Abnormal Psychology Reviewer (Barlow) PDF

Abnormal Psychology David Barlow Board Exam Reviewer Nino-Mhar Malana, RPm Abnormal Behavior in Historical Context  Psychological dis...

Abnormal Psychology David Barlow Board Exam Reviewer Nino-Mhar Malana, RPm Abnormal Behavior in Historical Context  Psychological disorder, a psychological dysfunction within an individual associated with distress or impairment in functioning and a response that is not typical or culturally expected.  Psychological dysfunction refers to a breakdown in cognitive, emotional, or behavioral functioning.  That the behavior must be associated with distress to be classified as abnormal adds an important component and seems clear: the criterion is satisfied if the individual is extremely upset.  The concept of impairment is useful, although not entirely satisfactory. For example, many people consider themselves shy or lazy. This doesn’t mean that they’re abnormal. But if you are so shy that you find it impossible to date or even interact with people and you make every attempt to avoid interactions even though you would like to have friends, then your social functioning is impaired.  Atypical or not culturally expected. At times, something is considered abnormal because it occurs infrequently; it deviates from the average. The greater the deviation, the more abnormal it is.  The most widely accepted definition used in DSM-5 describes behavioral, psychological, or biological dysfunctions that are unexpected in their cultural context and associated with present distress and impairment in functioning, or increased risk of suffering, death, pain, or impairment.  Psychopathology is the scientific study of psychological disorders.  Although there is a great deal of overlap, counseling psychologists tend to study and treat adjustment and vocational issues encountered by relatively healthy individuals, and clinical psychologists usually concentrate on more severe psychological disorders.  Also, programs in professional schools of psychology, where the degree is often a Psy.D., focus on clinical training and de-emphasize or eliminate research training. In contrast, Ph.D. programs in universities integrate clinical and research training.  Psychiatrists first earn an M.D. degree in medical school and then specialize in psychiatry during residency training that lasts 3 to 4 years. Psychiatrists also investigate the nature and causes of psychological disorders, often from a biological point of view; make diagnoses; and offer treatments.  Psychiatric social workers typically earn a master’s degree in social work as they develop expertise in collecting information relevant to the social and family situation of the individual with a psychological disorder. Social workers also treat disorders, often concentrating on family problems associated with them.  Psychiatric nurses have advanced degrees, such as a master’s or even a Ph.D., and specialize in the care and treatment of patients with psychological disorders, usually in hospitals as part of a treatment team.  Finally, marriage and family therapists and mental health counselors typically spend 1–2 years earning a master’s degree and are employed to provide clinical services by hospitals or clinics, usually under the supervision of a doctoral-level clinician.  Many mental health professionals take a scientific approach to their clinical work and therefore are called scientist-practitioners.  How many people in the population as a whole have the disorder? This figure is called the prevalence of the disorder.  Statistics on how many new cases occur during a given period, such as a year, represent the incidence of the disorder.  Most disorders follow a somewhat individual pattern, or course. For example, some disorders, such as schizophrenia, follow a chronic course, meaning that they tend to last a long time, sometimes a lifetime. Other disorders, like mood disorders, follow an episodic course, in that the individual is likely to recover within a few months only to suffer a recurrence of the disorder at a later time. This pattern may repeat throughout a person’s life. Still other disorders may have a time-limited course, meaning the disorder will improve without treatment in a relatively short period.  The anticipated course of a disorder is called the prognosis. So we might say, “the prognosis is good”, meaning the individual will probably recover, or “the prognosis is guarded”, meaning the probable outcome doesn’t look good.  Etiology, or the study of origins, has to do with why a disorder begins (what causes it) and includes biological, psychological, and social dimensions. Historical Conceptions of Abnormal Behavior The Supernatural Tradition  Humans have always supposed that agents outside our bodies and environment influence our behavior, thinking, and emotions. These agents—which might be divinities, demons, spirits, or other phenomena such as magnetic fields or the moon or the stars—are the driving forces behind the supernatural model.  Although many have thought that the mind can influence the body and, in turn, the body can influence the mind, most philosophers looked for causes of abnormal behavior in one or the other. This split gave rise to two traditions of thought about abnormal behavior, summarized as the biological model and the psychological model.  During the last quarter of the 14th century, religious and lay authorities supported these popular superstitions and society as a whole began to believe more strongly in the existence and power of demons and witches. The Catholic Church had split, and a second center, complete with a pope, emerged in the south of France to compete with Rome. In reaction to this schism, the Roman Church fought back against the evil in the world that it believed must have been behind this heresy.  During these turbulent times, the bizarre behavior of people afflicted with psychological disorders was seen as the work of the devil and witches.  Treatments included exorcism, in which various religious rituals were performed in an effort to rid the victim of evil spirits.  Other approaches included shaving the pattern of a cross in the hair of the victim’s head and securing sufferers to a wall near the front of a church so that they might benefit from hearing Mass.  Mental depression and anxiety were recognized as illnesses, although symptoms such as despair and lethargy were often identified by the church with the sin of acedia, or sloth.  Common treatments were rest, sleep, and a healthy and happy environment. Other treatments included baths, ointments, and various potions.  In the 14th century, one of the chief advisers to the king of France, a bishop and philosopher named Nicholas Oresme, also suggested that the disease of melancholy (depression) was the source of some bizarre behavior, rather than demons.  As we see in the handling of the severe psychological disorder experienced by late-14th-century King Charles VI of France, both influences were strong, sometimes alternating in the treatment of the same case. King Charles VI of France was under a great deal of stress, partly because of the division of the Catholic Church. A variety of remedies and rituals of all kinds were tried, but none worked. High-ranking officials and doctors of the university called for the “sorcerers” to be discovered and punished.  With a perceived connection between evil deeds and sin on the one hand and psychological disorders on the other, it is logical to conclude that the sufferer is largely responsible for the disorder, which might well be a punishment for evil deeds.  In the Middle Ages, if exorcism failed, some authorities thought that steps were necessary to make the body uninhabitable by evil spirits, and many people were subjected to confinement, beatings, and other forms of torture.  Mass hysteria may simply demonstrate the phenomenon of emotion contagion, in which the experience of an emotion seems to spread to those around us.  Paracelsus, a Swiss physician who lived from 1493 to 1541, rejected notions of possession by the devil, suggesting instead that the movements of the moon and stars had profound effects on people’s psychological functioning.  The Roman Catholic Church requires that all healthcare resources be exhausted first before spiritual solutions such as exorcism can be considered. The Biological Tradition  The Greek physician Hippocrates is considered to be the father of modern Western medicine. He and his associates left a body of work called the Hippocratic Corpus, written between 450 and 350 b.c., in which they suggested that psychological disorders could be treated like any other disease.  Hippocrates considered the brain to be the seat of wisdom, consciousness, intelligence, and emotion. Therefore, disorders involving these functions would logically be located in the brain.  Hippocrates also recognized the importance of psychological and interpersonal contributions to psychopathology, such as the sometimes negative effects of family stress; on some occasions, he removed patients from their families.  The Roman physician Galen, later adopted the ideas of Hippocrates and his associates and developed them further, creating a powerful and influential school of thought within the biological tradition that extended well into the 19th century.  One of the more interesting and influential legacies of the Hippocratic-Galenic approach is the humoral theory of disorders.  Hippocrates assumed that normal brain functioning was related to four bodily fluids or humors: blood, black bile, yellow bile, and phlegm.  Blood came from the heart, black bile from the spleen, phlegm from the brain, and choler or yellow bile from the liver.   Physicians believed that disease resulted from too much or too little of one of the humors; for example, too much black bile was thought to cause melancholia (depression).  The humoral theory was, perhaps, the first example of associating psychological disorders with a “chemical imbalance”, an approach that is widespread today.  Terms derived from the four humors are still sometimes applied to personality traits. For example, sanguine (literal meaning “red, like blood”) describes someone who is ruddy in complexion, presumably from copious blood flowing through the body, and cheerful and optimistic, although insomnia and delirium were thought to be caused by excessive blood in the brain.  Melancholic means depressive (depression was thought to be caused by black bile flooding the brain).  A phlegmatic personality (from the humor phlegm) indicates apathy and sluggishness but can also mean being calm under stress.  A choleric person (from yellow bile or choler) is hot tempered.  King Charles VI’s physician moved him to the less stressful countryside was to restore the balance in his humors.  In addition to rest, good nutrition, and exercise, two treatments were developed. In one, bleeding or bloodletting, a carefully measured amount of blood was removed from the body, often with leeches. The other was to induce vomiting; indeed, in a well-known treatise on depression published in 1621, Anatomy of Melancholy, Robert Burton recommended eating tobacco and a half-boiled cabbage to induce vomiting.  In ancient China and throughout Asia, a similar idea existed. But rather than “humors,” the Chinese focused on the movement of air or “wind” throughout the body. Unexplained mental disorders were caused by blockages of wind or the presence of cold, dark wind (yin) as opposed to warm, life-sustaining wind (yang). Treatment involved restoring proper flow of wind through various methods, including acupuncture.  Hippocrates also coined the word hysteria to describe a concept he learned about from the Egyptians, who had identified what we now call the somatic symptom disorders. In these disorders, the physical symptoms appear to be the result of a medical problem for which no physical cause can be found, such as paralysis and some kinds of blindness.  Behavioral and cognitive symptoms of what we now know as advanced syphilis, a sexually transmitted disease caused by a bacterial microorganism entering the brain, include believing that everyone is plotting against you (delusion of persecution) or that you are God (delusion of grandeur), as well as other bizarre behaviors.  Louis Pasteur’s germ theory of disease, developed in about 1870, facilitated the identification of the specific bacterial microorganism that caused syphilis.  John P. Grey’s position was that the causes of insanity were always physical. Therefore, the mentally ill patient should be treated as physically ill. The emphasis was again on rest, diet, and proper room temperature and ventilation, approaches used for centuries by previous therapists in the biological tradition.  Under Grey’s leadership, the conditions in hospitals greatly improved and they became more humane, livable institutions. But in subsequent years they also became so large and impersonal that individual attention was not possible.  In the 1930s, the physical interventions of electric shock and brain surgery were often used. Benjamin Franklin made numerous discoveries during his life with which we are familiar, but most people don’t know that he discovered accidentally, and then confirmed experimentally in the 1750s, that a mild and modest electric shock to the head produced a brief convulsion and memory loss (amnesia) but otherwise did little harm.  Emil Kraepelin was the dominant figure during this period and one of the founding fathers of modern psychiatry. He was extremely influential in advocating the major ideas of the biological tradition, but he was little involved in treatment. His lasting contribution was in the area of diagnosis and classification. The Psychological Tradition  During the first half of the 19th century, a strong psychosocial approach to mental disorders called moral therapy became influential. The term moral actually referred more to emotional or psychological factors rather than to a code of conduct. Its basic tenets included treating institutionalized patients as normally as possible in a setting that encouraged and reinforced normal social interaction.  Moral therapy as a system originated with the well-known French psychiatrist Philippe Pinel and his close associate Jean-Baptiste Pussin.  When Pinel arrived in 1791, Pussin had already instituted remarkable reforms by removing all chains used to restrain patients and instituting humane and positive psychological interventions. Pussin persuaded Pinel to go along with the changes.  After William Tuke followed Pinel’s lead in England, Benjamin Rush, often considered the founder of U.S. psychiatry, introduced moral therapy in his early work at Pennsylvania Hospital.  Asylums had appeared in the 16th century, but they were more like prisons than hospitals. It was the rise of moral therapy in Europe and the United States that made asylums habitable and even therapeutic.  Unfortunately, after the mid-19th century, humane treatment declined because of a convergence of factors. First, it was widely recognized that moral therapy worked best when the number of patients in an institution was 200 or fewer, allowing for a great deal of individual attention.  A second reason for the decline of moral therapy has an unlikely source. The great crusader Dorothea Dix campaigned endlessly for reform in the treatment of insanity.  A schoolteacher who had worked in various institutions, she had firsthand knowledge of the deplorable conditions imposed on patients with insanity, and she made it her life’s work to inform the American public and their leaders of these abuses. Her work became known as the mental hygiene movement.  In addition to improving the standards of care, Dix worked hard to make sure that everyone who needed care received it, including the homeless. Through her efforts, humane treatment became more widely available in U.S. institutions. As her career drew to a close, she was rightly acknowledged as a hero of the 19th century.  Franz Mesmer suggested to his patients that their problem was caused by an undetectable fluid found in all living organisms called “animal magnetism”, which could become blocked.  Mesmer is widely regarded as the father of hypnosis, a state in which extremely suggestible subjects sometimes appear to be in a trance.  Many distinguished scientists and physicians were interested in Mesmer’s powerful methods of suggestion. One of the best known, Jean-Martin Charcot. A distinguished neurologist, Charcot demonstrated that some techniques of mesmerism were effective with a number of psychological disorders, and he did much to legitimize the fledgling practice of hypnosis.  A close second was their discovery that it is therapeutic to recall and relive emotional trauma that has been made unconscious and to release the accompanying tension. This release of emotional material became known as catharsis.  An Integrative Approach to Psychopathology  No influence operates in isolation. Each dimension—biological or psychological—is strongly influenced by the others and by development, and they weave together in various complex and intricate ways to create a psychological disorder.  Huntington’s disease, a degenerative brain disease that appears in early to middle age, usually the early 40s. This disease has been traced to a genetic defect that causes deterioration in a specific area of the brain, the basal ganglia. It causes broad changes in personality, cognitive functioning, and, particularly, motor behavior, including involuntary shaking or jerkiness throughout the body.  Phenylketonuria (PKU), which can result in intellectual disability (previously called “mental retardation”). This disorder, present at birth, is caused by the inability of the body to metabolize (break down) phenylalanine, a chemical compound found in many foods. Like Huntington’s disease, PKU is caused by a defect in a single gene, with little contribution from other genes or the environmental background.  In linkage studies, scientists study individuals who have the same disorder, such as bipolar disorder, and also share other features, such as eye color; because the location of the gene for eye color is known, this allows scientists to attempt to “link” known gene locations (for eye color, in this example) with the possible location of a gene contributing to the disorder.  The environment may occasionally turn on certain genes. This type of mechanism may lead to changes in the number of receptors at the end of a neuron, which, in turn, would affect biochemical functioning in the brain.  The brain and its functions are plastic, subject to continual change in response to the environment, even at the level of genetic structure.  For years, scientists have assumed a specific method of interaction between genes and environment. According to this diathesis–stress model, individuals inherit tendencies to express certain traits or behaviors, which may then be activated under conditions of stress.  Each inherited tendency is a diathesis (vulnerability), which means, literally, a condition that makes someone susceptible to developing a disorder. When the right kind of life event, such as a certain type of stressor, comes along, the disorder develops.  The smaller the vulnerability, the greater the life stress required to produce the disorder; conversely, with greater vulnerability, less life stress is required.  There was reason to believe, from prior work with animals, that individuals with at least two copies of the long allele (LL) were able to cope better with stress than individuals with two copies of the short allele (SS).  Gene–environment correlation model or reciprocal gene–environment model. Some evidence now indicates that genetic endowment may increase the probability that an individual will experience stressful life events.  For example, people with a genetic vulnerability to develop a certain disorder, such as blood–injection–injury phobia, may also have a personality trait—let’s say impulsiveness— that makes them more likely to be involved in minor accidents that would result in their seeing blood. In other words, they may be accident prone because they are continually rushing to complete things or to get to places without regard for their physical safety.  Neither nature (genes) nor nurture (environmental events) alone, but rather a complex interaction of the two, influences the development of our behavior and personalities. The Central Nervous System  The human nervous system includes the central nervous system, consisting of the brain and the spinal cord, and the peripheral nervous system, consisting of the somatic nervous system and the autonomic nervous system.  Dendrites have numerous receptors that receive messages in the form of chemical impulses from other nerve cells, which are converted into electrical impulses.  The other kind of branch, called an axon, transmits these impulses to other neurons.  Neurons are not actually connected to each other. There is a small space through which the impulse must pass to get to the next neuron. The space between the axon of one neuron and the dendrite of another is called the synaptic cleft.  The biochemicals that are released from the axon of one neuron and transmit the impulse to the dendrite receptors of another neuron are called neurotransmitters.  The brain stem is the lower and more ancient part of the brain. Found in most animals, this structure handles most of the essential automatic functions, such as breathing, sleeping, and moving around in a coordinated way.  The forebrain is more advanced and evolved more recently.  The lowest part of the brain stem, the hindbrain, contains the medulla, the pons, and the cerebellum. The hindbrain regulates many automatic activities, such as breathing, the pumping action of the heart (heartbeat), and digestion.  The cerebellum controls motor coordination, and recent research suggests that abnormalities in the cerebellum may be associated with the psychological disorder autism, although the connection with motor coordination is not clear.  Also located in the brain stem is the midbrain, which coordinates movement with sensory input and contains parts of the reticular activating system, which contributes to processes of arousal and tension, such as whether we are awake or asleep.  At the top of the brain stem are the thalamus and hypothalamus, which are involved broadly with regulating behavior and emotion. These structures function primarily as a relay between the forebrain and the remaining lower areas of the brain stem.  At the base of the forebrain, just above the thalamus and hypothalamus, is the limbic system.  Limbic means border, so named because it is located around the edge of the center of the brain.  The limbic system, which figures prominently in much of psychopathology, includes such structures as the hippocampus (sea horse), cingulate gyrus (girdle), septum (partition), and amygdala (almond), all of which are named for their approximate shapes.  This system helps regulate our emotional experiences and expressions and, to some extent, our ability to learn and to control our impulses. It is also involved with the basic drives of sex, aggression, hunger, and thirst.  The basal ganglia, also at the base of the forebrain, include the caudate (tailed) nucleus. Because damage to these structures may make us change our posture or twitch or shake, they are believed to control motor activity.  The largest part of the forebrain is the cerebral cortex, which contains more than 80% of all neurons in the central nervous system. This part of the brain provides us with our distinctly human qualities, allowing us to look to the future and plan, to reason, and to create.  The left hemisphere seems to be chiefly responsible for verbal and other cognitive processes.  The right hemisphere seems to be better at perceiving the world around us and creating images.  Each hemisphere consists of four separate areas, or lobes: temporal, parietal, occipital, and frontal.  The temporal lobe is associated with recognizing various sights and sounds and with long-term memory storage.  The parietal lobe is associated with recognizing various sensations of touch and monitoring body positioning.   The occipital lobe is associated with integrating and making sense of various visual inputs.  The frontal lobe is the most interesting from the point of view of psychopathology. The front (or anterior) of the frontal lobe is called the prefrontal cortex, and this is the area responsible for higher cognitive functions such as thinking and reasoning, planning for the future, as well as long-term memory. This area of the brain synthesizes all information received from other parts of the brain and decides how to respond. The Peripheral Nervous System  The peripheral nervous system coordinates with the brain stem to make sure the body is working properly.  Its two major components are the somatic nervous system and the autonomic nervous system.  The somatic nervous system controls the muscles, so damage in this area might make it difficult for us to engage in any voluntary movement, including talking.  The autonomic nervous system includes the sympathetic nervous system and parasympathetic nervous system.  The primary duties of the autonomic nervous system are to regulate the cardiovascular system (for example, the heart and blood vessels) and the endocrine system (for example, the pituitary, adrenal, thyroid, and gonadal glands) and to perform various other functions, including aiding digestion and regulating body temperature.  The sympathetic nervous system is primarily responsible for mobilizing the body during times of stress or danger by rapidly activating the organs and glands under its control.  When the sympathetic division goes on alert, three things happen. The heart beats faster, thereby increasing the flow of blood to the muscles; respiration increases, allowing more oxygen to get into the blood and brain; and the adrenal glands are stimulated.  One of the functions of the parasympathetic system is to balance the sympathetic system. In other words, because we could not operate in a state of hyperarousal and preparedness forever, the parasympathetic nervous system takes over after the sympathetic nervous system has been active for a while, normalizing our arousal and facilitating the storage of energy by helping the digestive process.  The endocrine system works a bit differently from other systems in the body. Each endocrine gland produces its own chemical messenger, called a hormone, and releases it directly into the bloodstream.   The adrenal glands produce epinephrine (also called adrenaline) in response to stress, as well as salt-regulating hormones;  the thyroid gland produces thyroxine, which facilitates energy metabolism and growth;  the pituitary is a master gland that produces a variety of regulatory hormones;  and the gonadal glands produce sex hormones such as estrogen and testosterone.  The hypothalamus connects to the adjacent pituitary gland, which is the master or coordinator of the endocrine system. The pituitary gland, in turn, may stimulate the cortical part of the adrenal glands on top of the kidneys. As we noted previously, surges of epinephrine tend to energize us, arouse us, and get our bodies ready for threat or challenge. When athletes say their adrenaline was really flowing, they mean they were highly aroused and up for the competition. The cortical part of the adrenal glands also produces the stress hormone cortisol. This system is called the hypothalamic–pituitary–adrenocortical axis, or HPA axis. Neurotransmitters  Research on neurotransmitter function focuses primarily on what happens when activity levels change. We can study this in several ways. We can introduce substances called agonists that effectively increase the activity of a neurotransmitter by mimicking its effects; substances called antagonists that decrease, or block, a neurotransmitter; or substances called inverse agonists that produce effects opposite to those produced by the neurotransmitter.  After a neurotransmitter is released, it is quickly drawn back from the synaptic cleft into the same neuron. This process is called reuptake. Some drugs work by blocking the reuptake process, thereby causing continued stimulation along the brain circuit. Amino-acid neurotransmitters  Glutamate, is an excitatory transmitter that “turns on” many different neurons, leading to action.  Gamma-aminobutyric acid, or GABA for short, which is an inhibitory neurotransmitter. Thus, the job of GABA is to inhibit (or regulate) the transmission of information and action potentials.  Because these two neurotransmitters work in concert to balance functioning in the brain, they have been referred to as the “chemical brothers”.  GABA was discovered before glutamate and has been studied for a longer period; its best-known effect is to reduce anxiety.   Scientists have discovered that a particular class of drugs, the benzodiazepines, or minor tranquilizers, makes it easier for GABA molecules to attach themselves to the receptors of specialized neurons. Thus, the higher the level of benzodiazepine, the more GABA becomes attached to neuron receptors and the calmer we become (to a point).  The GABA system rides on many circuits distributed widely throughout the brain. GABA seems to reduce overall arousal somewhat and to temper our emotional responses.  In addition to reducing anxiety, minor tranquilizers have an anticonvulsant effect, relaxing muscle groups that may be subject to spasms.  Furthermore, the GABA system seems to reduce levels of anger, hostility, aggression, and perhaps even positive emotional states such as eager anticipation and pleasure, making GABA a generalized inhibiting neurotransmitter, much as glutamate has a generalized excitatory function. Monoamine neurotrasmitters  Serotonin  The technical name for serotonin is 5-hydroxytryptamine (5HT).  Serotonin is believed to influence a great deal of our behavior, particularly the way we process information.  The serotonin system regulates our behavior, moods, and thought processes. Extremely low activity levels of serotonin are associated with less inhibition and with instability, impulsivity, and the tendency to overreact to situations.  Low serotonin activity has been associated with aggression, suicide, impulsive overeating, and excessive sexual behavior.  Several classes of drugs primarily affect the serotonin system, including the tricyclic antidepressants such as imipramine (known by its brand name, Tofranil).  However, the class of drugs called selective-serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac), affects serotonin more directly than other drugs, including the tricyclic antidepressants.  SSRIs are used to treat a number of psychological disorders, particularly anxiety, mood, and eating disorders.  Norepinephrine  A third neurotransmitter system in the monoamine class important to psychopathology is norepinephrine (also known as noradrenaline).   We have already seen that norepinephrine, like epinephrine (referred to as a catecholamine), is part of the endocrine system.  Norepinephrine seems to stimulate at least two groups (and probably several more) of receptors called alpha-adrenergic and beta-adrenergic receptors.  In the central nervous system, a number of norepinephrine circuits have been identified. One major circuit begins in the hindbrain, an area that controls basic bodily functions such as respiration.  Another circuit appears to influence the emergency reactions or alarm responses that occur when we suddenly find ourselves in a dangerous situation, suggesting that norepinephrine may bear some relationship to states of panic.  More likely, however, is that this system, with all its varying circuits coursing through the brain, acts in a more general way to regulate or modulate certain behavioral tendencies and is not directly involved in specific patterns of behavior or in psychological disorders.  Dopamine  Dopamine is a major neurotransmitter that is in the monoamine class and that is also termed a catecholamine because of the similarity of its chemical structure to epinephrine and norepinephrine.  Dopamine has been implicated in the pathophysiology of schizophrenia and disorders of addiction.  Some research also indicates it may play a significant role in depression and attention deficit hyperactivity disorder.  Remember the wonder drug reserpine that reduced psychotic behaviors associated with schizophrenia? This drug and more modern antipsychotic treatments affect a number of neurotransmitter systems, but their greatest impact may be that they block specific dopamine receptors, thus lowering dopamine activity.  Dopamine circuits merge and cross with serotonin circuits at many points and therefore influence many of the same behaviors. For example, dopamine activity is associated with exploratory, outgoing, pleasure-seeking behaviors, and serotonin is associated with inhibition and constraint; thus, in a sense they balance each other.  One of a class of drugs that affects the dopamine circuits specifically is L-dopa, which is a dopamine agonist (increases levels of dopamine).  One of the systems that dopamine switches on is the locomotor system, which regulates ability to move in a coordinated way and, once turned on, is influenced by serotonin activity. Because of these connections, deficiencies in dopamine have been associated with disorders such as  Parkinson’s disease, in which a marked deterioration in motor behavior includes tremors, rigidity of muscles, and difficulty with judgment. L-dopa has been successful in reducing some of these motor disabilities.  Cognitive science, which is concerned with how we acquire and process information and how we store and ultimately retrieve it (one of the processes involved in memory).  Along similar lines, Martin Seligman and his colleague Steven Maier, also working with animals, described the phenomenon of learned helplessness, which occurs when rats or other animals encounter conditions over which they have no control.  Another influential psychologist, Albert Bandura, observed that organisms do not have to experience certain events in their environment to learn effectively. Rather, they can learn just as much by observing what happens to someone else in a given situation. This fairly obvious discovery came to be known as modeling or observational learning.  According to the concept of prepared learning, we have become highly prepared for learning about certain types of objects or situations over the course of evolution because this knowledge contributes to the survival of the species.  The alarm reaction that activates during potentially life-threatening emergencies is called the flight or fight response.  Emotion scientists now agree that emotion is composed of three related components—behavior, physiology, and cognition.  The principle of equifinality is used in developmental psychopathology to indicate that we must consider a number of paths to a given outcome.  Clinical Assessment and Diagnosis  Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder.  Diagnosis is the process of determining whether the particular problem afflicting the individual meets all criteria for a psychological disorder, as set forth in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.  Affect refers to the feeling state that accompanies what we say at a given point. Usually our affect is “appropriate”; that is, we laugh when we say something funny or look sad when we talk about something sad.  The first neuroimaging technique, developed in the early 1970s, uses multiple X-ray exposures of the brain from different angles; that is, X-rays are passed directly through the head. As with any X-ray, these are partially blocked or attenuated more by bone and less by brain tissue. The degree of blockage is picked up by detectors in the opposite side of the head. A computer then reconstructs pictures of various slices of the brain. This procedure, which takes about 15 minutes, is called a computerized axial tomography (CAT) scan or CT scan. This gives an image of the brain structure.  Several more recently developed procedures give greater resolution (specificity and accuracy) than a CT scan without the inherent risks of X-ray tests. A now commonly used scanning technique is called nuclear magnetic resonance imaging (MRI). The patient’s head is placed in a high-strength magnetic field through which radio frequency signals are transmitted. These signals “excite” the brain tissue, altering the protons in the hydrogen atoms. This gives an image of the brain structure.  Subjects undergoing a positron emission tomography (PET) scan are injected with a tracer substance attached to radioactive isotopes, or groups of atoms that react distinctively. This substance interacts with blood, oxygen, or glucose. When parts of the brain become active, blood, oxygen, or glucose rushes to these areas of the brain, creating “hot spots” picked up by detectors that identify the location of the isotopes. Thus, we can learn what parts of the brain are working and what parts are not. This gives an image of the brain functioning.  A second procedure used to assess brain functioning is called single photon emission computed tomography (SPECT). It works much like PET, although a different tracer substance is used and this procedure is somewhat less accurate. It is also less expensive, however, and requires far less sophisticated equipment to pick up the signals. Therefore, SPECT is used more often than PET scans. This gives an image of the brain functioning.  Functional Magnetic Resonance Imaging (fMRI) procedures have largely replaced PET scans in the leading brain-imaging centers because they allow researchers to see the immediate response of the brain to a brief event, such as seeing a new face.  In an electroencephalogram (EEG), electrodes are placed directly on various places on the scalp to record the different low-voltage currents.  When brief periods of EEG patterns are recorded in response to specific events, such as hearing a psychologically meaningful stimulus, the response is called an event-related potential (ERP) or evoked potential.  If we want to determine what is unique about an individual’s personality, cultural background, or circumstances, we use what is known as an idiographic strategy.  But to take advantage of the information already accumulated on a particular problem or disorder, we must be able to determine a general class of problems to which the presenting problem belongs. This is known as a nomothetic strategy.  The term classification itself is broad, referring simply to any effort to construct groups or categories and to assign objects or people to these categories on the basis of their shared attributes or relations—a nomothetic strategy.  If the classification is in a scientific context, it is most often called taxonomy, which is the classification of entities for scientific purposes, such as insects, rocks, or—if the subject is psychology—behaviors.  If you apply a taxonomic system to psychological or medical phenomena or other clinical areas, you use the word nosology. All diagnostic systems used in healthcare settings, such as those for infectious diseases, are nosological systems.  The term nomenclature describes the names or labels of the disorders that make up the nosology (for example, anxiety or mood disorders).  The classical (or pure) categorical approach to classification originates in the work of Emil Kraepelin and the biological tradition in the study of psychopathology.  Emil Kraepelin was one of the first psychiatrists to classify psychological disorders from a biological point of view.  Kraepelin first identified what we now know as the disorder of schizophrenia. His term for the disorder at the time was dementia praecox. Dementia praecox refers to deterioration of the brain that sometimes occurs with advancing age (dementia) and develops earlier than it is supposed to, or “prematurely” (praecox). DSM  The first Diagnostic and Statistical Manual (DSM-I), published in 1952 by the American Psychiatric Association. Only in the late 1960s did systems of nosology begin to have some real influence on mental health professionals.  In 1968, the American Psychiatric Association published a second edition of its Diagnostic and Statistical Manual (DSM-II).  The year 1980 brought a landmark in the history of nosology: the third edition of the Diagnostic and Statistical Manual (DSM-III). Under the leadership of Robert Spitzer, DSM-III departed radically from its predecessors.  Three changes stood out. 1. First, DSM-III attempted to take an atheoretical approach to diagnosis, relying on precise descriptions of the disorders as they presented to clinicians rather than on psychoanalytic or biological theories of etiology. 2. The second major change in DSM-III was that the specificity and detail with which the criteria for identifying a disorder were listed made it possible to study their reliability and validity. 3. Third, DSM-III (and DSM-III-R) allowed individuals with possible psychological disorders to be rated on five dimensions, or axes. This framework, called the multiaxial system, allowed the clinician to gather information about the individual’s functioning in a number of areas rather than limiting information to the disorder itself.  Axis I. The disorder itself, such as schizophrenia or mood disorder, was represented only on the first axis.  Axis II. What were thought to be more enduring (chronic) disorders of personality were listed on Axis II.  Axis III consisted of any physical disorders and conditions that might be present.  Axis IV the clinician rated, in a dimensional fashion, the amount of psychosocial stress the person reported.  Axis V. And the current level of adaptive functioning was indicated on Axis V.  The fourth edition of the DSM (DSM-IV) was published in 1994.  Perhaps the most substantial change in DSM-IV was that the distinction between organically based disorders and psychologically based disorders that was present in previous editions was eliminated.   The multiaxial system remained in DSM-IV, with some changes in the five axes. Specifically, only personality disorders and intellectual disability were now coded on Axis II. DSM IV Axes  Axis I. Pervasive developmental disorders, learning disorders, motor skills disorders, and communication disorders, previously coded on Axis II, were now all coded on Axis I.  Axis II. Only personality disorders and intellectual disability were now coded on Axis II.  Axis III. Consisted of any physical disorders and conditions that might be present.  Axis IV. The new Axis IV is used for reporting psychosocial and environmental problems that might have an impact on the disorder.  Axis V. Axis V was essentially unchanged. It indicates the current level of adaptive functioning.  In 2000, a committee updated the text that describes the research literature accompanying the DSM-IV diagnostic category and made minor changes to some of the criteria themselves to improve consistency. This text revision (DSM-IV-TR) helped clarify many issues related to the diagnosis of psychological disorders.  In the almost 20 years since the publication of DSM-IV our knowledge has advanced considerably and, after over 10 years of concerted effort, DSM-5 was published in the spring of 2013.  The manual is divided into three main sections. The first section introduces the manual and describes how best to use it. The second section presents the disorders themselves, and section 3 includes descriptions of disorders or conditions that need further research before they can qualify as official diagnoses.  Perhaps the most notable change is the removal of the multiaxial system since the former axes I, II, and III have been combined into the descriptions of the disorders themselves, and clinicians can make a separate notation for relevant psychosocial or contextual factors (formerly axis IV) or extent of disability (formerly axis V) associated with the diagnosis.  The use of dimensional axes for rating severity, intensity frequency, or duration of specific disorders in a relatively uniform manner across all disorders has also been substantially expanded in DSM-5, as previously proposed.  In DSM-5 the term “mental retardation” has been dropped in favor of the more accurate term “intellectual disability”, which is consistent with recent changes by other organizations.  Individuals are often diagnosed with more than one psychological disorder at the same time, which is called comorbidity.  Research Methods  Kiesler labeled the tendency to see all participants as one homogeneous group the patient uniformity myth. Comparing groups according to their mean scores (“Group A improved by 50% over Group B”) hides important differences in individual reactions to our interventions.  One type of correlational research that is much like the efforts of detectives is called epidemiology, the study of the incidence, distribution, and consequences of a particular problem or set of problems in one or more populations.  Epidemiologists study the incidence and prevalence of disorders among different groups of people.  Like other types of correlational research, epidemiological research can’t tell us conclusively what causes a particular phenomenon. Knowledge about the prevalence and course of psychological disorders is extremely valuable to our understanding, however, because it points researchers in the right direction.  When behavior changes as a result of a person’s expectation of change rather than as a result of any manipulation by an experimenter, the phenomenon is known as a placebo effect (from the Latin word placebo, which means “I shall please”).  As an alternative to using no-treatment control groups to help evaluate results, some researchers compare different treatments. In this design, the researcher gives different treatments to two or more comparable groups of people with a particular disorder and can then assess how or whether each treatment helped the people who received it. This is called comparative treatment research.  One of the more important strategies used in single-case experimental design is repeated measurement, in which a behavior is measured several times instead of only once before you change the independent variable and once afterward.  Endophenotypes are the genetic mechanisms that ultimately contribute to the underlying problems causing the symptoms and difficulties experienced by people with psychological disorders. In the case of schizophrenia, for example, researchers are not looking for a “schizophrenia gene” (genotype); instead, they are searching for the gene or genes responsible for the working memory problems characteristic of people with this disorder (endophenotype), as well as the genes responsible for other problems experienced by people with this disorder.  The basic principle of genetic linkage analysis is simple. When a family disorder is studied, other inherited characteristics are assessed at the same time. These other characteristics—called genetic markers—are selected because we know their exact location. If a match or link is discovered between  the inheritance of the disorder and the inheritance of a genetic marker, the genes for the disorder and the genetic marker are probably close together on the same chromosome.  The second strategy for locating specific genes, association studies, also uses genetic markers. Whereas linkage studies compare markers in a large group of people with a particular disorder, association studies compare such people to people without the disorder. Prevention Intervention Strategies  Health promotion or positive development strategies involve efforts to blanket entire populations of people—even those who may not be at risk—to prevent later problems and promote protective behaviors. The intervention is not designed to fix existing problems but, instead, focuses on skill building, for example, to keep problems from developing.  Universal prevention strategies focus on entire populations and target certain specific risk factors (for example, behavior problems in inner-city classrooms) without focusing on specific individuals.  The third approach to prevention intervention—selective prevention—specifically targets whole groups at risk (for example, children who have parents who have died) and designs specific interventions aimed at helping them avoid future problems.  Finally, indicated prevention is a strategy for those individuals who are beginning to show signs of problems (for example, depressive symptoms) but do not yet have a psychological disorder.  A variation of correlation research is to compare different people at different ages. For a cross-sectional design, researchers take a cross section of a population across the different age groups and compare them on some characteristic.  In cross-sectional designs, the participants in each age group are called cohorts; Brown and Finn studied three cohorts: 12-year-olds, 15-year-olds, and 17-year-olds. The members of each cohort are the same age at the same time and thus have all been exposed to similar experiences.  Differences among cohorts in their opinions about alcohol use may be related to their respective cognitive and emotional development at these different ages and to their dissimilar experiences. This cohort effect, the confounding of age and experience, is a limitation of the cross-sectional design.  Rather than looking at different groups of people of differing ages, researchers may follow one group over time and assess change in its members directly. The advantages of longitudinal designs are that they do not suffer from cohort effect problems and they allow the researchers to assess individual change.  Longitudinal designs can suffer from a phenomenon similar to the cohort effect on cross-sectional designs. The cross-generational effect involves trying to generalize the findings to groups whose experiences are different from those of the study participants.  Anxiety, Trauma- and Stressor-Related, and Obsessive-Compulsive and Related Disorders  Anxiety is a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future.  Social, physical, and intellectual performances are driven and enhanced by anxiety.  Fear is an immediate emotional reaction to current danger characterized by strong escapist action tendencies and, often, a surge in the sympathetic branch of the autonomic nervous system. Panic Attack  In psychopathology, a panic attack is defined as an abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms that usually include heart palpitations, chest pain, shortness of breath, and, possibly, dizziness.  Two basic types of panic attacks are described in DSM-5: expected and unexpected. Unexpected attacks are important in panic disorder. Expected attacks more common in specific phobias or social phobia.  If you know you are afraid of high places or of driving over long bridges, you might have a panic attack in these situations but not anywhere else; this is an expected (cued) panic attack.  By contrast, you might experience unexpected (uncued) panic attacks if you don’t have a clue when or where the next attack will occur. Biological Contributions  As with almost all emotional traits and psychological disorders, no single gene seems to cause anxiety or panic. Instead, contributions from collections of genes in several areas on chromosomes make us vulnerable when the right psychological and social factors are in place.  Depleted levels of gammaaminobutyric acid (GABA), part of the GABA–benzodiazepine system, are associated with increased anxiety, although the relationship is not quite so direct.  The noradrenergic system has also been implicated in anxiety, and evidence from basic animal studies, as well as studies of normal anxiety in humans, suggests the serotonergic neurotransmitter system is also involved.  But increasing attention in the last several years is focusing on the role of the corticotropin-releasing factor (CRF) system as central to the expression of anxiety (and depression) and the groups of genes that increase the likelihood that this system will be turned on.  This is because CRF activates the hypothalamic– pituitary–adrenocortical (HPA) axis, which is part of the CRF system, and this CRF system has wide-ranging effects on areas of the brain implicated in anxiety, including the emotional brain (the limbic system), particularly the hippocampus and the amygdala; the locus coeruleus in the brain stem; the prefrontal cortex; and the dopaminergic neurotransmitter system.  The CRF system is also directly related to the GABA–benzodiazepine system and the serotonergic and noradrenergic neurotransmitter systems.  The area of the brain most often associated with anxiety is the limbic system which acts as a mediator between the brain stem and the cortex. The more primitive brain stem monitors and senses changes in bodily functions and relays these potential danger signals to higher cortical processes through the limbic system.  The late Jeffrey Gray, a prominent British neuropsychologist, identified a brain circuit in the limbic system of animals that seems heavily involved in anxiety. The system that Gray calls the behavioral inhibition system (BIS).  BIS is activated by signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger. Danger signals in response to something we see that might be threatening descend from the cortex to the septal–hippocampal system.  The BIS also receives a big boost from the amygdala.   When the BIS is activated by signals that arise from the brain stem or descend from the cortex, our tendency is to freeze, experience anxiety, and apprehensively evaluate the situation to confirm that danger is present.  The BIS circuit is distinct from the circuit involved in panic. Gray and Graeff identified what Gray calls the fight/flight system (FFS).  This circuit originates in the brain stem and travels through several midbrain structures, including the amygdala, the ventromedial nucleus of the hypothalamus, and the central gray matter.  When stimulated in animals, this circuit produces an immediate alarm-and-escape response that looks very much like panic in humans.  The FFS is activated partly by deficiencies in serotonin, suggest Gray and McNaughton.  One important study suggested that cigarette smoking as a teenager is associated with greatly increased risk for developing anxiety disorders as an adult, particularly panic disorder and generalized anxiety disorder. Psychological Contributions  Freud thought anxiety was a psychic reaction to danger surrounding the reactivation of an infantile fearful situation.  Behavioral theorists thought anxiety was the product of early classical conditioning, modeling, or other forms of learning.  A general “sense of uncontrollability” may develop early as a function of upbringing and other disruptive or traumatic environmental factors.  Parents who provide a “secure home base” but allow their children to explore their world and develop the necessary skills to cope with unexpected occurrences enable their children to develop a healthy sense of control. Social Contributions  Stressful life events trigger our biological and psychological vulnerabilities to anxiety. Most are social and interpersonal in nature—marriage, divorce, difficulties at work, death of a loved one, pressures to excel in school, and so on. Some might be physical, such as an injury or illness.  DSM-5 now makes it explicit that panic attacks often co-occur with certain medical conditions, particularly cardio, respiratory, gastrointestinal, and vestibular (inner ear) disorders, even though the majority of these patients would not meet criteria for panic disorder.  Based on epidemiological data, Weissman and colleagues found that 20% of patients with panic disorder had attempted suicide. Generalized Anxiety Disorder  The DSM-5 criteria specify that at least 6 months of excessive anxiety and worry (apprehensive expectation) must be ongoing more days than not.  Whereas panic is associated with autonomic arousal, presumably as a result of a sympathetic nervous system surge (for instance, increased heart rate, palpitations, perspiration, and trembling), GAD is characterized by muscle tension, mental agitation, susceptibility to, fatigue (probably the result of chronic excessive muscle tension), some irritability, and difficulty sleeping.  Focusing one’s attention is difficult, as the mind quickly switches from crisis to crisis. Statistics  About two-thirds of individuals with GAD are female in both clinical samples. But this sex ratio may be specific to developed countries. In the South African study mentioned here, GAD was more common in males.  Some people with GAD report onset in early adulthood, usually in response to a life stressor.  The median age of onset based on interviews is 31.  GAD is prevalent among older adults. In the large national comorbidity study and its replication, GAD was found to be most common in the group over 45 years of age and least common in the youngest group, ages 15 to 24. Treatment  Benzodiazepines are most often prescribed for generalized anxiety, and the evidence indicates that they give some relief, at least in the short term.  Furthermore, benzodiazepines carry some risks. First, they seem to impair both cognitive and motor functioning. Specifically, people don’t seem to be as alert on the job or at school when they are taking benzodiazepines.  The drugs may impair driving, and in older adults they seem to be associated with falls, resulting in hip fractures.  More important, benzodiazepines seem to produce both psychological and physical dependence, making it difficult for people to stop taking them.  There is stronger evidence for the usefulness of antidepressants in the treatment of GAD, such as paroxetine (also called Paxil) and venlafaxine (also called Effexor).  In the early 1990s, we developed a cognitive-behavioral treatment (CBT) for GAD in which patients evoke the worry process during therapy sessions and confront anxiety-provoking images and thoughts head-on.  CBT and the antidepressant drug sertraline (Zoloft) were equally effective immediately following treatment compared with taking placebo pills for children with GAD and other related disorders. Panic Disorder and Agoraphobia  Panic disorder (PD), in which individuals experience severe, unexpected panic attacks; they may think they’re dying or otherwise losing control.  In many cases but not all, PD is accompanied by a closely related disorder called agoraphobia, which is fear and avoidance of situations in which a person feels unsafe or unable to escape to get home or to a hospital in the event of a developing panic symptoms or other physical symptoms, such as loss of bladder control.  In DSM-IV, panic disorder and agoraphobia were integrated into one disorder called panic disorder with agoraphobia, but investigators discovered that many people experienced panic disorder without developing agoraphobia and some people develop agoraphobia in the absence of panic disorder.  Many people who have panic attacks do not necessarily develop panic disorder. To meet criteria for panic disorder, a person must experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences.  A few individuals do not report concern about another attack but still change their behavior in a way that indicates the distress the attacks cause them. They may avoid going to certain places or neglect their duties around the house for fear an attack might occur if they are too active.  The term agoraphobia was coined in 1871 by Karl Westphal, a German physician, and, in the original Greek, refers to fear of the marketplace.  Most agoraphobic avoidance behavior is simply a complication of severe, unexpected panic attacks.  We know that anxiety is diminished for individuals with agoraphobia if they think a location or person is “safe”, even if there is nothing effective the person could do if something bad did happen.  Agoraphobic avoidance seems to be determined for the most part by the extent to which you think or expect you might have another attack rather than by how many attacks you actually have or how severe they are. Thus, agoraphobic avoidance is simply one way of coping with unexpected panic attacks.  Other methods of coping with panic attacks include using (and eventually abusing) drugs and/or alcohol. Some individuals do not avoid agoraphobic situations but endure them with “intense dread.”  Most patients with panic disorder and agoraphobic avoidance also display another cluster of avoidant behaviors that we call interoceptive avoidance, or avoidance of internal physical sensations.  These behaviors involve removing oneself from situations or activities that might produce the physiological arousal that somehow resembles the beginnings of a panic attack.  Some patients might avoid exercise because it produces increased cardiovascular activity or faster respiration, which reminds them of panic attacks and makes them think one might be beginning.  Other patients might avoid sauna baths or any rooms in which they might perspire. Statistics  PD is fairly common. Approximately 2.7% of the population meet criteria for PD during a given 1-year period and 4.7% met them at some point during their lives, two-thirds of them women.  Onset of panic disorder usually occurs in early adult life—from midteens through about 40 years of age. The median age of onset is between 20 and 24.  Important work on anxiety in the elderly suggests that health and vitality are the primary focus of anxiety in the elderly population.  As we have said, most (75% or more) of those who suffer from agoraphobia are women. For a long time, we didn’t know why, but now it seems the most logical explanation is cultural.  It is more accepted for women to report fear and to avoid numerous situations. Men, however, are expected to be stronger and braver, to “tough it out.”  Men consume large amounts of alcohol. The problem is that they become dependent on alcohol, and many begin the long downward spiral into serious addiction.  Approximately 60% of the people with panic disorder have experienced such nocturnal attacks. In fact, panic attacks occur more often between 1:30 a.m. and 3:30 a.m. than any other time. In some cases, people are afraid to go to sleep at night. Causes  Clark emphasizes the specific psychological vulnerability of people with this disorder to interpret normal physical sensations in a catastrophic way. In other words, although we all typically experience rapid heartbeat after exercise, if you have a psychological or cognitive vulnerability, you might interpret the response as dangerous and feel a surge of anxiety.  One hypothesis that panic disorder and agoraphobia evolve from psychodynamic causes suggested that early object loss and/or separation anxiety might predispose someone to develop the condition as an adult.  Dependent personality tendencies often characterize a person with agoraphobia. These characteristics were hypothesized as a possible reaction to early separation. Treatment  A large number of drugs affecting the noradrenergic, serotonergic, or GABA–benzodiazepine neurotransmitter systems, or some combination, seem effective in treating panic disorder.  Including high-potency benzodiazepines, the newer selective-serotonin reuptake inhibitors (SSRIs) such as Prozac and Paxil.  And the closely related serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine.  SSRIs are currently the indicated drug for panic disorder based on all available evidence, although sexual dysfunction seems to occur in 75% or more of people taking these medications.  On the other hand, high-potency benzodiazepines such as alprazolam (Xanax), commonly used for panic disorder, work quickly but are hard to stop taking because of psychological and physical dependence and addiction.  The strategy of exposure-based treatments is to arrange conditions in which the patient can gradually face the feared situations and learn there is nothing to fear.  Gradual exposure exercises, sometimes combined with anxiety-reducing coping mechanisms such as relaxation or breathing retraining, have proved effective in helping patients overcome agoraphobic behavior whether associated with panic disorder or not.  Panic control treatment (PCT) developed at one of our clinics concentrates on exposing patients with panic disorder to the cluster of interoceptive (physical) sensations that remind them of their panic attacks. The therapist attempts to create “mini” panic attacks in the office by having the patients exercise to elevate their heart rates or perhaps by spinning them in a chair to make them dizzy.  General conclusions from these studies suggest no advantage to combining drugs and CBT initially for panic disorder and agoraphobia.  Furthermore, the psychological treatments seemed to perform better in the long run (6 months after treatment had stopped).  This suggests the psychological treatment should be offered initially, followed by drug treatment for those patients who do not respond adequately or for whom psychological treatment is not available. Specific Phobia  A specific phobia is an irrational fear of a specific object or situation that markedly interferes with an individual’s ability to function.  Four major subtypes of specific phobia have been identified:  blood–injection–injury type  situational type (such as planes, elevators, or enclosed places)  natural environment type (for example, heights, storms, and water)  and animal type  A fifth category, “other,” includes phobias that do not fit any of the four major subtypes (for example, situations that may lead to choking, vomiting, or contracting an illness or, in children, avoidance of loud sounds or costumed characters).  Those with blood–injection–injury phobias almost always differ in their physiological reaction from people with other types of phobia.  The average age of onset for this phobia is approximately 9 years.  Phobias characterized by fear of public transportation or enclosed places are called situational phobias.  Claustrophobia, a fear of small enclosed places, is situational, as is a phobia of flying.  The main difference between situational phobia and panic disorder is that people with situational phobia never experience panic attacks outside the context of their phobic object or situation. Therefore, they can relax when they don’t have to confront their phobic situation.  Sometimes very young people develop fears of situations or events occurring in nature. These fears are called natural environment phobias. The major examples are heights, storms, and water.  In any case, these phobias have a peak age of onset of about 7 years.  They are not phobias if they are only passing fears. They have to be persistent (lasting at least six months) and to interfere substantially with the person’s functioning, leading to avoidance of boat trips or summer vacations in the mountains where there might be a storm.  Fears of animals and insects are called animal phobias. Again, these fears are common but become phobic only if severe interference with functioning occurs.  The age of onset for these phobias, like that of natural environment phobias, peaks around 7 years. Statistics  Not surprisingly, fears of snakes and heights rank near the top.  Notice also that the sex ratio among common fears is overwhelmingly female with a couple of exceptions.  Among these exceptions is fear of heights, for which the sex ratio is approximately equal.  As with common fears, the sex ratio for specific phobias is, at 4:1, overwhelmingly female; this is also consistent around the world.  The median age of onset for specific phobia is 7 years of age, the youngest of any anxiety disorder except separation anxiety disorder.  Specific phobias seem to decline with old age. Causes  An individual with claustrophobia who recently came to our clinic reported being trapped in an elevator for an extraordinarily long period. These are examples of phobias acquired by direct experience, where real danger or pain results in an alarm response (a true alarm).  This is one way of developing a phobia, and there are at least three others: experiencing a false alarm (panic attack) in a specific situation, observing someone else experience severe fear (vicarious experience), or, under the right conditions, being told about danger. Treatment  Almost everyone agrees that specific phobias require structured and consistent exposure-based exercises.  Nevertheless, most patients who expose themselves gradually to what they fear must be under therapeutic supervision. Individuals who attempt to carry out the exercises alone often attempt to do too much too soon and end up escaping the situation, which may strengthen the phobia.  For separation anxiety, parents are often included to help structure the exercises and also to address parental reaction to childhood anxiety. Separation Anxiety Disorder  Separation anxiety disorder is characterized by children’s unrealistic and persistent worry that something will happen to their parents or other important people in their life or that something will happen to the children themselves that will separate them from their parents (for example, they will be lost, kidnapped, killed, or hurt in an accident).  Children often refuse to go to school or even to leave home, not because they are afraid of school but because they are afraid of separating from loved ones.  All young children experience separation anxiety to some extent; this fear usually decreases as they grow older.  It is also important to differentiate separation anxiety from school phobia. In school phobia, the fear is clearly focused on something specific to the school situation; the child can leave the parents or other attachment figures to go somewhere other than school.  In treating separation anxiety in children, parents are often included to help structure the exercises and also to address parental reaction to childhood anxiety. Social Anxiety Disorder (Social Phobia)  SAD is more than exaggerated shyness.  Individuals with just performance anxiety, which is a subtype of SAD, usually have no difficulty with social interaction, but when they must do something specific in front of people, anxiety takes over and they focus on the possibility that they will embarrass themselves.  The most common type of performance anxiety, to which most people can relate, is public speaking.  Other situations that commonly provoke performance anxiety are eating in a restaurant or signing a paper or check in front of a person or people who are watching.  Anxiety-provoking physical reactions include blushing, sweating, trembling, or, for males, urinating in a public restroom (“bashful bladder” or paruresis). Statistics  In a given 1-year period, the prevalence is 6.8%, and 8.2% in adolescents. This makes SAD second only to specific phobia as the most prevalent anxiety disorder, afflicting more than 35 million people in the United States alone, based on current population estimates.  Unlike other anxiety disorders for which females predominate, the sex ratio for SAD is nearly 50:50.  SAD usually begins during adolescence, with a peak age of onset around 13 years.  SAD also tends to be more prevalent in people who are young (18–29 years), undereducated, single, and of low socioeconomic class. Causes  Mogg and colleagues showed that socially anxious individuals more quickly recognized angry faces than “normals”, whereas “normals” remembered the accepting expressions.  Why should we inherit a tendency to fear angry faces? Our ancestors probably avoided hostile, angry, domineering people who might attack or kill them.  Jerome Kagan and his colleagues have demonstrated that some infants are born with a temperamental profile or trait of inhibition or shyness that is evident as early as 4 months of age.  Four-month-old infants with this trait become more agitated and cry more frequently when presented with toys or other age-appropriate stimuli than infants without the trait. Treatment  Clark and colleagues evaluated a cognitive therapy program that emphasized real-life experiences during therapy to disprove automatic perceptions of danger. This is a superior treatment.  Subsequent studies indicated that this treatment was clearly superior to a second very credible treatment, interpersonal psychotherapy (IPT) both immediately after treatment and at a 1-year follow-up, even when delivered in a center specializing in treatment with IPT.  Results of numerous studies suggest that severely socially anxious adolescents can attain relatively normal functioning in school and other social settings after receiving cognitive behavioral treatment.  Since 1999, the SSRIs Paxil, Zoloft, and Effexor have received approval from the Food and Drug Administration for treatment of SAD based on studies showing effectiveness compared with placebo.  One impressive study compared Clark’s cognitive therapy described earlier with the SSRI drug Prozac, along with instructions to the patients with SAD to attempt to engage in more social situations (self-exposure).  Both treatments did well, but the psychological treatment was substantially better at all times, with most patients cured or nearly cured with few remaining symptoms.  Several exciting studies suggest that adding the drug D-cycloserine (DCS) to cognitive-behavioral treatments significantly enhances the effects of treatment.  This drug works in the amygdala, a structure in the brain involved in the learning and unlearning of fear and anxiety.   Unlike SSRIs, this drug is known to facilitate extinction of anxiety by modifying neurotransmitter flow in the glutamate system. Selective Mutism  Now grouped with the anxiety disorders in DSM-5, selective mutism (SM) is a rare childhood disorder characterized by a lack of speech in one or more settings in which speaking is socially expected.  In fact, speech in selective mutism commonly occurs in some settings, such as home, but not others, such as school, hence the term “selective”.  In order to meet diagnostic criteria for SM, the lack of speech must occur for more than one month and cannot be limited to the first month of school. Trauma-and Stressor-Related Disorders  DSM-5 consolidates a group of formerly disparate disorders that all develop after a relatively stressful life event, often an extremely stressful or traumatic life event.  This set of disorders—trauma and stressor-related disorders—include attachment disorders in childhood following inadequate or abusive childrearing practices, adjustment disorders characterized by persistent anxiety and depression following a stressful life event, and reactions to trauma such as posttraumatic stress disorder and acute stress disorder. Posttraumatic Stress Disorder (PTSD)  DSM-5 describes the setting event for PTSD as exposure to a traumatic event during which an individual experiences or witnesses death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation.  Victims reexperience the event through memories and nightmares.  When memories occur suddenly, accompanied by strong emotion, and the victims find themselves reliving the event, they are having a flashback.  Victims most often avoid anything that reminds them of the trauma.  They are sometimes unable to remember certain aspects of the event. It is possible that victims unconsciously attempt to avoid the experience of emotion itself, like people with panic disorder, because intense emotions could bring back memories of the trauma.  Victims typically are chronically overaroused, easily startled, and quick to anger.  New to DSM-5 is the addition of “reckless or self-destructive behavior” under the PTSD E criteria as one sign of increased arousal and reactivity.  Also new to DSM-5 is the addition of a “dissociative” subtype describing victims who do not necessarily react with the reexperiencing or hyperarousal, characteristic of PTSD.  Since many individuals experience strong reactions to stressful events that typically disappear within a month, the diagnosis of PTSD cannot be made until at least one month after the occurrence of the traumatic event.  In PTSD with delayed onset, individuals show few or no symptoms immediately or for months after a trauma, but at least 6 months later, and perhaps years afterward develop full-blown PTSD.  As we noted, PTSD cannot be diagnosed until a month after the trauma. In DSM-IV a disorder called acute stress disorder was introduced. This is really PTSD, or something very much like it, occurring within the first month after the trauma, but the different name emphasizes the severe reaction that some people have immediately. Statistics  In the population as a whole, surveys indicate that 6.8% have experienced PTSD at some point in their life.  The highest rates are associated with experiences of rape; being held captive, tortured, or kidnapped; or being badly assaulted.  What accounts for the discrepancies between the low rate of PTSD in citizens who endured bombing and shelling in London and Beirut and the relatively high rate in victims of assaultive violence? Close exposure to the trauma seems to be necessary to developing this disorder.  Since a diagnosis of PTSD predicts suicidal attempts independently of any other problem, such as alcohol abuse, every case should be taken very seriously. Causes  We know that intensity of exposure to assaultive violence contributes to the etiology of PTSD, but does not account for all of it.  A family history of anxiety suggests a generalized biological vulnerability for PTSD.  Nevertheless, as with other disorders, there is little or no evidence that genes directly cause PTSD.  While all experienced the same traumatic experience, specific characteristics of what is referred to as the serotonin transporter gene involving two short alleles (SS) described as increasing the probability of becoming depressed.  Breslau, Davis, and Andreski demonstrated among a random sample of 1,200 individuals that characteristics such as a tendency to be anxious, as well as factors such as minimal education, predict exposure to traumatic events in the first place and therefore an increased risk for PTSD.  Family instability is one factor that may instill a sense that the world is an uncontrollable, potentially dangerous place.  The results from a number of studies are consistent in showing that, if you have a strong and supportive group of people around you, it is much less likely you will develop PTSD after a trauma.  Positive coping strategies involving active problem solving seemed to be protective, whereas becoming angry and placing blame on others were associated with higher levels of PTSD.  A number of studies show that support from loved ones reduces cortisol secretion and hypothalamic–pituitary–adrenocortical (HPA) axis activity in children during stress.  It seems clear that PTSD involves a number of neurobiological systems, particularly elevated or restricted corticotropin-releasing factor (CRF), which indicates heightened activity in the HPA axis. Treatment  In psychoanalytic therapy, reliving emotional trauma to relieve emotional suffering is called catharsis.  Unlike the object of a specific phobia, a traumatic event is difficult to recreate, and few therapists want to try. Therefore, imaginal exposure, in which the content of the trauma and the emotions associated with it are worked through systematically, has been used for decades under a variety of names.  At present, the most common strategy to achieve this purpose with adolescents or adults is to work with the victim to develop a narrative of the traumatic experience that is then reviewed extensively in therapy.  Cognitive therapy to correct negative assumptions about the trauma—such as blaming oneself in some way, feeling guilty, or both—is often part of treatment.  Some of the drugs, such as SSRIs (e.g., Prozac and Paxil), that are effective for anxiety disorders in general have been shown to be helpful for PTSD, perhaps because they relieve the severe anxiety and panic attacks so prominent in this disorder. Adjustment disorders  Adjustment disorders describe anxious or depressive reactions to life stress that are generally milder than one would see in acute stress disorder or PTSD but are nevertheless impairing in terms of interfering with work or school performance, interpersonal relationships, or other areas of living.  The stressful events themselves would not be considered traumatic but it is clear that the individual is nevertheless unable to cope with the demands of the situation and some intervention is typically required.  If the symptoms persist for more than six months after the removal of the stress or its consequences, the adjustment disorder would be considered “chronic”. Attachment disorders  Attachment disorders refers to disturbed and developmentally inappropriate behaviors in children, emerging before five years of age, in which the child is unable or unwilling to form normal attachment relationships with caregiving adults.  These seriously maladaptive patterns are due to inadequate or abusive child-rearing practices.  In either case the result is a failure to meet the child’s basic emotional needs for affection, comfort, or even providing for the basic necessities of daily living.  In reactive attachment disorder the child will very seldom seek out a caregiver for protection, support, and nurturance and will seldom respond to offers from caregivers to provide this kind of care.  Generally they would evidence lack of responsiveness, limited positive affect, and additional heightened emotionality, such as fearfulness and intense sadness.  In disinhibited social engagement disorder, a similar set of child rearing circumstances— perhaps including early persistent harsh punishment—would result in a pattern of behavior in which the child shows no inhibitions whatsoever to approaching adults.  Such a child might engage in inappropriately intimate behavior by showing a willingness to immediately accompany an unfamiliar adult figure somewhere without first checking back with a caregiver. Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder  In other anxiety disorders, the danger is usually in an external object or situation, or at least in the memory of one. In OCD, the dangerous event is a thought, image, or impulse that the client attempts to avoid as completely as someone with a snake phobia avoids snakes.  Obsessions are intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate.  Compulsions are the thoughts or actions used to suppress the obsessions and provide relief.  Based on statistically associated groupings, there are four major types of obsessions and each is associated with a pattern of compulsive behavior.  symmetry obsessions account for most obsessions (26.7%)  “forbidden thoughts or actions” (21%)  cleaning and contamination (15.9%)  and hoarding (15.4%)  Symmetry refers to keeping things in perfect order or doing something in a specific way.  Obsessions with symmetry lead to ordering and arranging or repeating rituals.  People with aggressive (forbidden) obsessive impulses may feel they are about to yell out a swear word in church.  Forbidden thoughts or actions seem to lead to checking rituals. Checking rituals serve to prevent an imagined disaster or catastrophe.  Many are logical, such as repeatedly checking the stove to see whether you turned it off, but severe cases can be illogical. For example, Richard thought that if he did not eat in a certain way he might become possessed.  A mental act, such as counting, can also be a compulsion.  Obsessions with contamination lead to washing rituals that may restore a sense of safety and control.  It is also common for tic disorder, characterized by involuntary movement (sudden jerking of limbs, for example), to co-occur in patients with OCD (particularly children) or in their families.  More complex tics with involuntary vocalizations are referred to as Tourette’s disorder.  In some cases, these movements are not tics but may be compulsions, as they were in the case of Frank in Chapter 3 who kept jerking his leg if thoughts of seizures entered his head.  The obsessions in tic-related OCD are almost always related to symmetry. Statistics  OCD has a ratio of female to male that is nearly 1:1.  Age of onset ranges from childhood through the 30s, with a median age of onset of 19.  The age of onset peaks earlier in males (13 to 15) than in females (20 to 24). Causes  When clients with OCD equate thoughts with the specific actions or activity represented by the thoughts, this is called thought–action fusion. Thought–action fusion may, in turn, be caused by attitudes of excessive responsibility and resulting guilt developed during childhood, when even a bad thought is associated with evil intent. Treatment  The most effective seem to be those that specifically inhibit the reuptake of serotonin, such as clomipramine or the SSRIs, which benefit up to 60% of patients with OCD, with no particular advantage to one drug over another.  The most effective approach is called exposure and ritual prevention (ERP), a process whereby the rituals are actively prevented and the patient is systematically and gradually exposed to the feared thoughts or situations.  More recent innovations to evidence-based psychological treatments for OCD have examined the efficacy of cognitive treatments with a focus on the overestimation of threat, the importance and control of intrusive thoughts, the sense of inflated responsibility present in patients with OCD who think they alone may be responsible for preventing a catastrophe, as well as the need for perfectionism and certainty present in these patients.  ERP, with or without the drug, produced superior results to the drug alone, with 86% responding to ERP alone versus 48% to the drug alone.  Combining the treatments did not produce any additional advantage.  Psychosurgery is one of the more radical treatments for OCD. “Psychosurgery” is a misnomer that refers to neurosurgery for a psychological disorder.  Jenike and colleagues reviewed the records of 33 patients with OCD, most of them extremely severe cases who had failed to respond to either drug or psychological treatment. After a specific surgical lesion to the cingulate bundle (cingulotomy), approximately 30% benefited substantially. Body Dysmorphic Disorder  Most people fantasize about improving something, but some relatively normal-looking people think they are so ugly they refuse to interact with others or otherwise function normally for fear that people will laugh at their ugliness.  This curious affliction is called body dysmorphic disorder (BDD), and at its center is a preoccupation with some imagined defect in appearance by someone who actually looks reasonably normal.  The disorder has been referred to as “imagined ugliness”.  For many years, BDD was considered a somatoform disorder because its central feature is a psychological preoccupation with somatic (physical) issues.  But increasing evidence indicated it was more closely related to OCD, accounting for its relocation to the obsessive-compulsive and related disorders section in DSM-5.  People with BDD complain of persistent, intrusive, and horrible thoughts about their appearance, and they engage in such compulsive behaviors as repeatedly looking in mirrors to check their physical features.  Quite understandably, suicidal ideation, suicide attempts, and suicide itself are typical consequences of this disorder.  The prevalence of BDD is hard to estimate because by its very nature it tends to be kept secret.  In mental health clinics, the disorder is also uncommon because most people with BDD seek other types of health professionals, such as plastic surgeons and dermatologists.  BDD is seen equally in men and women.  Men tend to focus on body build, genitals, and thinning hair and tend to have more severe BDD.  Women focus on more varied body areas and are more likely to also have an eating disorder.  Age of onset ranges from early adolescence through the 20s, peaking at the age of 16–17.  One study of 62 consecutive outpatients with BDD found that the degree of psychological stress, quality of life, and impairment were generally worse than comparable indices in patients with depression, diabetes, or a recent myocardial infarction (heart attack) on several questionnaire measures.  Perhaps more significantly, there are two, and only two, treatments for BDD with any evidence of effectiveness, and these treatments are the same found effective in OCD. First, drugs that block the re-uptake of serotonin, such as clomipramine (Anafranil) and fluvoxamine (Luvox), provide relief to at least some people.  A second controlled study reported similar findings for fluoxetine (Prozac), with 53% showing a good response compared with 18% on placebo after 3 months.  Exposure and response prevention, the type of cognitive-behavioral therapy effective with OCD, has also been successful with BDD.  As with OCD, cognitive-behavioral therapy tends to produce better and longer lasting outcomes compared to medication alone. Other Obsessive-Compulsive and Related Disorders Hoarding Disorder  The three major characteristics of this problem are excessive acquisition of things, difficulty discarding anything, and living with excessive clutter under conditions best characterized as gross disorganization.  Basically, these individuals usually begin acquiring things during their teenage years and often experience great pleasure, even euphoria, from shopping or otherwise collecting various items.  These individuals then experience strong anxiety and distress about throwing anything away, because everything has either some potential use or sentimental value in their minds, or simply becomes an extension of their own identity.  The average age when these people come for treatment is approximately 50, after many years of hoarding.  Cognitive and emotional abnormalities associated with hoarding alluded to above include extraordinarily strong emotional attachment to possessions, an exaggerated desire for control over possessions, and marked deficits in deciding when a possession is worth keeping or not (all possessions are believed to be equally valuable).  People who hoard animals comprise a special group that is now being investigated more closely.   Animal hoarders are characterized by the failure or inability to care for the animals or provide suitable living quarters, which results in threats to health and safety due to unsanitary conditions associated with accumulated animal waste.  The hoarding group was characterized by attribution of human characteristics to their animals, the presence of more dysfunctional current relationships (with other people) and significantly greater mental health concerns. Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin Picking Disorder) Trichotillomania  The urge to pull out one’s own hair from anywhere on the body, including the scalp, eyebrows, and arms, is referred to as trichotillomania.  This behavior results in noticeable hair loss, distress, and significant social impairments.  Compulsive hair pulling is more common than once believed and is observed in between 1% and 5% of college students, with females reporting the problem more than males.  There may be some genetic influence on trichotillomania, with one study finding a unique genetic mutation in a small number of people. Excoriation  (skin picking disorder) is characterized, as the label implies, by repetitive and compulsive picking of the skin, leading to tissue damage.  There can be significant embarrassment, distress, and impairment in terms of social and work functioning.  Excoriation is also largely a female disorder.  Prior to DSM-5, both disorders were classified under impulse control disorders, but it has been established that these disorders often co-occur with obsessive-compulsive disorder and body dysmorphic disorder, as well as with each other.  Until recently it was assumed that the repetitive behaviors of hair pulling and skin picking function to relie