuals are biased to recollect wins with greater ease than losses. They then reframe their memories regarding gambling experiences in a way that focuses on positive experiences (wins) and disregards negative experiences
(losses). This causes them to rationalize their decision to continue gambling.
Additional cognitive distortions
Illusion of control Individuals have a higher expectancy for success than objective probability would warrant.
Switching and double switching Individuals recognize errors and process gambling-related situations in a rational way when they are not actively participating but abandon rational thought when they personally take part in gambling.
Gambling Disorder
The pathways model approaches gambling disorder from a developmental perspective, proposing that three main paths lead to three distinct subtypes of people with gambling disorder. The person with the behaviorally conditioned subtype had few symptoms prior to developing the disorder but, through frequent exposure to gambling, develops positive associations, distorted cognitions, and poor decision making about gambling. The individual in the emotionally vulnerable subtype had pre-existing depression, anxiety, and perhaps a history of trauma; gambling helps this individual feel better. The third type of person with pathological gambling has preexisting impulsivity, attentional difficulties, and antisocial characteristics. For this individual, the risk of gambling provides thrills and excitement.
The pathways model suggests that differing therapeutic approaches may work for each of the three subtypes of gambling disorder, but cognitive-behavioral therapy has the greatest empirical support. The clinician begins teaching clients to understand the triggers for their gambling by having them describe their pattern of gambling behaviors. For example, common triggers include unstructured or free time, negative emotional states, reminders such as sports broadcasts or advertisements, and available money. Using this information to help clients analyze when they gamble and when they do not, the clinician then helps them
increase pleasant activities, think of ways to handle cravings or urges, become more assertive, and correct their irrational cognitions. At the end of treatment, the clinician helps prepare clients for setbacks using relapse-prevention methods in which the goal is not complete abstinence but a reduction to a point below pretreatment levels. The individual who shows positive effects may also show personality changes that will serve to protect against relapse.
Brief motivational interviewing may also be a beneficial treatment for individuals with problem gambling. The individual may choose to pursue complete abstinence or moderation as a goal of this treatment; both can be equally effective in reducing the amount of money gambled, the number of days the individual gambles, as well as the individual’s perception of having achieved treatment-related goals.
Other
Non-Substance Related Disorders
In addition to classifying gambling disorder as a
non-substance-related disorder, the DSM-5 authors considered adding Internet gaming disorder to the category. For now, however, they have included it in Section 3 as a disorder requiring further study.
Although there is ample evidence to indicate that Internet gaming is becoming a problematic behavior in its own right, the available research was not considered sufficiently well developed yet to justify inclusion in the diagnostic system. Therefore, the DSM-5 work group believed further investigations are required to produce reliable prevalence estimates.
Other disorders the work group considered adding were “sex addiction,” “exercise addiction,” and “shopping addiction,” to name a few. However, the group believed there were even fewer empirical studies in peer-reviewed articles to justify their inclusion even in Section 3.
Substance
Disorders: The Biopsychosocial Perspective
The biopsychosocial model provides an extremely useful approach for understanding substance use disorders and approaches to treatment.
Genetics clearly plays a role in the development of these disorders, and the action of substances on the central nervous system also operates to maintain dependence.
Developmental issues in particular are critical for understanding the nature of these disorders, which often have their origins during late childhood and early adolescence.
Moreover, because alcohol, drugs, and medications with high abuse potential continue to be widely available, sociocultural factors play a strong role in maintaining dependence among users.
Addictions have characterized human behavior throughout the millennia; however, with more widespread public education and advances in both genetics and psychotherapeutic interventions, it is possible that we will see advances in prevention as well.
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Paraphilic Disorders, Sexual Dysfunctions, and Gender Dysphoria SSY 230: Lecture 11
What Patterns of Sexual Behavior Represent Psychological Disorders?
When it comes to sexuality, deciding which patterns of behavior represent psychological disorders becomes a complicated process, perhaps more so than in other areas of human behavior.
When we are evaluating the “normality” of a given sexual behavior, the context is extremely important, as are customs and mores, which change across cultures and over time. Attitudes and behaviors related to sexuality are continually evolving.
Perhaps because the topic has so many taboos, there was little scientific research on sexual disorders until relatively recently. The three individuals credited with paving the way for contemporary research on human sexuality are Alfred Kinsey, William Masters, and Virginia Johnson.
Paraphilic Disorders
The term paraphilia (para meaning “faulty” or “abnormal,” and philia meaning “attraction”) literally means a deviation from the norm in terms of the object of a person’s sexual attraction.
Paraphilias are behaviors in which an individual has recurrent, intense sexually arousing fantasies, sexual urges, or behaviors related to:
(1) nonhuman object,
(2) children or other nonconsenting persons, or
(3) the suffering or humiliation of self or partner
Clinicians diagnose paraphilic disorder when the paraphilia causes intense distress and impairment and has lasted for at least 6 months. The major categories of paraphilic disorders are listed in the following slide.
Paraphilic Disorders-Major Categories
Pedophilic Disorder
Sexual arousal from the presence of children or
adolescents
Exhibitionistic
Disorder
Sexual arousal from exposing the genitals to unsuspecting
stranger
Voyeuristic Disorder
Sexual pleasure from observing nudity or sexual activity of others
Fetishistic Disorder and Partialism
Sexual arousal from an object (fetishism) or from a part of the body (partialism)
Frotteuristic Disorder
Sexual urges about and sexually arousing fantasies of rubbing against or fondling a nonconsenting person
Sexual Masochism and Sexual Sadism Sexual arousal from being made to suffer
(masochism) or from inflicting suffering on another person
(sadism)
Transvestic Disorder
Cross-dressing
associated with intense distress or impairment
Paraphilic Disorders
A person’s nonnormative sexual behavior is not pathological in and of itself. The symptoms of a paraphilia must include fantasies, urges, or behaviors to bring about “recurrent and intense sexual arousal” that cannot be achieved in another fashion. Neither the DSM nor the ICD regard deviation from heterosexual intercourse as a criterion for a paraphilic disorder.
The essential feature of a paraphilic disorder, then, is that people with one of these disorders are so psychologically dependent on the particular form or target of their desire that they are otherwise unable to experience sexual arousal. Even if people with these disorders do not actually fulfill their urges or fantasies, they are obsessed with thoughts about acting upon them. Their attraction can become so strong and compelling that they lose sight of any goals other than achieving sexual fulfillment in this specific way. During periods in which the individual feels especially stressed, the symptoms may become more intense.
The life course of paraphilic disorders is that they begin in adolescence and tend to be chronic; however, the urge to commit acts that others consider sexually deviant may decline in later life. Paraphilic disorders also are more prevalent in men than women.
Having a paraphilic disorder is not illegal, but acting on paraphilic urges may be. As a result, the person who reports having such a disorder runs the risk of being arrested, convicted, and then required to register as a sex offender. Because people do not voluntarily report paraphilias to mental health care professionals, these disorders can be difficult to diagnose, and self-reports in surveys may actually prove to be more informative. Online reporting of paraphilias, in turn, produces more self-reports than do telephone surveys.
Pedophilic Disorder
People diagnosed with pedophilic disorder are sexually aroused by children or adolescents. Clinicians use this diagnosis for adults who are at least 18 years of age and at least 5 years older than the children to whom they are attracted.
The key feature of this disorder is that the individual experiences an intensity of sexual arousal when with children that may be equal to, if not greater than, that which he or she experiences with individuals who are physically mature. This diagnosis includes people who have acted upon their urges with children as well as those whose attraction is represented by viewing Internet pornography involving children but who do not act on those urges.
As mentioned, it is difficult to obtain prevalence data on paraphilic disorders, and particularly on pedophilic disorder given the illegality of the behavior. Perhaps the best estimate comes from a study in which researchers examined its prevalence through an online survey. If they could be assured of not getting caught, 6 percent of men and 2 percent of women stated that they would have sex with a child. The likelihood of these same individuals viewing Internet sex with children was somewhat higher, with 9 percent of men and 3 percent of women stating they would view child pornography.
For both men and women, interest in sex with children was associated with higher rates of antisocial or criminal behavior, as well as higher rates of abuse in childhood.
Exhibitionistic Disorder
People who engage in exhibitionism have fantasies, urges, and behaviors suggesting that they derive sexual arousal from exposing their genitals to an unsuspecting stranger.
In exhibitionistic disorder, these fantasies, urges, and behaviors cause significant distress or impairment. Exhibitionistic disorder begins early in adulthood and persists throughout life.
A number of studies were conducted which showed high rates of comorbidity with other psychiatric disorders including major depressive disorder and substance abuse.
The existence of comorbid conditions, along with the reluctance of people with the disorder to come forward, present numerous challenges both for developing an understanding of the causes of the disorder and for planning its treatment. The most important step in treatment is accurately assessing both the disorder itself and these comorbid conditions.
Voyeuristic Disorder
People who engage in voyeurism derive sexual pleasure from observing the nudity or sexual activity of others who are unaware of being watched.
Correspondingly, people with voyeuristic disorder are sexually aroused by observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.
Voyeurism is related to exhibitionism and is the most common of the paraphilic disorders. People with either of these disorders are also likely to engage in sadomasochistic behaviors and cross-dressing.
Fetishistic Disorder and Partialism
People with fetishistic disorder are aroused by an object not specifically intended to be used in a sexual context. There is a wide range of objects to which people with fetishistic disorder can develop attachments. However, they do not include articles of clothing associated with cross-dressing or objects such as vibrators that people use in tactile genital stimulation.
In a related disorder, partialism, the individual is sexually aroused by the presence of a specific body part. Again, as with all paraphilic disorders, the attraction to objects or body parts must be recurrent, intense, and have lasted at least 6 months.
Frotteuristic Disorder
The person with frotteuristic disorder has recurrent, intense sexual urges and sexually arousing fantasies of rubbing against or fondling a nonconsenting person.
Among men diagnosed with paraphilic disorders, approximately 10 to 14 percent have committed acts of frotteurism.
Men with frotteuristic disorder seek out crowded places, such as a rush-hour subway train, where they can safely rub up against their unsuspecting victims, and public transportation does seem to be a major site at which this behavior takes place.
Victims report feeling violated and may go out of their way to avoid crowds, yet few if any file police reports.
Sexual Masochism and Sexual Sadism Disorders
The term masochism describes the act of seeking pleasure from being in pain. People with sexual masochism disorder are sexually aroused by being beaten, bound, or otherwise made to suffer. Conversely, people with sexual sadism disorder become sexually aroused by the physical or psychological suffering of another person. The DSM-5 does not classify the use of bondage, domination, and sadomasochism (BDSM) as a disorder in and of itself.
As is true for several of the paraphilic disorders, there is very little in the way of scientific research on sexual masochism and sexual sadism disorders. People with these disorders tend not to seek treatment because they feel no need to change, and because their behaviors often occur in the context of a consensual relationship. Even among consenting adults, acts of sexual masochism and sadism are shrouded in secrecy. Yet preference for BDSM activities remains relatively common.
Transvestic Disorder
Transvestism, also called “cross-dressing,” refers to the behavior of dressing in the clothing of the other sex. Men make up the large majority of individuals who show this behavior.
A clinician would diagnose an individual with transvestic disorder only if he showed the symptoms of a paraphilic disorder, namely distress or impairment. Psychologists would consider a man who frequently cross-dresses and derives sexual pleasure from this behavior as a transvestite, but they would not diagnose him with a disorder.
The DSM-IV-TR limited this behavior to heterosexual males, but DSM-5 opened the diagnosis to women or gay men who have this sexual interest.
Theories and Treatment of Paraphilic Disorders
As we mentioned at the outset, deciding what is normal in the area of sexuality is an issue fraught with difficulty and controversy. Critics argued against including several of the paraphilic disorders in DSM-5 because they felt that to do so pathologizes a sexual behavior that happens to be infrequent.
Moreover, they maintained that breaking the law is not a sufficient basis for determining that an individual engaging in a paraphilic behavior has a psychological disorder. This criticism is particularly leveled at the diagnoses of exhibitionistic, voyeuristic, and frotteuristic disorder, which don’t have victims in the same sense as do the other paraphilic disorders.
Researchers and advocates within the field of sexual sadism and sexual masochism were critical of including these disorders in DSM-5 at all, arguing that they do not share the qualities of the other paraphilic disorders because they are engaged in by consenting adults. The DSM authors, they believe, should base their decisions about psychiatric diagnoses on empirical evidence rather than on political or moral considerations. The present system, though imperfect, nevertheless satisfies some of its critics in that behaviors such as BDSM in and of themselves are not regarded as disorders.
Theories and Treatment of Paraphilic Disorders
To be sure, many challenges face researchers who attempt to understand the causes of a disorder that leads to so much damage and has so many legal ramifications. Apart from the difficulty of identifying people with the disorder, even those who are available for scrutiny by researchers may not represent the population from which they are drawn.
For example, most of the people we can study for disorders involving criminal acts such as pedophilic disorder are likely to have been arrested. Even in paraphilic disorders that do not involve a criminal offense, self-selection can determine who decides to participate in research. The problem of unrepresentative samples means that prevalence estimate data are likely to be biased and unreliable.
The main point to keep in mind is that by defining the disorders in this area as accompanying intense distress or impairment, authors of the DSM-5 hoped to avoid judging a behavior’s normality and instead to base the criteria for a disorder on an individual’s subjective experience of distress or degree of impairment in everyday life.
Biological Perspectives
Although it recognizes the role of psychological and sociocultural factors, the biological perspective emphasizes altered genetic, hormonal, and sensory factors in paraphilic disorders.
For men, the male sex hormone testosterone is the focus of theories and treatment, but dopamine and serotonin also play roles in male sexuality. Consequently, the World Federation of Societies of Biological Psychiatry advocates treatment of paraphilic disorders in men that includes SSRIs, antiandrogens, and luteinizing hormone-release hormone (LHRH), which acts as a suppressor in men for the production of testosterone.
Medications that stimulate LHRH receive support as effective treatments in reducing paraphilic symptoms in men. However, they carry the drawback that by reducing testosterone below the level achieved even by castration, they also decrease conventional nonparaphilic sexual activity and desire. Medications that target LHRH also result in a number of side effects such as loss of bone mineral content, cardiovascular disease, fatigue, sleep disorders, and hot flashes and therefore are not recommended for lifelong treatment.
Psychological Perspectives
Freud’s psychoanalytic understanding of the paraphilic disorders was the dominant psychological perspective throughout the twentieth century. According to Freud, these disorders were “perversions” representing both biological and psychological factors in early development.
The influential theorist John Money, in contrast, regarded paraphilias as the expressions of lovemaps—internal representations of an individual’s sexual fantasies and preferred practices. People form lovemaps in the late childhood years, when they first begin to discover and test ideas regarding sexuality. “Misprints” in this process can result in the establishment of sexual habits and practices that deviate from the norm. A paraphilia, according to this view, is due to a lovemap gone awry. The individual is, in a sense, programmed to act out fantasies that are socially unacceptable and potentially harmful.
The majority of the psychological literature on paraphilic disorders focuses on pedophilic disorder. A common theme in this literature is the idea of a “victim-to-abuser cycle” or “abused-abusers phenomena,” meaning that abusers were themselves abused at some point in their lives, probably when they were young. Arguing against these explanations is the fact that most abuse victims do not go on to abuse or molest children. On the other hand, some people with pedophilic disorder who were abused as children show an age preference that matches their age when they were abused, suggesting that they are replicating behaviors that were directed toward them as children.
Psychological Perspectives
Treatments within the psychological perspective seem most effective when combining individual with group therapy. In the group context, in particular, empathy training can help these individuals understand how their victims are feeling. Clinicians may also help clients learn how to control their sexual impulses. Relapse prevention, much as in treatment of addictive disorders, helps clients accept that even if they slip, this does not mean that they cannot overcome their disorder.
Clinicians no longer recommend a method used in the past known as aversion training, in which they teach clients to associate negative outcomes with sexual attraction toward children and use masturbatory reconditioning to change their orientation away from children.
Psychotherapy is the recommended treatment at the first level, particularly CBT. At increasing levels of severity, defined according to whether treatment is effective or not, clinicians add hormonal treatment starting with antiandrogens, progressing to progesterone, and finally neurohormones that act on the areas in the pituitary gland that control the release of sex hormones. At this point in treatment, appropriate only for the most severe cases, the goal is complete suppression of sexual desire and activity.
Another focus of treatment may be clinicians themselves. Due to stigmatization of people with these disorders, particularly pedophilic disorder, clinicians may be less willing to offer them treatment. In one intervention, researchers presented therapists in training with a 10-minute video that effectively challenged typical myths about pedophilia, such as the idea that it is a choice and that people with this disorder act upon their urges.
Sexual Dysfunctions
A sexual dysfunction is a marked divergence in an individual’s response in the sexual response cycle, along with feelings of significant distress or impairment.
To consider it a sexual dysfunction, clinicians must not be able to attribute this divergence to a psychological disorder, effects of a substance such as a drug of abuse or medication, or a general medical condition.
The DSM-5 differentiates between sexual dysfunctions that are lifelong and those that are acquired, as well as whether they are generalized or situational.
People with a lifelong sexual dysfunction experienced its symptoms continually since the time at which they became sexually active. By contrast, people with acquired sexual dysfunctions were asymptomatic prior to developing the symptoms.
Those dysfunctions that are situational occur with only certain types of sexual stimulation, situations, or partners. Generalized dysfunctions affect the individual in all sexual situations.
Sexual Response Cycle
Legendary researchers Masters and Johnson were the first scientists to systematically observe the sexual responses of men and women under controlled laboratory conditions. They identified four phases of the sexual response cycle—excitement (arousal), plateau, orgasm, and resolution.
During the excitement (or arousal) stage, the individual’s sexual interest heightens, and the body prepares for sexual intercourse (vaginal lubrication in the female, penile erection in the male). Sexual excitement continues to build during the plateau phase, and during the orgasm phase the individual experiences muscular contractions in the genital area that bring intense sensations of pleasure. The resolution phase is a period of return to a physiologically normal state. People differ in their typical patterns of sexual activity; some progress more readily through the phases and others at a slower pace. Not every sexual encounter necessarily includes all phases, however, and arousal and desire may occur
simultaneously with the processing of sexual stimuli.
Sexual Dysfunctions
Physiological factors and chronic health conditions are strongly related to the risk of developing sexual dysfunctions. These conditions can include diabetes, cardiovascular disease, other genitourinary diseases, psychological disorders, other chronic diseases, and smoking. In the case of some of these medical conditions, it is the medication and not the condition itself that places the individual at risk. For example, medications that treat high blood pressure can have the side effect of lowering sexual responsiveness in men.
Not surprisingly, perhaps, reliable prevalence data on these disorders are few. Definitions of many disorders have changed periodically, leading to differing estimates, and people are reluctant to report they are experiencing symptoms. Only recently have researchers begun to arrive at measurable criteria based on the unique assessment methods these disorders require. Fortunately, work toward the DSM-5 led to improved and more rigorous diagnostic procedures that eventually will lead to more reliable data sources.
In a research context, the Female Sexual Function Index is an empirical measure used in a number of studies to investigate the prevalence of sexual dysfunctions in women and to gauge the efficacy of treatment. The FSFI is a 19-item multidimensional self-report scale that asks questions related to sexual functioning within the past month, with subscales related to specific domains of lubrication, desire, subjective arousal, orgasm, satisfaction, and pain associated with intercourse. Another, more behaviorally oriented approach asks individuals to record sexual events on a daily basis in the form of a self-report diary.
Arousal DisordersPeople whose sexual disorders occur during the initial phases of
the sexual response cycle have low or no sexual desire or are
unable to achieve physiological arousal. As a result, they may
avoid having or be unable to have sexual intercourse.
Male Hypoactive Sexual Desire Disorder and Female Sexual Interest/Arousal Disorder
The man with male hypoactive sexual desire disorder has an abnormally low level of sexual activity or may have no interest in sexual activity. In addition, a man with this disorder either has relatively few or no sexual fantasies.
A woman with female sexual interest/arousal disorder is interested in having intercourse, but her body does not physiologically respond during the arousal phase. The DSM-5 merged female hypoactive desire dysfunction and female
arousal dysfunction into a single syndrome called female sexual interest/arousal disorder because the two dysfunctions could not reliably be distinguished.
Arousal Disorders
Some reports indicate that low sexual desire is relatively prevalent among women, with estimates in some samples ranging as high as 55 percent, although the majority of studies from around the world place the prevalence at closer to 40 percent. In general, the percent of women who are distressed about having low sexual desire is far lower than is true for men. Therefore, if a sexual dysfunction were defined for women that was characterized by low levels of desire, it would apply to a large percentage of women, and not necessarily those who were truly distressed.
Because low sexual desire seems to be relatively common, the issue for diagnosing women is that loss of desire might not be the best or only criterion to use in deciding who has a sexual dysfunction. DSM-5 therefore defines this disorder as including loss of sexual interest across a range of behaviors instead of only loss of interest. The behaviors that suggest low sexual interest include lower levels of arousal, fewer erotic thoughts, less enjoyment of sexual activity, and less intense sensations during sexual activity.
Arousal Disorders
Erectile Disorder
Men with erectile disorder cannot attain or maintain an erection during sexual activity that is sufficient to allow them to initiate or maintain sexual activity. Even if they are able to achieve an erection, they are unable to penetrate or to experience pleasure during a sexual encounter.
Although once thought of as either physiologically or psychologically caused, erectile disorder is now understood as having multiple causes that cannot be clearly separated into these two categories. A very rough estimate of the prevalence of erectile disorder is 26 to 28 per 1,000 man-years, with higher rates among older men.
Disorders Involving Orgasm
Female Orgasmic Disorder
Inability to achieve orgasm, a distressing delay in achieving orgasm, or reduced intensity of orgasm constitutes female orgasmic disorder.
The factors relating to a woman’s reporting of female orgasmic disorder include stress, anxiety, depression, relationship satisfaction, and age-related changes in the genital area that can lead to pain, discomfort, irritation, or bleeding.
In general, women are more likely than men to report sexual difficulties involving the subjective quality of the experience. Men are more likely to report physical problems in achieving or maintaining an erection.
Disorders Involving Orgasm
Delayed Ejaculation and
Premature Ejaculation
Men who have a marked delay in ejaculation or who rarely if ever experience ejaculations have delayed ejaculation.
Men with premature (early) ejaculation reach orgasm in a sexual encounter with minimal sexual stimulation before, on, or shortly after penetration and before wishing to do so (within 1 minute).
Clinicians prefer to apply a psychiatric diagnosis only when the individual is distressed about the condition. The prevalence rate for premature ejaculation varies widely, from 8 to 30 percent, and seems to depend on age group and country.
The distinction between the nature of orgasmic difficulties for men and women led a group of clinicians and social scientists called the Working Group for a New View of Women’s Sexual Problems to criticize the DSM for failing to take into account the greater focus in women on relational aspects of sexuality and individual variations in women’s sexual experiences. They proposed that the profession define sexual problems as difficulties in any aspect of sexuality—emotional, physical, or relational.
Disorders Involving Pain
Clinicians diagnose sexual pain disorders characterized by the experience of difficulty in a sexual relationship due to painful sensations in the genitals from intercourse, genito-pelvic pain/penetration disorder.
Genito-pelvic pain/penetration disorder can affect both males and females. The individual experiences recurrent or persistent genital pain before, during, or after sexual intercourse.
Theories and Treatment of Sexual Dysfunction
Sexual dysfunctions represent an interaction of complex physiological, psychological, and sociocultural factors, and thus the biopsychosocial perspective is well suited to understand them.
To help a client with a sexual dysfunction, the clinician must first conduct a comprehensive assessment that includes a physical examination and psychological testing, including of the client’s partner if appropriate.
In addition, the clinician must assess the individual’s use of substances including not only drugs and alcohol, but also all medications, including psychotherapeutic ones.
Biological Perspectives
Perhaps one of the best-researched sexual dysfunctions is erectile disorder. In 1970, Masters and Johnson claimed that virtually all men (95 percent) with erectile disorder (ED) had psychological difficulties such as anxiety and job stress, boredom with long-term sexual partners, and other relationship issues. Since that time, researchers have arrived at very different conclusions as a result of new and more sophisticated assessment devices sensitive to the presence of physiological abnormalities.
Health care professionals now view more than half the cases of erectile disorder as attributable to physical problems of a vascular, neurological, or hormonal nature, or to impaired functioning caused by drugs, alcohol, and smoking. Thus, clinicians treating men with erectile disorder may first consider physiological contributions to the individual’s symptoms before concluding that psychological factors are the cause.
Medications to treat erectile disorder include the prescription drugs Viagra, Levitra, and Cialis. These are all in the category of phosphodiesterase (PDE) inhibitors, which work by increasing blood flow to the penis during sexual stimulation. What makes such medications appealing is the fact that they are so much less invasive than previous treatments for erectile disorder, such as surgery and implants, and so much less awkward than vacuum pumps or penile injections. These medications work when accompanied by the experience of sexual excitement, unlike other treatments in which the man achieves an erection artificially and independent of what is going on sexually with the man or his partner.
Biological Perspectives
Treatment of female sexual interest/arousal disorder that follows from the biological perspective incorporates hormonal replacement therapy (estrogen and progesterone), estrogen cream applied directly to the vagina, and testosterone therapy. Doctors may also give women a PDE inhibitor (“female Viagra”), but its efficacy remains undemonstrated. This drug is not to be confused with flibanserin, approved by the FDA in 2015 under the trade name Addyi. Though also dubbed the “female Viagra,” Addyi actually works by a different
mechanism than PDE inhibitors and is meant to increase a woman’s interest in sexual activity. Data on its efficacy suggest that flibanserin may have beneficial effects, though more research is needed .
Genito-pelvic pain/penetration disorder presents a different set of challenges. From a biological perspective, the physical symptoms can come from a variety of sources, including disturbances in the muscle fibers in the pelvic area (called the “pelvic floor”). When treating these disorders, however, the clinician may be unable to trace the exact cause of the individual’s pain. The best approach appears to be multifaceted, including application of corticosteroids and physical therapy to promote muscle relaxation and improved blood circulation. The clinician may also use electrical nerve stimulation to relieve the individual’s pain and prescribe pharmacological agents such as amitriptyline and pregabalin (Lyrica®) .
Psychological Perspectives
While recognizing the role of physiological factors, the psychological perspective emphasizes the further contributing effects, if not the causal role, of cognitions, emotions, and attitudes toward sexuality.
Learned associations between sexual stimuli and pleasurable feelings can play an important role in sexual excitability. In the case of erectile disorder, one team of researchers identified as a predisposing factor a man’s belief in the “macho myth” of sexual infallibility. Belief in this myth makes males more prone to developing dysfunctional thoughts (such as, “I’m incompetent”) when they have an unsuccessful sexual experience. Once the man activates these thoughts, they impair his ability to process erotic stimuli and have sexual thoughts and images. By turning his attentional focus away from the encounter and toward his feelings of incompetence and sadness, they make him less able to achieve and maintain an erection during future sexual encounters .
Researchers have also identified a man’s self-image about the size of his genitals as a factor in erectile dysfunction. Among a sample of military men aged 40 and under, those with lower genital self-image had higher rates of sexual anxiety, which in turn was related to higher rates of erectile dysfunction.
For women, preoccupation with body image is known to interfere with sexual functioning, perhaps interacting with attitudes toward sexuality in general.
In addition to discomfort with their bodies, individuals may hold negative “sexual self-schemas” such as feeling unloved, inadequate, and unworthy. They then transfer these self-schemas onto sexual situations, causing them to become anxious when they feel that an inability to achieve an orgasm will make their partner become tired. This belief in their own incompetence in sexual situations understandably inhibits their enjoyment.
The quality of the relationship may also contribute to sexual dysfunction, particularly for women, whose sexual desire is sensitive to interpersonal factors including the frequency of positive interactions . Researchers have also identified the cognitive factors relevant in genito-pelvic pain/penetration disorder that compound the physical causes, making women with this disorder highly sensitized even to words related to sex.
Psychological Perspective
The core treatment of sexual dysfunctions involving disturbances of arousal and orgasm follows from the principles that Masters and Johnson established, namely treating both partners in a couple, reducing anxiety about sexual performance, and developing specific skills such as sensate focus, in which the interaction is intended to lead not to orgasm but to the experience of pleasurable sensations during the phases prior to orgasm. This procedure reduces the couple’s anxiety levels until eventually they are able to focus not on their feelings of inadequacy but instead on the sexual encounter itself. Clinicians may also teach the partners to masturbate or to incorporate methods of sexual stimulation other than intercourse, such as clitoral stimulation alone.
Expanding on these methods, therapists rely upon principles derived from cognitive-behavioral therapy that focus on the individual’s thoughts that can inhibit sexual arousal and desire. As we saw earlier, distorted body image and negative sexual self-concept can interfere with sexual satisfaction. Restructuring those cognitions could therefore help alleviate sexual dysfunction symptoms. Furthermore, helping clients understand that each sexual encounter does not need to be perfect but can be “good enough” can help couples focus on sexual pleasure rather than on performance.
Clinicians often involve the client’s partner, encouraging both people to communicate more effectively and to have more positive intimate experiences.. For sexual pain disorders, cognitive-behavioral therapy alone does not seem to be effective, but it is most beneficial when integrated with muscle relaxation, biofeedback, and education. Women can learn to train or retrain their pelvic muscles to reduce painful muscle contractions during intercourse as well as to decrease their anxiety levels and self-consciousness.
Gender Dysphoria
We turn now to disorders in which individuals experience distress from perceiving a mismatch between their biological sex, the sex determined by their chromosomes, and their inner sense of gender, called gender identity. In the DSM-5, the term gender dysphoria refers to distress that may accompany the incongruence between a person’s experienced or expressed gender and that person’s assigned gender.
Not everyone experiences distress as the result of this incongruence, but many are distressed if they are unable to receive treatment through hormones and/or surgery. In the current criteria for disorder, the individual experiences identification with the other sex. The feeling of being “in the wrong body” causes feelings of discomfort and a sense of inappropriateness about the person’s assigned gender. Both these conditions must be present for a clinician to assign the diagnosis. Thus, the clinical problem is the dysphoria, not the individual’s gender identity.
Another term that relates to cross-gender identification is transsexualism, which also describes the inner feeling of belonging to the other sex (individuals who experience this may be referred to as “trans”). The term is generally considered equivalent to transgender identity.
Some people with gender dysphoria wish to live as members of the other sex, and they act and dress accordingly. Unlike individuals with transvestic disorder, these people do not derive sexual gratification from cross-dressing. Further, many other identities fall in the category of transgender, including gender nonconforming, nonbinary, and agender. These terms correspond with the notion that not all transgender people see themselves as the opposite gender. Instead they might not feel they belong to any particular gender.
Gender Dysphoria
The DSM-5 authors presented a strong case for using the term gender dysphoria to replace gender identity disorder, with the specification whether the individual is a child or post-adolescent. One reason for this proposed change was to take away the stigma attached to the label of cross-gender identification as a “disorder.” Thus, having cross-gender identification does not necessarily imply that an individual is distressed or has a disorder. Only if that person feels dysphoria about having the sexual makeup with which he or she was born can a diagnosis be applied. Moreover, although some groups would advocate for the notion of removing gender dysphoria entirely from the diagnostic nomenclature, to do so could preclude individuals who wish to seek gender-affirming surgery from insurance coverage because there would be no diagnosis for the clinician to give.
Some individuals with gender dysphoria may choose to pursue gender-affirming medical procedures. These range from taking hormones to a variety of surgical procedures such as facial feminization surgery, chest reconstructive surgery (“top” surgery), and genital reconstructive surgery (“bottom” surgery). Each of these procedures requires psychological and other evaluations to ensure that the individual does not have any mental health conditions that might affect judgment or decision making and does have documented and persistent gender dysphoria.
Theories and Treatment of Gender Dysphoria
Clinicians who work with transgender individuals experiencing gender dysphoria can provide support through psychotherapy and help clients decide whether they want to seek out other options such as hormone therapy or gender-affirming surgery. The American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (TGNP) suggest that clients achieve the most positive outcomes when they receive social support or trans-affirmative care and are seen from an interdisciplinary perspective, and seek to prepare their trainees in psychology to work with clients who identify as TGNP.
According to the World Professional Association for Transgender Health (WPATH), clinicians ideally provide an assessment of a client’s well-being, without regard to diagnostic criteria, in determining whether a particular client is able to exercise good judgment and decision making around pursuing medical treatments. In this way, clinicians can be seen in a gatekeeper role, in which their determination can affect a client’s ability to pursue gender-affirming treatments.
Theories and Treatment of Gender Dysphoria
Given that clinicians will continue to treat individuals with gender dysphoria, new approaches are emerging based on transgender theory that emphasize a more fluid view of gender than the binary male-female dichotomy, a perspective also articulated in the APA TGNP Guidelines. Clinicians can begin by using the gender terminology the client prefers. Rather than assume that people’s motivations, behaviors, and attitudes are based on their socially defined identities, clinicians can also recognize that these categories are conditional. For example, they can avoid using terms like real or biological gender. Through this approach, often referred to as affirmative psychotherapy, clinicians can provide education about medical options and help transgender clients safely explore their gender identity and connect with sources of social support.
Even though transgender identity itself is depathologized in DSM-5, clients will nevertheless continue to face transphobia, the negative stereotyping and fear of transgender individuals. Providing transgender individuals with social support may also improve their feelings of well-being.
Rather than recommending gender reassignment surgery to help clients cope with social pressures to conform to one gender or another, clinicians can instead let their clients define their own gender identities. Through this process, transgender individuals can explore more openly and without bias their multiple, intersecting identities.
Activity prompt:
Think about how diagnoses change over time (ex. gender identity disorder to gender dysphoria) and how that is impacted by societal perceptions and political changes. What current diagnoses, if any, can you imagine being phased out/adjusted in the years to come? Why? If none, explain why not.
Paraphilic
Disorders, Sexual Dysfunctions, and Gender Dysphoria:
The Biopsychosocial Perspective
The sexual disorders constitute three discrete sets of difficulties in aspects of sexual functioning and behavior.
Although many unanswered questions remain about their causes, we need a biopsychosocial perspective to understand how individuals acquire and maintain these diverse problems over time.
Moreover, researchers and clinicians are increasingly developing models that incorporate integrated treatment.
The growing research base the DSM-5 authors used reflects not only expansion of the empirical approaches to sexual disorders but also the adoption of a broader, more inclusive, and socioculturally sensitive approach to understanding and treatment.
Source
Images 1,2, and 4:
https://venngage.com/gallery/post/not-just-a-mans-world-sexual-dysfunction-among-women-and-what-to-do-about-it /
Image 3 https://www.treated.com/erectile-dysfunction/psychological-causes-of-ed
Image 5: http://www.imop.gr/en/node/2475
Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education.