Psy 222 Sim - Week 1 - 9

College of Arts and Sciences Education
BS Psychology Program
2nd Floor, DPT Building
Matina Campus, Davao City
Phone No.: (082)300-5456/305-0647 Local 118
PART 1: QUALITY ASSURANCE POLICY
Course Outline: PSY 222 – Abnormal Psychology
Course Facilitator: Joannie Villareal Intong, MPsy.

Email: joannie_intong@umindanao.edu.ph
Student Consultation: Thru LMS, e-mail, or by phone
Mobile: 0917 100 6439
Phone: (082) 228 5106
Effectivity Date: August 17, 2020
Mode of Delivery: Online Blended Delivery
Time Frame: 108 Hours
Student Workload: Expected Self-Directed Learning
Requisites: Psy 123
Credit: 6.0 Units
Attendance Requirements: For online sessions and examinations: minimum
of 95% attendance
Course Outline Policy
Areas of Concern Details

Contact and Non-contact This 6-unit course self-instructional manual is designed for
Hours blended learning mode of instructional delivery with
scheduled face to face or virtual sessions. The expected
number of hours will be 108, including the virtual sessions
and conduct of examinations.
Assessment Task Submission of assessment tasks shall be on the 3rd, 5th, 7th
Submission and 9th week of the term. The assessment paper shall be
attached with a cover page indicating the title of the
assessment task, the name of the course coordinator,
date of submission and student name. The document
should be emailed to the course coordinator. It is also
expected that you already paid your tuition and other fees
before the submission of the assessment task.
If the assessment task is done in real time through the

features in the Blackboard Learning Management System,
the schedule shall be arranged ahead of time by the
course coordinator.
Plagiarism Check To ensure honesty and authenticity, all assessment tasks

are required to be run through plagiarism check with a
maximum similarity index of 30%. This means that any
PSY 222 – ABNORMAL PSYCHOLOGY 1

Phone No.: (082)300-5456/305-0647 Local 118
output/paper that goes beyond 30%, the students will

either opt to redo her/his paper or explain in writing
addressed to the course coordinator the reasons for the
similarity.
In addition, if the paper has reached more than 30%

similarity index, the student may be called for a
disciplinary action in accordance with the University’s
OPM on Intellectual and Academic Honesty.
Please note that academic dishonesty such as cheating

and commissioning other students or people to complete
the task for you have severe punishments (reprimand,
warning, expulsion).
Penalties for Late The score for an assessment item submitted after the
Assignments/Assessments designated time on the due date, without an approved
extension of time, will be reduced by 5% of the possible
maximum score for that assessment item for each day or
part day the assessment item is late.
However, if the late submission of assessment paper has

a valid reason, a letter of explanation should be
submitted and approved by the course coordinator. If
necessary, you will also be required to present/attach
evidence.
Return of Assignment/ Assessment tasks will be returned to you two (2) weeks
Assessments after the submission. This will be returned by email or via
Blackboard portal.
For group assessment tasks, the course coordinator will

require some or few of the students for online or virtual
sessions to ask clarificatory questions to validate the
originality of the assessment task submitted and to
ensure that all the group members are involved.
Assignment Resubmission You should request in writing addressed to the course

coordinator his/her intention to resubmit an assessment
task. The resubmission is premised on the student’s
failure to comply with the similarity index and other
reasonable grounds such as academic literacy standards
or other reasonable circumstances e.g. illness,
accidents, financial constraints.
Re-marking of Assessment You should request in writing addressed to the program

Papers and Appeal coordinator your intention to appeal or contest the score
given to an assessment task. The letter should explicitly
explain the reasons/points to contest the grade. The

Phone No.: (082)300-5456/305-0647 Local 118
program coordinator shall communicate with the students

on the approval and disapproval of the request.
If disapproved by the course coordinator, you can elevate

you case to the program head or the dean with the original
letter of request. The final decision will come from the
dean of college.
Grading System All culled from Blackboard sessions and submissions of

requirements/exercises done through CF’s email:
Course Discussions
and Exercises 40%
First Exam 5%
Second Exam 5%
Third Exam 5%
Fourth Exam 5%
Fifth Exam 5%
Sixth Exam 5%
Seven Exam 5%
Final Exam 25%
Total 100%
Preferred Referencing APA 7th Edition

Style
Student Communication You are required to create a umindanao email account

which is a requirement to access the Blackboard portal.
Then, the course coordinator shall enroll the students to
have access to the materials and resources of the
course. All communication formats: chat, submission
of assessment tasks, requests, raising of issues and
concern etc. shall be through the portal and other
university recognized platforms.
For students who have not created their student email,

please contact the course coordinator or program head.
Contact Details of the Dean KHRISTINE MARIE D. CONCEPCION, Ph.D.

Email: artssciences@umindanao.edu.ph
Phone: 305 0647 loc 118
Contact Details of the SHEENA MAY A. LACUESTA

Program Head Email: BSPsychology@umindanao.edu.ph
Phone: 305 0647 loc 182
Students with Special Students with special needs shall communicate with the
Needs course coordinator about the nature of his/her special
needs. Depending on the nature of the need, the course
coordinator with the approval of the program coordinator

Phone No.: (082)300-5456/305-0647 Local 118
may provide alternative assessment tasks or extension

of the deadline of submission of assessment tasks.
However, the alternative assessment tasks should still be
in the service of achieving the desired course learning
outcomes.
Online Tutorial Students who need tutorial will be identified by the

Registration program through the faculty members. They will be
informed by their Course Coordinator/Program
Coordinator to enroll in the tutorial classes. Moreover,
these tutorials sessions are also open to all students who
are interested.
To enroll in the tutorial classes, please send an email to

bspsychologytutorial@umindanao.edu.ph
The email must include the following details:
Name:
Year Level:
Enrolled Courses/Subjects and Course Coordinator:
Contact Number:
Email Address:
Instructional Help Desk JOANNIE VILLAREAL INTONG, MPSY.

Contact Details Email: joannie_intong@umindanao.edu.ph
Mobile: 0917 100 6439
SHEENA MAY A. LACUESTA

Email: BSPsychology@umindanao.edu.ph
Phone: 305 0647 loc 182
Well-being Welfare Guidance Services and Testing Center

Support Help Desk Contact FB Page Link: https://www.facebook.com/GSTCCASE/
Details Phone: (082) 227-5456 Local 130
CASE Guidance Facilitator

ZERDSZEN P. RAÑISES, RGC
Contact Number: 0950 466 5431
Email Address: gstcmain@umindanao.edu.ph
Library Contact Details BRIGIDA E. BACANI

Head – LIC
University of Mindanao – Learning and Information
Center
E-mail Address: library@umindanao.edu.ph
Facebook: UM Learning and Learning Center-Davao
City
Cellphone Number: 0951 376 6681

Phone No.: (082)300-5456/305-0647 Local 118
Course Information – see/download course syllabus in the Black Board LMS
CF’s Voice: Hello, psychology students! Welcome to this course, PSY 222: Abnormal
Psychology. For several years of working and teaching this course, it became
part of a psychology student's life to get excited and, at the same time,
fascinated by what this subject will become in their journey in the field.
According to the American Psychological Association, abnormal psychology is

the “area of psychological investigation concerned with understanding the
nature of individual pathologies of the mind, mood, and behavior.” To gain more
insight into this fascinating branch of the psychology field, we need to dig
deeper into our available resources.
The question is, why is it essential to study abnormal psychology? How it will
change our perspective towards not only to ourselves but at the same time to
other individuals who were part of the society. Does abnormality is just looking
at the surface or beyond it? Does merely being deviant to the community too
we belong already considered abnormality? These may be some of the
questions that we will go through as we try to determine our behavior and
mental states.
CO As the student journey to the further development of the person's body, mind,
and environment concerning the personal behavior and personality, the
following course outcome to be illustrated by the student: first, to gain sound
and comprehensive knowledge of abnormal behavior and mental disorders,
second, acquire an in-depth knowledge understanding of the various factors
that causes mental and personality disorders. Third, anticipate and help prevent
the development of mental illnesses and other personality maladjustments and
the treatment currently available for these mental disorders. Furthermore, the
last one actively participates in promoting mental health and preventing mental
illness occurrence. Thus, in this course, the student is expected to recall the
knowledge or read in advance the rudiments of introduction to psychology,
theories of personality, and other biological related subjects to illustrate the
possible influence on human behavior and cognition.
Let us begin!

Phone No.: (082)300-5456/305-0647 Local 118
PART 2: INSTRUCTION PROPER
Big Picture
Week 1-3: Unit Learning Outcomes (ULO): At the end of the unit, the student will be able to
a. Demonstrate the basic history content of Abnormal Behavior.

b. Analyze the integrative approach to Psychopathology.
c. Discover the methods on Clinical Assessment and Diagnosis.
Big Picture in Focus: ULOa. Demonstrate the basic history content of Abnormal
Behavior.
LESSON ONE
Metalanguage
This lesson provides a summary of past and future ideas about abnormal
behavior. It introduces the concept of abnormal behavior and its definitional
components while also describing the science of psychopathology; it defines some
primary professions in the field and terms for understanding psychological disorders;
it describes supernatural, biological, and psychological models of abnormal behavior
in a historical context; and it summarizes a multidimensional integrative approach to
understanding psychological disorders.
Consider the following essential terms:
• A psychological disorder is characterized by an irregular pattern of

functioning or behavior. This term generally refers to a psychological
dysfunction in a person that causes anxiety or deficiency in the functioning
and a not normal or culturally appropriate reaction.
• Abnormal psychology, on the other hand, is a field of psychology dealing

with the classification, causes, and treatment of abnormal behavior patterns.
These words would represent what, why, and how a person can be categorized
as an abnormality, a deviant, or merely a normal behavior concerning his or her
behavior.
Essential Knowledge
I. UNDERSTANDING PSYCHOPATHOLOGY
A. What is a Psychopathological Disorder?
1. Psychological disorder or Abnormal Behavior, a psychological
dysfunction within a person has associated with distress or impairment
in functioning and a not usual or culturally anticipated reaction. Let us
take a look at one person's case first and see what this means.

Phone No.: (082)300-5456/305-0647 Local 118
The Case of JUDY: The Girl Who Fainted at the Sight of Blood
Judy, a 16-year-old, was referred to our anxiety disorders clinic after increasing episodes
of fainting. About 2 years earlier, in Judy’s first biology class, the teacher had shown
a movie of a frog dissection to illustrate various points about anatomy.
This was a particularly graphic film, with vivid images of blood, tissue, and muscle. About
halfway through, Judy felt a bit lightheaded and left the room. But the images did not leave
her. She continued to be bothered by them and occasionally felt slightly queasy. She began
to avoid situations in which she might see blood or injury. She stopped looking at magazines
that might have gory pictures. She found it difficult to look at raw meat, or even Band-Aids,
because they brought the feared images to mind. Eventually, anything her friends or parents
said that evoked an image of blood or injury caused Judy to feel lightheaded. It got so bad
that if one of her friends exclaimed, “Cut it out!” she felt faint.
Beginning about 6 months before her visit to the clinic, Judy actually fainted when she
unavoidably encountered something bloody. Her family physician could find nothing wrong
with her, nor could several other physicians. By the time she was referred to our clinic she
was fainting 5 to 10 times a week, often in class. Clearly, this was problematic for her and
disruptive in school; each time Judy fainted, the other students flocked around her, trying to
help, and class was interrupted. Because no one could find anything wrong with her, the
principal finally concluded that she was being manipulative and suspended her from school,
even though she was an honor student.
Judy was suffering from what we now call blood–injection–injury phobia. Her reaction
was quite severe, thereby meeting the criteria for phobia, a psychological disorder
characterized by marked and persistent fear of an object or situation. But many people have
similar reactions that are not as severe when they receive an injection or see someone who
is injured, whether blood is visible or not. For people who react as severely as Judy, this
phobia can be disabling. They may avoid certain careers, such as medicine or nursing, and,
if they are so afraid of needles and injections that they avoid them even when they need
them, they put their health at risk.
2. The three criteria on looking Psychological disorder are the following:

a. Psychological Dysfunction refers to a breakdown in cognitive,
emotional, or behavioral functioning.
• If you are out on a date, for example, it should be
enjoyable. Your emotions are not working properly if you
have extreme fear all evening and only want to go home,
even though there is nothing to be afraid of and the
severe fear exists on any date. On the other hand, all of
your friends believe that the person who asked you out
is unstable and threatening in some way, being afraid
and avoiding the date is not dysfunctional.
• As a result, these problems are often thought of as being

on a continuum or dimension rather than as categories
that exist or do not exist (Widiger & Crego, 2013). This
is another reason why possessing a dysfunction does
not qualify you for a psychological disorder.

Phone No.: (082)300-5456/305-0647 Local 118
b. Personal Distress or Impairment - The behavior must be

associated with distress to be classified as abnormal. It adds an
essential component and seems clear: the criterion is satisfied
if the individual is distraught.
• Judy was obviously upset, and she was also suffering
from her phobia. However, bear in mind that this
criterion does not describe abnormal behavior on its
own. It's perfectly natural to be sad, for example, if
someone close to you passes away. Suffering and
suffering are an inevitable aspect of life in the human
condition. This isn't going to change anytime soon.
Furthermore, certain conditions are devoid of pain and
discomfort by design.
The concept of impairment is useful, although not entirely

satisfactory.
• Many people, for example, regard themselves as shy or
lazy. This is not to suggest they are out of the ordinary.
However, if you are so shy that dating or even
Distress and suffering are a natural
part of life and do not in themselves engaging with people is difficult for you, and you make
constitute a psychological disorder. every effort to avoid interactions even when you want
to make friends, your social functioning is impaired.
c. Atypical or Not Culturally Expected - Anything may be

considered odd if it happens infrequently; it deviates from the
standard. The bigger the variance, the more out of the ordinary
it is. You can define someone as abnormally short or abnormally
tall if their height varies greatly from the average, but this is not
a description of disorder.
• It is not normal to plan for blood to spurt from your
clothes, but Lady Gaga did so during a performance,
and it only added to her celebrity. J. D. Salinger, and
author of The Catcher in the Rye, retreated to a small
town in New Hampshire for years and refused to see
any outsiders, but he continued to write. On stage,
some male rock singers wear make-up. These
individuals are well compensated and appear to enjoy
their jobs. Most of the time, the more productive you
are in society's eyes, the more eccentricities you will be
tolerated. As a result, "differing from the norm" is not a
good definition for abnormal behavior.
We accept extreme behaviors by
entertainers, such as Lady Gaga, that • Another point of view is that if you break social norms,
would not be tolerated in other
members of our society. your behavior is abnormal, even if many people agree
with you. When it comes to psychological disorders, this
definition is helpful when considering important cultural
differences.
• An informative example of this view is provided by

Robert Sapolsky (2002), the prominent neuroscientist

Phone No.: (082)300-5456/305-0647 Local 118
who, during his studies, worked closely with the Masai

people in East Africa. One day, Sapolsky’s Masai friend
Rhoda asked him to bring his vehicle as quickly as
possible to the Masai village, where a woman had been
acting aggressively and had been hearing voices
• Jerome Wakefield (1999, 2009), informative example of

this view is provided by Robert Sapolsky (2002), the
prominent neuroscientist who, during his studies,
Some religious behaviors may seem worked closely with the Masai people in East Africa. One
unusual to us but are culturally or day, Sapolsky’s Masai friend Rhoda asked him to bring
individually appropriate. his vehicle as quickly as possible to the Masai village,
where a woman had been acting aggressively and had
been hearing voices.
3. Finally, defining “normal” and “abnormal” is difficult (Lilienfeld &

Marino, 1995, 1999) and the debate rages on (McNally, 2011). The
DSM-5's most widely accepted definition describes behavioral,
psychological, or biological dysfunctions that are unexpected in their
cultural context and are linked to current distress and impairment
in functioning, as well as an increased risk of suffering, death,
pain, or impairment. If we pay close attention to what is functional or
dysfunctional (or out of control) in a given society, this definition can be
useful across cultures and subcultures.
B. The Science of Psychopathology

1. Psychopathology is the scientific study of psychological disorders.
Some Fields that are Specially Trained Professionals

Receive the Ph.D. degree (or sometimes an Ed.D., doctor of education, or
Psy.D., doctor of psychology) and follow a course of graduate-level study
Clinical lasting approximately 5 years, which prepares them to conduct research into
psychologists and the causes and treatment of psychological disorders and to diagnose, assess,
counseling and treat these disorders. Although there is a great deal of overlap, counseling
psychologists 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.
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
Psychiatrists
of view; make diagnoses; and offer treatments. Many psychiatrists emphasize
drugs or other biological treatments, although most use psychosocial
treatments as well.

Phone No.: (082)300-5456/305-0647 Local 118
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
Psychiatric social
concentrating on family problems associated with them. Psychiatric nurses
workers
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.
Marriage and
Typically spend 1–2 years earning a master’s degree and are employed to
Family Therapists
provide clinical services by hospitals or clinics, usually under the supervision of
and Mental Health
a doctoral-level clinician.
Counselors
2. The Scientist Practitioner – The mental health professionals that take

a scientific approach to their clinical work (Hayes, Barlow, & Nelson-
Gray, 1999).
Mental health practitioners may function as scientist-practitioners in one or more of three ways:
1. They may keep up with the latest scientific developments in their field and therefore use the most
current diagnostic and treatment procedures. In this sense, they are consumers of the science of
psychopathology to the advantage of their patients,
2. Scientist-practitioners evaluate their own assessments or treatment procedures to see whether they
work. They are accountable not only to their patients but also to the government agencies and
insurance companies that pay for the treatments, so they must demonstrate clearly that their treatments
work.
3. Scientist-practitioners might conduct research, often in clinics or hospitals, that produces new
information about disorders or their treatment, thus becoming immune to the fads that plague our
field, often at the expense of patients and their families. For example, new “miracle cures” for
psychological disorders that are reported several times a year in popular media would not be used by
a scientist-practitioner if there were no sound scientific data showing that they work.
3. Clinical Description - The term "presents" refers to a traditional

shorthand way of describing why someone came to the clinic. A clinical
description is a description of a specific disorder's unique combination
of behaviors, thoughts, and feelings. Clinical description refers to both
the types of problems or disorders that you'd find in a clinic or hospital,
as well as the assessment and treatment activities.
a. Prevalence – refers to the number of people in a population
who have the disorder. (How many people in the population as
a whole have the disorder?)
b. Incidence – refers to the statistics on how many new cases

occurring during a given period, such as a year, sex ratio (what
percentage of males and females have the disorder) and, age.
c. Course – refers to the pattern. (For example, some disorders,

such as schizophrenia, follow a chronic course, meaning that
they tend to last a long time, sometimes a lifetime.)

Phone No.: (082)300-5456/305-0647 Local 118
• Episodic Course – the individual is likely to recover

within a few months only to suffer a recurrence of the
disorder at a later time
• Time-Limit Course – the disorder will improve without
treatment in a relatively short period
• Acute Onset – the disorder begins suddenly
• Insidious Onset – develop gradually over an extended
period
d. Prognosis – “the prognosis is good” meaning the individual will

probably recover, or “the prognosis is guarded” meaning the
probable outcome doesn’t look good.
4. Causation, Treatment, and Etiology Outcomes

a. Etiology – the study of origins, has to do with why a disorder
begins (what causes it) and includes biological, psychological,
and social dimensions.
b. Treatment – The study of psychological disorders is frequently

important. If a new drug or psychosocial treatment is effective in
treating a disorder, it may provide information about the
disorder's nature and causes.
• The cause is not always implied by the effect. To give an
example, you might take aspirin to relieve a tension
headache that developed after a long day of exams. If
you feel better afterward, it is unlikely that the headache
was caused by a lack of aspirin. Despite this, many
people seek treatment for psychological disorders, and
Children experience panic and treatment can reveal useful information about the
anxiety differently from adults, so disorder's nature.
their reactions may be mistaken for
symptoms of physical illness.
• The In keeping with our integrative multidimensional
perspective, the latest and most effective drug and
psychosocial treatments (nonmedical treatments that
focus on psychological, social, and cultural factors) are
described in the context of specific disorders.
C. Historical Conceptions of Abnormal Behavior

1. For several decades, humans have tried to understand and explain how
to control problematic behaviors. With massive efforts, they accumulate
all their theories in three models. Moreover, these models might be the
driving forces behind human behavior and mental states. The following
models below will be further discussed in the next section.
• Supernatural Model
• Biological Model
• Psychological Model
II. THE SUPERNATURAL TRADITION

A. Demons and Witches

Phone No.: (082)300-5456/305-0647 Local 118
1. During the last quarter of the 14th century, religious and lay authorities
backed up popular beliefs in demons and witches. Society began to
believe more strongly in their existence and power. The Catholic
Church had split, and a rival center in the south of France, complete
with a pope, had emerged to compete with Rome. In response to the
schism, the Roman Church waged war against the evil in the world that
it believed was responsible for the heresy.
• People have started to use sorcery and magic to solve their
problems. Furthermore, strange behavior was attributed to
the devil and witches.
• People who were possessed by evil spirits were likely to

blame for any misfortune in the community, prompting harsh
measures against the possessed.
a. Exorcism, in which various religious rituals were
performed in an attempt to rid the victim of evil spirits,
was one of the treatments.
b. Other methods included shaving a cross pattern into

the victim's hair and securing victims to a wall near the
front of a church so that they could benefit from hearing
Mass.
B. Stress and Melancholy

1. Even during this period, a strong opinion reflected the enlightened view
that insanity was a natural phenomenon caused by mental or emotional
stress, and that it could be treated (Alexander & Selesnick, 1966).
2. Although symptoms like despair and lethargy were often associated

with the sin of acedia, or sloth, mental depression and anxiety were
recognized as illnesses (Kemp, 1990).
a. Common treatments were rest, sleep, and a healthy and
happy environment. Other treatments included baths,
ointments, and various potions.
3. In the 14th century, Nicholas Oresme, a bishop and philosopher who

served as one of the kings of France's chief advisors, suggested that
the disease of melancholy (depression) was the cause of some odd
behavior rather than demons. Some claimed that demonic powers were
the most common reasons for odd actions during the Middle Ages (e.g.,
Zilboorg & Henry, 1941), while others believed that the supernatural
had little or no effect. As we can see in the treatment of late-14th-
century King Charles VI of France's extreme psychological condition,
both influences were high, often alternating in the treatment of the same
event.
The Case of CHARLES VI: The Mad King

In the summer of 1392, King Charles VI of France was under a great deal of stress, partly
because of the division of the Catholic Church. As he rode with his army to the province of Brittany,
a nearby aide dropped his lance with a loud clatter and the king, thinking he was under attack, turned

Phone No.: (082)300-5456/305-0647 Local 118
on his own army, killing several prominent knights before being subdued from behind. The army
immediately marched back to Paris. The king’s lieutenants and advisers concluded that he was mad.
During the following years, at his worst the king hid in a corner of his castle believing he was
made of glass or roamed the corridors howling like a wolf. At other times he couldn’t remember who
or what he was. He became fearful and enraged whenever he saw his own royal coat of arms and
would try to destroy it if it was brought near him.
The people of Paris were devastated by their leader’s apparent madness. Some thought it
reflected God’s anger, because the king failed to take up arms to end the schism in the Catholic
Church; others thought it was God’s warning against taking up arms; and still others thought it was
divine punishment for heavy taxes (a conclusion some people might make today). But most thought
the king’s madness was caused by sorcery, a belief strengthened by a great drought that dried up
the ponds and rivers, causing cattle to die of thirst. Merchants claimed their worst losses in 20 years.
Naturally, the king was given the best care available at the time. The most famous healer in the
land was a 92-year-old physician whose treatment program included moving the king to one of his
residences in the country where the air was thought to be the cleanest in the land. The physician
prescribed rest, relaxation, and recreation. After some time, the king seemed to recover. The
physician recommended that the king not be burdened with the responsibilities of running the
kingdom, claiming that if he had few worries or irritations, his mind would gradually strengthen and
further improve.
Unfortunately, the physician died and the insanity of King Charles VI returned more seriously
than before. This time, however, he came under the influence of the conflicting crosscurrent of
supernatural causation. “An unkempt evil- eyed charlatan and pseudo-mystic named Arnaut
Guilhem was allowed to treat Charles on his claim of possessing a book given by God to Adam by
means of which man could overcome all affliction resulting from original sin” (Tuchman, 1978, p.
514). Guilhem insisted that the king’s malady was caused by sorcery, but his treatments failed to
bring about a cure.
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. “On one
occasion, two Augustinian friars, after getting no results from magic incantations and a liquid made
from powdered pearls, proposed to cut incisions in the king’s head. When this was not allowed by
the king’s council, the friars accused those who opposed their recommendation of sorcery”
(Tuchman, 1978, p. 514). Even the king himself, during his lucid moments, came to believe that the
source of madness was evil and sorcery. “In the name of Jesus Christ,” he cried, weeping in his
agony, “if there is any one of you who is an accomplice to this evil I suffer, I beg him to torture me
no longer but let me die!” (Tuchman, 1978, p. 515).
C. Treatments for Possession

1. Possession is not necessarily synonymous with sin; it can be
spontaneous, and the possessed person can be blameless.
Exorcisms, on the other hand, have the advantage of being relatively
painless. Surprisingly, they, like other kinds of faith healing, can often
work.
2. When exorcism failed in the Middle Ages, some rulers claimed that
extreme measures were needed to render the body uninhabitable to

Phone No.: (082)300-5456/305-0647 Local 118
evil spirits, and many people were subjected to imprisonment,

beatings, and other types of abuse (Kemp, 1990).
3. A creative “therapist” came up with the concept of hanging people

over a pit full of poisonous snakes to frighten the evil spirits out
of their bodies (to say nothing of terrifying the people themselves).
Surprisingly, this strategy sometimes worked; that is, the most
distressed, unusually acting people would spontaneously come to their
senses and experience temporary relief from their symptoms.
4. Many other treatments based on the hypothesized therapeutic

element of shock were developed, including dunking in ice-cold
water.
D. Mass Hysteria
1. In the Middle Ages, they were advocates of the devil's possession.
Throughout Europe, huge crowds of people were compelled to run out
into the streets, dance, scream, rave, and hop about in patterns as if
they were at a late-night festival (still called a rave today, but with
music). Saint Vitus' Dance and tarantism were two words used to
describe this activity.
2. Several explanations, in addition to possession, were given in an effort

to justify the inexplicable. One possible explanation is a reaction to
insect bites. Another explanation was mass hysteria, as we all know
it.
E. Modern Mass Hysteria

1. Mass hysteria can simply be an example of the phenomenon of
emotion contagion, in which one's emotional experience spreads to
those around them (Wang, 2006).
2. If anyone close to you becomes afraid or sad, it's possible that you will
experience fear or sorrow as well. When a scenario like these
transforms into a full-fledged panic attack, it affects whole populations
(Barlow, 2002).
3. As a consequence, if one person pinpoints a “cause” for the problem,

others are likely to attribute their own reactions to the same source. This
widespread reaction is often referred to as mob psychology in popular
culture.
F. The Moon and the Stars

1. Instead of believing in demon possession, Paracelsus, a Swiss
physician who lived from 1493 to 1541, claimed that the motions of the
moon and stars had significant effects on people's psychological
functioning. Paracelsus hypothesized that the gravitational influence
of the moon on bodily fluids may be a potential cause of mental illnesses

Phone No.: (082)300-5456/305-0647 Local 118
2. This popular theory gave rise to the term lunatic, which comes from the
Latin luna, which means "moon." Any of your friends may say, "It must
have been the full moon," while describing something insane they did
one night. While there is no scientific evidence to support it, the idea
that celestial bodies control human behavior continues (Raison, Klein,
& Steckler, 1999).
III. THE BIOLOGICAL TRADITION

A. Hippocrates and Galen
1. Hippocrates (460–377 B.C.) was a Greek physician who is credited
with founding modern Western medicine. He and his colleagues wrote
the Hippocratic Corpus, which was written between 450 and 350 B.C.
(Maher & Maher, 1985a) and proposed that psychological disorders
should be treated like any other illness.
2. They believed that psychological disorders might also be caused by

brain pathology or head trauma and could be influenced by heredity
(genetics).
3. The brain, according to Hippocrates, is the seat of wisdom,

consciousness, knowledge, and emotion. Hippocrates also
acknowledged the role of psychological and behavioral factors in
psychopathology, such as the sometimes-harmful effects of family
tension, and he isolated patients from their families on occasion.
4. Galen (circa 129–198), a Roman physician, later accepted Hippocrates'

and his associates' ideas and expanded them further, resulting in a
strong and influential school of thought within the biological tradition that
lasted well into the nineteenth century.
Four Humors: The Bodily Fluids

Came from the heart; sanguine (literal meaning “red, like blood”) describes
someone who is ruddy in complexion, presumably from copious blood flowing
Blood
through the body, and cheerful and optimistic, although insomnia and delirium were
thought to be caused by excessive blood in the brain.
Came from the spleen; Melancholic means depressive (depression was thought to
Black Bile
be caused by black bile flooding the brain).
Came from the liver; A choleric person (from yellow bile or choler) is hot tempered
Yellow Bile
(Maher & Maher, 1985a).
Came from the brain; A phlegmatic personality (from the humor phlegm) indicates
Phlegm
apathy and sluggishness but can also mean being calm under stress.
5. Physicians believed illness was caused by too much or too little of

one of the humors; for example, melancholia was thought to be
caused by too much black bile (depression).
6. Hippocrates also coined the expression "hysteria" to describe a

definition he learned from the Egyptians, who had described what are
now known as "somatic symptom disorders." Physical symptoms,

Phone No.: (082)300-5456/305-0647 Local 118
such as paralysis and certain cases of blindness, tend to be the result

of a medical condition for which no physical cause can be identified.
7. The location of the wandering uterus was reflected in a number of

physical symptoms. Marriage or, on rare occasions, vaginal
fumigation to entice the uterus back to its normal state, can be
recommended as a remedy (Alexander & Selesnick, 1966).
B. The 19th Century

1. The discovery of the essence and cause of syphilis, as well as strong
encouragement from the well-respected American psychiatrist John P.
Grey, re-energized the view of biological tradition in the nineteenth
century.
a. Syphilis is a sexually transmitted disease caused by a bacterial
microorganism entering the brain, induces bizarre actions such
as thinking that someone is conspiring against you (delusion of
persecution) or that you are God (delusion of grandeur).
b. Psychosis - Researchers found that a subgroup of seemingly

psychotic patients declined gradually, becoming paralyzed and
dying within 5 years of onset, leading to beliefs that were not
based in reality (delusions), illusions that were not based in
reality (hallucinations), or both.
c. Louis Pasteur’s germ theory of disease, developed in about

1870, facilitated the identification of the specific bacterial
microorganism that caused syphilis.
d. John P. Grey - Grey was elected superintendent of the Utica

State Hospital in New York, the country's oldest, in 1854. He
later became the editor of the American Journal of Insanity,
which was the forerunner of the new American Journal of
Psychiatry, the APA's flagship publication.
• Grey claimed that insanity was often caused by physical
factors. As a result, the mentally ill patient must be
treated as if he or she were physically ill. Rest, diet, and
adequate room temperature and ventilation were
stressed once more, as they had been for decades
• Hospitals changed significantly under Grey's

leadership, becoming more humane and livable
environments. However, over time, they became so big
and impersonal that individual attention was no longer
possible.
C. The Development of Biological Treatments

1. Electric shock and brain surgery were typical physical treatments in the
1930s. Their results, as well as those of new medicines, were
discovered by chance.

Phone No.: (082)300-5456/305-0647 Local 118
• Insulin, for example, was often offered to psychotic patients

who were not eating to stimulate appetite, but it often seemed
to calm them down.
• In 1927, Manfred Sakel, a Viennese physician, started using

higher and higher dosages until patients convulsed and were
temporarily comatose.
• The treatment was called insulin shock therapy, but it was

discontinued because it was too risky, often resulting in
prolonged coma or death.
2. A mild and modest electric shock to the head induced a brief

convulsion and memory loss (amnesia) but did little harm, as
Benjamin Franklin discovered accidentally and then verified
experimentally in the 1750s. Franklin's friend and colleague, a Dutch
physician, tried it on himself and found that the shock also left him
"strangely elated," leading him to wonder if it could be used as a cure
for depression (Finger & Zaromb, 2006, p. 245).
3. In the 1920s, Hungarian psychiatrist Joseph von Meduna

independently found that schizophrenia was unusual in epilepsy
patients (which ultimately did not prove to be true). Some of his
adherents came to the conclusion that triggered brain seizures could be
used to treat schizophrenia.
4. In 1938, a surgeon in London, Ugo Cerletti and Lucio Bini, treated a

depressed patient by sending six small shocks directly into his brain,
triggering convulsions (Hunt, 1980). The patient made a full recovery.
5. The first effective medications for serious psychotic disorders were

produced in a systematic fashion during the 1950s. A variety of
medicinal ingredients, including opium (derived from poppies), as
well as countless herbs and folk remedies, had been used as sedatives
prior to that time (Alexander & Selesnick, 1966).
• With the discovery of Rauwolfia serpentine (later called
reserpine) and another class of drugs known as neuroleptics
(major tranquilizers), hallucinatory and delusional thinking
patterns in certain patients may be minimized for the first time;
these drugs often regulated agitation and violence.
• By the 1970s, the benzodiazepines (brand names like Valium

and Librium) had become one of the most commonly
prescribed medications on the planet. Prescriptions declined
slightly as the risks and side effects of tranquilizers, as well as
their restricted efficacy, became more evident.
6. According to Alexander and Selesnick, “the general history of drug

treatment for mental illness has been one of initial excitement
followed by disappointment” over the ages (1966, p. 287).
Phone No.: (082)300-5456/305-0647 Local 118
D. Consequences of the Biological Tradition

1. Gray and his colleagues diminished or removed interest in treating
psychiatric patients in the late nineteenth century, despite the fact that
they claimed mental illnesses were caused by an as-yet-undiscovered
brain disease and therefore were incurable. The only choice was to
admit these patients to the hospital.
2. During this period, Emil Kraepelin (1856–1926) was the dominant

figure and one of the founding fathers of modern psychiatry. Kraepelin
(1913) was one of the first to identify the distinctions between various
psychological disorders, noting that each may have a different age
of onset and course, as well as slightly different clusters of
presenting symptoms and, most likely, a different cause.
3. The quest for biological causes had started by the end of the 1800s,
and a systematic approach to psychological disorders and their
classification had begun. Furthermore, the treatment was performed
in compliance with humane standards.
IV. THE PSYCHOLOGICAL TRADITION

• The most successful therapy was to reeducate the client through
rational discussion, enabling rationality to prevail (Maher & Maher,
1985a). This was a forerunner of contemporary psychosocial treatment
approaches to psychopathology causation, which incorporate not only
psychological causes but also social and cultural ones.
• These philosophers wrote about the importance of fantasies, dreams,

and cognitions, foreshadowing subsequent developments in
psychoanalysis and cognitive science to some degree. They also called
for humane and responsible treatment of people suffering from
mental disorders.
A. Moral Therapy
1. Rather than a code of ethics, the word moral applied to emotional or
psychological causes. Its basic tenets included treating
institutionalized patients as normally as possible in an
environment that facilitated and reinforced normal social contact
(Bockoven, 1963), enabling them to participate in a range of social and
interpersonal interactions.
2. When Pinel arrived in 1791, Pussin had already introduced major

changes, including the abolition of all restraining chains and the
introduction of humane and positive psychological treatments.
Pinel was convinced to embrace the changes by Pussin. Pinel deserves
praise for doing so, first at La Bicêtre and then at the Salpétrière
women's hospital, where he asked Pussin to join him (Gerard, 1997).
Again, they built a humane and socially conducive climate that
yielded "miracle" results.

Phone No.: (082)300-5456/305-0647 Local 118
3. In the 16th century, asylums first appeared, but they were more like jails
than hospitals. Asylums became habitable and even therapeutic with
the advent of moral therapy in Europe and the United States.
4. Horace Mann, chairman of the Worcester State Hospital's board of

trustees, published on 32 patients who had been declared incurable in
1833. Moral therapy was used to treat these patients, and they
were treated and returned to their families. Just 12 patients out of
100 who were viciously assaultive before care appeared to be
aggressive a year later. Before treatment, 40 patients regularly ripped
off any new clothes provided by attendants; after treatment, only 8
patients continued to do so. These were impressive figures back then,
and they are still remarkable today (Bockoven, 1963).
B. Asylum Reform and the Decline of Moral Therapy

1. Unfortunately, due to a convergence of causes, humane care started to
decline after the mid-nineteenth century.
a. For starters, moral therapy was generally accepted as
successful. Following the Civil War, large waves of refugees
entered the country, bringing with them their own communities
of mentally ill people. Since immigrant groups were thought
not to merit the same rights as “native” Americans (whose
ancestors had immigrated just 50 or 100 years ago!), they were
not given moral consideration even though hospital staff
were available.
b. Dorothea Dix (1802–1887), the great crusader, advocated

vigorously for improvement in the treatment of insanity. She had
intimate knowledge of the deplorable conditions placed on
patients with insanity as a schoolteacher who had served in
numerous institutions. The mental hygiene movement was
named after her work. Dix worked tirelessly not only to
increase the quality of care, but also to ensure that anyone who
needed it, including the homeless, received it.
c. The decision in the middle of the nineteenth century that mental

illness was caused by brain pathology and thus incurable
dealt a final blow to moral therapy.
d. In the twentieth century, they reappeared in a number of schools

of thought. Psychoanalysis, based on Sigmund Freud's (1856–
1939) elaborate theory of the nature of the mind and the role
of unconscious mechanisms in deciding actions, was the
first major approach. The second was behaviorism, which
focuses on how learning and adaptation influence the
development of psychopathology and is associated with John B.
Watson, Ivan Pavlov, and B. F. Skinner.
C. Psychoanalytic Theory

Phone No.: (082)300-5456/305-0647 Local 118
1. The issue, according to Franz Anton Mesmer (1734–1815), was caused

by an undetectable fluid present in all living organisms called "animal
magnetism," which could become blocked.
• Franklin came to the realization that animal magnetism, also
known as mesmerism, was nothing more than a powerful
suggestion (McNally, 1999). Mesmer is commonly regarded as
the founder of hypnosis, a condition in which highly suggestible
people tend to be in a trance at times.
2. Charcot, a respected neurologist, showed that certain mesmerism

methods were successful in treating a range of psychiatric conditions,
and he helped to legitimize the fledgling practice of hypnosis. In
1885, a young man named Sigmund Freud traveled to Paris to study
with Charcot.
3. Freud joined up with Josef Breuer (1842–1925) after returning from

France, who had been experimenting with a slightly different hypnotic
technique. Breuer asked his patients to explain their problems,
disputes, and fears in as much detail as possible while they were in the
highly suggestible state of hypnosis.
• First, patients were often emotional when they spoke, and
they felt relieved and strengthened after waking up from
hypnosis.
• Second, they would almost never have understood the

connection between their emotional issues and their
psychological disorder.
o Breuer and Freud had “discovered” the unconscious
mind and its apparent influence on the production of
psychological disorders. This is one of the most
important developments in the history of
psychopathology and, indeed, of psychology as a whole.
o A therapeutic for remembering and reliving traumatic

pain that has been rendered unconscious, as well as
releasing the tension that comes with it. Catharsis is the
term for the release of emotional content.
➢ Insight - A fuller understanding of the
relationship between current emotions and
earlier events.
• Psychoanalytic theory has had a strong impact, and it is still

important to be familiar with its basic concepts, even though
much of it is unproven; the following is a brief overview of the
theory. We concentrate on three main aspects of it:
o First, the structure of the mind and the distinct functions
of personality that sometimes clash with one another.
o Second, the defense mechanisms with which the mind

defends itself from these clashes, or conflicts.

Phone No.: (082)300-5456/305-0647 Local 118
o Third, the stages of early psychosexual development

that provide grist for the mill of our inner conflicts.
a. Structure of the Mind - The id, ego, and superego are the
three main sections or functions of the mind, according to
Freud. Freud created the mental constructs mentioned in this
section to understand unconscious processes based on these
and other observations. The id and superego, he claimed, are
almost entirely unconscious. Only the secondary workings of the
ego, which are a small part of the consciousness, are
completely conscious.
b. Defense Mechanism have been researched clinically, and

there is some evidence that they may be useful in
psychopathology studies (Vaillant, 2012).
• For example, Perry and Bond (2012) found a
correlation between psychological health and the
reduction of unadaptive defense mechanisms and
the strengthening of adaptive defense mechanisms
like humor and sublimation. As a consequence, the
idea of defensive mechanisms or, in today's terms,
coping styles remains key in the study of
psychopathology.
Examples of Defense Mechanisms are listed below (APA, 2000):
Refuses to acknowledge some aspect of objective reality or subjective

Denial
experience that is apparent to others.
Transfers a feeling about, or a response to, an object that causes discomfort
Displacement
onto another, usually less-threatening, object or person.
Falsely attributes own unacceptable feelings, impulses, or thoughts to another
Projection
individual or object.
Conceals the true motivations for actions,
Rationalization thoughts, or feelings through elaborate reassuring or self- serving but incorrect
explanations.
Substitutes behavior, thoughts, or feelings that are the direct opposite of
Reaction Formation
unacceptable ones.
Repression Blocks disturbing wishes, thoughts, or experiences from conscious awareness.
Directs potentially maladaptive feelings or impulses into socially acceptable
Sublimation
behavior.
c. Psychosexual Stages - Oral, anal, phallic, latency, and genital

phases all reflect distinct patterns of fulfilling our basic needs
and satisfying our need for physical pleasure.
• All nonpsychotic psychiatric problems, according to
Freud, were triggered by underlying unconscious
conflicts, the anxiety that arose from those conflicts,
and the use of ego defense mechanisms. Such diseases
were named neurosis, or neurotic disorders, by

Phone No.: (082)300-5456/305-0647 Local 118
Sigmund Freud, after an old word for nervous system

disorders.
D. Humanistic Theory
1. Jung and Adler, by contrast, emphasized the positive, optimistic side
of human nature. Jung talked about setting goals, looking toward the
future, and realizing one’s fullest potential. Adler believed that human
nature reaches its fullest potential when we contribute to the welfare of
other individuals and to society as a whole. He believed that we all
strive to reach superior levels of intellectual and moral
development.
a. Self-actualizing - The underlying idea is that if we were given
the opportunity to evolve, we might all achieve our full potential
in every aspect of our lives.
2. Abraham Maslow (1908–1970) was most systematic in describing the

structure of personality. He suggested a need hierarchy, starting with
our most basic physiological needs for food and sex and expanding
to our needs for self-actualization, affection, and self-esteem.
3. Carl Rogers (1902–1987) is, from the point of view of therapy, the most
influential humanist. Rogers (1961) was the first to create client-
centered therapy, which was later called person-centered therapy.
The goal of this approach is to encourage the client to improve during
therapy without being hindered by self-threats.
a. The humanistic approach needs unconditional positive
regard, or the full and almost unqualified approval of most of the
client's feelings and behavior.
E. The Behavioral Model

1. The Cognitive-Behavioral Model was the first step toward a more
empirical approach to psychological aspects of psychopathology.
a. Pavlov and Classical Conditioning - Ivan Petrovich Pavlov
(1849–1936), a Russian psychologist, pioneered the study of
classical conditioning, a method of learning in which a neutral
stimulus is combined with a response until that response is
elicited.
b. The Beginnings of Behavior Therapy - Joseph Wolpe (1915–

1997), became acquainted with the study of Pavlov and the
larger field of behavioral psychology. For treating his patients,
many of whom suffered from phobias, he invented a series of
therapeutic procedures. Systematic desensitization was his
most well-known method.
• In systematic desensitization people were gradually
exposed to the objects or circumstances they dreaded
in order to extinguish their fear; that is, they could test
reality and see that nothing unpleasant occurred in the
presence of the phobic object or scene, similar to the
care of little Peter.

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: psychological disorder, phobia, abnormal behavior, psychopathology, scientist-

practitioner, presenting problem, clinical description, prevalence, incidence, course,
prognosis, etiology, exorcism, psychosocial treatment, moral therapy, mental hygiene
movement, psychoanalysis, behaviorism, unconscious, catharsis, psychoanalytic model, id,
ego, superego, intrapsychic conflicts, defense mechanisms, psychosexual stages of
development, self-actualizing, person-centered therapy, unconditional positive regard,
behavioral model, systematic desensitization, reinforcement, shaping.
Self-Help: You can also refer to the sources below to help you further understand the
lesson:
1. Barlow, David H. & Durand, Mark V. (2015). Abnormal Psychology: An Integrative

Approach,7th Edition. Wadsworth: Cengage Learning
2. Bjork, D. W. (1993). B.F. Skinner: A life. New York: Basic.
3. Bolles, R. C. (1993). The story of psychology: A thematic history. Pacific Grove, CA:
Brooks/Cole.
4. Grob, G. (1994). The mad among us: A history of the care of America’s mentally ill.
New York: MacMillan.
5. Hatfield, A. B., & Lefley, H. P. (1993). Surviving mental illness. New York: Guilford.
6. Hunt, M. M. (1993). The story of psychology. New York: Doubleday.
7. Rosen, G. (1975). Madness in society: Chapters in the historical sociology of mental

illness. New York: Anchor Books.
8. Rosenhan, D. (1973). On being sane in insane places. Science, 179, p. 253.
9. Spanos, N. P. (1978). Witchcraft in the histories of psychiatry: A critical appraisal and

an alternative conceptualization. Psychological Bulletin, 35, 417–439.
10. Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15, 113–118.
11. Watson, R. I. (1991). The great psychologists: A history of psychological thought. (5th
ed.). Reading, MA: Addison Wesley Longman.
12. Weitz, R. D. (1992). A half century of psychological practice. Professional Psychology:

Research and Practice, 23, 448-452.

Phone No.: (082)300-5456/305-0647 Local 118
LESSON ONE: SUMMATIVE TEST

General Instructions: All the student must answer Let’s Check and Analyze Assessment
Tasks in LMS under Quiz section which will be posted from MONDAY to FRIDAY from 7:00AM
to 5:30PM. When you answer short-response items, please check your plagiarism and
grammar. If committed around 30% plagiarism, the paper will return to the student and
required to edit the quizzes and assignments. After editing, the paper will be submitted via
CF’s email address indicated in this module.
NOTE: Refer to PART 3: Course Schedules for all of the Summative Test deadlines.
Let’s Check
Now that the student knows the essential knowledge under lesson one, which is all about the
history of psychopathology. Let us try to check the student's understanding of these terms.
1. The criterion that a particular behavior be atypical or not culturally expected is

insufficient to define abnormality because
a. behavior that occurs infrequently is considered abnormal in every culture.
b. society is less willing to tolerate eccentricity in people who are productive.
c. behaviors vary very little from one culture to another.
d. many people behave in ways that deviate from the average, but this doesn't
mean that they have a disorder.
2. A male college student begins feeling sad and lonely. Although still able to go to
classes and work at his job, he finds himself feeling down much of the time and
worrying about what is happening to him. Which part of the definition of abnormality
applies to his situation?
a. Personal distress c. Impaired functioning
b. Cultural factors d. Violation of societal norms
3. A ___________ is what first brought the individual to therapy; the ____________

represents the unique combination of behaviors, thoughts, and feelings that make up
a specific disorder.
a. diagnosis; symptoms c. clinical description; presenting problem
b. incidence, prevalence d. presenting problem; clinical description
4. At various times in history, in an attempt to explain problematic, irrational behavior,

humans have focused on supernatural causes that include all of the following EXCEPT
a. magnetic fields. c. bodily humors.
b. demons and evil spirits. d. the moon and stars.
5. The belief of homophobic people that the "sin" of homosexuality has resulted in
HIV/AIDS is related to the historical concept of ______________ as a cause of
madness.
a. divine punishment c. hysteria
b. faith healing d. sorcery
6. The first significant supporting evidence for a biological cause of a mental disorder was
the 19th century discovery that the psychotic disorder called general paresis was
caused by the same bacterial microorganism that causes __________.

Phone No.: (082)300-5456/305-0647 Local 118
a. malaria c. syphilis
b. Alzheimer's disease d. hysteria
7. With the discovery of the major tranquilizers called _____________, psychotic

symptoms such as hallucinations, delusions, and aggressiveness were able to be
controlled.
a. neuroleptics c. bromides
b. benzodiazepines d. opiates
8. In contrast to the asylums of the early 18th century, the psychosocial approach called
moral therapy advocated all of the following EXCEPT
a. restraint and seclusion.
b. normal social interaction.
c. individual attention from the hospital staff.
d. nurturing interpersonal relationships.
9. Realizing that patients were often unaware of material previously recalled under
hypnosis, Charcot, Breuer, and Freud hypothesized the existence of ___________, a
concept considered one of the most important developments in the history of
psychopathology.
a. neurosis c. the Electra complex
b. the unconscious mind d. catharsis
10. You have just read a newspaper article about a savage rape and murder. You wonder
how someone could commit such a horrible crime. Then you recall from your study of
Freudian theory that according to Freud, anyone could be a killer or rapist if _________
impulses were not well controlled.
a. egoistic b. phallic c. id d. mesmeric
11. When Johnny wanted a cookie before dinner, he thought about just going and taking
one without permission. However, after thinking about it, he decided to get permission
from his mom. Johnny was operating according to the _______ principle.
a. pleasure b. reality c. moral d. Oedipal
12. The concept of defense mechanisms is referred to as ____________ in contemporary

terminology.
a. coping styles c. maladaptive thinking
b. strategic adjustment d. self-defeating actions
13. In their theories about human nature, psychoanalysts Carl Jung and Alfred Adler both
a. regarded human nature as possessing many negative qualities.
b. completely accepted Freud's ideas.
c. believed that there were no barriers to the internal and external growth of the
individual.
d. emphasized a strong drive toward individual self-actualization.
14. Which of the following is NOT associated with the humanistic theories of Carl Rogers?
a. Unconditional positive regard c. Empathy
b. Hierarchy of needs d. Person-centered therapy

Phone No.: (082)300-5456/305-0647 Local 118
15. The causes of psychopathology are currently assumed to be

a. unidimensional. c. impossible to determine.
b. multiply determined. d. untestable scientifically.
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson one is not enough; what
matters is that the student should also be able to explain some concepts. Now, the CF will
require the student to explain the answers thoroughly in the given problem.
1. Explain the inadequacies of the various perspectives, and explain why the concept of
a multidimensional integrative approach to psychopathology appears to be the more
logical approach. (10 Points)
2. Explain how the behavioral model developed and how it has influenced the
understanding and treatment of psychopathology. (10 points)
3. Describe psychoanalytic theory. Refer to concepts such as anxiety, defense

mechanisms, and psychosexual development. (10 points)
In a Nutshell
Activity 1. In this chapter, we learned about the history of psychopathology. In this section, I
want you to write down what you had learned or realized in this lesson. Provide at least 200
words.
Q&A List
In this section, students may raise their questions, concerns, and ideas regarding
lesson one. After being reviewed, questions related to the topics mentioned above will
discuss it in the LMS through Open Forum.
DO YOU HAVE ANY QUESTIONS FOR CLARIFICATIONS?
Questions/Issues Answers
1.
2.
3.
4.
5.
~End of Lesson One~

Phone No.: (082)300-5456/305-0647 Local 118
Big Picture in Focus: ULOb. Analyze the integrative approach to Psychopathology.
LESSON TWO
Metalanguage
This lesson outlines the primary components of a multidimensional model of

psychopathology. The multidimensional model considers genetic contributions, the
role of the nervous system, behavioral and cognitive processes, emotional influences,
cultural, social and interpersonal influences, and developmental factors in explaining
the causes of—and even the factors that maintain—psychological disorders. This
lesson describes these areas of influence as well as their interaction in producing
mental disorder.
• Multidimensional Models have been used to precisely analyze

psychopathological problems being observed in behavior and mental state. In
this model, looking in the perspective of biological influences, behavioral
influences, emotional and cognitive influences, and social influences as the
causes of why there are tendencies with human behaviors and cognitions.
• Genetic make-up of an individual was also seen as one contributor as to why

they are possible psychlogical problems occur. Genes are long molecules of
deoxyribonucleic acid (DNA) at various locations on chromosomes, within the
cell nucleus.
• Neurons are nerve cells that the brain uses to control every thought and action.
It means it is responsible for transmitting information throughout the nervous
system where all the commands happen.
• The biochemicals that are responsible for transmitting all that information that
are released from the axon of one neuron and transmit the impulse to the
dendrite receptors of another neuron are called neurotransmitters.
• Cognitive Science is another field in science that is concerned with how we

acquire and process information and how we store and ultimately retrieve it.
• Albert Bandura who is the proponent of the observational learning or model

took emphasis on how human being and animals get influence on the
environment they interact with. This discovery became significant for it was very
evident up until today.
• To define “emotion” is difficult, but most theorists agree that it is an action

tendency (Barlow, 2002); that is, a tendency to behave in a certain way (for
example, escape), elicited by an external event (a threat) and a feeling state
(terror) and accompanied by a (possibly) characteristic physiological response.

Phone No.: (082)300-5456/305-0647 Local 118
These terms will reflect on what, why, and how an individual can be considered
an abnormality, just deviancy, and just a normal behavior associating with his or her
behavior.
Essential Knowledge
I. ONE-DIMENSIONAL VERSUS MULTIDIMENSIONAL MODELS

A. What Caused Judy’s Phobia?
1. To say that psychopathology is caused by a physical abnormality or by
conditioning is to accept a linear or one-dimensional model, which
attempts to trace the origins of behavior to a single cause.
2. But in the case if Judy, we are looking of a multidimensional

integrative approach to psychopathological problems. Which means,
we look at different perspectives. Please, see figure below as an
example under the case of Judy.
II. GENETIC CONTRIBUTIONS TO PSYCHOPATHOLOGY

A. The Nature of Genes
1. We know that normal human cell composed of 46 chromosomes
arranged in 23 pairs. One chromosome comes from the mother and the
other one is from the father.
2. The first 22 pairs of chromosomes provide programs or directions for

the development of the body and brain, and the last pair is called sex
chromosomes which determines an individual’s sex.
3. The DNA molecules that contain genes have a certain structure, a

double helix. A double helix is two spirals intertwined, turning in
opposite directions.

Phone No.: (082)300-5456/305-0647 Local 118
a. Dominant Gene – one of a pair of genes that strongly influences

a particular trait, and we need only one of them to determine.
For example, our eye color or hair color.
b. Recessive Gene – must be paired with another (recessive)

gene to determine a trait, otherwise, it won’t have any effect.
c. Polygenic refers to the influences absorb by our genes from the

interaction we have towards the environment we belong with.
d. Human Genome on the other hand refers to an individual’s

complete set of genes which basically consists of more than
20,000 genes (U.S. Department of Energy Office of Science,
2009), polygenic interactions can be quite complex.
B. The Interaction of Genes and the Environment

1. Scientists have now identified, in a preliminary way, the genetic
contribution to psychological disorders and related behavioral
patterns. The best estimates attribute about half of our enduring
personality traits and cognitive abilities to genetic influence (Rutter,
2006).
2. For psychological disorders, the evidence indicates that genetic factors

make some contribution to all disorders but account for less than half of
the explanation. If one of a pair of identical twins has schizophrenia,
there is a less-than-50% likelihood that the other twin will also
(Gottesman, 1991). Similar or lower rates exist for other psychological
disorders (Rutter, 2006).
a. The Diathesis-Stress Model – this model emphasized that
individuals inherit tendencies to express certain traits or
behaviors, which may then be activated under conditions of
stress. See the figure below as your reference.
• Using this model in relation to the case of Judy, you can

say that Judy might inherited a tendency to fain at sight
of blood. This tendency is the diathesis or vulnerability.
• In short, the diathesis is genetically based and the

stress is environmental but that they must interact to
produce a disorder. Just like Judy attending in a biology
class where there is a dissection task and visibility of
blood.

Phone No.: (082)300-5456/305-0647 Local 118
b. The Gene-Environment Correlation Model – Several

psychologists have found the web of interrelationships between
genes and environment to be even more complex. Some
evidence now indicates that genetic endowment may increase
the probability that an individual will experience stressful life
events (Rutter, 2006, 2010).
• People with a genetic vulnerability to develop a certain
disorder such as blood-injection-injury phobia, may also
have a personality trait like for example, impulsiveness
which makes the person more likely involved in minor
accidents that would result in their seeing blood. In short,
they may be accident prone because they always on a
rush.
C. Epigenetics and the Nongenomic “inheritance” of Behavior

1. Thus, it is probably too simplistic to say the genetic contribution to a
personality trait or to a psychological disorder is approximately 50%.
We can talk of a heritable (genetic) contribution only in the context of
the individual’s past and present environment (Dickens et al., 2011).
2. But, as noted above in the example of genetic influences on cognitive

abilities (Turkheimer et al., 2003), extremely chaotic early
environments can override genetic factors and alter
neuroendocrine function to increase the likelihood of later
behavioral and emotional disorders (Dickens et al., 2011).
3. Thus, neither nature (genes) nor nurture (environmental events) alone,

but rather a complex interaction of the two, influences the development
of our behavior and personalities.
III. NEUROSCIENCE AND ITS CONTRIBUTIONS TO PSYCHOPATHOLOGY

A. The Central Nervous System
1. The CNS basically processes all information received from our sense
organs and reacts as necessary. It sorts out what is relevant, such as a
certain taste or a new sound, from what is not.
a. Neurons are brain nerve cell which is responsible for the control
of every thought and action.

Phone No.: (082)300-5456/305-0647 Local 118
b. Neurotransmitters refers to the biochemicals that are released

from the axon of one neuron and transmit the impulse to the
dendrite receptors of another neuron.
• Major neurotransmitters relevant to psychopathology
include norepinephrine (noradrenaline), serotonin,
dopamine, gamma-aminobutyric acid (GABA), and
glutamate.
• Excesses or insufficiencies in some neurotransmitters

are associated with different groups of psychological
disorders.
o For example, reduced levels of GABA were
initially thought to be associated with excessive
anxiety (Costa, 1985). High level of Dopamine
linked to the schizophrenia. High level on
Norepinephrine correlates to depression and,
possibly, low levels of serotonin (Siever, Davis,
& Gorman, 1991).
B. The Structure of the Brain
Some major subdivisions of the human cerebral cortex and a few of their primary functions. (Reprinted, with
permission, from Kalat, J. W. (2009). Biological Psychology, 10th edition, © 2009 Wadsworth.)
C. The Peripheral Nervous System

1. The PNS coordinates with the brain stem to make sure the body is
working properly.
a. Somatic Nervous System – the system that controls the
muscles, so damage in this area might make it difficult for us to
engage in any voluntary movement, including talking.

Phone No.: (082)300-5456/305-0647 Local 118
b. Autonomic Nervous System - It includes two subsystems, the

sympathetic nervous systems and parasympathetic nervous
system. The primary duties of ANS are to regulate the
cardiovascular system and the endocrine system and to perform
various other functions, including aiding digestion and regulating
body temperature.
2. Endocrine System – works differently in the body. Each endocrine

gland produces its own chemical messenger called hormone, and
releases it directly into the bloodstream.
a. Adrenal Gland produce epinephrine (also called adrenaline) in
response to stress, as well as salt-regulating hormones.
b. Thyroid Gland produces thyroxine, which facilitates energy

metabolism and growth.
c. Pituitary Gland is a master gland that produces a variety of

regulatory hormones.
d. Gonadal Gland produces sex hormones such estrogen and

testosterone.
e. The endocrine system is closely related to the immune system;

it is also implicated in a variety of disorders. In addition to
contributing to stress-related physical disorders, endocrine
regulation may play a role in depression, anxiety, schizophrenia,
and other disorders (McEwen, 2013).
• For example, some depressed patients may respond
better to an antidepressant medication if it is
administered in combination with a thyroid hormone
(Nierenberg et al., 2006), or for some older depressed

Phone No.: (082)300-5456/305-0647 Local 118
men coadministration of testosterone may enhance

antidepressant effects.
D. Neurotransmitters
1. The biochemical neurotransmitters in the brain and nervous system that
carry messages from one neuron to another continue to receive intense
attention from psychopathologists (Nestler, Hyman, & Malenka, 2008).
2. Neuroscientists have identified several neural pathways that seem to

play roles in various psychological disorders (Tau & Peterson, 2010).
• For example, abnormal activity of neurotransmitter serotonin is
often described as causing depression, and abnormalities in the
neurotransmitter dopamine have been implicated in
schizophrenia (Harmer et al., 2009).
• The substances called Agonist effectively increase the activity

of neurotransmitter by mimicking its effects. While substances
called Antagonist decreases or block a neurotransmitter. The
Inverse Agonist on the other hand produce effects opposite to
those produced by the neurotransmitter.
3. Glutamate and GABA – the two major neurotransmitters affect much

of what we do. Each substance is in the amino acid category of
neurotransmitters. These two is also known as “chemical brothers” as
it makes a balance functioning in the brain.
a. Glutamate is an excitatory transmitter that “turns on” many
different neurons, leading to action.
b. Gamma-aminobutyric acid (GABA) – is an inhibitory

neurotransmitter or regulate the transmission of information and
action potentials.
• GABA reduces postsynaptic activity, which, in turn,
inhibits a variety of behaviors and emotion. GABA was
discovered before glutamate and has been studied for a
longer period; its best-know effect is to reduce anxiety
(Sullivan & LeDoux, 2004).
• One example drug that makes it easier for GABA

molecules to attach themselves to the receptors of
specialized neurons is called Benzodiazepines. It
means, the higher benzodiazepine, the more GABA
becomes attached to neuron receptors and the calmer
we become.
• Drug compounds that increase GABA are also under

evaluation as treatments for insomnia (Sullivan, 2012).
• The GABA system seems to reduce levels of anger,

hostility, aggression, and perhaps even positive
emotional states, which makes the GABA a generalized

Phone No.: (082)300-5456/305-0647 Local 118
inhibiting neurotransmitter, much as glutamate has a

generalized excitatory function (Sharp, 2009).
4. Serotonin which has a technical name 5-hydroxytryptamine (5HTP). It

is in the monoamine category of neurotransmitters, along with
norepinephrine and dopamine.
• It was genetically influenced dysregulation in this system that
contributed to depression in the New Zealand study described
earlier Caspi et al., 2003).
• Extremely low activity levels of serotonin are associated with

less inhibition and with instability, impulsivity, and the tendency
to overreact to situation. It has been associated with
aggression, suicide, impulsive overeating, and excessive
sexual behavior (Berman, McCloskey, Fanning, Schumacher,
& Coccaro, 2009).
• It does not necessarily happen if serotonin activity is slow,

however. Therefore, low serotonin activity may make us more
vulnerable to certain problematic behavior without directly
causing it.
• SSRI (Selective-serotonin reuptake inhibitors) are used to

treat a number of psychological disorders, particularly anxiety,
mood, and eating disorders.
5. Norepinephrine is the third neurotransmitter in the monoamine class

important to psychopathology. This neurotransmitter stimulates at least
two groups of receptors, alpha-adrenergic and beta-adrenergic
receptors. One common drug is called Beta-blockers which keeps
blood pressure and heart rate down.
• Another circuit appears to influence the emergency reactions or
alarm responses (Sullivan & LeDoux, 2004) that occur when we
suddenly find ourselves in a dangerous situation, suggesting
that norepinephrine may bear some relationship to states of
panic (Gray & McNaughton, 1996).
6. 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 (Le Foll, Gallo, Le
Strat, Lu, & Gorwood, 2009).
• Dopamine have a more general effect which best described as

a switch that turns on various brain circuits possible associated
with certain types of behavior. Once the switch is turned on,
other neurotransmitters may then inhibit or facilitate emotions or
behavior (Armbruster et al., 2009).

Phone No.: (082)300-5456/305-0647 Local 118
• Dopamine circuits merge and cross with serotonin circuits at

many points and therefore influence many of the same behavior.
• For example, dopamine activity is associated with

exploratory, outgoing, pleasure-seeking behaviors and
serotonin is associated with inhibition and constraint; this, in a
sense they balance each other (Depue et al., 1994).
• 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 judgement.
E. Implications for Psychopathology

1. Psychological disorders typically mix emotional, behavioral, and
cognitive symptoms, so identifiable lesions (or damage) localized in
specific structures of the brain do not, for the most part, cause the
disorders.
• For example, genetic contributions might lead to patterns of
neurotransmitter activity that influence personality. Thus,
some impulsive risk takers may have low serotonergic activity
and high dopaminergic activity.
F. Psychosocial Influences on Brain Structure and Function

1. Psychopathologists are exploring the causes of psychopathology,
whether in the brain or in the environment, people are suffering and
require the best treatments we have.
2. Sometimes the effects of treatment tell us something about the nature

of psychopathology.
• For example, if clinician thinks OCD is caused by a specific brain
function or dysfunction or by learned anxiety to scary or
repulsive thoughts, this view would determine choice of
treatment.
3. Could psychological treatment be powerful enough to affect the circuit

directly? The answer seems to be yes. To take one of the first
examples, Lewis R. Baxter and his colleagues used brain imaging on
patients who had not been treated and then took an additional,
important scientific step (Baxter et al., 1992). They treated the patients
with a cognitive-behavioral therapy known to be effective in OCD
called exposure and response prevention (described more fully in
Chapter 5) and then repeated the brain imaging.
4. Placebos alone are not usually as effective as active medication, but

every time clinicians prescribe pills, they are also treating patient
psychologically by inducing positive expectation for change, and
this intervention changes brain function.
G. Interactions of Psychosocial Factors and Neurotransmitter Systems

Phone No.: (082)300-5456/305-0647 Local 118
1. In one classic experiment, Insel, Scanlan, Champoux, and Suomi

(1988) raised two groups of rhesus monkeys identically except for their
ability to control things in their cages.
• The Insel and colleagues’ experiment is an example of a
significant interaction between neurotransmitters and
psychosocial factors.
• Other experiments suggest that psychosocial influences directly

affect the functioning and perhaps even the structure of the
central nervous systems. Scientists have observed that
psychosocial factors routinely change the activity levels of
many of our neurotransmitter systems (Barik et al., 2013).
H. Psychosocial Effects on the Development of Brain Structure and

Function
1. It also seems that the structure of neurons themselves, including the
number of receptors on a cell, can be changed by learning and
experience during development (McEwen, 2013) and that these
effects on the central nervous system continue throughout our lives
(Suárez et al., 2009).
2. Early psychological experiences affect the development of the nervous

system and thus determines vulnerability to psychological
disorders later in life. It seems that the very structure of the nervous
system is constantly changing as a result of learning and
experience, even into old age, and that some of these changes
become permanent (Suárez et al., 2009).
IV. BEHAVIORAL AND COGNITIVE SCIENCE

A. Conditioning and Cognitive Processes
1. Robert Rescorla (1988) concluded that simply pairing two events
closely in time (such as the meat powder and the metronome in Ivan
Pavlov’s laboratories) is not what’s important in this type of learning; at
least, it is a simple summary. Rather, a variety of judgements and
cognitive processes combine to determine the final outcome of
this learning, even in lower animals such as rats.
2. In other words, complex cognitive processing of information, as well as

emotional processing, is involved when conditioning occurs, even in
animals.
B. Learned Helplessness
1. Basing to the experiment of Maier and Seligman, this occurs when rats
or other animals encounter conditions over which they have no
control (Maier & Seligman, 1976).
• If the animals learn their behavior has no effect on their
environment, sometimes they get shocked and sometimes they
don’t, no matter what they do, they become “helpless”; in other
words, they give up attempting to cope and seem to develop
the animal equivalent of depression.

Phone No.: (082)300-5456/305-0647 Local 118
• Seligman theorized that the same phenomenon may happen

with people who are faced with uncontrollable stress in their
lives. People make an attribution that they have no control, and
they become depressed (Miller & Norman, 1979).
2. Later, Seligman proposed a different attribution, which he called

Learned Optimism. In this, if people faced with considerable stress
and difficulty in their lives nevertheless display an optimistic, upbeat
attitude, they are likely to function better psychological and
physically (Seligman, 1998, 2002).
C. Social Learning
1. Albert Bandura (1973, 1986) discovered that individuals learn just as
much by observing what happens to someone else in a given situation.
And this was called later as modeling or observational learning.
2. The basic idea in all Bandura’s work is that a careful analysis of

cognitive processes may well produce the most accurate scientific
predictions of behavior. Concepts of probability learning, information
processing, and attention have become increasingly important in
psychopathology (Barlow, 2002).
D. Prepared Learning
1. According to this concept, 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 (Mineka, 1985).
2. When we know that certain situations or objects (snakes or spider) will

bring harm to an individual, we are more likely to learn fear and think of
ways to avoid such dangers. In the absence of experience, however,
we are less likely to fear guns or electrical outlets, even though they are
potentially deadlier.
E. Cognitive Science and the Unconscious

1. We are not aware of much goes on inside our heads, but our
unconscious is not necessarily the seething caldron of primitive
emotional conflicts envision by Freud. Rather, we simply seem able to
process and store information, and act on it, without having the
slightest awareness of what the information is or why we are
acting on it (Uleman, Saribay, & Gonzalez, 2008).
a. Blind sight or Unconscious Vision - Lawrence Weiskrantz
(1992) had relate this case on a young man who undergone a
surgery in a specific part on the cortex (the center for control of
vision) and then went blind. As part of routine test, surprisingly,
the young man was able to guess the test he was being asked
about and able to reached and touched the physician’s hand.
He was asking again if he can see or not, but the patient said
that he could not see a thing.

Phone No.: (082)300-5456/305-0647 Local 118
V. EMOTIONS
• As the first emotion theorist, Charles Darwin (1872), pointed out more
than 100 years ago, this kind of reaction seems to be programmed in
all animals, including humans, which activates during potentially life-
threatening emergencies called the Fight or Flight Reponses.
• The whole purpose of the physical rush of adrenaline that we feel in

extreme danger is to mobilize us to escape the danger (flight) or to fend
it off (fight).
A. The Physiology and Purpose of Fear

1. According to Walter Cannon (1929) speculated on the reasons how our
physiological aspect prepares to respond to stimuli from the
environment.
• Fear activates your cardiovascular system. Your blood
vessels constrict, thereby raising aerial pressure and
decreasing the blood flow to your extremities (fingers and toes).
• Excess blood is redirected to the skeletal muscles, where it

is available to the vital organs that may be needed in an
emergency.
• “White with Fear”, meaning, people turn pale as a result of

decreased blow to the skin.
• Breathing becomes faster and, usually, deeper to provide

necessary oxygen to rapidly circulating blood.
• Increased blood circulation carries oxygen to the brain,

stimulating cognitive processes and sensory functions, which
make you more alert and able to think more quickly during
emergencies.
B. Emotional Phenomena
1. Emotion is difficult to define, but most theorist agree that it is an action
tendency (Barlow, 2002); that is, a tendency to behave in a certain
way (e.g., escape), elicited by an external event (a threat) and a
feeling state (terror) and accompanied by a (possibly)
characteristic physiological response (Barrett, 2012).
2. Emotions are usually short-lived, temporary states lasting from several

minutes, hours, occurring in response to an external event. While Mood
in the other hand, is a more persistent period of affect or emotionality.
• Affect refers to the momentary emotional tone that
accompanies what we say or do. It can also be used more
generally to summarize commonalities among emotional states
characteristic of an individual.
C. The Components of Emotion

Phone No.: (082)300-5456/305-0647 Local 118
1. Emotion scientists now agree that emotion is composed of three related

components: Behavior, Physiology, and Cognition.
2. Emotion scientists who concentrate on behavior think that basic

patterns of emotion differ from one another in fundamental ways; for
example, anger may differ from sadness not only hot it feels but
also behaviorally and physiologically.
3. If a person looks scared, his or her facial expression will communicate

the possibility of danger to his or her friends, who may have been aware
that a threat is imminent.
• Your facial communication increases their chance for survival
because they can now respond more quickly to the threat when
it occurs. This may be one reason emotions are contagious just
like what we discussed in chapter 1 about mass hysteria (Wang,
2006).
4. In other research on neurobiological connections between emotional

centers of the brain and parts of the eye or the ear that allow emotional
activation without the influence of higher cognitive processes (LeDoux,
1996, 2002).
• In short, you may experience various emotions quickly and
directly without necessarily thinking about the, or being
aware of why you feel the way you do.
5. With the study of Richard S. Lazarus (1968, 1991, 1995), he proposed

that changes in a person’s environment are appraised in terms of their
potential impact on that person. In short, thinking and feeling cannot
be separated.
• But a lot of cognitive scientists opposed to this idea, although
cognitive and emotional systems interact and overlap, they are
fundamentally separate (Teasdale, 1993)

Phone No.: (082)300-5456/305-0647 Local 118
D. Anger and Your Heart

1. We have known for years that negative emotions such as hostility and
anger increase a person’s risk of developing heart disease (Chesney,
1986).
2. Sustained hostility with angry outburst and repeatedly and

continually suppressing anger contributes more strongly to death from
heart disease than other well-known risk factors, including smoking,
high blood pressure, and high cholesterol levels (Harburg, Kaciroti,
Gleiberman, Julius, & Schork, 2008).
3. Suarez et al. (2002) demonstrated how anger may cause this effect.
Inflammation produced by an overactive immune system in particularly
hostile individuals may contribute to clogged arteries (and decreased
heart-pumping efficiency).
• Interestingly, it seems that adopting a forgiving attitude can
neutralize the toxic effects of anger on cardiovascular activity.
E. Emotions and Psychopathology

1. We now know that suppressing almost any kind of emotional response,
such as anger or fear, increases sympathetic nervous system activity,
which may contribute to psychopathology (Fairholme et al., 2010).
2. Emotions and mood also affect our cognitive processes: if your mood
is positive, then your associations, interpretations, and
impressions also tend to be positive (Diener, Oishi, & Lucas, 2003).
3. Leading psychopathologists are beginning to outline the nature of

emotion disruption (dysregulation) and to understand how these
disruptions interfere with thinking and behavior in various psychological
disorders (Kring & Sloan, 2010).
VI. CULTURAL, SOCIAL, AND INTERPRESONAL FACTORS

A. Voodoo, the Evil Eye, and Other Fears
1. In several cultures, individuals may suffer from Fright Disorders, which
characterized by exaggerated startle responses, and other observable
fear and anxiety reactions.
a. Susto (in Latin American) – describes various anxiety-based
symptoms, including insomnia, irritability, phobias, and the
marked somatic symptoms of sweating and increased heart rate
(tachycardia).
• It has only one cause: the individual believes that he or
she has become the object of black magic, or witchcraft,
and is suddenly badly frightened.
b. Voodoo (in Haitian) – Cannon (1942) examined this

phenomenon of voodoo death, suggested that the sentence of
death by a medicine man may create an intolerable autonomic
arousal in the participant, who has little ability to cope because
there is no social support.

Phone No.: (082)300-5456/305-0647 Local 118
• From all accounts, an individual who is from physical and

psychological point of view functioning in a perfectly
healthy and adaptive way suddenly dies because of
marked changes in the social environment.
2. In some cultures, the sinister influence is called the evil eye (Tan,
1980), and the resulting fright disorder can be fatal.
3. Thus, cultural factors influence the form and content of

psychopathology and may differ even among cultures side by side in
the same country.
B. Gender
1. Gender roles have a strong and sometimes puzzling effect on
psychopathology (Kistner, 2009).
2. We think these substantial differences on gender have to do with

cultural expectations of men and women (gender roles).
• For example, an equal number of men and women may have an
experience that could lead to an insect or small-animal phobia,
such as being bitten to show or even admit fear. So, a man is
more likely to hide or endure the fear until he gets over it. It is
more acceptable for women to acknowledge fearfulness, so a
phobia develops. It is also more acceptable for a man to be shy
than to show fear, so he is more likely to admit social discomfort.
3. It even seems that men and women may respond differently to the same
standardized psychological treatment (Felmingham & Bryant, 2012).
4. The pressures for males to be thin are less apparent, and of the few
males who develop bulimia, a substantial percentage are gay; for these
individuals, cultural imperatives to be thin are present in many
specific instances (Rothblum, 2002).
5. Our gender does not cause psychopathology. But because gender

role is a social and cultural factor that influences the form and content
of disorder, we attend closely to it in the chapters that follow.
C. Social Effects on Health and Behavior

1. A lot of studies demonstrated how social relationships and contacts
affects to people (Miller, 2011). The lower you score on a social index
that measures the richness of your social life, the shorter your life
expectancy.
2. The risk of depression for people who live alone is approximately 80%
higher than for people who live with others, based on a count of new
prescriptions for anti-depressant medication (Pulkki-Raback et al.,
2012).

Phone No.: (082)300-5456/305-0647 Local 118
3. Social isolation increases the risk of death as much as smoking

cigarettes and more than physical inactivity or obesity (Holt-Lunstad,
Smith, & Layton, 2010).
• Interestingly, it is not just the absolute number of social contacts
that is important. It is the actual perception of loneliness.
Thus, some people can live along with few ill effects. Others
might feel lonely despite frequent social contacts (Cacioppo
& William, 2008).
4. Social and interpersonal factors seem to influence psychological and

neurobiological variables such as the immune systems (Cacioppo &
William, 2008).
5. Thus, we cannot study psychological and biological aspects of

psychological disorders (or physical disorders, for that matter) without
taking into account the social and cultural context.
D. Global Incidence of Psychological Disorders

1. Important surveys from the World Health Organization (WHO) reveal
that mental disorders account for 13% of the global burden of disease
(WHO, 2011).
2. Ten to twenty percent of all primary medical services in poor countries

are sought by patients with psychological disorders, principally anxiety
and mood disorders (including suicide attempts), as well as alcoholism,
drug abuse, and childhood developmental disorders (WHO, 2011)
3. These shocking statistics suggest that in addition to their role in

causation, social and cultural factors substantially maintain
disorders because most societies have not yet developed the social
context for alleviating and ultimately preventing them. Changing
societal attitudes is just one of the challenges facing us as the century
unfolds.
VII. LIFE-SPAN DEVELOPMENT

1. To understand psychopathology, we must appreciate how
experiences during different periods of development may
influence our vulnerability to other types of stress or to differing
psychology disorders (Charles & Carstensen, 2010).
a. The Principal of Equifinality – is used in developmental
psychopathology to indicate that we must consider a number of
paths to a given outcome (Cicchetti, 1991).
• For example, a delusional syndrome may be an aspect
of schizophrenia, but it can also arise from amphetamine
abuse.

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: multidimensional integrative approach, genes, diathesis-stress model,

vulnerability, gene-environment correlation model, epigenetics, neuroscience, neuron,
synaptic cleft, neurotransmitters, hormone, brain circuits, agonist, antagonist, inverse agonist,
reuptake, glutamate, gamma-aminobutyric acid (GABA), serotonin, norepinephrine,
dopamine, cognitive science, learned helplessness, modeling, prepared learning, emotion,
mood, affect, equifinality
lesson:

1. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
2. Beck, A. T., & Clark, D. A. (1988). Anxiety and depression: An information processing
perspective. Anxiety Research, 1, 23-36.
3. Blatt, S. J., & Lerner, H. (1991). Psychodynamic perspectives on personality theory. In

M. Hersen, A. E. Kazdin, & A. S. Bellack (Eds.) The clinical psychology
handbook (2nd ed.). New York: Pergamon, 147-169.
4. Damasio, A. R. (1995). Descartes’ error: Emotion, reason, and the human brain. New
York: Avon Books.
5. Ellis, A., & Harper, R. A. (1976). A guide to rational living. North Hollywood, CA:
Wilshire Book Company.
6. Gross, C. G. (1998). Brain, vision, memory: Tales in the history of neuroscience.

Cambridge: MIT Press.
7. Hundert, E. (1991). A synthetic approach to psychiatry’s nature-nurture debate.

Integrative Psychiatry, 7, 76-83.
8. Kihlstrom, J. F. (1987). The cognitive unconscious. Science, 237, 1445-1452.
9. Marshall, L. H., & Magoun, H. W. (Eds) (1998). Discoveries in the human brain:
Neuroscience prehistory, brain structure, and function. Totowa, NJ: Humana
Press.
10. Mineka, S., Davidson, M., Cook, M., & Keir, R. (1984). Observational conditioning of
snake fear in rhesus monkeys. Journal of Abnormal Psychology, 93, 355-372.
11. Ramachandran, V. S., & Blakeslee, S. (1998). Phantoms in the brain: Probing the
histories of the human mind. New York: William Morrow & Company.
12. Rosenhan, D. (1973). On being sane in insane places. Science, 179, p. 253

Phone No.: (082)300-5456/305-0647 Local 118
LESSON TWO: SUMMATIVE TEST

Let’s Check
Now that the student knows the essential knowledge under lesson two, which is all about the
integrative approach to psychopathology. Let us try to check the student's understanding of
these terms.
1. The best description of the multidimensional integrative approach to understanding

psychopathology is that it is based on
a. biological dimensions.
b. biological and psychological dimensions.
c. biological and psychological dimensions, as well as emotional influences.
d. biological and psychological dimensions, as well as emotional and
developmental influences.
2. Your uncle spent most of his teen years in a hospital undergoing treatment for a severe
physical illness. As an adult, he is rather shy and withdrawn, particularly around
women. He has been diagnosed with social phobia, which you believe is entirely due
to lack of socialization during his teen years. Your theory or model of what caused his
phobia is ________.
a. multidimensional c. one-dimensional
b. integrative d. biological
3. The most recent estimates are that genetics contribute approximately __________ to
the development of personality characteristics such as shyness or activity level.
a. 10-20% b. 30-50% c. 75-85% d. nothing
4. In the diathesis-stress model, "diathesis" refers to

a. an inherited disorder.
b. conditions in the environment that can trigger a disorder depending upon
how severe the stressors are.
c. an inherited tendency or condition that makes a person susceptible to
developing a disorder.
d. the inheritance of multiple disorders.
5. The idea that our inherited tendencies influence the probability that we will encounter
stressful life events is a characteristic of the _________________.
a. diathesis-stress model c. genetic model
b. reciprocal gene-environment model d. psycho-social model
6. The central nervous system is made up of the _______________.

Phone No.: (082)300-5456/305-0647 Local 118
a. brain and spinal cord c. spinal cord only

b. brain only d. nerves leading to and from the
brain
7. Neurotransmitters are important because they
a. allows neurons to send signals to other neurons.
b. maintains the oxygenation of the brain.
c. prevents the development of psychopathology.
d. allows the brain to maintain its structural integrity.
8. The chemicals that allow transmission of signals between neurons are called
________.
a. re-uptake inhibitors c. neurotransmitters
b. hormones d. genes
9. The part of the brain stem that regulates vital activities such as heartbeat, breathing,
and digestion is the __________.
a. cerebellum c. hindbrain
b. reticular activating system (RAS) d. thalamus
10. Drugs that decrease the activity of a neurotransmitter are called _____________.
a. agonists b. blockers c. reuptake inhibitors d. antagonists
11. The neurotransmitter associated with both schizophrenia and Parkinson's disease is
_________.
a. GABA b. norepinephrine c. dopamine d. serotonin
12. When one examines the current state of knowledge regarding genetics and life
experience effects on brain structure and function, the best overall conclusion is that
most psychological disorders are
a. the result of a complex interaction of genetics and faulty neurotransmitter
circuits.
b. the result of stressful early life experiences and the negative effects such
experiences have on brain structure or function.
c. the result of both biological and psychosocial factors.
d. beyond our current ability to understand in any meaningful way.
13. Candace believes that no matter how hard she studies; she will never succeed in
college. This behavior can best be explained by _______________.
a. personality disorder c. learned helplessness
b. faulty neurotransmitter circuits d. internal conflicts
14. According to Seligman, if a person who is faced with considerable stress and difficulty
in his/her life displays an optimistic, upbeat attitude, he/she is likely to function better
psychologically and physically. He called this ______________.
a. learned optimism c. learned awareness
b. learned helplessness d. learned predictability
15. The fact that women are more likely to suffer from insect phobias than men is most
likely due to
a. biological differences. c. cultural expectations.
b. differences in neurochemical pathways. d. genetic influences.

Phone No.: (082)300-5456/305-0647 Local 118
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson two is not enough; what
1. What are the basic components of the multidimensional integrative model, and what
does the term integrative mean in this model? (10 Points)
2. Name three important neurotransmitters and describe what impact each one is thought
to have on human experience. (10 points)
3. Explain the principle of equifinality and its use in developmental psychopathology. (10
points)
In a Nutshell
Activity 1. In this lesson, we learned about the integrative approach to psychopathology. In

this section, I want you to write down what you had learned or realized in this lesson. Provide
at least 300 words.
Q&A List
lesson two. After being reviewed, questions related to the topics mentioned above will
1.
2.
3.
4.
5.
~End of Lesson Two~

Phone No.: (082)300-5456/305-0647 Local 118
Big Picture in Focus: ULOc. Discover the methods on Clinical Assessment and
Diagnosis.
LESSON THREE
Metalanguage
This lesson outlines the procedures for clinical evaluation and diagnosis the
analysis of psychopathology needs both realms. Clinical assessment is the process of
systematically evaluating and measuring psychological, biological, and social
factors in people with mental conditions in order to obtain idiographic data that can
aid in care planning. Diagnosis is the method of deciding whether a distressing
condition meets the requirements for a psychiatric illness. This lesson covers
assessment techniques (clinical interviewing, behavioral assessment, physical
examination, psychological and neuropsychological testing, neuroimaging
procedures, and psychophysiological assessment), psychometric issues related
to assessment and diagnosis (reliability, validity, and standardization), the DSM
system's nature and history, and issues surrounding diagnosis and classification (e.g.,
categorical, dimensional, and prototypic approaches).
• Clinical Assessment is the systematic assessment and calculation of

psychological, biological, and social factors in a person who may be suffering
from a mental illness.
• Diagnosis is the method of deciding if certain factors satisfy any of the criteria
for a particular psychological disorder.
• When evaluating psychological disorders, always consider the reliability

(consistency), validity (accuracy), and standardization (norming) of the
evaluation.
• Clinicians can first interview and take an informal mental status exam of the
patient to determine different aspects of psychological disorders. Behavioral
Assessment refers to more formal observations of behavior.
• During an evaluation, a number of psychological assessments can be used,

such as projective tests, in which the patient responds to unclear stimuli by
projecting unconscious thoughts; personality inventories, in which the patient
fills out a self-report questionnaire to determine personal traits; and
intelligence testing, which yields an intelligence quotient score (IQ).
• Neuropsychological tests designed to classify potential areas of brain

dysfunction may be used to determine biological aspects of psychological
disorders. Neuroimaging may be used to determine brain structure and
function more explicitly. Finally, psychophysiological assessment refers to

Phone No.: (082)300-5456/305-0647 Local 118
observable changes in the nervous system that indicate emotional or

psychological experiences that may be related to a mental illness.
• The term classification refers to any attempt to create classes or categories

and assign objects or individuals to them based on common characteristics or
relationships. Classic categorical, dimensional, and prototypical
approaches are examples of classification methods. The Diagnostic and
Statistical Manual, Fifth Edition (DSM-5) is our latest classification scheme,
and it is based on a prototypical approach in which some basic characteristics
are defined, but “non-essential” variations do not necessarily affect the
classification.
These terms will reflect on what are the processes of making a clinical
assessment and how significant each corner to come up or draw conclusions on its
diagnosis.
Essential Knowledge
I. ASSESSING PSYCHOLOGICAL DISORDERS

The process of clinical assessment and diagnosis are central to the study of
psychological disorders.
1. Clinical Assessment – refers to the systematic assessment and
measurement of psychological, biological, and social factors in a person
who may be suffering from a mental illness
2. Diagnosis – refers to the method of deciding whether a person's

current problem meets all of the criteria for a psychological disorder
as described by the DSM-5 (which will be discuss in the last part of this
lesson). Let's look at a recent case study in which a patient and a
therapist conduct an interview:
THE CASE OF FRANK: Young, Serious, and Anxious

Frank was referred to one of our clinics for evaluation and possible treatment of severe distress and
anxiety centering on his marriage. He arrived neatly dressed in his work clothes (he was a mechanic).
He reported that he was 24 years old and that this was the first time he had ever seen a mental health
professional. He wasn’t sure that he needed (or wanted) to be there, but he felt he was beginning to
“come apart” because of his marital difficulties. He figured that it certainly wouldn’t hurt to come once to
see whether we could help. What follows is a transcript of parts of this first interview.
Therapist: What sorts of problems have been troubling you during the past month?
Frank: I’m beginning to have a lot of marital problems. I was married about 9 months ago, but I’ve been
really tense around the house and we’ve been having a lot of arguments.
Therapist: Is this something recent?
Frank: Well, it wasn’t too bad at first, but it’s been worse lately. I’ve also been really uptight in my job,
and I haven’t been getting my work done.
Note that we always begin by asking the patient to describe for us, in a relatively open-ended way,
the major difficulties that brought him or her to the office. When dealing with adults, or children old enough
(or verbal enough) to tell us their story, this strategy tends to break the ice. It also allows us to relate
details of the patient’s life revealed later in the interview to the central problems as seen through the
patient’s eyes.

Phone No.: (082)300-5456/305-0647 Local 118
After Frank described this major problem in some detail, we asked him about his marriage, his job,
and other current life circumstances. Frank reported that he had worked steadily in an auto body repair
shop for the past 4 years and that, 9 months previously, he had married a 17-year-old woman. After
getting a better picture of his current situation, we returned to his feelings of distress and anxiety.
Therapist: When you feel uptight at work, is it the same kind of feeling you have at home?
Frank: Pretty much; I just can’t seem to concentrate, and lots of times I lose track of what my wife’s
saying to me, which makes her mad and then we’ll have a big fight.
Therapist: Are you thinking about something when you lose your concentration, such as your work, or
maybe other things?
Frank: Oh, I don’t know; I guess I just worry a lot.
Therapist: What do you find yourself worrying about most of the time?
Frank: Well, I worry about getting fired and then not being able to support my family. A lot of the time I
feel like I’m going to catch something—you know, get sick and not be able to work. Basically, I guess I’m
afraid of getting sick and then failing at my job and in my marriage, and having my parents and her
parents both telling me what an ass I was for getting married in the first place.
During the first 10 minutes or so of the interview, Frank seemed to be quite tense and anxious and
would often look down at the floor while he talked, glancing up only occasionally to make eye contact.
Sometimes his right leg would twitch a bit. Although it was not easy to see at first because he was looking
down, Frank was also closing his eyes tightly for a period of 2 to 3 seconds. It was during these periods
when his eyes were closed that his right leg would twitch.
The interview proceeded for the next half hour, exploring marital and job issues. It became
increasingly clear that Frank was feeling inadequate and anxious about handling situations in his life. By
this time, he was talking freely and looking up a little more at the therapist, but he was continuing to close
his eyes and twitch his right leg slightly.
Therapist: Are you aware that once in a while you’re closing your eyes while you’re telling me this?
Frank: I’m not aware all the time, but I know I do it.
Therapist: Do you know how long you’ve been doing that?
Frank: Oh, I don’t know, maybe a year or two.
Therapist: Are you thinking about anything when you close your eyes?
Frank: Well, actually I’m trying not to think about something.
Therapist: What do you mean?
Frank: Well, I have these really frightening and stupid thoughts, and. . .it’s hard to even talk about it.
Therapist: The thoughts are frightening?
Frank: Yes, I keep thinking I’m going to take a fit, and I’m just trying to get that out of my mind.
Therapist: Could you tell me more about this fit?
Frank: Well, you know, it’s those terrible things where people fall down and they froth at the mouth, and
their tongues come out, and they shake all over. You know, seizures. I think they call it epilepsy.
Therapist: And you’re trying to get these thoughts out of your mind?
Frank: Oh, I do everything possible to get those thoughts out of my mind as quickly as I can.
Therapist: I’ve noticed you moving your leg when you close your eyes. Is that part of it?
Frank: Yes, I’ve noticed if I really jerk my leg and pray real hard for a little while the thought will go away.
(Excerpt from Nelson, R. O., & Barlow, D. H., 1981. Behavioral assessment: Basic strategies and initial
procedures. In D. H. Barlow, Ed., Behavioral assessment of adult disorders. New York: Guilford Press.)
What is wrong with Frank?

• The first interview shows an inexperienced young man who is under a lot of stress,
questioning his ability to handle marriage and a career.
• He claims that he adores his wife and wants their marriage to succeed, and that he is
attempting to be as attentive as possible at work, a role that provides him with a great
deal of fulfillment and enjoyment.
Phone No.: (082)300-5456/305-0647 Local 118
A. Key Concepts in Assessment

1. The process of clinical assessment in psychopathology has been
likened to a funnel (Hunsley & Mash, 2010).
• The clinician starts by gathering a large amount of data from the
client through a wide variety of functions in order to pinpoint the
root of the issue.
• After having a general understanding of the person's overall

functioning, the clinician narrows the emphasis by ruling out
issues in certain areas and focusing on the areas that seem to
be the most important.
2. We need to consider the three fundamental principles that help us

evaluate the importance of our tests in order to understand how
clinicians assess psychological problems: reliability, validity, and
standardization (Ayearst & Bagby, 2010)
B. The Clinical Interview

1. Psychologists, psychiatrists, and other mental health practitioners use
this as the foundation for any clinical practice.
2. The interview collects data on current and past actions, behaviors,

and feelings, as well as a detailed history of the individual's life in
general and the issue at hand.
3. To organize information obtained during an interview, many clinicians

use a mental status exam.
a. Mental Status Exam – challenge for clinicians is to arrange
their evaluations of other individuals in such a way that they can
decide whether or not a psychological illness is present (Nelson
& Barlow, 1981).
• While mental status examinations can be structured
and comprehensive (Wing, Cooper, & Sartorius, 1974),
they are usually conducted quickly by trained
practitioners when interviewing or examining a patient.
The exam is divided into five parts (see Figure 3.2).
b. Semi structured Clinical Interviews – these are questions that

have been carefully phrased and checked to extract relevant
knowledge in a consistent way, allowing clinicians to be certain
that they have inquired about the most important aspects of
specific disorders (Summerfeldt, Kloosterman, & Antony, 2010).
• Advantage – because the wording and timing of
questions have been fine-tuned for several years, the
clinician may be assured that a semi structured interview
can achieve its goal.
• Disadvantage – it takes away some of the spontaneity

of two people communicating about a problem; if used
rigidly, a semi structured interview will prevent the

Phone No.: (082)300-5456/305-0647 Local 118
patient from providing valuable information that isn't

directly related to the questions being asked.
C. Physical Examination
1. Patients with complications should first see a family physician for a
physical examination. A clinician may suggest a physical exam if the
patient presenting with psychological problems has not had one in the
previous year, with special consideration to the medical conditions
that are often associated with the specific psychological problem.
2. On careful physical inspection, several conditions posing as behavioral,

cognitive, or mood issues can have a direct link to a temporary toxic
state.
• This toxic state could be caused by bad food, the wrong
amount or type of medicine or onset of a medical condition.
• For example, thyroid difficulties, particularly hyperthyroidism

(overactive thyroid gland). May produce symptoms that mimic
certain anxiety disorders, such as generalized anxiety
disorder.
3. Psychologist and other mental health practitioners are well-versed in

the medical conditions, as well as the use and misuse of medications,
that may lead to the patient's problems.
D. Behavioral Assessment
1. Aside from the mental status test, behavioral evaluation goes a step
further by formally assessing an individual's emotions, feelings, and
actions in particular circumstances or contexts by direct observation.
2. Target patterns are described and observed in behavioral assessment

with the aim of identifying the factors that seem to affect them.

Phone No.: (082)300-5456/305-0647 Local 118
a. The ABCs of Observation – observational evaluation is often

concerned with the present moment. The clinician's focus is
generally on the immediate action, its antecedents (what
happened before the behavior), and its implications (what
happened after the behavior) (Haynes et al., 2009).
• In the case of the violent boy, an observer would note
that (1) his mother asked him to put his glass in the sink
(antecedent), (2) the boy threw the glass (behavior),
and (3) his mother's lack of response is the sequence of
events (consequences).
• This antecedent-behavior-consequence (ABC)

sequence could indicate that the boy was being
rewarded for his aggressive outburst while avoiding
having to clean up after himself. And since he received
no negative repercussions for his actions (his mother did
not scold or reprimand him), he would most likely
retaliate aggressively the next time he is unable to
complete a task.
b. Self-Monitoring – people can also observe their own behavior

to find patterns, a technique known as self-monitoring or self-
observation (Haynes, O’Brien, & Kaholokula, 2011).
• The aim is to make it easier for clients to keep track of
their actions. Self-monitoring is important when habits
occur only in private (such as purging by people with
bulimia).
• Behavior Rating Scales – A BRS is a standardized and

systematic method of observing behavior using a
checklist. This is used as a pre-treatment screening
method and then again during treatment to measure
changes in the person's actions (Myers & Collett, 2006).
• Reactivity is a phenomenon that can cause

observational data to be skewed. When you observe
how people behave, just being present with them will
cause them to change their actions (Haynes et al.,
2011).
E. Psychological Testing
1. Tests used to diagnose psychological problems, on the other hand,
must follow the high expectations we have listed. They must be
trustworthy, in the sense that two or more people conducting the same
test to the same person would reach the same conclusion about the
issue, and they must be valid, in the sense that they measure what they
claim to measure (Hunsley & Mash, 2011).
2. Psychological tests provide both specialized methods for determining

cognitive, emotional, or behavioral responses that may be linked to

Phone No.: (082)300-5456/305-0647 Local 118
a specific condition and more general tools for assessing long-standing

personality traits including a suspicion bias.
a. Projective Tests – the theory behind this test is that people
transfer their own personality and implicit fears onto other
people and objects, in this case, vague stimuli and expose their
unconscious thoughts to the therapist without understanding it.
• The Rorschach inkblot test, the Thematic
Apperception Test, and the sentence-completion
process are some examples of projective tests.
b. Personality Inventories – What is required from these types of

tests, according to Meehl (1945), is not whether the questions
make sense on the surface, but rather what the answers to
these questions expect.
• The Minnesota Multiphasic Personality Inventory
(MMPI), which was created in the late 1930s and early
1940s and first published in 1943, is the most commonly
used personality inventory in the United States
(Hathaway & McKinley, 1943).
c. Intelligence Testing – Intelligence tests were developed for

one specific purpose: to predict who do well in school.
• In 1904, the French government commissioned Alfred
Binet and his colleague Théodore Simon to create a
test that would classify "slow learners" who would
benefit from remedial assistance.
• The test resulted in an intelligence quotient, or IQ, score.

IQ scores were originally determined based on a child's
mental age. A kid who passed all questions on the 7-
year-old level but none on the 8-year-old level, for
example, was given a mental age of 7. The IQ score was
calculated by dividing the child's mental age by his
physical age and multiplying by 100.
• Some recent scholars claim that intelligence

encompasses more than just the ability to adapt to the
environment, the ability to generate new ideas, and
the ability to efficiently process knowledge
(Gottfredson & Saklofske, 2009).
F. Neuropsychological Testing
1. Sophisticated tests now exist that can detect the location of brain
dysfunction. Fortunately, these methods are widely accessible and
relatively inexpensive, and technical advancements in virtual
teleconferencing have led to attempts to perform such tests for people
in remote areas (Lezak, Howieson, Bigler, & Tranel, 2012).
2. Neuropsychological Tests assess skills in areas such as receptive

and expressive language, concentration, listening, and abstraction,

Phone No.: (082)300-5456/305-0647 Local 118
allowing clinicians to make informed guesses regarding a person's

success and the presence of brain disability.
3. This method of research evaluates brain impairment by analyzing how

it affects a person's ability to perform specific tasks.
a. The Bender Visual–Motor Gestalt Test is a relatively simple
neuropsychological test that is often used with children
(Brannigan & Decker, 2006).
b. The Luria-Nebraska Neuropsychological Battery and the

Halstead-Reitan Neuropsychological Battery are two of the
most common advanced tests for organic (brain) damage that
allow for more accurate determinations of the problem's position
(Reitan & Davison, 1974)
G. Neuroimaging: Pictures of the Brain

1. Using a method known as neuroimaging, we have recently acquired the
ability to look through the nervous system and take increasingly precise
pictures of the structure and function of the brain (Adinoff & Stein,
2011).
a. Images of Brain Structure
• X-ray Exposure – first neuroimaging technique
developed in the early 1970s.
• Computerized Axial Tomography (CAT) – a computer

then reconstructs pictures of various slices of the brain.
• Magnetic Resonance Imaging – another method of

scanning the patient's head is put in a high-intensity
magnetic field, which transmits radio frequency signals.
The signal is lighter or darker where there are lesions or
damage (Adinoff & Stein, 2011).
b. Images of Brain Structure

• Positron Emission Tomography (PET) - In a PET
scan, a tracer material containing radioactive isotopes,
or groups of atoms that behave differently, is injected
into the subject. This material reacts to blood, oxygen,
or glucose in some way (Adinoff & Stein, 2011).
• Single Photon Emission Computed Tomography

(SPECT) - This method is similar to PET, but it uses a
different tracer material and is less precise. It is,
however, less costly and necessitates much less
advanced equipment to detect the signals (Adinoff &
Stein, 2011).
• Functional MRI (fMRI) - In the leading brain-imaging

centers, fMRI procedures have increasingly replaced
PET scans because they enable researchers to see the

Phone No.: (082)300-5456/305-0647 Local 118
brain's immediate reaction to a brief occurrence, such as

seeing a new face.
o The most popular fMRI technique used to
research psychological disorders is BOLD-
fMRI (Blood-Oxygen-Level-Dependent
fMRI) (Adinoff & Stein, 2011).
2. Neuroimaging can be divided into two categories:

• Procedures that analyze the anatomy of the brain, such as the
size of different parts and whether there is any damage, fall into
this category.
• The second group includes procedures that map blood flow and
other metabolic activity to investigate the brain's actual
functioning.
H. Psychophysiological Assessment
1. Measurable changes in the nervous system that reflect emotional or
psychological events are included in this assessment. The
measurements can be taken directly from the brain or from other parts
of the body in a peripheral manner.
a. Electroencephalogram (EEG) – another method for
measuring electrical activity in the head related to the firing
of a particular group of neurons reveals brain wave activity;
brain waves are generated by a low-voltage electrical current
running through the neurons.
• Event-Related Potential (ERP) or evoked potential –
this is when a brief cycle of EEG patterns is registered in
response to particular events, such as hearing a
psychologically significant stimulus.
• The waking behaviors of an average, stable, comfortable

adult are distinguished by a daily pattern of voltage
changes known as Alpha Waves.

Phone No.: (082)300-5456/305-0647 Local 118
• EEG recordings show a pattern of Delta Waves during

the deepest, most comfortable period, which occurs 1 to
2 hours after a person falls asleep.
b. Electrodermal Responding/Galvanic Skin Response (GSR)

– this measure of sweat gland activity regulated by the
peripheral nervous system.
c. Direct measurement of penile circumference in males or

vaginal blood flow in females in response to erotic stimuli,
typically movies or slides, may be used to determine sexual
arousal.
d. Biofeedback is a technique in which the patient's physiological

responses, such as blood pressure readings, are measured and
fed back to him (on a continuous basis) by meters or gauges so
that he can attempt to control them (Ovsiew, 2005).
II. DIAGNOSING PSYCHOLOGICAL DISORDERS

• The clinician can form general conclusions and establish a prognosis
which refers to the likely future course of a disorder under certain
conditions.
a. Idiographic Strategy – we use this strategy to figure out what
is special about a person's personality, cultural context, or
circumstances (Barlow & Nock, 2009).
b. Nomothetic Strategy – in order to take advantage of the

knowledge already gathered on a specific issue or disorder, we
must be able to identify a general class of problems to which the
presenting problem belongs; in other words, this strategy aims
to label or define the problem (Barlow & Nock, 2009).
• Classification – any attempt to create classes or
categories and assign items or individuals to these
nomothetic strategies is referred to as classification
(Widiger & Crego, 2013).
• Taxonomy – this refers to the scientific classification of

the context, which usually refers to the classification of
entities for scientific purposes, such as insects, rocks, or
behaviors whether the topic is psychology (Widiger &
Crego, 2013).
• Nosology - this term refers to the application of a

taxonomic scheme to psychological or medical
phenomena or other therapeutic fields (Widiger & Crego,
2013).

Phone No.: (082)300-5456/305-0647 Local 118
• Nomenclature – the names or marks given to the

diseases that make up the nosology (for example,
anxiety or mood disorders) (Widiger & Crego, 2013).
A. Classification Issues
1. Any science relies on classification, and much of what we've said so far
is common sense.
2. Concepts of "normal" and "abnormal" are disputed in

psychopathology, as is the belief that a behavior or cognition is part of
one disorder but not another.
a. Categorical and Dimensional Approaches – How do we
characterize human actions in various ways to avoid reinventing
the wheel every time we see a new collection of problem
behaviors and to find general concepts of psychopathology?
• Traditional (or pure) the Categorical Approach – to
classification is based on Emil Kraepelin’s (1856-1926)
work and the biological tradition of psychopathology
research.
o We believe that any diagnosis has a specific
underlying pathophysiological cause, such as a
bacterial infection or a malfunctioning endocrine
system, and that each disorder is distinct in this
method.
o When it comes to the complexities of psychiatric

problems, the traditional categorical approach is
simply inadequate (Widiger & Edmundson,
2011).
• Dimensional Approach – in this approach, we take

note of the patient's various cognitions, moods, and
behaviors and rate them on a scale.
o While dimensional methods have been used in
the past to study psychopathology, especially
personality disorders, they have proven to be
unsatisfactory (Widiger & Edmundson, 2011).
b. Prototypical Approach – defines certain important features of

an individual so that you (and others) can identify it, but it also
allows for certain non-essential variations that do not affect the
classification.
• If anyone asked you to describe a dog, you might easily
provide a general description (essential, categorical
characteristics), but you would not be able to precisely
describe a particular dog. Dogs come in a variety of
colors, sizes, and even species (the non-essential,
dimensional differences), but they all have some
doggish traits that distinguish them from cats.

Phone No.: (082)300-5456/305-0647 Local 118
c. Reliability - While clinician bias is always a possibility, the more

accurate the nosology, or classification method, the less likely it
is that bias will creep in during diagnosis.
• When it comes to diagnosing personality disorders,
there is a lack of consensus among clinicians, indicating
that more accurate criteria are required.
d. Validity – When the signs and symptoms selected as diagnostic

category criteria are reliably correlated or "go together," and
what they identify varies from other categories, this is referred
to as validity.
• Familial Aggregation – the degree to which the
patient's families are affected by the condition (Kupfer,
First, & Regier, 2002).
B. Diagnosis before 1980

1. Just three of the nine systems classified “phobic disorder” as a distinct
category as late as 1959, despite the fact that there were at least nine
systems of varying utility for classifying psychiatric conditions worldwide
(Marks, 1969).
2. Kraepelin was the first to recognize what is now known as

schizophrenia. Dementia praecox was his name for the condition at
the time (Kraepelin, 1919).
• Dementia Praecox – refers to brain impairment that occurs with
advancing age (dementia) and progresses faster than it should,
or "prematurely" (praecox).
3. Philippe Pinel, a French psychiatrist, classified psychological

conditions as distinct individuals, like depression (melancholia),
however Kraepelin’s theory that psychological disorders are essentially
biological disturbances had the most influence on the growth of our
nosology and contributed to an early focus on classical categorical
strategies.
4. The World Health Organization did not include a section on mental

illnesses in the sixth edition of the International Classification of
Diseases (ICD) and Related Health Problems until 1948.
5. The American Psychiatric Association published the Diagnostic

and Statistical Manual (DSM-I) in 1952. Only in the late 1960s did
nosology programs begin to have a significant impact on mental health
practitioners.
6. The Diagnostic and Statistical Manual (DSM-II) of the American

Psychiatric Association was updated in 1968.
7. The eighth edition of the ICD was published by WHO in 1969.

Nonetheless, these schemes lacked specificity, with all of them varying
significantly from one another and relying heavily on unproven

Phone No.: (082)300-5456/305-0647 Local 118
etiological hypotheses that were not generally recognized by all mental

health practitioners.
C. DSM III and DSM III-R

1. The third edition of the Diagnostic and Statistical Manual (DSM-III) was
published in 1980, marking a watershed moment in the history of
nosology (American Psychiatric Association, 1980).
• DSM-III, under the direction of Robert Spitzer, was a radical
departure from its predecessors. There were three notable
changes:
o The DSM-III tried an atheoretical approach to diagnosis,
focusing on precise explanations of diseases as they
appeared to physicians rather than psychoanalytic or
biological theories of etiology to make diagnoses.
o The specificity and detail in which the criteria for defining

a condition were specified in the DSM-III enabled
researchers to investigate their reliability and validity.
(However, due to some shortcomings, this version was
revised in 1987.)
o The DSM-III (and DSM-III-R) required people with

potential psychological disorders to be graded on five
axes.
2. Multiaxial System – are the axes of dimensions that permitted the

clinician to collect data on the individual's functioning in a variety of
areas rather than just the disorder itself.
Axis I Clinical Psychiatric Syndromes

Axis II Personality Disorders and Specific Developmental Disorders
Axis III Physical Disorders or Conditions
Axis IV Severity of Psychosocial Stressors
Axis V Adaptive Functioning
3. At the start of the 1990s, the DSM-III-R was used by more practitioners
around the world than the ICD method, which was intended to be
universally available (Maser et al., 1991).
D. DSM IV and DSM IV-TR

1. The International Classification of Diseases (ICD-10) 10th edition
was published in 1993, and treaty commitments require the United
States to use the ICD-10 codes in all health-related matters.
2. The Diagnostic and Statistical Manual (DSM-IV) was published in

1994. The task force agreed to rely on expert consensus as little as
possible.
• The revisers attempted to review the extensive literature in all
areas relating to the diagnostic method (Widiger et al., 1996,
1998) in order to find broad sets of data that might have been

Phone No.: (082)300-5456/305-0647 Local 118
collected for other purposes but may be useful to DSM-IV with

reanalysis.
• A total of 12 independent research or field trials looked at the

reliability and validity of various sets of concepts or standards,
as well as the likelihood of developing a new diagnosis in certain
cases (Widiger et al., 1998).
3. The Multiaxial Format in DSM-IV – it was remained in this edition with

some changes in the five axes.
Axis I Clinical Disorders

Axis II Personality Disorders and Mental Retardation
Axis III Medical Conditions
Axis IV Psychosocial and Environmental Factors
Axis V Global Assessment if Functioning (a rating scale)
E. DSM-5
1. In the almost 20 years since the publication of DSM-IV, advancement
and other consideration showed in the picture. After 10 years of effort,
DSM-5 was published in the spring of 2013.
2. DSM-5 also collaborated with ICD-11 (published in 2014). DSM-5 is

largely unchanged from DSM-IV although some new disorders are
introduced and other disorders have been reclassified.
3. The new structure of DSM-5 has 3 main sections:

• First section introduces the manual and describes how best to
use it.
• Second, presents the disorders themselves.
• Third, includes descriptions of disorders or conditions that need
further research before they can qualify as official diagnoses.
4. The multiaxial system was removed in the DSM-5 since the former
axes I, II, & 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 axes V) associated with diagnosis
(Regier et al., 2009).
5. Social and Cultural Considerations in DSM-5 - by emphasizing

levels of stress in the environment, DSM-III and DSM-IV facilitated a
more complete picture of the individual. Furthermore, DSM-IV
corrected a previous omission by including a plan for integrating
important social and cultural influences on diagnosis, a feature that
remains in DSM-5.
6. Criticisms of DSM-5:
• Fuzzy categories that blur at the edges, making diagnostic
decisions difficult at times.

Phone No.: (082)300-5456/305-0647 Local 118
• Comorbidity – diagnosing with more than one psychological

disorder at the same time.
7. A caution about labeling and stigma

• Labeling – a similar issue that arises if we categorize people If
the condition is linked to a loss of cognitive or behavioral
function, the diagnosis has negative connotations and leads to
stigma, which is a collection of stereotypical negative views,
biases, and behaviors that lead to a reduction of life
opportunities for the devalued community in question, such as
those with mental illnesses (Hinshaw & Stier, 2008).

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: clinical assessment, diagnosis, reliability, validity, standardization, mental status
exam, behavioral assessment, self-monitoring, projective tests, personality inventories,
intelligence quotient, neuropsychological test, false positive, neuroimaging,
psychophysiological assessment, electroencephalogram (EEG), idiographic strategy,
nomothetic strategy, classification, taxonomy, nosology, nomenclature, classical categorical
approach, dimensional approach, prototypical approach, familial aggregation, comorbidity,
labeling
lesson:

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC.
3. Burke, M. J., & Normand, J. (1987). Computerized psychological testing: Overview and
critique. Professional Psychology: Research and Practice, 18, 42-51.
4. Danna, R. H. (1993). Multicultural assessment perspectives for professional

psychology. Boston: Allyn & Bacon.
5. Golden, C. J. (1990). Clinical interpretation of objective psychological tests. Boston:

Allyn and Bacon.
6. Halleck, S. L. (1991). Evaluation of the psychiatric patient: A primer. New York:

Plenum.
7. Kellerman, H. (1991). Handbook of psychodiagnostics testing: An analysis of

personality in the psychological report. Boston: Allyn and Bacon.
8. Lukas, S. R. (1993). Where to start and what to ask: An assessment handbook. New
York: Norton.
9. Mash, E. J., & Terdal, L. G. (Eds.) (1988). Behavioral assessment of childhood

disorders (2nd ed.). New York: Guilford.
10. Matarazzo, J. D. (1992). Psychological testing and assessment in the 21st century.
American Psychologist, 47, 1007-1018.
11. Pope, B. (1979). The mental health interview: Research and application. New York:
Pergamon Press.
12. Trzepacz, P. T. (1993). The psychiatric mental status examination. New York: Oxford
University Press.
13. Widiger, T. A., & Trull, T. J. (1991). Diagnosis and clinical assessment. Annual Review
of Psychology, 42, 109–133.

Phone No.: (082)300-5456/305-0647 Local 118
LESSON THREE: SUMMATIVE TEST

Let’s Check
Now that the student knows the essential knowledge under lesson three, which is all about
the clinical assessment and diagnosis. Let us try to check the student's understanding of these
terms.
1. The systematic evaluation and measurement of psychological, biological, and social

factors in a person with a possible mental disorder is known as clinical
________________.
a. assessment c. validation
b. interpretation d. standardization
2. A measurement which is consistent is considered to be _____________.

a. valid b. reliable c. standardized d. accurate
3. The process of clinical assessment results in narrowing the focus to

a. concentrate on problem areas that seem most relevant.
b. considers a broad range of problems.
c. covers all possible problems.
d. concentrate on all problem areas equally.
4. In terms of psychological assessment, which of the following describes the concept of

validity?
a. Two or more "raters" get the same answers
b. An assessment technique is consistent across different measures
c. Scores are used as a norm for comparison purposes
d. An assessment technique measures what it is designed to measure
5. In trying to understand and help an individual with a psychological problem, the

psychologist will obtain detailed information about the person's life as part of a
_____________.
a. physical exam c. mental status exam
b. clinical interview d. brain scan
6. All of the following describe how a psychologist conducts a clinical interview EXCEPT
a. attempts to facilitate communication.
b. uses non-threatening ways of seeking information.
c. keeps patient information confidential in all circumstances.
d. applies appropriate listening skills.

Phone No.: (082)300-5456/305-0647 Local 118
7. Behavioral assessments are used to formally assess an individual’s thoughts,

feelings, and behavior in ____________.
a. general b. context c. the abstract d. theory
8. The ABCs of observation refer to the ___________ sequence.

a. affect-behavior-cognition c. antecedent-behavior-consequence
b. antecedent-behavior-cognition d. affect-behavior-consequence
9. Hannibal is presented with a series of cards that are blots of ink. He is asked to state
what he sees on these cards. Hannibal is probably taking a(n)
a. personality inventory. c. projective test.
b. response inventory. d. intelligence test.
10. The Thematic Apperception Test (TAT) differs from the Rorschach inkblot test in that
the person taking the TAT is asked to use his or her imagination to
a. tells a complete story about a picture.
b. draws a picture based on a story that is read aloud by the examiner.
c. writes down responses after reading a short story.
d. tells a story and draw a picture about it.
11. Which of the following describes a neuropsychological test?

a. Determines the possible contribution of brain impairment to the person's
condition
b. Uses imaging to assess brain structure and/or function
c. Assesses long-standing patterns of behavior
d. Ascertains the structure and patterns of cognition
12. A neuropsychological test measures ability in all but which of the following areas?
a. Attention and concentration c. Learning and abstraction
b. Perceptual abilities d. Adaptive personality traits
13. When an assessment strategy shows a problem when none exists, it is referred to as
a ________.
a. false negative c. negative outcome
b. false positive d. forecast error
14. A healthy adult at rest is most likely to show an EEG pattern characterized by a high
level of _____________.
a. alpha waves b. delta waves c. critical waves d. irregular
15. One important advantage of using a classification and diagnostic system like DSM-5
is that knowing a patient's diagnosis
a. helps the therapist to develop a treatment plan and prognosis.
b. allows patients to fully participate in their own treatment.
c. permits the insurance company to have access to patients' records.
d. allows the therapist to see the patient as an individual.

Phone No.: (082)300-5456/305-0647 Local 118
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson three is not enough; what
CASE 1: “How can You Assess Mental State?”
History
A 42-year-old woman comes into hospital for a laparoscopic cholecystectomy. The
admitting doctor has concerns about her mental state. There are concerns about whether she
is healthy enough to cope with an operation and the recovery from it. The doctor takes a
psychiatric history.
Question
In addition to the history what assessment will give more information about this
woman’s mental health, before a decision about whether to proceed with surgery or whether
to ask a psychiatrist to see her? Elaborate your answer as much as possible. (40 points)
In a Nutshell
Activity 1. In this lesson, we learned about the clinical assessment and diagnosis. In this
section, I want you to write down what you had learned or realized in this lesson. Provide at
least 400 words.
Q&A List
lesson three. After being reviewed, questions related to the topics mentioned above will
1.
2.
3.
4.
5.
~End of Lesson Three~

Phone No.: (082)300-5456/305-0647 Local 118
Big Picture
Week 4-5: Unit Learning Outcomes (ULO): At the end of the unit, the student will be able
to
a. Assess the research methods and processes in abnormal psychology.

b. Compare and contrast anxiety, Trauma- and Stressor-Related, and Obsessive-
Compulsive Disorder
Big Picture in Focus: ULOa. Assess the research methods and processes in abnormal
psychology.
LESSON FOUR
Metalanguage
This lesson outlines components of the research process in abnormal

psychology. Establishment of testable hypotheses, internal validity defense, styles of
research design (case study, correlational, community and single-case experimental
design, genetic linkage and analysis, cross-sectional, and longitudinal designs), the
importance of cultural factors influencing research, and research ethics are among
these components. This lesson also looks at the approaches used to figure out what
habits are problematic, why people have behavioral disorders (etiology), and what
constitutes successful treatment and a positive treatment outcome. There is a
discussion of new clinical trial content.
• Research entails formulating a hypothesis that is then put to the test. The aim
of abnormal psychology research is to develop theories that can be used to
describe the existence, causes, or treatment of a condition.
• Internal validity (are changes in a dependent variable induced by changes in

an independent variable?) and external validity (do the findings of a study
apply beyond the context of that study?) are also important concepts to
consider. Attempts to monitor confounding variables by randomization, as well
as the use of analogue models and the analysis of the generalizability of
research results to situations and circumstances outside of the particular study
in question, are all related to these.
• A person case study is a method of studying one or more people in depth.

Despite their importance in the theoretical advancement of psychology, case
studies are not subject to experimental supervision and must therefore be
suspect in terms of both internal and external validity.
• Correlational research can tell us whether two variables have a relationship,

but it can't tell us whether that relationship is causal. Epidemiological analysis

Phone No.: (082)300-5456/305-0647 Local 118
is a form of correlational study that shows the prevalence, distribution, and

implications of a problem in one or more populations.
• Experiments may be done in one of two ways: group or single event. Both
designs control a variable (or variables) and analyze the results to determine
the essence of a causal relationship. It's important to note that the only form of
research that can tell us about cause-and-effect relationships is experiments.
• The role of genetics in behavior is the subject of genetic science. Family

studies, adoption studies, twin studies, genetic linkage analyses, and
association studies are some of the research methods used.
• Cross-sectional and longitudinal research methods are used to study

psychopathology over time. Both study variations in behavior or behaviors
across ages, but the former examines different individuals at different ages
while the latter examines the same individuals at various ages.
• Ethics are critical to the research process, and many professional associations
have ethical standards in place to ensure the safety of research participants.
Informed consent and customer participation in study design, execution, and
interpretation are used to resolve ethical issues.
These terms will reflect on what are the things you need to consider in order to
go further in conducting researches in the field of psychopathology.
Essential Knowledge
I. EXAMINING ABNORMAL BEHAVIOR

A. Important Concepts
1. “What problems cause distress and impair functioning?”
• This question answers the nature of the problems people report.
2. “Why do people behave in unusual ways?”

• In this question, we consider the causes, or etiology of abnormal
behavior.
3. “How do we help them behave in more adaptive ways?”

• In here, we describe how researchers evaluate treatments.
B. Basic Components of a Research Study

1. The basic research process starts with an educated guess, called
hypothesis, about what you expect to find.
• Hypotheses are just educated guesses about how the world
works. You may assume that children may become more
aggressive as a result of watching violent television shows.
However, this worry may be a testable hypothesis (Proulx &
Heine, 2009).
o Testability – this term refers to the ability to back up a
theory (Wagner et al., 2012).

Phone No.: (082)300-5456/305-0647 Local 118
• Once you have decided how to test this theory, you will need to
create a research design that involves the characteristics you
want to assess in the people you're researching (dependent
variable) as well as the influences on their conduct (independent
variable).
3. Finally, two forms of validity are specific to research studies:

a. Internal Validity – is the extent to which you can be confident
that the independent variable is causing the dependent variable
to change.
• Confound (confounding variable) – any factor that
occurs in a study that causes the results to be
incomprehensible because a variable other than the
independent variable which influence the dependent
variable.
• Generalizability – applies to how much the findings

relate to someone who has a disability.
• To ensure validity in their studies, consider the three

strategies:
o Control Group – in this group, people are close
to the experimental group in any way except that
members of the experimental group are
subjected to the independent variable and those
in the control group are not.
o Randomization – is the method of assigning

people to various study groups in such a way that
each individual has an equal chance of being put
in either group.
o Analogue Models – in regulated laboratory

settings, construct aspects that are comparable
(analogous) to the phenomenon being studied.
b. External Validity – relates to how well your findings apply to

topics beyond your research; in other words, how well your
findings reflect people who are not study participants.
C. Statistical versus Clinical Significance

1. In psychological research, statistical significance typically means the
probability of obtaining the observed effect by chance is small.
• For example, consider a study evaluating whether a medication
naltrexone). When applied to a psychiatric intervention, helps
people with alcohol addiction remain sober longer (Anton et al.,
2006).
2. How critical is it if those small differences are significant? The challenge

is distinguishing between statistical significance (a quantitative

Phone No.: (082)300-5456/305-0647 Local 118
measure of the difference between groups) and clinical significance

(whether or not the difference was significant to those affected)
(Thirthalli & Rajkumar, 2009).
3. Calculating the actual statistical measurements necessitates the use of

fairly complex methods that account for how much each treated and
untreated individual in a research study improves or deteriorates (Fritz,
Morris, & Richler, 2012).
• In short, instead of just looking at the results of the group
as a whole, individual differences are considered as well.
4. Montrose Wolf (1978) argued for the evaluation of social validity.

Obtaining feedback from the individual being handled, as well as
significant others, regarding the significance of the improvements that
have arisen is a part of this procedure.
5. The treatment effect is clinically important if the effect is substantial

enough to impress those who are directly involved.
6. We will be able to better measure the outcomes of our therapies using

statistical methods for evaluating impact size and determining
subjective assessments of change.
D. The “Average” Client

1. The majority of the time, we look at study results and generalize about
the population, ignoring individual differences. The Patient Uniformity
Myth was coined by Kiesler (1966) to describe the propensity to market
all participants as one homogeneous group.
II. TYPES OF RESEARCH METHODS

A. Studying Individual Cases
1. Case Study Method – entails thorough investigation of one or more
persons that exhibit behavioral and physical patterns (Yin, 2012).
2. Case studies are based on a clinician's findings of discrepancies

between one individual or a group of people with a disability, people
with other disorders, and people who do not have any psychiatric
disorders.
3. The use of case study approach is decreasing over time, despite the
fact that it has led to many important events in the field of psychology.
• While relying heavily on individual instances, it is possible that
coincidental events occur that are unrelated to the disorder
being studied.
• Unfortunately, life's coincidences often lead to incorrect

assumptions about what causes such disorders and which
treatments tend to be successful.

Phone No.: (082)300-5456/305-0647 Local 118
B. Research by Correlation
1. Correlation – A statistical association between two variables.
• Correlational designs are used to investigate phenomena in
real time.
• Correlation does not imply causation; in other words, just

because two occurrences happen at the same time does not
mean one caused the other.
• For example, the prevalence of marital disputes in families

is linked to children's behavior issues (Yoo & Huang, 2012).
• Positive Correlation – means that the other component has a

lot of power or quantity (e.g., more child disruptive behavior).
At the same time, lower strength or quantity in one variable
(marital distress) is linked to lower strength or quantity in the
other (relationship satisfaction).
• Negative Correlation – this correlation on the other hand

shows that as one variable increases, the other decreases.
2. Epidemiology – refers to a study of the incidence, distribution, and

consequences of a particular problem or set of problems in one or more
populations.
a. Prevalence – this is the number of people with a disorder at any
one time.
• For example, about 40% of college students in the
United States engage in binge drinking (consuming five
or more drinks in a row) (Beets et al., 2009).
b. Incidence – in relation to disorder, this is the estimated number

of new cases during a specific period of time.
• For example, the prevalence of binge drinking among
college students has decreased only marginally since
1980 (Substance Abuse and Mental Health Services
Administration, 2012), implying that despite attempts to
minimize heavy drinking, it remains an issue.

Phone No.: (082)300-5456/305-0647 Local 118
C. Research by Experiment
1. An experiment entails manipulating an independent variable and
observing the results of that variable. We cannot tell which of these
variables affected the other when we manipulate the independent
variable between social supports and psychiatric disorders.
a. Group Experimental Designs – the researcher is more
involved with this method. They alter an independent variable to
see if it affects the behavior of the participants in the group.
• For example, researchers are developing an intervention
to support older adults who are especially affected by
insomnia (Epstein, Sidani, Bootzin, & Belyea, 2012).
• Adding or removing a variable in a way that does not

occur normally is referred to as manipulating a
variable.
• A clinical trial is a form of group intervention that is

increasingly being used in the treatment of psychiatric
disorders (Durand & Wang, 2011).
b. Control Group – this is nearly identical to the treatment group

in such factors as age, gender, socioeconomic backgrounds,
and the problems they are reporting.
• Treatment Group – People in this group always hope to
improve. The placebo effect is the term for this
phenomenon. Participants' behavior changes as a result
of their anticipation of improvement rather than any
manipulation by an experimenter in this phenomenon
(Kendall & Comer, 2011).
• Placebo Control Group - Members of the control group

are given a placebo to make them think they are
receiving medication (Kendall & Comer, 2011).
c. Double-blind Control – is a variant of the placebo control group

procedure.
• As the name implies, not only are the study's participants
"blind," or ignorant of which community they are in or
what care they are receiving (single blind), but so are
the researchers or therapists who are delivering
treatment (double blind) (Munder, Flückiger, Gerger,
Wampold, & Barth, 2012).
d. Comparative Treatment Research - In this design, the

researcher administers various treatments to two or more
similar groups of people with the same condition, and then
assesses how or not each treatment aided the people who
received it (Harvey, Inglis, & Espie, 2002).

Phone No.: (082)300-5456/305-0647 Local 118
D. Single-Case Experimental Designs

1. Individuals are studied in a systematic manner under a variety of
experimental conditions in this process. Psychopathology is concerned
with real people's pain, and this approach has significantly aided our
understanding of the causes that contribute to individual
psychopathology (Barlow, Nock, & Hersen, 2009).
a. Repeated Measurement – a single-case experiment technique
in which a behavior is evaluated multiple times rather than only
once before and after changing the independent variable.
• The variability or degree of change over time (top), the
pattern or course of change (middle), and the extent or
degree of behavior change with various interventions
(bottom).
• Once again, before-and-after scores do not always

reveal what is causing behavioral changes.
b. Withdrawal Designs – another technique in which a researcher

attempts to figure out whether the independent variable is the
cause of behavior changes.
c. Multiple Baseline – This is a popular single-case experimental design

approach that avoids some of the disadvantages of a withdrawal design.
Rather than stopping the intervention to see how it works, the
researcher begins it at various times in different environments (home
versus school), with different attitudes (yelling at spouse/partner or
boss), and with different individuals (Durand, 1999).
III. GENETICS AND BEHAVIOR ACROSS TIME AND CULTURES

A. Studying Genetics
1. Geneticists look at phenotypes, or an individual's observable traits or
behavior, as well as genotypes, or a person's specific genetic makeup
(Kendler, 2005).
2. Beginning in 1990, scientists from all over the world collaborated to start
the human genome project (genome means "all of an organism's
genes").
3. Endophenotypes are hereditary mechanisms that lead to the

underlying conditions that cause the symptoms and difficulties that
people with psychiatric disorders encounter (Grebb & Carlsson, 2009).
• For example, researchers are not looking for a "schizophrenia
gene" (genotype); instead, they're looking for the gene or genes
that cause the working memory issues that people with this
disorder have (endophenotype), as well as the genes that cause
other problems in people with this disorder.
4. These complex approaches can be summarized into four categories:

basic genetic epidemiology, advanced genetic epidemiology,

Phone No.: (082)300-5456/305-0647 Local 118
gene finding, and molecular genetics (Kendler, 2005) (see Table

4.2).
a. Family Studies - Scientists simply look at a behavioral pattern

or emotional characteristic in the sense of the family. The
proband is the member of the family who possesses the trait
being studied.
• If the phenotype is influenced by genetics, it should
appear more often in first-degree relatives (parents,
siblings, or offspring) than in second-degree or distant
relatives.
b. Adoption Studies - Researchers classify adoptees with a

specific behavioral pattern or psychological condition and try to
track down first-degree relatives who were raised in various
family settings.
c. Twin Studies - Nature provides a beautiful experiment that

allows behavioral geneticists to get as close to the role of genes
in development as possible: identical (monozygotic) twins
(Johnson, Turkheimer, Gottesman, & Bouchard Jr., 2009).
• In twin research, the obvious scientific question is
whether identical twins are more likely than fraternal
twins to have the same characteristic, such as fainting at
the sight of blood.
• Height correlations are 0.45 for first-degree relatives and

fraternal twins, and 0.90 for identical twins, according to
Plomin (1990).
• Yet the twins themselves influence each other’s

behavior, and in some cases, identical twins may
affect each other more than fraternal twins (Johnson
et al., 2009).

Phone No.: (082)300-5456/305-0647 Local 118
d. Genetic Linkage Analysis and Association Studies - To

locate a defective gene, there are two general strategies:
genetic linkage analysis and association studies (Zheng, Yang,
Zhu, & Elston, 2012).
• Genetic Linkage Analysis is straightforward. Other
inherited traits are tested at the same time as a family
disorder is examined. These other traits, known as
genetic markers, are chosen because their precise
location is known.
• This linkage analysis, as well as a second one that

claimed to find a correlation between bipolar disorder
and the X chromosome, have yet to be replicated; that
is, separate researchers have been unable to find similar
linkages in other families (Craddock & Jones, 2001).
• Association research, the second technique for

locating individual genes, also employs genetic markers.
Unlike linkage studies, which compare markers in a
broad number of people with a specific disease,
association studies compare people with the disorder to
people who do not have it (Zheng et al., 2012).
B. Studying Behavior over Time

1. This form of research demonstrates that the pattern of onset of this
condition differs significantly from what parents say after the fact
(parents appear to recall sudden changes in their child's actions when,
in fact, the changes occur gradually) (Rogers, 2009).
a. Preventing mental health issues will save countless families
considerable emotional trauma, as well as significant financial
savings. Over time, prevention research has broadened to
include a variety of methods.
b. Positive development strategies (health promotion),

universal prevention strategies, selective prevention
strategies, and indicated prevention strategies are the four
broad categories in which these various approaches can be
classified (Daniels, Adams, Carroll, & Beinecke, 2009).
• Health promotion or positive development
strategies aim to reach out to all individuals, including
those who aren't at risk, in order to avoid future issues
and encourage protective habits (Bailey, 2009).
• 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.
• Selective prevention - targets whole populations at risk

(for example, children with deceased parents) and

Phone No.: (082)300-5456/305-0647 Local 118
develops tailored strategies to help them avoid potential

issues.
2. Cross-Sectional Designs - researchers take a cross section of a

population across the different age groups and compare them on some
characteristic.
• Cohort – they called this to the participants in each
group in cross-sectional designs.
• 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.
Members of one cohort differ from members of other
cohorts in age and in their exposure to cultural and
historical experiences. You would expect a group of
12-year-olds in the 1980s to have received a great
deal of education about drug and alcohol use (such
as the “Just Say No” program), whereas the 17-year-
olds may not have. 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.
• Cohort effect, the confounding of age and experience,

is a limitation of the cross-sectional design.
3. Longitudinal Designs - 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.
• In one such study, researchers tracked a large number
of families (11,044) for three years to see how spanking
affected their children's attitudes (Gershoff, Lans ford,
Sexton, Davis-Kean, & Sameroff, 2012).
• Psychopathologists often combine longitudinal and

cross-sectional designs in a technique known as
sequential design, which entails studying various
cohorts repeatedly across time.
C. Studying Behavior across Cultures

1. Studying the differences in behavior of people from different cultures
can tell us a great deal about the origins and possible treatments of
abnormal behaviors.
2. Unfortunately, the majority of research literature comes from Western

cultures, resulting in an ethnocentric view of psychopathology that
can hinder our interpretation of conditions and treatment options
(Gaw, 2008).

Phone No.: (082)300-5456/305-0647 Local 118
3. The methods we have outlined can be used to research abnormal

behavior in people from all walks of life. According to some scholars,
the effects of different cultures are treated differently (López &
Guarnaccia, 2012).
4. Researchers would have difficulty comparing incidence and prevalence

rates if people of different cultures perceive the same habits differently.
Common Chinese rituals, for example, involve referring to dead
relatives and local deities, behaviors that may be associated with
schizophrenia in other cultures (Lin, Hwu, & Tsuang, 2012).
E. Replication
1. Researchers will be assured that what they are seeing is not a
coincidence if they can replicate their results.
2. A research program's strength lies in its ability to reproduce findings in

various ways in order to increase trust in the findings. You will notice
that replication is one of the most critical aspects of any of the study
techniques we have discussed.
F. Research Ethics
1. The American Psychological Association published Ethical Principles of
Psychologists and Code of Ethics, which provides general guidelines
for performing research, to protect those who engage in psychological
research and to explain the roles of researchers (Knapp, Gottlieb,
Handelsman, & VandeCreek, 2012a, 2012b).
2. The Society for Research in Child Development (2007) endorsed

ethical research guidelines that discuss several concerns specific to
child research. These guidelines, for example, include not only
confidentiality, protection from injury, and debriefing, but also informed
consent from children's caregivers and, if they are 7 or older, the
children themselves.
3. The participation of customers in key aspects of this study, referred to

as participatory action research, is a final and significant advancement
in the field that will continue to “keep the face” on psychological
disorders (Chevalier & Buckles, 2013).

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: clinical assessment, diagnosis, reliability, validity, standardization, mental status
exam, behavioral assessment, self-monitoring, projective tests, personality inventories,
intelligence quotient, neuropsychological test, false positive, neuroimaging,
psychophysiological assessment, electroencephalogram (EEG), idiographic strategy,
nomothetic strategy, classification, taxonomy, nosology, nomenclature, classical categorical
approach, dimensional approach, prototypical approach, familial aggregation, comorbidity,
labeling
lesson:

2. Bersoff, D. N. (1995). Ethical conflicts in psychology. Washington, DC: American

Psychological Association.
3. Bromley, D. B. (1986). The case-study method in psychology and related disciplines.

New York: Wiley
4. Critelli, J. W., & Neumann, K. F. (1984). The placebo: Conceptual analysis of a

construct in transition. American Psychologist, 39, 32–39.
5. Estes, W. K. (1991). Statistical models in behavioral research. Hillsdale, NJ: Erlbaum
6. Garber, J., & Hollon, S. D. (1991). What can specificity designs say about causality in
psychopathology research? Psychological Bulletin, 110, 129-136.
7. Greenberg, L. S., & Pinsof, W. M. (1994). Reassessing psychotherapy research. New

York: Guilford.
8. Hayes, S. C., Barlow, D. H., & Nelson-Gray, R. O. (1999). The scientist practitioner:
Research and accountability in the age of managed care, Boston, MA: Allyn &
Bacon.
9. Hock, R. R. (1992). Forty studies that changed psychology: Explorations into the
history of psychological research. Englewood Cliffs, NJ: Prentice-Hall.
10. Kazdin, A. E. (Ed.) (1992). Methodological issues and strategies in clinical research.
Washington, DC: American Psychological Association.
11. Keith-Speigel, P., & Koocher, G. P. (1985). Ethics in psychology: Professional

standards and cases. New York: Random House.

Phone No.: (082)300-5456/305-0647 Local 118
LESSON FOUR: SUMMATIVE TEST

Let’s Check
Now that the student knows the essential knowledge under lesson four, which is all about the
research methods on psychopathology. Let us try to check the student's understanding of
these terms.
1. A researcher studies the impact of stress on college students' exam scores. Whether
the results of this study help us to understand the relationship between job
performance and stress level of real-life organizational workers is a question of
a. internal validity. c. external validity.
b. study confounds. d. the original research hypothesis.
2. Your friend has trouble making commitments in relationships. You believe that this is
because her parents had a bitter divorce when she was young. Your belief that a child
who lives through a bitter parental divorce will have trouble making commitments in
relationships as an adult would be considered a(n) _________.
a. hypothesis c. empirical conclusion
b. independent variable d. applied theory
3. The dependent variable in a research study is the variable that
a. is expected to influence or change the variable being studied.
b. is the empirical result of the study.
c. is expected to be changed or influenced in the study.
d. forms the most important component of the hypothesis.
4. While studying the impact of nutrition on intelligence, a researcher has one group of
rats on a vitamin-rich diet and the other group eating Big Macs. While observing the
rats run a complicated maze, the researcher notes that the vitamin-enhanced rats'
maze is more brightly lit than the Big Mac rats' maze. The difference in lighting in this
study is a(n) _________.
a. confound c. dependent variable
b. independent variable d. hypothesis
5. A researcher separates participants into two groups. Group A receives an active
medication, and Group B receives an empty capsule that looks and feels like the real
medication. Group B is the ______ group.
a. treatment b. analog c. control d. experimental
6. In research, the term “clinical significance” refers to

a. whether the effects observed in the study are due to chance.
b. the external validity of the study.

Phone No.: (082)300-5456/305-0647 Local 118
c. whether the treatment was meaningful for those affected.

d. randomization of the sampling procedure.
7. The type of study that generally does not follow the scientific method and typically
contains many confounds is the
a. case study. c. true experiment.
b. correlation model. d. longitudinal study.
8. The more time one spends exercising, the less one generally weighs. The correlation
between time on a treadmill each month and overall body weight would represent a(n)
______ correlation.
a. positive b. zero c. negative d. causal
9. Epidemiology is the study of
a. the effectiveness of the correlational model in determining cause.
b. research methods.
c. various forms of therapy.
d. incidence, distribution, and consequences of a problem in a population.
10. While trying to discover the nature of the relationship between stress and blood
pressure, a researcher asks participants to complete a difficult task. The researcher
monitors the participants' blood pressure, while some are exposed to noisy distractions
and others stay in a quiet environment. This type of research study is a(n)
______________.
a. correlational study c. analog study
b. experiment d. placebo control study
11. The purpose of a control group in experimental research is to
a. control for the expectation of some research subjects that they will improve
just because they are in a research study.
b. determines whether a treatment or independent variable actually influenced
change in the independent variable.
c. determines statistical significance.
d. control the dependent variable.
12. In a double-blind study,

a. participants are not aware of who is in the treatment and control groups, but
the researcher providing the treatment does know.
b. neither the researcher providing the treatment nor the participants are aware
of who is in the treatment and who is in the control group.
c. neither the researcher providing the treatment nor the research participants
can ever be made aware of the research findings.
d. participants are not aware that they are participating in a research study.
13. Single-case experimental designs utilize several strategies such as ____________ to
improve their internal validity.
a. repeated measurement c. random assignment
b. process measures d. placebo controls
14. A phenotype is defined as an individual's

a. hidden characteristics. c. genetic influences.
b. observable characteristics d. unique genetic makeup.
15. While conducting a family study, a researcher determines that the siblings and parents
of the person with a disorder are much more likely than the general public to have the
Phone No.: (082)300-5456/305-0647 Local 118
disorder, although cousins, uncles, and grandparents are only moderately more likely
to have the disorder than the general public. This is an example of a disorder with
a. no genetic component.
b. a single gene influence.
c. a genetic component.
d. strong environmental and very weak genetic components.
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson four is not enough; what
1. Provide definitions for the term’s hypothesis, independent variable, dependent

variable, and confound. Discuss how you could use a control group and randomization
to ensure that the results of an experiment are accurate. (20 Points)
2. Describe the procedures of the cross-sectional and longitudinal research methods.

What are the uses and limitations of each of these methods? (20 points)
In a Nutshell
Activity 1. In this lesson, we learned about the research methods in psychopathology. In this
section, I want you to write down what you had learned or realized in this lesson. Provide at
least 400 words.
Q&A List
lesson four. After being reviewed, questions related to the topics mentioned above will
1.
2.
3.
4.
5.
~End of Lesson Four~

Phone No.: (082)300-5456/305-0647 Local 118
Big Picture in Focus: ULOb. Compare and contrast anxiety, Trauma- and Stressor-
Related, and Obsessive-Compulsive Disorder
LESSON FIVE
Metalanguage
This lesson explores the concepts of anxiety, fear, and the illnesses that are
associated with them. Anxiety is a negative affective future-oriented condition in which
an individual is preoccupied with the prospect of uncontrollable danger or misfortune.
Fear is a present-oriented mood condition marked by intense impulses to flee and an
increase in sympathetic nervous system activity. This lesson covers the nature and
phenomenology of anxiety and panic attacks, as well as each of the main anxiety
disorders generalized anxiety disorder, panic disorder and agoraphobia, particular
phobias, and social anxiety disorder (social phobia), trauma- and stressor-related
disorders (acute stress disorder and posttraumatic stress disorder), and obsessive-
compulsive and phobia-related disorders (obsessive-compulsive and phobia-related
disorders) (obsessive-compulsive disorder and body dysmorphic disorder). Case
examples, as well as summaries of symptomatology, course, prevalence, and
etiological factors, are provided for each. Psychological and drug treatments are
also discussed, as well as the DSM-5 revision's diagnostic changes and how they will
affect our understanding of these disorders in the future.
• A panic attack is the body's warning response to true fear, but there is no risk.
• Anxiety in Generalized Anxiety Disorder (GAD) is based on small daily

events rather than a single major worry or concern.
• Panic Disorder characterized by crippling, overwhelming anxiety attacks that

are often accompanied by a variety of physical symptoms. It is often, but not
always, followed by agoraphobia (the fear of and avoidance of “unsafe”
situations).
• A person with phobic disorders avoids conditions that cause extreme anxiety,
panic, or both. The fear in specific phobia is based on a specific object or
circumstance.
• Social anxiety disorder (SAD) is a fear of being in the company of others,

particularly in circumstances that involve some sort of “performance” in front of
others. The apprehension is often focused on the fear of behaving in an
embarrassing or degrading manner that will result in negative judgment from
others.
• Posttraumatic stress disorder (PTSD) is characterized by the avoidance of

traumatic memories or images. It's diagnosed when the signs occur more than
a month after the traumatic incident or if they last more than a month.

Phone No.: (082)300-5456/305-0647 Local 118
• Obsessive-compulsive disorder (OCD) focuses on preventing or neutralizing

frightening or repulsive intrusive thoughts (obsessions) via ritualistic conduct
(compulsions).
Essential Knowledge
I. THE COMPLEXITY OF ANXIETY DISORDERS

A. Anxiety, Fear, and Panic: Some Definitions
1. Anxiety is a negative mood disorder marked by physical stress
symptoms and anxiety about the future (American Psychiatric
Association, 2013).
• Anxiety is stressful, so why do we appear to be conditioned to
feel it almost every time we perform a significant task?
Surprisingly, anxiety is beneficial to our health, at least in
small doses. For over a century, psychologists have
understood that when we are a little nervous, we perform better
(Yerkes & Dodson, 1908).
• Anxiety affects and improves emotional, physical, and

intellectual output. None of us will be able to do much without it.
Howard Liddell (1949) coined the term "shadow of
intelligence" to describe anxiety.
• According to Liddell (1949), the human desire to plan in some

detail for the future is related to the nagging sense that
something might go wrong and that we should be prepared. As
a consequence, anxiety is a mood condition that is centered on
the future.
2. The word "fear" refers to a reaction that activates an immediate

alarm device in response to a threat. Fear, like anxiety, can be
beneficial to our wellbeing. It protects us by inducing a huge
autonomic nervous system response (increased heart rate and
blood pressure, for example), which, coupled with our subjective
sense of fear, motivates us to flee (flee) or attack (attack) (fight).
• Anxiety is a fearful, future-focused mood condition marked
by apprehension because we cannot anticipate or monitor
what will happen next. Fear, on the other hand, is an
emotional response to a current threat that is marked by
strong escapist impulses and, in many cases, a spike in the
sympathetic branch of the autonomic nervous system
(Craske et al., 2010).
3. What happens if you experience the alarm response of fear when

there is nothing to be afraid of—that is, if you have a false alarm?
Consider the case of Gretchen:

Phone No.: (082)300-5456/305-0647 Local 118
THE CASE OF GRETCHEN: Attack by PANIC

I was 25 when I had my first attack. It was a few weeks after I’d come home from the hospital.
I had had my appendix out. The surgery had gone well, and I wasn’t in any danger, which
is why I don’t understand what happened. But one night I went to sleep and I woke up a few
hours later—I’m not sure how long—but I woke up with this vague feeling of apprehension.
Mostly I remember how my heart started pounding. And my chest hurt; it felt like I was
dying—that I was having a heart attack. And I felt kind of queer, as if I were detached from
the experience. It seemed like my bedroom was covered with a haze. I ran to my sister’s
room, but I felt like I was a puppet or a robot who was under the control of somebody else
while I was running. I think I scared her almost as much as I was frightened myself. She
called an ambulance (Barlow, 2002).
• Panic is the name given to this sudden overwhelming

reaction after the Greek god Pan, who terrorized travelers
with bloodcurdling screams.
• A panic attack is characterized as an extreme fear or

acute discomfort that is accompanied by physical
symptoms such as heart palpitations, chest pain,
shortness of breath, and possibly dizziness in
psychopathology.
4. Two basic types of panic attacks are described in DSM-5: expected

and unexpected.
a. If you know you are afraid of heights or driving over long
bridges, you might have a panic attack in these conditions
but not elsewhere; this is referred to as an expected "cued"
panic attack.
b. Unexpected (uncued) panic attacks, on the other hand,

can occur if you have no idea when or where the next attack
will occur.

Phone No.: (082)300-5456/305-0647 Local 118
5. During physiological evaluations of our patients, we have reported

panic attacks over the years (see, for example, Hofmann & Barlow,
1996). Figure 5.2 depicts a physiological surge recorded in one
patient. From minute 11 to minute 13, note the sudden drastic rise
in heart rate, which is followed by rises in muscle tension (frontalis
EMG) and finger temperature. Within 3 minutes, the huge
autonomic surge peaked and subsided.
B. Causes of Anxiety and Related Disorders

1. Biological Contributions - Increasing evidence shows that we inherit
a tendency to be tense, uptight, and anxious.
• Panic disorder tends to run in families and is likely to have a
genetic aspect that varies from genetic contributions to
anxiety (Craske & Barlow, 2013).
• Unique brain pathways and neurotransmitter mechanisms are

related to anxiety. Depleted levels of gamma-aminobutyric
acid (GABA), a component of the GABA–benzodiazepine
system, are related to increased anxiety, though the
correlation is not as direct.
• The noradrenergic system has also been related to anxiety,

and evidence from simple animal research as well as human
studies of normal anxiety indicates that the serotonergic
neurotransmitter system is also involved (Hermans et al.,
2011).
• The limbic system (Hermans et al., 2011; see Figure 2.7c),

which functions as a mediator between the brain stem and the
cortex, is the region of the brain most commonly associated with
anxiety.
• The behavioral inhibition system (BIS), as defined by Jeffrey

Gray, is triggered by signals from the brain stem of unusual
events, such as significant changes in body functioning that
could signal risk. Risk signals move from the cortex to the
septal–hippocampal system in response to something that
appears to be risky. The amygdala gives a substantial boost
to the BIS (LeDoux, 1996, 2002).
• The BIS circuit is not to be confused with the panic circuit. Gray
(1982) and Graeff (1993) identified the fight/flight mechanism,
as Gray refers to it (FFS). According to Gray and McNaughton
(1996) and Graeff (1998), serotonin deficiency triggers the FFS
in portion.
2. Psychological Contributions - Anxiety was assumed to be the

consequence of early classical conditioning, modeling, or other types of
learning, according to behavioral theorists (Bandura, 1986). However,

Phone No.: (082)300-5456/305-0647 Local 118
recent and growing research supports an integrated model of anxiety

that incorporates a wide range of psychological causes.
• Interestingly, parental behavior in early childhood tend to
play a major role in cultivating this sense of control or
uncontrollability (Barlow et al., 2013).
• The psychological element that makes us more or less

vulnerable to anxiety later in life is a sense of control (or lack
thereof) that emerges from these early experiences.
• Additionally, as recently shown in patients with panic disorder,

you might not be aware of the cues or causes of extreme fear;
that is, they are unconscious. This is most likely because these
signals or stimuli can move directly from the eyes to the
amygdala in the emotional brain without passing through the
cortex, the source of consciousness, as demonstrated in animal
experiments (LeDoux, 2002).
3. Social Contributions - Physical reactions, such as headaches or

hypertension, and emotional reactions, such as panic attacks,
may also be caused by the same stressors (Barlow, 2002). The way
we react to stress seems to run in families. If you get headaches when
you're tired, chances are that some in your family do as well.
4. An Integrated Model - We developed a theory of anxiety creation

called the triple vulnerability theory by integrating the variables in an
integrated way (Barlow et al., 2013).
a. Generalized Biological Vulnerability - It's easy to see how an
uptight or high-strung personality might be inherited. However,
a generalized biological susceptibility to anxiety is insufficient to
induce anxiety.
b. Generalized Psychological Vulnerability - That is, based on

your early experiences, you may grow up thinking the world is
unsafe and out of control, and you may be unable to cope when
things go wrong.
c. Specific Psychological Vulnerability - You understand from

early experience, such as from your parents, that certain
circumstances or objects are threatening (even though they are
not).
C. Comorbidity of Anxiety and Related Disorders

1. Comorbidity – this refers to the co-occurrence of two or more
disorders in a single individual.
• The high comorbidity rates of anxiety and related disorders
(as well as depression) illustrate how many of these
disorders share the anxiety and panic symptoms listed here.

Phone No.: (082)300-5456/305-0647 Local 118
• They also have the same biological and psychological

limitations when it comes to anxiety and panic attacks.
• Major depression was by far the most prevalent additional

diagnosis for all anxiety disorders, occurring in 50% of cases
over the course of the patient's life.
• It is also worth mentioning that having additional diagnoses

of depression or alcohol or substance dependence makes it
less probable that you'll rebound from an anxiety disorder
and, even if you do, more likely that you'll relapse (Huppert,
2009).
D. Comorbidity with Physical Disorders

1. The existence of any anxiety disorder was found to be uniquely and
substantially related to thyroid disease, respiratory disease,
gastrointestinal disease, arthritis, migraine headaches, and allergic
disorders in a large sample (Sareen et al., 2006).
2. If a person has both an anxiety disorder and one of the physical

problems listed above, both the physical condition and the anxiety
problem can cause greater impairment and a lower quality of life than if
the person just had the physical disorder (Belik, Sareen, & Stein, 2009).
E. Suicide
1. They also came to the conclusion that the likelihood of someone with
panic disorder attempting suicide is close to that of someone with major
depression (Johnson, Weissman, & Klerman, 1990).
2. The Weissman study confirms that having any anxiety or associated

illness, not just panic disorder, raises the likelihood of having
suicidal ideation or attempting suicide, but the correlation is
strongest with panic disorder and posttraumatic stress disorder
(Sareen, 2011).
II. ANXIETY DISORDERS

A. Generalized Anxiety Disorder
THE CASE OF “IRENE”: Ruled by WORRY

Irene was a 20-year-old college student with an engaging personality but not many friends. She
came to the clinic complaining of excessive anxiety and general difficulties in controlling her life.
Everything was a catastrophe for Irene. Although she carried a 3.7 grade point average, she was
convinced she would flunk every test she took. As a result, she repeatedly threatened to drop courses
after only several weeks of classes because she feared that she would not understand the material.
Irene worried until she dropped out of the first college she attended after 1 month. She felt
depressed for a while, then decided to take a couple of courses at a local junior college, believing she
could handle the work there better. After achieving straight A’s at the junior college for 2 years, she
enrolled once again in a 4-year college as a junior. After a short time, she began calling the clinic in a

Phone No.: (082)300-5456/305-0647 Local 118
state of extreme agitation, saying she had to drop this or that course because she couldn’t handle it.
With great difficulty, her therapist and parents persuaded her to stay in the courses and to seek further
help. In any course Irene completed, her grade was between an A and a B-minus, but she still worried
about every test and every paper, afraid she would fall apart and be unable to understand and complete
the work.
Irene did not worry only about school. She was also concerned about relationships with her
friends. Whenever she was with her new boyfriend, she feared making a fool of herself and losing his
interest. She reported that each date went extremely well, but she knew the next one would probably
be a disaster. As the relationship progressed and some sexual contact seemed natural, Irene was
worried sick that her inexperience would make her boyfriend consider her naive and stupid.
Nevertheless, she reported enjoying the early sexual contact and admitted that he seemed to enjoy it
also, but she was convinced that the next time a catastrophe would happen.
Irene was also concerned about her health. She had minor hypertension, probably because she
was somewhat overweight. She then approached every meal as if death itself might result if she ate
the wrong types or amounts of food. She became reluctant to have her blood pressure checked for
fear it would be high or to weigh herself for fear she was not losing weight. She severely restricted her
eating and as
a result had an occasional episode of binge eating, although not often enough to warrant concern.
Although Irene had an occasional panic attack, this was not a major issue to her. As soon as the
panic subsided, she focused on the next possible catastrophe. In addition to high blood pressure, Irene
had tension headaches and a “nervous stomach,” with a lot of gas, occasional diarrhea, and some
abdominal pain. Irene’s life was a series of impending catastrophes. Her mother reported that she
dreaded a phone call from Irene, let alone a visit, because she knew she would have to see her
daughter through a crisis. For the same reason, Irene had few friends. Even so, when she temporarily
gave up her anxiety, she was fun to be with.
1. Clinical Description
• Irene had GAD, which is the basic condition that characterizes
all of the anxiety and associated disorders mentioned in this
chapter (Brown, Barlow, & Liebowitz, 1994).
• Excessive anxiety and concern (apprehensive expectation)

must be ongoing for at least 6 months, according to the DSM-
5 guidelines. Furthermore, shutting off or managing the worry
mechanism must be difficult.
• Even though the upcoming challenge is important, once it is

done, the worrying ceases. It never stopped for Irene. As soon
as the latest crisis was over, she went on to the next one.
• When asked, “Do you worry excessively about minor things?”

Individuals with GAD react “yes” 100 percent of the time,
compared to around 50 percent of those with anxiety disorders
in other groups (Barlow, 2002).

Phone No.: (082)300-5456/305-0647 Local 118
• The most common problems for children with GAD are

academic, athletic, or social success, as well as family issues
(Furr, Tiwari, Suveg, & Kendall, 2009).
• Older adults, understandably, concentrate on their wellbeing;

they still have trouble sleeping, which seems to intensify
anxiety (Ayers, Thorp, & Wetherell, 2009).
2. Statistics
• Roughly 3.1 percent of the population meets GAD standards
in a given year, and 5.7 percent at any point in their lives. The
one-year prevalence for teenagers only (ages 13–17) is
marginally smaller, at 1.1 percent (Kessler et al., 2012).
• Anxiety clinics like ours estimate that only about ten percent of
their patients meet GAD guidelines, compared to 30 to 50
percent for panic disorder. This may be due to the fact that
most GAD patients seek support from their primary care
physicians, where they can be found in large numbers (Roy-
Byrne & Katon, 2000).

Phone No.: (082)300-5456/305-0647 Local 118
• In both clinical samples and epidemiological studies (where

individuals with GAD are detected from population surveys),
which involve people who do not actually seek care, about two-
thirds of those with GAD are female (Carter, Wittchen, Pfister,
& Kessler, 2001).
• According to interviews, the median age of onset is 31

(Kessler, Berglund, et al., 2005), but many people, including
Irene, have felt nervous and tense their entire lives. GAD is a
chronic disease after it has developed.
• According to Bruce and colleagues (2005), there was only a 58

percent chance of recovery 12 years after the start of a GAD
episode.
• GAD was found to be most prevalent in the population over 45

years of age and least common in the youngest group, ages 15
to 24 (Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010);
recorded prevalence rates of GAD in older adults were as high
as 10%.
3. Causes
• Kendler and colleagues (2005) found that the tendency to
become nervous, rather than GAD itself, tends to be inherited.
• Multiple studies have shown that people with GAD are less
sensitive to physiological tests like heart rate, blood
pressure, skin conductance, and respiration rate than
people with other anxiety disorders. As a consequence,
people with GAD are known as autonomic restrictors (Barlow et
al., 1996).
• According to Borkovec, this form of anxiety may be what causes

these people to be autonomic restrictors. That is, they are
focusing so hard on upcoming problems that they don't
have enough attentional ability left over to generate images
of the imminent danger, images that would evoke more
negative affect and autonomic behavior. To put it another
way, they avoid photos that are associated with the hazard
(Fisher & Wells, 2009).
• People with GAD are nervous all of the time. They devote
more of their attention to sources of danger than people who are
not concerned (Roemer & Orsillo, 2013).
4. Treatment
• Benzodiazepines are widely prescribed for generalized
anxiety, and research suggests that they offer some relief, at
least temporarily. Just a few studies have looked at the effects

Phone No.: (082)300-5456/305-0647 Local 118
of these medications over a longer period of time than eight

weeks (Mathew & Hoffman, 2009).
• Benzodiazepines carry some risks:

o Degradation of both cognitive and motor functions (van
Laar, Volkerts, & Verbaten, 2001).
o People who used this medication did not seem to be as

alert at work or school.
o Can affect driving, and they tend to be related to falls in

older adults, resulting in hip fractures (Wang, Bohn,
Glynn, Mogun, & Avorn, 2001).
o Benzodiazepines tend to induce psychological as well as

physical dependency, making it impossible for people to
avoid using them (Mathew & Hoffman, 2009).
• There is more support for the efficacy of antidepressants like

paroxetine (also known as Paxil) and venlafaxine (also
known as Effexor) in the treatment of GAD. These drugs may
be a better alternative (Mathew & Hoffman, 2009).
• In the short term, psychological treatments for GAD tend to

be just as effective as medications, but psychological
treatments are more effective in the long run (Roemer& Orsillo,
2013).
• The patient learns to counteract and manage the worry

process through cognitive therapy and other coping
strategies (Craske & Barlow, 2006).
• Studies show that brief therapeutic therapies like these can

help people with GAD overcome their implicit cognitive biases
(Mogg, Bradley, Millar, & White, 1995).
• Meditational approaches assist in teaching the patient to be

more accepting of these emotions (Orsillo & Roemer, 2011).
• Mindfulness-based therapies for GAD are now being adapted

and evaluated with teens, with some positive outcomes (Semple
& Burke, 2012)
5. Conclusion to Irene’s Case:

• Irene was treated with the CBT approach developed at our clinic
after attempting a range of medications and finding herself better
able to cope with life. She went to college and graduate school,
married, and has a good career as a nursing home counselor.
Irene, on the other hand, also finds it difficult to relax and avoid
worrying. She still has mild to moderate anxiety, particularly when

Phone No.: (082)300-5456/305-0647 Local 118
she is anxious, and she uses minor tranquilizers on occasion to

help her psychological coping skills.
B. Panic Disorder and Agoraphobia
THE CASE OF “MRS. M”: Self-Imprisoned

Mrs. M. was 67 years old and lived in a second-floor walk- up apartment in a lower-middle-class
section of the city. Her adult daughter, one of her few remaining contacts with the world, had
requested an evaluation with Mrs. M.’s consent. I rang the bell and entered a narrow hallway; Mrs.
M. was nowhere in sight. Knowing that she lived on the second floor, I walked up the stairs and
knocked on the door at the top. When I heard Mrs. M. ask me to come in, I opened the door. She
was sitting in her living room, and I could quickly see the layout of the rest of the apartment. The living
room was in the front; the kitchen was in the back, adjoining a porch. To the right of the stairs was
the one bedroom, with a bathroom opening from it.
Mrs. M. was glad to see me and seemed very friendly, offering me coffee and homemade
cookies. I was the first person she had seen in 3 weeks. Mrs. M. had not left that apartment in 20
years, and she had suffered from panic disorder and agoraphobia for more than 30 years.
As she told her story, Mrs. M. conveyed vivid images of a wasted life. And yet she continued
to struggle in the face of adversity and to make the best she could of her limited existence. Even
areas in her apartment signaled the potential for terrifying panic attacks. She had not answered the
door herself for the past 15 years because she was afraid to look into the hallway. She could enter
her kitchen and go into the areas containing the stove and refrigerator, but for the past 10 years she
had not been to the part of the room that overlooked the backyard or out onto the back porch. Thus,
her life for the past decade had been confined to her bedroom, her living room, and the front half of
her kitchen. She relied on her adult daughter to bring groceries and visit once a week. Her only other
visitor was the parish priest, who came to deliver communion every 2 to 3 weeks when he could. Her
only other contact with the outside world was through the television and the radio. Her husband, who
had abused both alcohol and Mrs. M., had died 10 years earlier of alcohol-related causes. Early in
her stressful marriage, she had her first terrifying panic attack and had gradually withdrawn from the
world. As long as she stayed in her apartment, she was relatively free of panic. Therefore, and
because in her mind there were few reasons left near the end of her life to venture out, she declined
treatment.
• To meet the criteria for panic disorder, a person must have an
unanticipated panic attack and develop extreme anxiety
about the likelihood of another attack, as well as the effects
or consequences of the attack.
• They may avoid going to certain places or neglect their

responsibilities at home because they are afraid of being
assaulted if they are too busy.
o The majority of agoraphobic avoidance activity is a side
effect of serious, sudden panic attacks (Barlow, 2002).
o Simply put, if you've had sudden panic attacks and are

scared, you'll have another, you'll want to be in a safe
spot, or at the very least with someone who knows what

Phone No.: (082)300-5456/305-0647 Local 118
you're going through, so you can get to a hospital easily,

or at the very least go into your bedroom and lie down
(the home is usually a safe place).
o A list of typical situations commonly avoided by

someone with agoraphobia is found in Table 5.1.
• Even though agoraphobic activity is initially closely related to

panic attacks, it may become relatively independent of them
(White & Barlow, 2002).
• As a result, according to the DSM-5, agoraphobia can be

described as either avoiding situations or enduring them with
extreme fear and anxiety.
o In fact, about half of people with agoraphobia found in
population surveys match this definition, despite the fact
that these cases are uncommon in clinics (Wittchen,
Gloster, Beesdo-Baum, Fava, & Craske, 2010).
• Most patients with panic disorder and agoraphobic avoidance

often exhibit interoceptive avoidance, or the avoidance of
internal sensory stimuli (Brown, White, & Barlow, 2005).
o These habits include withdrawing oneself from
circumstances or events that may trigger
physiological arousal, which is close to the start of a
panic attack.
o A list of situations or activities typically avoided within the

interoceptive cluster is found in Table 5.2.

Phone No.: (082)300-5456/305-0647 Local 118
2. Statistics
• About 2.7 percent of the population meets PD requirements
in a given year, and 4.7 percent meet them at any stage in
their lives, with two-thirds of them being women (Kessler,
Berglund, et al., 2005). Another, smaller group (1.4 percent of
the population) develops agoraphobia without ever
experiencing a full-fledged panic attack.
• Panic disorder typically starts in early adulthood, between

the ages of mid-teens and around 40. The average age of
onset is between 20 and 24 years old (Kessler, Berglund, et
al., 2005).
• Unexpected panic attacks and panic disorder have been

identified
o These children, on the other hand, do not report fear of
death or losing control, likely because they are not yet at
a level of cognitive development where they can draw
these inferences (Nelles & Barlow, 1988).
• The prevalence of PD, as well as comorbid panic disorder and

agoraphobia, increases with age, from 5.7 percent at 30–44 to
2.0 percent or less after 60. (Kessler, Berglund, et al., 2005).
• Women account for the majority of agoraphobics (at least

75%). We did not know why for a long time, but it now seems
that the most plausible answer is cultural (Wolitzky-Taylor et al.,
2010).
a. Cultural Influences
• Panic disorder incidence rates were strikingly similar in
the United States, Canada, Puerto Rico, New Zealand,
Italy, Korea, and Taiwan, with the exception of Taiwan,
which had significantly lower rates (Horwath &
Weissman, 1997).
• Subjective feelings of fear or angst do not occur in

certain cultures; that is, people in these cultures do not
pay attention to or record these feelings, preferring to
concentrate on bodily sensations (Lewis-Fernández et
al., 2010).
• Susto – Even though an extreme fright is the cause,

this condition is recognized in Latin America and is
characterized by sweating, elevated heart rate, and
insomnia but not by reports of anxiety or fear.
• Ataques de nervios - Anxiety-related, culturally defined

syndrome that is common among Hispanic Americans,

Phone No.: (082)300-5456/305-0647 Local 118
particularly those from the Caribbean (Hinton, Lewis-

Fernández, & Pollack, 2009).
• Kyol goeu or “wind overload” - A fascinating

manifestation of panic disorder has been identified by
Devon Hinton, a psychiatrist/anthropologist, and his
colleagues among Khmer (Cambodian) and
Vietnamese refugees in the United States. During panic
attacks, this Kyol goeu (too much wind or gas in the
body, which can cause blood vessels to burst) becomes
the target of disastrous thought (Hinton & Good, 2009).
b. Nocturnal Panic
• Approximately 60% of the people with panic disorder
have experienced such nocturnal attacks (Craske &
Rowe, 1997; Uhde, 1994).
• People with panic disorder often begin to panic when

they start sinking into delta sleep, and then they
awaken amid an attack. Because there is no obvious
reason for them to be anxious or panicky when they are
sound asleep, most of these individuals think they are
dying (Craske & Barlow, 1988; Craske & Barlow, in
press).
• What causes nocturnal panic? Currently, our best

information is that the change in stages of sleep to slow
wave sleep produces physical sensations of “letting
go” that are frightening to an individual with panic
disorder (Craske, Lang, Mystkowski, Zucker, &
Bystritsky, 2002).
o Since nocturnal panic attacks don't happen
during REM sleep, there isn't much in the way of
dream or nightmare occurrence when they
happen. As a result, it is unlikely for these
patients to be dreaming.
o Sleep Apnea - a suffocating sensation triggered

by a delay in breathing while sleeping. People
who are considerably overweight are more likely
to develop this disorder.
o Sleep Terrors - It's not unusual for them to

scream and leap out of bed, as if someone was
chasing them. Night terrors are more prevalent at
a later stage of sleep (stage 4 sleep), which is
also when sleepwalking happens.
o Isolated Sleep Paralysis - occurs when a

person is either falling asleep or waking up, but

Phone No.: (082)300-5456/305-0647 Local 118
often when waking up, during the transitional

state between sleep and waking. During this
time, the person is unable to move and has a
panic attack-like feeling of terror; there are also
vivid hallucinations on occasion (Ramsawh,
Raffa, White, & Barlow, 2008).
o Paradis, Friedman, and Hatch (1997) reported

that African Americans with panic disorder had a
substantially higher incidence of isolated sleep
paralysis (59.6%) than other groups (see Figure
5.5).
3. Causes
• We all inherit a susceptibility to stress, which is a propensity to
be neurobiologically overreactive to everyday events (some
more than others) (generalized biological vulnerability).
• External and internal stimuli that were present during the panic
attack were easily correlated in an individual's mind with
particular circumstances (Bouton et al., 2001).
• Women who had a history of physical problems and were

worried for their health were more likely to experience panic
disorder than another anxiety disorder like social phobia
(Rudaz, Craske, Becker, Ledermann, & Margraf, 2010).

Phone No.: (082)300-5456/305-0647 Local 118
• This proclivity for perceiving unwanted bodily stimuli as harmful

represents a psychological susceptibility to fear and associated
disorders. Figure 5.6 illustrates the causal sequence for the
creation of panic disorder.
• Roughly 8% to 12% of the population has experienced an

unexplained panic attack in the previous year, most frequently
during a time of extreme stress. The bulk of these people do not
feel anxiety (Telch et al., 1989).
• David Clark (1986, 1996) stresses people with this disorder's

particular psychological susceptibility to misinterpreting
typical physical sensations. In other words, while we all
experience rapid heartbeat after exercise, if you are mentally or
cognitively vulnerable, you can misunderstand the
phenomenon.
4. Treatment
a. Medication – High-potency benzodiazepines, the newer
selective-serotonin reuptake inhibitors (SSRIs) such as Prozac
and Paxil, and the closely associated serotonin-norepinephrine
reuptake inhibitors (SNRIs) such as venlafaxine, as well as
other medications affecting the noradrenergic, serotonergic, or
GABA–benzodiazepine neurotransmitter systems, or (Barlow &
Craske, 2013).
• Based on all available data, SSRIs are currently the
preferred treatment for panic disorder, despite the
fact that sexual dysfunction tends to occur in 75
percent or more of people taking these drugs (Lecrubier,
Bakker, et al., 1997).
• High-potency benzodiazepines, such as alprazolam

(Xanax), are effective rapidly but difficult to avoid taking
due to psychological and physical dependency and
addiction. As a result, they are not as highly
recommended as SSRIs.
b. Psychological Intervention
• Gradual exposure exercises, when paired with
anxiety-relieving coping strategies like relaxation or
breathing retraining, have been shown to be effective in
helping patients resolve agoraphobic behavior, whether
or not it is related to panic disorder (Craske & Barlow, in
press).
• Panic control treatment (PCT) developed at one of our

clinics focuses on introducing panic disorder patients to
a cluster of interoceptive (physical) stimuli that cause
panic attacks.

Phone No.: (082)300-5456/305-0647 Local 118
• While these therapies are very effective, they are still

relatively new and not yet available to many people who
suffer from panic disorder, as delivering them
necessitates specialized training for therapists (McHugh
& Barlow, 2010).
c. Combined Psychological and Drug Treatments

• A new research funded by the National Institute of
Mental Health looked at the impact of psychiatric and
drug therapies independently and in combination
(Barlow, Gorman, Shear, & Woods, 2000).
• Patients were randomly assigned to one of five

treatment conditions in this double-blind study:
psychological treatment alone (CBT); drug treatment
alone (imipramine—IMI—a tricyclic antidepressant—
was used since this study started before SSRIs were
available); combined treatment condition (IMI + CBT);
and two “control” conditions, one using placebo alone
(PBO), and one using PBO + CBT (to determine the
extent to which any advantage for combined treatment
was caused by placebo contribution).
• The majority of studies indicate that drugs, especially

benzodiazepines, can inhibit the efficacy of
psychological therapies. Furthermore, long-term use of
benzodiazepines has been related to cognitive decline
(Deckersbach, Moshier, Tuschen-Caffier, & Otto, 2011).
• The results of these studies show that initially combining

medications and CBT for panic disorder and
agoraphobia has little benefit. Furthermore,
psychological treatments tended to be more successful
over time (6 months after treatment had stopped). This
indicates that psychological treatment should be

Phone No.: (082)300-5456/305-0647 Local 118
provided first, followed by drug treatment for patients

who do not respond well to psychological treatment or
for whom it is not available.
C. Specific Phobia
• A specific phobia is an irrational fear of a particular object or
circumstance that seriously restricts one's ability to function.
• According to polls, the majority of people have particular fears

of a number of items or circumstances (Myers et al., 1984).
• Table 5.4 indicates several other phobias that our clinics have
seen that are especially crippling (Antony & Barlow, 2002). This
form of list is of little or no interest to psychopathologists, but it
does demonstrate the nature of the named phobias.
• While this subtyping technique is helpful, we all know that most

people who suffer from phobias have a range of phobias
(LeBeau et al., 2010).
• Blood-Injection-Injury Phobia - People with blood–injection–

injury phobias have a physiological response that is almost
always different from people with other forms of phobias
(Hofmann, Alpers, & Pauli, 2009).
o This is possibly due to the fact that people who have this
phobia inherit a strong vasovagal reaction to blood,
injury, or the likelihood of getting an injection, both of
which cause a drop in blood pressure and a tendency to
faint. The fear grows as a result of the probability of
obtaining this answer. The average onset age for this
phobia is around 9 years old (LeBeau et al., 2010).
• Situational Phobia - Phobias characterized by fear of public

transportation or enclosed places.
o Claustrophobia, a fear of small enclosed places, is
situational, as is a phobia of flying.
o Situational phobia, including panic disorder and

agoraphobia, occurs in the mid-teens to mid-twenties
(LeBeau et al., 2010).
• Natural Environment Phobia - young people develop phobias

of natural conditions or occurrences. Height, winds, and water
are all good examples. These fears tend to be related (Antony
& Barlow, 2002): if you are afraid of one circumstance or
occurrence, such as deep water, you are likely to be afraid of
another, such as storms.

Phone No.: (082)300-5456/305-0647 Local 118
• Animal Phobia - fears of animals and insects. The fear that

people with animal phobias feel is not the same as a slight
revulsion. These phobias, like natural environment phobias,
peak about the age of seven years (LeBeau et al., 2010).
2. Statistics
• Table 5.5 shows the ones most frequently present in the general
population, as classified by Agras, Sylvester, and Oliveau
(1969).
• Over a one-year period, the overall prevalence is 8.7%, but

15.8% among adolescents (Kessler et al., 2012).

Phone No.: (082)300-5456/305-0647 Local 118
• Table 5.6 shows the distribution of the 48 patients who came to

our anxiety disorders clinic with a particular phobia as their
primary concern many years ago; the data is broken down by
type.
• Specific phobia has the youngest median age of onset of any

anxiety condition, with the exception of separation anxiety
disorder (Kessler, Berglund, et al., 2005).
• Once a phobia has formed, it is likely to last a lifetime (run a

chronic course) (Kessler, Berglund, et al., 2005); as a result,
the question of care, which will be addressed shortly, becomes
critical.
• Although general reports of fear decrease with age,

performance-related fears of activities such as taking a test or
speaking in front of a large audience can increase. Specific
phobias tend to decrease with age (Ayers et al., 2009).
• Pa-leng, also known as frigo phobia or "fear of the cold," is a

form of phobia found in Chinese cultures. Only traditional ideas
in this case, the Chinese principles of yin and yang can be
interpreted in the sense of pa-leng (Tan, 1980).

Phone No.: (082)300-5456/305-0647 Local 118
3. Causes
• Direct Experiences – phobias acquired where real danger or
pain results in an alarm response (a true alarm).
• This is one of at least three ways to acquire a phobia:

experiencing a false alarm (panic attack) in a real situation,
observing someone else experiencing extreme fear (vicarious
experience), or being told about danger under the right
circumstances.
• Ordinary fear can cause minor distress, but it is usually

overlooked. This argument was best demonstrated by Peter
DiNardo and colleagues (1988), who observed a group of dogs
phobic as well as a matched control group.
• In summary, several things have to occur for a person to

develop a phobia:
i. A traumatic conditioning experience is frequently
implicated (even hearing about a frightening event is
sufficient for some individuals).
ii. If we are "prepared," anxiety is more likely to develop;

that is, we seem to have an inherited fear of
circumstances that have always been dangerous to
humans, such as being attacked by wild animals or
being stuck in small spaces.
iii. We must also be open to developing anxiety regarding

the likelihood of the incident happening again.

Phone No.: (082)300-5456/305-0647 Local 118
iv. Who develops and reports a specific phobia is heavily

influenced by social and cultural factors? As a result,
women account for the vast majority of reported specific
phobias (LeBeau et al., 2010).
4. Treatment
• Almost all agrees that standardized and effective exposure-
based activities are necessary for specific phobias (Craske
et al., 2006).
• In addition, if they are fearful of getting another panic attack in

this case, it is beneficial to aim treatment at panic attacks in the
same way that panic disorder is treated (Craske et al., 2006).
• Parents are often involved in separation anxiety activities to

help organize the exercises and to resolve parental responses
to childhood anxiety (Choate, Pincus, Eyberg, & Barlow, 2005).
• Individuals must tense different muscle groups during exposure

exercises in order to maintain a high enough blood pressure to
complete the exercise (Ayala, Meuret, & Ritz, 2009).
• It is also now clear, based on brain imaging studies, that these

therapies alter brain activity in the long term by altering neuronal
circuitry in the amygdala, insula, and cingulate cortex
(Hauner et al., 2012).
D. Social Anxiety Disorder (Social Phobia)
THE CASE OF “BILLY”: Too Shy

Billy was the model boy at home. He did his homework, stayed out of trouble, obeyed his
parents, and was generally so quiet and reserved he didn’t attract much attention. When he got to
junior high school, however, something his parents had noticed earlier became painfully evident. Billy
had no friends. He was unwilling to attend social or sporting activities connected with school, even
though most of the other kids in his class went to these events. When his parents decided to check
with the guidance counselor, they found that she had been about to call them. She reported that Billy
did not socialize or speak up in class and was sick to his stomach all day if he knew he was going to
be called on. His teachers had difficulty getting anything more than a yes or no answer from him.
More troublesome was that he had been found hiding in a stall in the boy’s restroom during lunch,
which he said he had been doing for several months instead of eating. After Billy was referred to our
clinic, we diagnosed a severe case of social phobia, an irrational and extreme fear of social situations.
Billy’s phobia took the form of extreme shyness. He was afraid of being embarrassed or humiliated
in the presence of almost everyone except his parents.
THE CASE OF “STEVE AND CHUCK”: Star Players?

In the second inning of an All-Star game, Los Angeles Dodger second baseman Steve Sax
fielded an easy grounder, straightened up for the lob to first, and bounced the ball past first baseman
Al Oliver, who was less than 40 feet away. It was a startling error even in an All-Star game studded
with bush league mishaps. But hard-core baseball fans knew it was one more manifestation of a
leading mystery of the 1983 season: Sax, 23, the National League Rookie of the Year the previous

Phone No.: (082)300-5456/305-0647 Local 118
season, could not seem to make routine throws to first base. (Of his first 27 errors that season, 22
were bad throws.)
Chuck Knoblauch won a Golden Glove Award at second base in 1997 but led the league in
errors in 1999 with 26, most of them throwing errors. Announcers and reporters observed that his
throws would be hard and on target to first base if he made a difficult play and had to quickly turn and
throw the ball “without thinking about it.” But if he fielded a routine ground ball and had time to think
about the accuracy of his throw, he would throw awkwardly and slowly—and often o# target. %e
announcers and reporters concluded that, because his arm seemed "ne on the difficult plays, his
problem must be “mental.” For the 2001 season, he was moved to le& "eld to avoid having to make
that throw, and by 2003 was out of baseball.
• SAD is more than exaggerated shyness. SAD is not just an
issue for athletes; well-known lecturers and performers all
over the world suffer from it (Bögels et al., 2010).
• Having intolerable anxiety during a show was once referred to

as "stage fright." When surrounded by familiar people,
however, both stage frights and shyness often do not fit the
individual's usual patterns. But what if the condition were
reversed?
• People with performance anxiety typically have no problem

communicating with others, but when they have to do something
unique in front of others, anxiety takes over and they worry
about humiliating themselves. Remember public speaking.
• As a result of the individual's distress, physical reactions such

as blushing, sweating, shaking, or, in the case of males,
urinating in a public restroom ("bashful bladder" or paruresis)
are normal.
2. Statistics
• SAD affects up to 12.1 percent of the general population at
some point in their lives. The prevalence is 6.8% in adults and
8.2% in adolescents over a one-year period (Kessler et al.,
2012).
• There are even more individuals who are shy, but not to the
degree that they meet the criteria for social phobia. Unlike other
anxiety disorders where females predominate, SAD has an
approximately 50:50 sex ratio. In a recent 12-month period,
45.6 percent of people suffering from SAD sought clinical
support (Wang et al., 2005).
• SAD generally starts in puberty, peaking about the age of 13

years (Kessler, Berglund, et al., 2005). SAD is also more
common in people who are young (18–29 years old) and
undereducated.

Phone No.: (082)300-5456/305-0647 Local 118
• In the United States, White Americans are more likely than

African Americans, Hispanic Americans, and Asian Americans
to be diagnosed with social anxiety disorder (as well as
generalized anxiety disorder and panic disorder) (Asnaani,
Richey, Dimaite, Hinton, & Hofmann, 2010).
• According to cross-national data, Asian cultures have the lowest

rates of SAD, while Russian and American samples have the
highest rates (Hofmann, Asnaani, & Hinton, 2010).
o The clinical presentation of anxiety disorders in Japan is
best described by the term shinkeishitsu. Taijin
kyofusho is one of the most common subcategories,
and it shares some characteristics with SAD (Hofmann
et al., 2010).
o It has recently been discovered that this syndrome exists

in many cultures around the world, but is most prevalent
in Asian cultures (Vriends, Pfatz, Novianti, & Hadiyono,
2013).
3. Causes
• Just as animals have a natural fear of danger, it appears that we
are also prepared to fear angry, critical, or rejecting people (Blair
et al., 2008).
• Lundh and Öst (1996) found that people with SAD were more
likely to remember critical expressions after seeing a series of
pictures of faces; Mogg and colleagues (2004) found that
socially anxious people recognized angry faces more
quickly than "normal," while "normal" remembered
accepting expressions.
• According to Fox and Damjanovic (2006), the eye region is the

most dangerous part of the face.
• According to Jerome Kagan and colleagues (Kagan & Snidman,

1999), some infants are born with a temperamental profile or
trait of inhibition or shyness that is visible as early as four
months of age.
o There is now evidence that people who have excessive
behavioral inhibition are more likely to develop
phobias.
• Three pathways of SAD:

a. First, someone may be born with a generalized
biological vulnerability to anxiety, a biological tendency
to be socially inhibited, or both.

Phone No.: (082)300-5456/305-0647 Local 118
b. Second, when someone is stressed, they may

experience an unanticipated panic attack in a social
situation, which becomes associated (conditioned) with
social cues.
c. Third, someone might go through a genuine social

trauma, resulting in a genuine alarm.
• Anxiety and panic may be triggered by this experience, which

may be repeated in future social situations. McCabe, Anthony,
Summerfeldt, Liss, and Swinson (2003) found that 92 percent
of adults with social phobia had experienced severe
teasing and bullying as a child, compared to only 35
percent to 50 percent of people with other anxiety
disorders.
• According to some researchers (Rapee & Melville, 1997),

parents of social phobia patients are significantly more
socially fearful and concerned about other people's
opinions than parents of panic disorder patients, and they pass
this fear on to their children (Lieb et al., 2000).
• Based on previous research, this suggests that the development

of SAD is caused by a combination of biological and
psychological events.

Phone No.: (082)300-5456/305-0647 Local 118
4. Treatment
• Clark and colleagues (2006) looked at a cognitive therapy
program that focused on real-life experiences during therapy to
disprove automatic fears of danger. This program significantly
improved the lives of 84 percent of those who received
treatment, and these results were maintained after a one-year
follow-up.
• A second highly credible treatment, interpersonal

psychotherapy (IPT), was found to be effective both
immediately following treatment and at a one-year follow-up,
even when delivered in a center specializing in IPT treatment
(Stangier, Schramm, Heidenreich, Berger, & Clark, 2011).
• It is worth noting that one of the main reasons why SAD

persists in the face of repeated exposure to social cues is
that people with SAD engage in a variety of avoidance and
safety behaviors to reduce the risk of rejection and, more
broadly, to keep patients from critically evaluating their
catastrophic beliefs about how embarrassed and foolish they
willll appear if they try to interact with so many people.
• Patients' beliefs about social mishaps are directly challenged

by showing them the actual consequences of such
mishaps, such as what would happen if you spilled something
all over yourself while talking to someone for the first time
(Hofmann & Otto, 2008).
o This treatment had an 82 percent completion rate and
a 73 percent response rate as a group intervention,
which was maintained at the 6-month follow-up
(Hofmann et al., 2013).
• When comparing individual and family-based treatment

approaches, family-based treatment appears to outperform
individual treatment when both parents of the child suffer
from anxiety (Kendall, et al., 2008).
• There are a number of drug treatments that have been shown

to be effective in some people, particularly for performance
anxiety, but the evidence does not appear to back up this claim
(Turner, Beidel, & Jacob, 1994).
o One noteworthy study compared Clark's cognitive
therapy with the SSRI drug Prozac, as well as
instructions to patients with SAD to try to engage in more
social situations (self-exposure).
o Evaluations were done before the 16-week treatment, at

the halfway point, post-treatment, and then after three
months of booster sessions. Finally, 12 months later,

Phone No.: (082)300-5456/305-0647 Local 118
researchers checked in with patients in both treatment

groups (Clark et al., 2003).
o Assessments were done before the 16-week treatment,

at the halfway point, post-treatment, and then after
three months of booster sessions. Finally, 12 months
later, researchers checked in with patients in both
treatment groups (Clark et al., 2003).
o The results are shown in Figure 5.11. Both treatments

were effective, but the psychological treatment was
consistently superior, with the majority of patients being
cured or nearly cured with few symptoms remaining.
o If these findings are confirmed, it may be possible to treat

not only SAD but all anxiety disorders in less time.
a. Selective Mutism – is a new classification that is now grouped

with the anxiety disorders ins DSM-5.
• SM is a rare childhood disorder characterized by a lack
of speech in one or more socially expected
situations.
• The inability to speak is not due to a lack of speech

knowledge or physical limitations, nor is it due to
another disorder in which speaking is uncommon or can
be impaired, such as autism spectrum disorder.
• One research approximately 100 percent of a series of

50 children with selective mutism have met requirements
for SAD. Estimates of the prevalence of SM average
around 0.5 percent of children with girls more affected
than boys (Viana, Beidal, & Rabian, 2009).
• The treatment uses many of the same cognitive

behavioral principles that have been shown to be
effective in treating social anxiety in children, but
with a stronger focus on speech. This method combines
behavioral interventions such as modeling, stimulus
fading, and shaping with a behavioral reward system
to allow for gradual exposure to the speaking situation
(Furr et al., 2012).
III. TRAUMA- AND STRESSOR-RELATED DISORDERS

A. Posttraumatic Stress Disorder
• Emotional issues can also develop as a result of physical abuse, such
as rape, car accidents, natural disasters, or the premature death of a
loved one. The most well-known of these conditions is post-traumatic
stress disorder (PTSD).

Phone No.: (082)300-5456/305-0647 Local 118
• According to the DSM-5, PTSD is characterized as exposure
to a traumatic event in which a person witnesses or
experiences death or imminent death, real or threatened
serious injury, or actual or imminent sexual violation.
• Discovering that a traumatic incident happened to a close family

member or acquaintance, or being constantly subjected to
specifics of a traumatic event (as first responders dealing with
human remains in a terrorist attack) are both setting events.
Victims relive the incident through flashbacks and nightmares
afterward. A flashback happens when memories surface
unexpectedly, followed by intense emotion, and the victims
find themselves reliving the incident.
• PTSD patients prefer to avoid activities or experiences that

remind them of their trauma. They often have a propensity to
restrict or numb their emotional responsiveness, which can
be problematic in interpersonal relationships. They are
easily startled and quick to rage, which was later applied to the
DSM-5 criterion of "reckless or self-destructive behavior."
• The “dissociative” subtype of PTSD is a recent addition to the

PTSD criteria, identifying victims that do not typically respond to
reexperiencing or hyperarousal. Rather, people with this
subtype of PTSD have lower arousal levels than normal, as well
as (dissociative) feelings of unreality (Wolf, Miller, et al., 2012).
THE CASE OF “THE JONESES”: One Victim, Many Traumas

Mrs. Betty Jones and her four children arrived at a farm to visit a friend. (Mr. Jones was at
work.) Jeff, the oldest child, was 8 years old. Marcie, Cathy, and Susan were 6, 4, and 2 years of
age. Mrs. Jones parked the car in the driveway, and they all started across the yard to the front door.
Suddenly Jeff heard growling somewhere near the house. Before he could warn the others, a large
German shepherd charged and leapt at Marcie, the 6-year-old, knocking her to the ground and tearing
viciously at her face. The family, too stunned to move, watched the attack helplessly. After what
seemed like an eternity, Jeff lunged at the dog and it moved away. The owner of the dog, in a state
of panic, ran to a nearby house to get help Mrs. Jones immediately put pressure on Marcie’s facial
wounds in an attempt to stop the bleeding. The owner had neglected to retrieve the dog, and it stood
a short distance away, growling and barking at the frightened family. Eventually, the dog was
restrained and Marcie was rushed to the hospital. Marcie, who was hysterical, had to be restrained
on a padded board so that emergency room physicians could stitch her wounds.
• This case is exceptional in that both Marcie and her 8-year-old

brother developed PTSD. In addition, even though they were
young, Cathy, 4, and Susan, 2, as well as their mother, showed
signs of the disorder (see Table 5.7) (Albano, Miller, Zarate,
Côté, & Barlow, 1997).

Phone No.: (082)300-5456/305-0647 Local 118
• Since many individuals experience intense reactions to stressful

event that usually vanish 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 little to no signs

immediately or for months after a trauma, but at least 6 months
later, and maybe years afterward experience full-blown PSTD
(O’Donnell et al., 2013).
• A new disorder called acute stress disorder was added to the

DSM-IV. Acute stress disorder was included in the DSM-IV
because many people who had severe early reactions to
trauma could not be diagnosed and thus could not get
insurance coverage for treatment.
2. Statistics
• Repeated bombings did not result in a statistically significant
increase in psychiatric disorders. Despite the prevalence of
short-term fear reactions, there were surprisingly few persistent
phobic reactions.” Classic studies after devastating fires,

Phone No.: (082)300-5456/305-0647 Local 118
earthquakes, and floods have yielded similar results (Green,

Grace, Lindy, Titchener, & Lindy, 1983).
• On the other hand, some studies have discovered a high

prevalence of PTSD following a traumatic event. Large
studies on the prevalence of PTSD in veterans of the Iraq and
Afghanistan wars are now available. Military mental health
officials were concerned that PTSD rates could be as high as
30% or higher, based on their experiences during the
Vietnam War (McNally 2012).
• Only 4.3 percent of military personnel developed PTSD,

according to a study of over 47,000 personnel. Exposure rates
increased to 7.6% for those who had been exposed to
combat, compared to 1.4 percent for those who had not been
exposed to combat (Smith et al., 2008).
• Surveys show that 6.8% of the population has experienced

PTSD at some point in their lives, with 3.5 percent
experiencing it in the last year (Kessler, Chiu, et al., 2005).
o The corresponding figure for adolescents is 3.9 percent
(Kessler et al., 2012).
o The findings are shown in Table 5.8. As can be seen, the

highest rates are related to rape, being held hostage,
tortured, or abducted, as well as being seriously
assaulted. After these encounters, which Breslau
categorizes as "assaultive abuse," the rates of PTSD
are much higher than in other categories.
• PTSD is common among women, particularly those who have

been sexually assaulted multiple times. PTSD rates are 2.4 to
3.5 times higher for women who have endured a single
sexual assault or rape compared to nonvictims, and 4.3 to
8.2 times higher for those who have been re-victimized
(Walsh et al., 2012).
• It appears that close exposure to the trauma is required for the

development of this condition (Friedman, 2009). However, this
is also noticeable among
3. Causes
• We know that the intensity of assaultive abuse exposure plays
a role in the etiology of PTSD (Friedman, 2009), but it doesn't
account for anything. Few people experience PTSD at lower
levels of trauma, but the rest do not. What is the root of these
disparities?
• True and colleagues (1993) found that a monozygotic (identical)

twin was more likely to develop PTSD than a dizygotic (fraternal)

Phone No.: (082)300-5456/305-0647 Local 118
twin when given the same amount of battle exposure and one
twin with PTSD. The correlation of symptoms in identical
twins was 0.28 to 0.41, while it was 0.11 to 0.24 in fraternal
twins, suggesting that there might be some genetic impact
in the development of PTSD.
• There is some evidence that the genes have a strong effect. The
Stress-diathesis Model, which was discussed in Lesson Two,
best describes the situation with these.
o Since genetic factors predispose individuals to be easily
depressed and anxious, a traumatic experience may be
more likely to result in PTSD (Uddin, Amstadter, Nugent,
& Koenen, 2012).
• Female undergraduates who witnessed a horrific shooting on

the campus of Northern Illinois University in 2008 were
researched. Almost all had the same traumatic experience, and
particular features of the serotonin transporter gene, which
involves two short alleles (SS) and is related to an increased risk
of depression (Caspi et al., 2012).
• Some environmental and social factors also played a role in the

development of PTSD risk. Minimal education is one of these
factors. Breslau, Davis, and Andreski demonstrated that those
affected by such a factor must deal with externalizing (acting
out) problems, which were particularly evident in 6-year-old
children who were more likely to experience trauma (such as
assaults) (Breslau, 2012).
• Foy and colleagues (1987) discovered that these vulnerabilities

were less important at high levels of trauma, because the
majority of the prisoners of war they studied (67 percent)
developed PTSD. Vulnerabilities, on the other hand, matter
a lot when it comes to determining whether a disorder will
develop at low levels of stress or trauma.
• Because family instability is one factor that can contribute to a

sense that the world is an uncontrollable, potentially dangerous
place (Suárez et al., 2009), it's not surprising that people
from unstable families are more likely to develop PTSD if
they are exposed to trauma.
• Several studies have found that having a strong and

supportive group of people around you make it much less
likely for you to develop PTSD after a traumatic event
(Friedman, 2009). The greater the breadth and depth of one's
social support network, the less likely one is to develop PTSD.
• A number of studies have found that when children are

stressed, support from loved ones reduces cortisol

Phone No.: (082)300-5456/305-0647 Local 118
secretion and activity of the hypothalamic–pituitary–

adrenocortical (HPA) axis (see, for example, Nachmias,
Gunnar, Mangelsdorf, Parritz, & Buss, 1996).
o It appears that PTSD is linked to a variety of
neurobiological systems, including elevated or restricted
corticotropin-releasing factor (CRF), which indicates
increased activity in the HPA axis, as discussed earlier
in this chapter and in Lesson 2 (Yehuda, Pratchett, &
Pelcovitz, 2012).
o Chronic arousal associated with HPA axis as well as

some other PTSD symptoms, may be linked to changes
in brain function and structure (& Magarinos, 2004).
• We have speculated that the “alarm reaction” that is a panic

attack is similar in both panic disorder and PTSD but that in
panic disorder the alarm is false. In PTSD, the initial alarm
is true in that real danger is present (Keane & Barlow, 2002).
• If the alarm is severe enough, we may develop a

conditioned or learned alarm reaction to stimuli that remind
us of the trauma (for example, being tucked into bed may have
reminded Marcie of the emergency room board) (Lissek &
Grillon, 2012).
• This model of the etiology of PTSD is presented in Figure 5.12.

Phone No.: (082)300-5456/305-0647 Local 118

Phone No.: (082)300-5456/305-0647 Local 118
4. Treatment
• Most clinicians agree that in order to overcome the disorder's
debilitating effects, victims of PTSD must confront the
original trauma, process intense emotions, and develop
effective coping mechanisms (Beck & Sloan, 2012). Reliving
emotional trauma to alleviate emotional suffering is referred to
as catharsis in psychoanalytic therapy.
• Imaginal Exposure, in which the trauma's content and

associated emotions are worked through in a systematic
manner. Throughout the decades, this method has been
referred to by various names.
• One strategy for achieving this goal with adolescents or adults

is narrative therapy. In this approach, the victim requests the
creation of a narrative of the traumatic event, which is then
thoroughly discussed in therapy.
• Treatment often includes cognitive therapy to correct negative

assumptions about the trauma, such as blaming oneself in some
way, feeling guilty, or both (Najavits, 2007).
• Early, structured interventions delivered as soon as

possible after the trauma to those who need help are now
being shown to be effective in preventing the development
of PTSD, and these preventive psychological approaches
appear to be more effective than medications (Shalev et al.,
2012).
• On the other hand, there is evidence that forcing trauma victims

to express their feelings about whether or not they are
distressed in a single debriefing session can be harmful (Ehlers
& Clark, 2003).
• Drugs can help with PTSD symptoms as well (Schneier et al.,

2012). Some drugs that are effective for anxiety disorders in
general, such as SSRIs (e.g., Prozac and Paxil), have been
shown to be helpful for PTSD, possibly because they relieve
the severe anxiety and panic attacks that are so common in
this disorder.
a. Adjustment Disorders
• Adjustment Disorder is a term used to describe anxious or
depressive reactions to life stress that are generally milder
than acute stress disorder or post-traumatic stress disorder
(PTSD), but still impair work or school performance,
interpersonal relationships, or other aspects of daily life
(Strain & Friedman, 2011).

Phone No.: (082)300-5456/305-0647 Local 118
• The adjustment disorder is considered “chronic” if the

symptoms persist for more than six months after the stress
or its consequences have been removed.
b. Attachment Disorders
• Attachment Disorder is a term used to describe a range of
disturbed and developmentally inappropriate behaviors
in children under the age of five who are unable or unwilling
to form normal attachment relationships with caring adults.
• Cases like frequently changing caregivers, maladaptive

patterns as a result of insufficient child-rearing, home
neglect, and others could be the result of a failure to meet
the child's basic emotional needs for affection, comfort,
or even providing for the necessities of daily living.
c. Reactive Attachment Disorder

• When a child has RAD, he or she will rarely seek out a
caregiver for protection, support, or nurturing, and will
also rarely respond to caregivers' offers to provide this type
of care.
• They would generally show a lack of responsiveness,

limited positive affect, and additional heightened
emotionality, such as fear and intense sadness.
d. Disinhibited Social Engagement Disorder

• DSED, a similar set of children rearing circumstances,
possibly including early, persistent harsh punishment,
would result in a pattern of behavior in which the child
approaches adults with no inhibitions.
• Such a child might engage in inappropriately intimate

behavior by agreeing to go somewhere with an
unfamiliar adult figure without first checking in with a
caregiver.
Note: In DSM-5 two separate disorders are described, the first and emotionally
withdrawn inhibited type (RAD), and the second and indiscriminately social
disinhibited type (DSED) (Gleason et al., 2011).
IV. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

A. Obsessive-Compulsive Disorder
• 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 avoid snakes (Clark & O’Connor, 2005).

Phone No.: (082)300-5456/305-0647 Local 118
• People with OCD fight this battle all day, every day, and
sometimes for the rest of their lives, and they usually lose.
• Obsessions are irrational and intrusive thoughts, images, or

urges that a person tries to resist or eliminate.
• Obsessions are suppressed by compulsions, which are

thoughts or actions that provide relief.
THE CASE OF “RICHARD”: Enslaved by Ritual

Richard, a 19-year-old college freshman majoring in philosophy, withdrew from school
because of incapacitating ritualistic behavior. He abandoned personal hygiene because the
compulsive rituals that he had to carry out during washing or cleaning were so time consuming that
he could do nothing else. Almost continual showering gave way to no showering. He stopped cutting
and washing his hair and beard, brushing his teeth, and changing his clothes. He let his room
infrequently and, to avoid rituals associated with the toilet, defecated on paper towels, urinated in
paper cups, and stored the waste in the closet. He ate only late at night when his family was asleep.
To be able to eat he had to exhale completely, making a lot of hissing noises, coughs, and hacks,
and then fill his mouth with as much food as he could while no air was in his lungs. He would eat only
a mixture of peanut butter, sugar, cocoa, milk, and mayonnaise. All other foods he considered
contaminants. When he walked, he took small steps on his toes while continually looking back,
checking and rechecking. Occasionally, he ran quickly in place. He withdrew his left arm completely
from his shirt sleeve as if he were crippled and his shirt was a sling.
Like everyone with OCD, Richard experienced intrusive and persistent thoughts and
impulses; in his case they were about sex, aggression, and religion. His various behaviors were
efforts to suppress sexual and aggressive thoughts or to ward of the disastrous consequences he
thought would ensue if he did not perform his rituals. Richard performed most of the repetitive
behaviors and mental acts mentioned in the DSM-IV criteria. Compulsions can be either behavioral
(hand-washing or checking) or mental (thinking about certain words in a specific order, counting,
praying, and so on) (Foa et al., 1996; Purdon, 2009; Steketee & Barlow, 2002). The important thing
is that they are believed to reduce stress or prevent a dreaded event. Compulsions are often “magical”
in that they may bear no logical relation to the obsession.
a. Types of Obsessions and Compulsions

• According to Matthews (2009), there are four major types
of obsessions, each of which is associated with a pattern
of compulsive behavior (see Table 5.10).
• Symmetry obsessions account for most obsessions

(26.7%), followed by “forbidden thoughts or actions”
(21%), cleaning and contamination (15.9%), and
hoarding (15.4%) (Bloch et al., 2008).
• Certain rituals are strongly associated with certain types

of obsessions (Bloch et al., 2008). For example, as shown
in Table 5.10, forbidden thoughts or actions appear to lead
to checking rituals. The purpose of checking rituals is to
prevent a fictitious disaster or catastrophe.

Phone No.: (082)300-5456/305-0647 Local 118
• Obsessions with symmetry lead to rituals of ordering,

arranging, or repeating them; obsessions with
contamination lead to rituals of washing that can help
people feel safe and in control (Rachman, 2006).
b. Tic Disorder and OCD

• Tic disorder, which is characterized by involuntary
movement (for example, sudden jerking of limbs), is also
common in patients with OCD (especially children) or their
families (Leckman et al., 2010).
• Approximately 10% to 40% of children and adolescents

with OCD have had tic disorder at some point in their lives
(Leckman et al., 2010). Tic-related OCD obsessions almost
always revolve around symmetry.
• Based on observations of a small group of children with

OCD and tics, these issues appear to have developed
following a bout of strep throat. PANDAS, or pediatric
autoimmune disorder associated with streptococcal
infection, is the name given to this syndrome (Leckman et
al., 2010).
• The PANDAS group is more likely to be male, have a rapid

onset of symptoms often associated with fever or sore
throat, have full remissions between episodes, show
symptom remission during antibiotic therapy, have evidence
of previous streptococcal infections, and present with

Phone No.: (082)300-5456/305-0647 Local 118
noticeable clumsiness (Murphy, Storch, Lewin, Edge, &

Goodman, 2012).
2. Statistics
• The lifetime prevalence of OCD is estimated to be between
1.6 percent and 2.3 percent, with a 1-year prevalence of 1
percent (Calamari et al., 2012).
• Nonclinical (“normal”) people are prone to intrusive and

distressing thoughts (Fullana et al., 2009).
• Spinella (2005) discovered that 13% of a "normal"

community sample of people had moderate obsessions
or compulsions that were not severe enough to meet OCD
diagnostic criteria.
• Many people have strange, sexual, or aggressive thoughts,

especially when they are bored, such as in class. Gail
Steketee and her colleagues gathered examples of ordinary
people's thoughts who did not have OCD. Table 5.11
summarizes some of these ideas.
• The female-to-male ratio in OCD is nearly 1:1. Although

there is some evidence in children that there are more males
than females (Hanna, 1995), this seems to be because boys
tend to develop OCD earlier. By mid-adolescence, the sex
ratio is approximately equal (Albano et al., 1996). (Albano et
al., 1996).
• The onset age ranges from childhood to the late thirties,

with a median onset age of 19 years (Kessler, Berglund,
et al., 2005). Males reach their peak at a younger age (13 to
15) than females (20 to 24). OCD is more likely to become
chronic once it has developed (Calamari et al., 2012).
• Obsessions are primarily related to religious practices in

Saudi Arabia and Egypt, particularly the Muslim emphasis
on cleanliness. Contamination is also a common theme in
India.
• Studies from England, Hong Kong, India, Egypt, Japan, and

Norway, as well as Canada, Finland, Taiwan, Africa, Puerto
Rico, Korea, and New Zealand, found essentially similar
types and proportions of obsessions and compulsions
(Horwath & Weissman, 2000).

Phone No.: (082)300-5456/305-0647 Local 118

Phone No.: (082)300-5456/305-0647 Local 118
3. Causes
• The tendency to develop anxiety as a result of having more
compulsive thoughts, on the other hand, may share the same
biological and psychological precursors as anxiety in
general (Barlow et al., 2013).
• Thought–action fusion occurs when people with OCD

associate their thoughts with specific actions or activities.
Thought–action fusion may also be triggered by childhood
behaviors of over-responsibility and shame, in which even a bad
thought is synonymous with evil intent (Taylor, Abramowitz,
McKay, & Cuttler, 2012).
o Several studies have found that the intensity of religious
belief, rather than the type of belief, is linked to thought–
action fusion and the severity of OCD (Rassin & Koster,
2003).
• Believing that certain thoughts are unacceptable and must be

suppressed (a psychological vulnerability) may increase the risk
of OCD (Salkovskis & Campbell, 1994).
• A model of the etiology of OCD that is somewhat similar to other

models of anxiety disorders is presented in Figure 5.13.
4. Treatment
• OCD medications have undergone rigorous testing. The most
successful seem to be those that directly inhibit serotonin
reuptake, such as clomipramine or SSRIs, which support up
to 60% of patients with OCD and have no clear advantage over
one another. When a drug is taken off the market, relapse is
common (Dougherty et al., 2012).
• The most successful method is exposure and ritual

prevention (ERP), which entails deliberately preventing rituals
when exposing the patient to the dreaded thoughts or
circumstances in a systematic and incremental manner
(Abramowitz, Taylor, & McKay, 2012).
o Richard, for example, would be repeatedly exposed to
non-contaminating objects or situations that he mistook
for contaminated, such as certain foods and household
chemicals, and his washing and checking rituals would
be disrupted.
o In extreme situations, patients can be admitted to the

hospital and have their bathroom sink faucets turned off
for a period of time to prevent them from washing their
hands repeatedly.
• Evidence-based psychological treatments for OCD have

looked at the efficacy of cognitive treatments with a focus on the

Phone No.: (082)300-5456/305-0647 Local 118
overestimation of threat, the importance and control of

intrusive thoughts, the sense of inflated responsibility
experienced by patients with OCD who believe they alone are
responsible for preventing a catastrophe, and the need for
perfectionism and certainty experienced by patients with OCD
(Whittal & Robichaud, 2012).
• Research has looked at the combined effects of medication and

psychological therapy (Tolin, 2012). Combining the treatments
resulted in no additional benefit. When the drug was taken
away, the medication-only group experienced a high rate of
relapse.
• Psychosurgery is one of the more radical treatments for OCD.

“Psychosurgery” is a misnomer that refers to neurosurgery for a
psychological disorder.
o These findings appear to be typical of surgical
procedures (Greenberg, Rauch, & Haber, 2010), and
they are similar to those of a procedure known as deep
brain stimulation, in which electrodes are inserted
through small holes drilled in the skull and connected to
a pacemaker-like device in the brain.
B. Body Dysmorphic Disorder

• While most people fantasize about improving themselves, some
relatively normal-looking people believe they are so ugly that
they refuse to interact with others or function normally for fear of
being laughed at. Body dysmorphic disorder (BDD) is a strange
affliction characterized by a preoccupation with some imagined
flaw in one's appearance by someone who appears to be
otherwise normal (Phillips, 1991).
THE CASE OF “JIM”: Ashamed To Be Seen

In his mid-20s, Jim was diagnosed with suspected social phobia; he was referred to our clinic
by another professional. Jim had just finished rabbinical school and had been offered a position at a
synagogue in a nearby city. He found himself unable to accept, however, because of marked social
difficulties. Lately he had given up leaving his small apartment for fear of running into people he knew
and being forced to stop and interact with them.
Jim was a good-looking young man of about average height, with dark hair and eyes. Although
he was somewhat depressed, a mental status exam and a brief interview focusing on current
functioning and past history did not reveal any remarkable problems. There was no sign of a psychotic
process (he was not out of touch with reality). We then focused on Jim’s social difficulties. We
expected the usual kinds of anxiety about interacting with people or “doing something” (performing)
in front of them. But this was not Jim’s concern. Rather, he was convinced that everyone, even his
good friends, was staring at a part of his body that he found grotesque. He reported that strangers
would never mention his deformity and his friends felt too sorry for him to mention it. Jim thought his
head was square! Like the Beast in Beauty and the Beast who could not imagine people reacting to
him with anything less than revulsion, Jim could not imagine people getting past his square head. To

Phone No.: (082)300-5456/305-0647 Local 118
hide his condition as well as he could, Jim wore soft floppy hats and was most comfortable in winter,
when he could all but completely cover his head with a large stocking cap. To us, Jim looked normal.
• People with BDD have persistent, intrusive, and horrible

thoughts about their appearance, and they engage in
compulsive behaviors like checking their physical features in
mirrors repeatedly.
• Table 5.12 shows the locations of imagined defects in 200

patients to give you a better idea of the types of concerns people
with BDD present to health professionals. These people had an
average of five to seven body areas that they were
concerned about (Phillips, Menard, Fay, & Weisberg, 2005).
• People with BDD frequently engage in a variety of checking or

compensating rituals in an attempt to alleviate their anxieties.
Excessive tanning (25 percent of the 200 subjects), as well as
excessive grooming and skin picking, are examples. Many
people who suffer from this condition become fixated on
mirrors (Veale & Riley, 2001).
• Between 33 percent and 50 percent of participants were

convinced their imagined bodily defect was real and a
reasonable source of concern in 200 cases examined by
Phillips, Menard, Fay, and Weisberg (2005) and 50 cases
reported by Veale, Boocock, and colleagues (1996).
• In cases where it is either delusional or not, because other

people with similar symptoms believe it is real when it is not,
different results were obtained. With the study done by Phillips
and his groups, two groups both respond equally well to
treatments for BDD and that the “delusional” group does
not respond to drug treatments for psychotic disorders
(Phillips et al., 2010). Thus, in DSM-5, patients receive a BDD
diagnosis, whether they are “delusional” or not.
2. Statistics
• According to studies, up to 70% of college students express at
least some dissatisfaction with their bodies, with 4% to 28%
of these appearing to meet all of the disorder's criteria
(Phillips, 2005).
• Overall, about 1% to 2% of individuals in community

samples and from 2% to 13% of student samples meet
criteria for BDD (Woolfolk & Allen, 2011).
• Both men and women are affected by BDD. 68.5 percent of

the 200 people studied by Phillips, Menard, Fay, and
Weisberg (2005) were females, but 62 percent of a large
number of people with BDD in Japan were males.

Phone No.: (082)300-5456/305-0647 Local 118
o Men 's BDD is more severe because they focus on

their body, genitals, and thinning hair. Women pay
more attention to a wider range of body parts and are
more likely to suffer from an eating disorder (Pope et
al., 2005).
• Age of onset ranges from early adolescence through the

20s, peaking at the age of 16–17 (Phillips, Menard, Fay, &
Weisberg, 2005).
• Only 21% of 183 patients in a prospective study improved

somewhat over the course of a year, and 15% of that group
relapsed during that year (Phillips, Pagano, Menard, & Stout,
2006).
• People with BDD behave in an unusual way because it

contradicts current cultural norms that place less emphasis on
changing facial features. In other words, people who simply
follow their culture's expectations are not disordered (as
noted in Lesson 1).
3. Causes
• The striking resemblance to OCD suggests that the two
disorders may have similar etiologies. Surprisingly, about 15%
of a group of 100 patients with eating disorders also had
comorbid BDD, with their body dysmorphic concerns unrelated
to weight or shape (Kollei, Schieber, de Zwaan, Svitak, & Martin,
2013).
4. Treatments
• First, drugs that block the re-uptake of serotonin, such as
clomipramine (Anafranil) and fluvoxamine (Luvox), help at
least some people (Hadley, Kim, Priday, & Hollander, 2006).
• Second, exposure and response prevention, the type of

cognitive-behavioral therapy that has been shown to help
people with OCD, has also been shown to help people with BDD
(Wilhelm, Otto, Lohr, & Deckersbach, 1999).
• Similar to OCD, cognitive-behavioral therapy produces

better and longer-lasting results than medication alone
(Buhlmann, Reese, Renaud, & Wilhelm, 2008). CBT, on the
other hand, is not as widely available as drugs.
a. Plastic Surgery and Other Medical Treatments

• BDD patients believe they are physically deformed in some
way and seek medical help to correct their deficiencies
(Woolfolk & Allen, 2011).

Phone No.: (082)300-5456/305-0647 Local 118
• The most common treatment was dermatology (skin),

which was followed by plastic surgery (45.2 percent) (23.2
percent). To put it another way, 11.9 percent of 268 patients
seeking dermatologist care met BDD criteria in one study
(Phillips et al., 2000).
• According to researchers, BDD affects anywhere from 8%

to 25% of all patients who seek plastic surgery (Crerand
et al., 2004). Rhinoplasty (nose jobs), facelifts, eyebrow
elevations, liposuction, breast augmentation, and
jawline surgery are the most common procedures.
• Phillips, Menard, Fay, and Pagano (2005) report that 81

percent of 50 people who sought surgery or other
medical advice were dissatisfied with the outcome.
• It is critical that plastic surgeons screen out these patients;

many do so in collaboration with psychologists who have
received medical training (Pruzinsky, 1988).
C. Other Obsessive-Compulsive and Related Disorders

1. Hoarding Disorder
• Estimates of prevalence range between 2 percent and 5 percent
of the population, which is twice as high as the prevalence of
OCD, with nearly equal numbers of men and women, and is
found worldwide (Frost, Steketee, & Tolin, 2012).
• 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 (Frost & Rasmussen,
2012).
• These people then feel anxious and distressed about

throwing anything away, because everything has either a
potential use or sentimental value in their minds, or it simply
becomes a part of their own identity.
• After many years of hoarding, these people are on average

around 50 years old when they seek treatment. They
frequently live alone (Frost & Rasmussen, 2012).
• New hoarding treatments developed at our clinic teach people

to assign different values to objects and to feel less anxious
about discarding items that are not as valuable (Grisham et al.,
2012).
2. Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin

Picking Disorder)

Phone No.: (082)300-5456/305-0647 Local 118
a. Trichotillomania
• Trichotillomania is the urge to pull one's own hair from any
part of the body, including the scalp, eyebrows, and arms.
• Compulsive hair pulling is more common than previously

thought, affecting between 1% and 5% of college
students, with females reporting the problem more
frequently than males (Scott, Hilty, & Brook, 2003).
• Trichotillomania may have a genetic component, as one

study discovered a rare genetic mutation in a small number
of people (Zuchner et al., 2006).
b. Excoriation
• Also known as skin picking disorder, this condition is
marked by compulsive and repetitive skin picking, which
causes tissue damage.
• Between 1% and 5% of the population suffers from

visible skin damage, necessitating medical attention in
some cases (Grant et al., 2012).
• Excoriation is also largely a female disorder.
• Prior to the DSM-5, both disorders were classified as

impulse control disorders, but it has since been
established that they frequently co-occur with obsessive-
compulsive disorder, body dysmorphic disorder, and
each other (Odlaug & Grant, 2012).
• The most evidence for success with these two disorders

comes from psychological treatments, particularly a
technique called "habit reversal training." Patients are
taught to be more aware of their repetitive behavior,
especially as it is about to begin, and to replace it with a
different behavior, such as chewing gum, applying a
soothing lotion to the skin, or some other reasonably
pleasurable but harmless activity (Nock et al., 2011).
• Drug treatments, mostly serotonin-specific reuptake

inhibitors, hold some promise, particularly for
trichotillomania, but the results have been mixed with
excoriation (Grant et al., 2012).

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: anxiety, fear, panic, panic attack, behavioral inhibition system, fight/flight system,
generalized anxiety disorder, panic disorder, agoraphobia, panic control treatment, specific
phobia, blood-injection-injury phobia, natural environment phobia, animal phobia, separation
anxiety disorder, social phobia, posttraumatic stress disorder, acute stress disorder,
adjustment disorders, attachment disorders, reactive attachment disorder, disinhibited social
engagement disorder, obsessive-compulsive disorder, obsessions, compulsions, body
dysmorphic disorder, trichotillomania, excoriation
lesson:

2. Barlow, D. H. (2000). Unraveling the mysteries of anxiety and its disorders from the
perspective of emotion theory. American Psychologist, 55, 1247-1263.
3. Barlow, D. H. (2001). Anxiety and its disorders: The nature and treatment of anxiety
and panic, 2nd ed. New York: Guilford.
4. Barlow, D. H., Brown, T. A., & Craske, M. G. (1994). Definitions of panic attacks and
panic disorder in the DSM-IV: Implications for research. Journal of Abnormal
Psychology, 103, 553-564.
5. Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory
perspective on the etiology of panic disorder. Psychological Review, 108, 4-32.
6. Clark, D. M (1988). A cognitive model of panic attacks. In S. Rachman & J. D. Maser

(Eds.), Panic: Psychological perspectives. Hillsdale, NJ: Lawrence Erlbaum,
71-89.
7. McNally, R. J. (1987). Preparedness and phobias: A review. Psychological Bulletin,

100, 283-303.
8. Clipson, C. & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA:
Houghton Mifflin Company. Chapter 2, Panic Disorder. Chapter 3, Obsessive-
Compulsive Disorder. Chapter 4, Posttraumatic Stress Disorder.
9. Craske, M. G. (2003). The origins of phobias and anxiety disorders: Why more women
than men? Amsterdam: Elsevier.
10. Eisen, A. R., Kearney, C. A., & Schaefer, C. E. (Eds.) (1995). Clinical handbook of
anxiety disorders in children and adolescents. Northvale, NJ: Jason Aronson.
11. McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor:
Theory, therapy and transformation. New York: Brunner/Mazel.

Phone No.: (082)300-5456/305-0647 Local 118
LESSON FIVE: SUMMATIVE TEST

Let’s Check
Now that the student knows the essential knowledge under lesson five, which is all about
Anxiety, Trauma- and Stressor-Related Disorders, and Obsessive-Compulsive Disorders. Let
us try to check the student's understanding of these terms.
1. Which of the following characterizes the mood-state known as anxiety?

a. Positive mood state c. Apprehension about the future
b. Reduced heart rate d. Muscle relaxation
2. People tend to have their best performance on tasks when they are ___________.
a. very anxious b. not anxious at all c. a little anxious d. fearful
3. According to Gray and McNaughton (1996), the fight-or-flight system is partially
activated by deficiencies in the neurotransmitter _______ in the brain.
a. serotonin b. dopamine c. acetylcholine d. norepinephrine
4. Which of the following is NOT a basic type of panic attack?
a. Expected b. Unexpected c. Cued d. Situation inevitable
5. Which of the following brain areas is NOT closely associated with anxiety?
a. Hippocampus b. Amygdala c. Prefrontal cortex d. Hypothalamus
6. Research suggests that anxiety and depression frequently
a. co-occurs.
b. are totally separate disorders.
c. can occur in the same person, but not at the same time.
d. shares no vulnerability.
7. Having an anxiety disorder increases the risk of ______________.

a. depression b. migraines c. suicidal ideation d. all of the above
8. For generalized anxiety disorder (GAD), the pharmacological treatment of choice has
been the category of drugs known as ___________.
a. benzodiazepines b. SSRIs c. tricyclics d. MAO inhibitors
9. An individual who suffers from panic disorder might become anxious about climbing
stairs, exercising, or being in hot rooms because these activities produce sensations
similar to those accompanying a panic attack. In psychological terms, the exercise and
hot rooms have become __________.
a. conditioned stimuli c. conditioned responses
b. unconditioned stimuli d. unconditioned responses

Phone No.: (082)300-5456/305-0647 Local 118
10. You are told about a child who has shown behavior consistent with "separation
anxiety." In order to determine if the child actually has a disorder or whether the
behavior is normal, you would first need to know
a. the child's age.
b. whether the child is a boy or a girl.
c. if other family members have anxiety disorders.
d. how long the child has shown this behavior.
11. In Japan, the anxiety syndrome termed taijin kyofusho involves a fear of
a. performing onstage. c. embarrassing oneself.
b. personally offending others. d. speaking to females.
12. Which of the following people is most likely to develop PTSD?

a. A child who has social support after surviving a trauma
b. A man who is very angry and blaming about a traumatic experience
c. A woman who was psychologically prepared for a possible disaster
d. An individual who watches extensive television coverage of a crisis
13. Actions, or sometimes thoughts, that an individual with OCD uses to reduce anxiety
are called ______.
a. operants b. fixations c. habits d. rituals
14. The most common type of obsession is related to ___________.

a. aggression b. sex c. contamination d. symmetry
15. A young child has thoughts about hating her younger brother and wishing he would
die. She becomes very anxious about these thoughts because she has developed the
idea that if anything really happened to him, it would be her fault. This pattern of
thinking is called _____________.
a. neutralizing c. thought suppression
b. thought-action fusion d. fundamental responsibility
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson five is not enough; what
matters is that the student should also be able to evaluate some criterions found in the DSM-
5. Now, the CF will require the student to EVALUATE THE GIVEN CASE by providing WHAT
THE PATIENT IS EXPERIENCING (what kind of disorder) using the DSM-5 found in the
COURSE RESOURCES Section.
Case Two: Under Anxiety Disorder – THE CASE OF LUCY
Lucy Gould “I’d rather have her with me, if that’s all right.” Lucy Gould was responding
to the clinician’s suggestion that her mother wait outside the office. “By now, I don’t have any
secrets from her.”
Since age 18, Lucy hadn’t gone anywhere without her mother. In fact, in those 6 years
she’d hardly been anywhere at all. “There’s no way I could go out by myself—it’s like entering
a war zone. If someone’s not with me, I can barely stand to go to doctor appointments and
stuff like that. But I still feel awfully nervous.”

Phone No.: (082)300-5456/305-0647 Local 118
The nervousness Lucy complained of hadn’t included actual panic attacks; she never
felt that she couldn’t breathe or was about to die. Rather, she experienced an intense motor
agitation that had caused her to flee from shopping malls, supermarkets, and movie theaters.
Nor could she ride on public transportation; buses and trains both terrified her. She had the
feeling, vague but always present, that something awful would happen there. Perhaps she
would become so anxious that she would pass out or wet herself, and no one would be able
to help her. She hadn’t been alone in public since the week before her high school
commencement. She had only been able to go up onto the platform to receive her diploma
because she was with her best friend, who would know what to do if she needed help.
Lucy had always been a timid, rather sensitive girl. The first week of kindergarten, she
had cried each time her mother left her by herself at school. But her father had insisted that
she “toughen up,” and within a few weeks she had nearly forgotten her terror. She’d
subsequently maintained a nearly perfect attendance record at school. Then, shortly after her
17th birthday, her father died of leukemia. Her terror of being away from home had begun
within a few weeks of his funeral.
To make ends meet, her mother had sold their house, and they had moved into a
condominium across the street from the high school. “It’s the only way I got through my last
year,” Lucy explained.
For several years, Lucy had kept house while her mother assembled circuit boards at
an electronics firm outside town. Lucy was perfectly comfortable in that role, even though her
mother was away for hours at a time. Her physical health had been good; she had never used
drugs or alcohol; and she had never had depression, suicidal ideas, delusions, or
hallucinations. But a year ago Lucy had developed insulin-dependent diabetes, which required
frequent trips to the doctor. She had tried to take the bus by herself, but after several failures—
once, in the middle of traffic, she had forced the rear door open and sprinted for home—she
had given up. Now her mother was applying for disability assistance so that she could remain
at home to provide the aid and attendance Lucy required.
Question for CASE TWO:

1. What is the diagnosis and what are the likely complications? Explain your answer
thoroughly. (20 Points)
2. How will you explain the diagnosis and possible treatment for Lucy? Explain your
answer thoroughly. (20 Points)
Case Three: Under Anxiety Disorder – THE CASE OF CECIL
Cecil Crane was only 24 when he was referred. “He came in here last week asking for a
rhinoplasty,” said the plastic surgeon on the telephone, “but his nose looks perfect to me. I
told him that, but he insisted there was something wrong with it. I’ve seen this kind of patient
before—if I operate, they’re never satisfied. It’s a lawsuit waiting to happen.”
When Cecil appeared a few days later, he had the most beautiful nose the clinician
had ever seen, apart from one or two Greek statues.
“What seems to be wrong with it?” “I was afraid you’d ask that,” said Cecil. “Everybody
says that.”
“But you don’t believe it?”
“Well, they look at me funny. Even at work—I sell suits at Macy’s—I sometimes feel
that the customers notice. I think it’s this bump here.”
Viewed from a certain angle, the area Cecil pointed out bore the barest suggestion of
a convexity. He complained that it had cost him his girlfriend, who always said it looked fine
Phone No.: (082)300-5456/305-0647 Local 118
to her. Weary of Cecil’s trying to look at his profile in every mirror he passed and banging on
about plastic surgery all the time, she’d finally sought greener pastures.
Cecil felt unhappy, though not depressed. He admitted that he was making a mess of
his life, but he had nevertheless maintained his interests in reading and going to the movies.
He thought his sex interest was good, though he’d had no chance to test it since the departure
of his girlfriend. His appetite was good, and his weight was about average for his height. His
flow of thought was unremarkable; its content, aside from his concern for his nose, seemed
quite ordinary. He even admitted that it was possible that his nose was less ugly than he
feared, though he thought that unlikely.
Cecil couldn’t say exactly when his worry about his nose began. It may have been
about the time he started shaving. He recalled frequently gazing at a silhouette of his profile
that had been cut from black paper during a seashore vacation with his family. Although
numerous relatives and friends had remarked that it was a good likeness, something about
the nose had bothered him. One day he had taken it down from the wall and, with a pair of
scissors, he’d tried to put it to rights. Within moments the nose lay in snippets on the kitchen
table, and Cecil was grounded for a month.
“I sure hope the plastic surgeon is a better artist than I am,” he commented.
Question for CASE THREE:

2. What are the possible treatment options? Explain your answer thoroughly. (20 Points)
In a Nutshell
Activity 1. In this lesson, we learned about Anxiety, Trauma- and Stressor-Related Disorders,
and Obsessive-Compulsive Disorders. In this section, I want you to write down what you had
learned or realized in this lesson. Provide at least 400 words.
Q&A List
lesson five. After being reviewed, questions related to the topics mentioned above will
1.
2.
3.
4.

Phone No.: (082)300-5456/305-0647 Local 118
5.
~End of Lesson Five~

Big Picture
to
a. Compare and contrast somatic symptom and related disorders and dissociative
disorders.
b. Illustrate the relationship of mood disorders and suicide.
Big Picture in Focus: ULOa. Compare and contrast somatic symptom and related
disorders and dissociative disorders.
LESSON SIX
Metalanguage
This lesson outlines the primary features of somatic symptom and related
disorders and dissociative disorders. With respect to the former, the symptoms,
prevalence, etiology, and treatment of somatic symptom disorder, illness anxiety
disorder, and conversion disorder (functional neurological symptom disorder) are
discussed, as well as psychological factors affecting a medical condition. For
dissociative disorders, depersonalization-derealization disorder and
dissociative amnesia (including dissociative fugue states) are discussed. The
lesson also describes the relation between malingering and factitious disorders in
the context of conversion reactions and dissociative identity disorder. In addition,
the major characteristics of dissociative trance and dissociative identity disorder are
described, including available treatment approaches.
• An individual with Somatic Symptom and Related Disorders is pathologically

concerned about the appearance or function of their bodies and brings these
concerns to the attention of health professionals, who typically find no
identifiable medical basis for the physical complaints.
• Dissociative Disorders on the other hand, are marked by shifts in

perceptions, such as a sense of disconnection from one's own self, the
world, or memories.
• Depersonalization-derealization disorder is a dissociative disorder in which

the individual's sense of personal reality (depersonalization) and the external
world's reality (derealization) are both temporarily lost.

Phone No.: (082)300-5456/305-0647 Local 118
Essential Knowledge
I. SOMATIC SYMPTOM AND RELATED DISORDERS

A. Somatic Symptom Disorder
• Illness anxiety disorder, psychosomatic symptom disorder,
psychological factors affecting medical condition, conversion disorder,
and factitious disorder are the five basic somatic symptom and
related disorders listed in the DSM-5. And, in general, they are all
pathologically preoccupied with their bodies.
• In 1859, a French physician named Pierre Briquet described patients

who came to him with seemingly endless lists of somatic complaints for
which he had no medical explanation (American Psychiatric
Association, 1980).
• Back in the day, Somatic Symptom Disorder was known as Briquet's

Syndrome.
THE CASE OF “LINDA”: Full-Time Patient

Linda, an intelligent woman in her 30s, came to our clinic looking distressed and pained. As she
sat down, she noted that coming into the office was difficult for her because she had trouble breathing
and considerable swelling in the joints of her legs and arms. She was also in some pain from chronic
urinary tract infections and might have to leave at any moment to go to the restroom, but she was
extremely happy she had kept the appointment. At least she was seeing someone who could help
alleviate her considerable suffering. She said she knew we would have to go through a detailed initial
interview, but she had something that might save time. At this point, she pulled out several sheets of
paper and handed them over. One section, some have pages long, described her contacts with the
health-care system for major difficulties only. Times, dates, potential diagnoses, and days
hospitalized were noted. The second section, one-and-a-half single-spaced pages, consisted of a list
of all medications she had taken for various complaints.
Linda felt she had any one of a number of chronic infections that nobody could properly
diagnose. She had begun to have these problems in her teenage years. She often discussed her
symptoms and fears with doctors and clergy. Drawn to hospitals and medical clinics, she had entered
nursing school after high school. During hospital training, however, she noticed her physical condition
deteriorating rapidly: she seemed to pick up the diseases she was learning about. A series of stressful
emotional events resulted in her leaving nursing school.
After developing unexplained paralysis in her legs, Linda was admitted to a psychiatric hospital,
and after a year she regained her ability to walk. On discharge she obtained disability status, which
freed her from having to work full time, and she volunteered at the local hospital. With her chronic
but fluctuating incapacitation, on some days she could go in and, on some days, she could not. She
was currently seeing a family practitioner and six specialists, who monitored various aspects of her
physical condition. She was also seeing two ministers for pastoral counseling.
• In the case at hand, Linda easily met all of the DSM-5's criteria. Linda
was severely impaired and had previously experienced paralysis

Phone No.: (082)300-5456/305-0647 Local 118
symptoms (which we refer to as a conversion symptom which will be

discuss later on this lesson).
• People with somatic symptom disorder do not always feel the

urgency to take action but continually feel weak and ill, and they
avoid exercising, thinking it will make them worse (Rief et al., 1998).
• Another important factor in this condition is that psychological or

behavioral factors, particularly anxiety and distress, are compounding
the severity and impairment associated with the physical symptoms,
rather than whether the physical symptom, in this case pain, has a clear
medical cause or not (Tomenson et al., 2012).
• In short, whether there are specific medical causes for discomfort or

not, these physical signs, such as pain, are true and hurt (Asmundson
& Carleton, 2009).
B. Illness Anxiety Disorder
THE CASE OF “GAIL”: Invisibly Ill

Gail was married at 21 and looked forward to a new life. As one of many children in a lower-
middle-class household, she felt weak and somewhat neglected and suffered from low self-esteem.
An older stepbrother berated and belittled her when he was drunk. Her mother and stepfather refused
to listen to her or believe her complaints. But she believed that marriage would solve everything; she

Phone No.: (082)300-5456/305-0647 Local 118
was finally someone special. Unfortunately, it didn’t work out that way. She soon discovered her
husband was continuing an affair with an old girlfriend.
Three years after her wedding, Gail came to our clinic complaining of anxiety and stress. She
was working parttime as a waitress and found her job extremely stressful. Although to the best of her
knowledge her husband had stopped seeing his former girlfriend, she had trouble getting the affair
out of her mind.
Although Gail complained initially of anxiety and stress, it soon became clear that her major
concerns were about her health. Any time she experienced minor physical symptoms such as
breathlessness or a headache, she was afraid she had a serious illness. A headache indicated a
brain tumor. Breathlessness was an impending heart attack. Other sensations were quickly
elaborated into the possibility of AIDS or cancer. Gail was afraid to go to sleep at night for fear that
she would stop breathing. She avoided exercise, drinking, and even laughing because the resulting
sensations upset her. Public restrooms and, on occasion, public telephones were feared as sources
of infection.
The major trigger of uncontrollable anxiety and fear was the news in the newspaper and on
television. Each time an article or show appeared on the “disease of the month,” Gail found herself
irresistibly drawn into it, intently noting symptoms that were part of the disease. For days afterward
she was vigilant, looking for the symptoms in herself and others and often noticing some physical
sensations that she would interpret as the beginnings of the disease. She even watched her dog
closely to see whether he was coming down with the dreaded disease. Only with great effort could
she dismiss these thoughts after several days. Real illness in a friend or relative would incapacitate
her for days at a time.
Gail’s fears developed during the first year of her marriage, around the time she learned of her
husband’s affair. At first, she spent a great deal of time and more money than they could afford going
to doctors. Over the years, she heard the same thing during each visit: “There’s nothing wrong with
you; you’re perfectly healthy.” Finally, she stopped going, as she became convinced her concerns
were excessive, but her fears did not go away and she was chronically miserable.
• The word "hypochondriasis" was once used to describe
illness anxiety disorder, and it is still commonly used today.
Illness anxiety disorder is characterized by a preoccupation with
the prospect of being ill rather than with the physical symptom
itself.
• Do you see any distinctions between Linda and Gail, who both
presented with somatic symptom disorder and illness anxiety
disorder, respectively? There is a lot of overlap (Creed &
Barsky, 2004), but Gail's symptoms are somewhat typical of
illness anxiety disorder. She was less concerned about the
single physical symptom and more concerned with the fact that
she was either sick or developing an illness.
• According to research, disease anxiety disorder and somatic

symptom disorder share many characteristics with anxiety and
mood disorders, particularly panic disorder (Creed & Barsky,
2004), such as similar onset ages, personality traits, and
familial aggregation patterns (running in families).

Phone No.: (082)300-5456/305-0647 Local 118
• Another significant characteristic of these disorders is that

promises from a number of physicians that all is fine and the
person is fine have only a temporary effect. It does not take long
for patients like Gail or Linda to return to another doctor's
office, assuming that the previous doctor overlooked anything.
o This is because many of these individuals mistakenly
believe they have a disease, a difficult-to-shake
belief sometimes referred to as “disease conviction”
(Haenen, de Jong, Schmidt, Stevens, & Visser, 2000).
2. Statistics
• The median incidence rate for hypochondriasis in primary
care settings is 6.7 percent, but as high as 16.6 percent for
distressing somatic symptoms, which may closely
approximate the combined prevalence of somatic symptom
disorder and disease anxiety disorder in these settings (Creed
& Barsky, 2004).
• Somatic symptom conditions, like most anxiety and mood

disorders, are long-term or chronic (Taylor & Asmundson,
2009).
• Some studies have shown that people with what is now known
as somatic symptom disorder are more likely to be women,
single, and from lower socioeconomic classes (Creed &
Barsky, 2004).
• Individuals may have psychological complaints, such as anxiety

or mood disorders, in addition to a number of somatic
complaints (Lieb et al., 2008).
• Culture-specific syndromes, including anxiety disorders,

seem to align well with somatic symptom disorders (Kirmayer &
Sartorius, 2007).
o Most Chinese men suffer from koro, a condition in which
they believe their genitals are retracting into the
abdomen, which is followed by extreme anxiety and
occasionally panic.
o According to Rubin (1982), typical sufferers are guilty of

unnecessary masturbation, inadequate intimacy, or
promiscuity.
o Anxiety about losing sperm, which occurs naturally

during sexual activity, is another culture-specific
condition that is common in India. The condition is
known as dhat, and it is characterized by a wide range
of physical symptoms such as dizziness, exhaustion,
and fatigue (Ranjith & Mohan, 2004).

Phone No.: (082)300-5456/305-0647 Local 118
o Other culture-specific somatic symptoms linked to

emotional causes include hot sensations in the head or
a feeling of something crawling in the head in African
patients, and a burning sensation in the hands and feet
in Pakistani or Indian patients (Kirmayer & Weiss, 1993).
3. Causes
• Because faulty interpretation of physical signs and sensations
as proof of physical illness is so important, almost all agrees that
these disorders are mostly cognitive or perception disorders
with significant emotional components (Witthöft & Hiller, 2010).
• Anxiety increases physical symptoms, creating a vicious

cycle (see Figure 6.1, which was originally designed to apply to
DSM-IV hypochondriasis but also applies to DSM-5 somatic
symptom disorder and illness anxiety disorder) (Witthöft & Hiller,
2010).
• Patients interpret ambiguous stimuli as dangerous (Haenen

et al., 2000). As a result, they are acutely aware (and terrified)
of any sign of illness or disease. For example, a minor headache
could be misinterpreted as a sure sign of a brain tumor.
• There is a good chance the underlying causes of these

disorders are the same as those linked to anxiety disorders.

Phone No.: (082)300-5456/305-0647 Local 118
Evidence shows, for example, that somatic symptom disorders

run in families and that there is a small genetic component
(Taylor, Thordarson, Jang, & Asmundson, 2006).
• Three other factors may contribute to this etiological process

(Côté et al., 1996; Kellner, 1985).
o First, as with many disorders, including anxiety
disorders, these disorders appear to develop in the
context of a stressful life event. Death or illness are
common occurrences in such situations (Noyes et al.,
2004).
o Second, people who develop these disorders are more

likely to have grown up in a family with a high prevalence
of disease.
o Third, there may be a significant social and

interpersonal influence (Barlow et al., 2013).
4. Treatment
• When it came to treatment, there was very little. Clinical reports,
however, show that reassurance and education appear to be
effective in some cases (Haenen et al., 2000); “surprisingly”
because patients with these disorders are not supposed to
benefit from reassurance about their health by definition.
o Mental health professionals may be able to reassure
patients in a more effective and sensitive manner,
devote enough time to all of the patient's concerns, and
pay attention to the "meaning" of the symptoms (for
example, their relationship to the patient's life stress).

Phone No.: (082)300-5456/305-0647 Local 118
• Explanatory Therapy is a treatment method in which the

clinician goes over the cause and origins of the patient's
symptoms in great detail. Another treatment option for this
disorder is Cognitive-Behavioral Therapy, which focuses on
identifying and challenging illness-related misinterpretations of
physical sensations, as well as teaching patients how to create
"symptoms" by concentrating attention on specific body areas
(Thomson & Page, 2007).
• A few reports also suggest the use of medications, particularly

antidepressants (Paxil or SSRIs), to treat anxiety and
depression.
C. Psychological Factors Affecting Medical Condition

1. The presence of a diagnosed medical condition such as asthma,
diabetes, or severe pain clearly caused by a known medical condition
that is adversely affected by one or more psychological or
behavioral factors is the most important feature of this disorder.
• For example, having severe anxiety that causes an asthmatic
condition to deteriorate. Another example is a diabetic
patient who refuses to check insulin levels on a regular
basis and intervene when necessary.
D. Conversion Disorder (Functional Neurological Symptom Disorder)

• It usually involves physical malfunctions such as paralysis,
blindness, or difficulty speaking (aphonia), with no physical
or organic pathology to explain the malfunction (Finkenbine
& Miele, 2004).
• Although conversion symptoms can mimic the full range of

physical malfunctioning, they suggest that sensory-motor
systems are being affected by a neurological disease
(Finkenbine & Miele, 2004).
• Another relatively common symptom is globus hystericus, a

lump in the throat that makes swallowing, eating, and
sometimes talking difficult (Finkenbine & Miele, 2004).
THE CASE OF “ELOISE”: Unlearning Walking

Eloise sat on a chair with her legs under her, refusing to put her feet on the floor. Her mother
sat close by, ready to assist her if she needed to move or get up. Her mother had made the
appointment and, with the help of a friend, had all but carried Eloise into the office. Eloise was a 20-
year-old of borderline intelligence who was friendly and personable during the initial interview and
who readily answered all questions with a big smile. She obviously enjoyed the social interaction.
Eloise’s difficulty walking developed over 5 years. Her right leg had given way and she began
falling. Gradually, the condition worsened to the point that 6 months before her admission to the
hospital Eloise could move around only by crawling on the floor.
Physical examinations revealed no physical problems. Eloise presented with a classic case of
conversion disorder. Although she was not paralyzed, her specific symptoms included weakness in

Phone No.: (082)300-5456/305-0647 Local 118
her legs and difficulty keeping her balance, with the result that she fell often. This particular type of
conversion symptom is called astasia-abasia.
Eloise lived with her mother, who ran a gift shop in the front her house in a small rural town.
Eloise had been schooled through special education programs until she was about 15; after this, no
further programs were available. When Eloise began staying home, her walking began to deteriorate.
2. Closely Related Disorders

• It can be difficult to distinguish conversion disorders from other
disorders such as malingering (faking).
• An attitude known as La Belle Indifférence is thought to be

related to conversion disorder, which manifests as symptoms in
some people with severe somatic symptom disorders.
• Stone, Smyth, Carson, Warlow, and Sharpe (2006) discovered

that people with actual physical disorders can have a blasé
attitude toward illness, and that some people with conversion
symptoms can become quite distressed.
• Stress appears to be a common trigger for conversion

symptoms. This stress is frequently manifested as a physical
injury. In one large survey, 324 out of 869 patients (37%) said
they had previously suffered a physical injury (Stone,
Carson, Aditya, et al., 2009).
• In any case, ruling out medical causes for the symptoms is

critical to making a conversion diagnosis, and this is the primary
diagnostic criterion in DSM-5, given advances in medical
screening procedures (APA, 2013).
• Some conversion symptoms include movements that are

perceived as involuntary, such as tremors. They used
functional magnetic resonance imaging (fMRI) to compare
brain activity during the conversion tremor and a voluntary
"mimicked" tremor in which patients were instructed to produce
the tremor on purpose in a clever experiment (Voon et al., 2010).
o In other words, if a person wants to move her arm and
then decides to do so, this part of the brain determines
whether the desired action has taken place. Because we
think about making a movement before we actually do it,
our brain assumes (correctly in most cases) that we are
the ones who made it happen.
a. Factitious Disorder – a conditions that is a hybrid of malingering

and conversion disorders. As with malingering, the symptoms are
under voluntary control, but there is no obvious reason for
voluntarily producing the symptoms other than to assume the sick
role and receive more attention.
• When this disorder is extended to other family members,
such as when a mother purposefully makes her child sick in

Phone No.: (082)300-5456/305-0647 Local 118
exchange for the attention and sympathy she receives as

the mother of a sick child, this is referred to as factitious
disorder imposed on another, also known as
Munchausen Syndrome by Proxy (Check, 1998).
• There is a difference between typical child abuse and

factitious disorder imposed on another. Refer to Table 6.2.
3. Unconscious Mental Processes

• Although unconscious cognitive processes appear to play a role
in much of psychopathology (though not always in the way
Freud imagined), nowhere is this phenomenon more readily and
dramatically apparent than when trying to distinguish between
conversion disorders and related conditions.
• Sackeim, Nordlie, and Gur (1979) hypnotized two participants

and suggested total blindness to each of them to see if there

Phone No.: (082)300-5456/305-0647 Local 118
was a difference between real unconscious processes and

faking.
• Grosz and Zimmerman (1965) evaluated a male who appeared

to have conversion symptoms of blindness in a previous case.
They discovered that he performed significantly worse on a
visual discrimination task than would be expected by chance.
Other sources of information later confirmed that he was almost
certainly lying.
• To review these distinctions, someone who is truly blind would

perform on visual discrimination tasks at a chance level. People
who suffer from conversion symptoms, on the other hand, can
see objects in their visual field and thus perform well on these
tasks, but this experience is separate from their awareness of
sight. Malingerers and, possibly, people with factitious disorders
do everything they can to hide their inability to see.
4. Statistics
• In neurological settings, the prevalence estimate is high,
averaging around 30%. According to one study, psychogenic,
non-epileptic seizures affect 30% of all patients referred to
epilepsy centers (Schoenberg, Marsh, & Benbadis, 2012).
• Conversion disorders, like severe somatic symptom disorder,

are mostly found in women (Brown & Lewis-Fernandez,
2011), and they usually start in adolescence or shortly
afterward.
• Some conversion symptoms are common in religious or

healing rituals in other cultures. Seizures, paralysis, and
trances are common among some rural fundamentalist religious
groups in the United States (Grifith, English, & Mayfield, 1980),
and they are frequently interpreted as signs of divine contact.
5. Causes
• Freud described four basic processes in the development of
conversion disorder.
o First, the person goes through a traumatic event, which
Freud defined as an unacceptable, unconscious conflict.
o Second, the person represses the conflict, making it

unconscious, because the conflict and the anxiety it
causes are unacceptable.
o Third, the anxiety grows and threatens to manifest itself

in consciousness, so the person “converts” it into
physical symptoms, relieving the pressure of having to
deal with the conflict directly (Primary Gain).

Phone No.: (082)300-5456/305-0647 Local 118
o Fourth, the individual receives much more attention and

sympathy from loved ones, as well as the opportunity to
avoid a difficult situation or task (Secondary Gain).
• Most people with conversion disorder have been through a

traumatic event that they must avoid at all costs (Brown & Lewis-
Fernandez, 2011).
• Mothers who were rated as "overinvolved" or

"overprotective" were more likely to pay attention to and
reinforce these psychologically based visual symptoms
(Wynick, Hobson, & Jones, 1997).
• Conversion disorder, like somatic symptom disorder, is

influenced by social and cultural factors. It is more common
in less educated, lower socioeconomic groups with limited
knowledge of disease and medical illness (Woolfolk & Allen,
2011).
• Using brain-imaging procedures, neuroscientists are

increasingly discovering a strong connection between the
conversion symptom and parts of the brain that regulate
emotion, such as the amygdala (Bryant & Das, 2012).
6. Treatment
• Identifying and attending to the traumatic or stressful life event,
if it is still present, is a key strategy in treating conversion
disorder (either in real life or in memory).
• The therapist must also make every effort to minimize any

reinforcing or supportive effects of the conversion symptoms
(secondary gain).
• A group of 45 patients with mostly motor behavior conversions

(for example, difficulty walking) responded well to treatment
after following similar cognitive-behavioral programs (Moene et
al., 2003).
II. DISSOCIATIVE DISORDERS

• More than a century ago, Morton Prince, the founder of the Journal of
Abnormal Psychology, observed that many people experience
dissociation on occasion. It's possible that it'll happen after a particularly
stressful event, such as an accident (Spiegel, 2010).
• About half of the general population will experience dissociation at some

point in their lives, and studies show that between 31 percent and 66
percent of people who experience a traumatic event will experience
this feeling (Keane, Marx, Sloan & DePrince, 2011).
• These kinds of experiences can be divided into two types.

Phone No.: (082)300-5456/305-0647 Local 118
o Depersonalization – an episode in which your perception shifts

and you lose track of your own reality for a brief period of time, as if
you were dreaming and watching yourself.
o Derealization – a state in which your sense of the external world's

reality is shattered. Things might appear to change shape or size,
and people might appear to be dead or mechanical.
A. Depersonalization-Derealization Disorder
1. Clinicians may diagnose depersonalization-derealization disorder
when feelings of unreality are so severe and frightening that they take
over an individual's life and prevent normal functioning.
THE CASE OF “BONNIE”: Dancing Away from Herself

Bonnie, a dance teacher in her late 20s, was accompanied by
her husband when she first visited the clinic and complained of
“flipping out.” When asked what she meant, she said, “It’s the
scariest thing in the world. It often happens when I’m teaching my
modern dance class. I’ll be up in front and I will feel focused on.
Then, as I’m demonstrating the steps, I just feel like it’s not really
me and that I don’t really have control of my legs. Sometimes I feel
like I’m standing in back of myself just watching. Also, I get tunnel
vision. It seems like I can only see in a narrow space right in front of
me and I just get totally separated from what’s going on around me.
Then I begin to panic and perspire and shake.” It turns out that
Bonnie’s problems began after she smoked marijuana for the first
time about 10 years before. She had the same feeling then and
found it scary, but with the help of friends she got through it. Lately
the feeling recurred more often and more severely, particularly when
she was teaching dance class.
2. According to surveys, this disorder affects between 0.8 and 2.8 percent
of the population (Spiegel et al., 2011).
3. The average age of onset was 16 years, and the disease was chronic
in nature. All of the patients were severely handicapped. These
individuals are also prone to anxiety, mood, and personality disorders
(Johnson et al., 2006).
4. It is unclear how these cognitive and perceptual deficits arise, but they
appear to correlate with the patients' reports of "tunnel vision"
(perceptual distortions) and "mind emptiness" (difficulty absorbing
new information) (Johnson et al., 2006).
5. Neuroimaging studies have now confirmed perception and emotion

regulation deficits (Simeon, 2009). Other research has found
Phone No.: (082)300-5456/305-0647 Local 118
dysregulation in the hypothalamic–pituitary–adrenocortical (HPA)

axis in these patients when compared to healthy controls (Spiegel et
al., 2013), implying emotional deficits once again.
B. Dissociative Amnesia
1. Generalized amnesia refers to the inability to remember anything,
including one's own identity. While selective amnesia refers to a failure
to recall specific events, usually traumatic, that occurred during a
specific period of time, localized amnesia refers to a failure to recall
specific events that occurred during a specific period of time (Spiegel et
al., 2013).
THE CASE OF “The Woman Who Lost Her Memory”

Several years ago, a woman in her early 50s brought her daughter to one of our clinics because of
the girl’s refusal to attend school and other severely disruptive behavior. The father, who refused to come
to the session, was quarrelsome, a heavy drinker, and, on occasion, abusive. The girl’s brother, now in
his mid-20s, lived at home and was a burden on the family. Several times a week a major battle erupted,
complete with shouting, pushing, and shoving, as each member of the family blamed the others for all
their problems. The mother, a strong woman, was clearly the peacemaker responsible for holding the
family together. Approximately every 6 months, usually after a family battle, the mother lost her memory
and the family had her admitted to the hospital. After a few days away from the turmoil, the mother
regained her memory and went home, only to repeat the cycle in the coming months. Although we did not
treat this family (they lived too far away), the situation resolved itself when the children moved away and
the stress decreased.
2. The woman had amnesia in this case, but not for the events
themselves, but for her intense emotional reactions to them. The
absence of subjective emotion experience, which is common in
depersonalization-derealization disorder and has been confirmed by
brain imaging studies (Phillips et al., 2001), becomes prominent here.
3. Dissociative fugue (Ross, 2009) is a subtype of dissociative amnesia,

with fugue literally meaning "flight" (fugitive is from the same root).
Memory loss in these unusual cases is linked to a specific event,
such as an unexpected trip (or trips). During these trips, a person may
adopt a new identity or become confused about their current one.
4. Dissociative amnesia is a type of amnesia that develops in adults after

adolescence. After the age of 50, it is uncommon for dissociative
amnesia to manifest for the first time (Sackeim & Devanand, 1991).
5. The prevalence of dissociative amnesia ranges from 1.8 percent to

7.3 percent, implying that it is the most common of all dissociative
disorders (Spiegel et al., 2011).
6. Amok (as in "running amok") is a seemingly distinct dissociative state

not found in Western cultures. Most people with this disorder are
males. Amok has gotten a lot of attention because people in this
trancelike state frequently assault and kill people and animals.

Phone No.: (082)300-5456/305-0647 Local 118

Phone No.: (082)300-5456/305-0647 Local 118
THE CASE OF “JEFFREY”: A Troubled Trip

An amnesia sufferer who had been searching for his identity for more than a month was
back in Washington state with his fiancée on Tuesday, but he still doesn’t remember his past
life or what happened, his mother said.
Jeffrey Alan Ingram, 40, was diagnosed in Denver with dissociative fugue, a type of
amnesia.
He has had similar bouts of amnesia in the past, likely triggered by stress, once
disappearing for 9 months. When he went missing this time, on September 6, he had been on
his way to Canada to visit a friend who was dying of cancer, said his fiancée, Penny Hansen.
“I think that the stress, the sadness, the grief of facing a best friend dying was enough,
and leaving me was enough to send him into an amnesia state,” Hansen told KCNC-TV.
When Ingram found himself in Denver on September 10, he didn’t know who he was. He
said he walked around for about 6 hours asking people for help, then ended up at a hospital,
where police spokeswoman Virginia Quinones said Ingram was diagnosed with a type of
amnesia known as dissociative fugue.
Searched for his identity. Ingram’s identity came to light last weekend after he
appeared on several news shows asking the public for help: “If anybody recognizes me, knows
who I am, please let somebody know.”
“Penny’s brother called her right away and told her ‘Did you watch this newscast?’ and ‘I
think that’s Jeff that they’re showing on television,’” said Marilyn Meehan, a spokeswoman for
Hansen.
Hansen had "led a missing person report after Ingram failed to show up at her mother’s
home in Bellingham, Washington, on his way to Canada, but officials searching for him had
turned up nothing.
On Monday night, two Denver police detectives accompanied Ingram on a flight to
Seattle, where he was reunited with his fiancée.
His mother, Doreen Tompkins of Slave Lake, Alberta, was in tears as she talked about
the struggle her son and the family still face.
“It’s going to be very difficult again, but you know what, I can do it,” she told CTV news of
Edmonton, Alberta. “I did it before, I can do it again. I’ll do it as many times as I have to just so
I can have my son.”
Memory never fully regained. Ingram had experienced an episode of amnesia in 1995
when he disappeared during a trip to a grocery store. Nine months later, he was found in a
Seattle hospital, according to Thurston County, Washington, officials. His mother said he never
fully regained his memory.
Meehan, who works with Hansen at the state Utilities and Transportation Commission,
said the couple would not give interviews because they want to concentrate on Ingram’s effort
to regain his memory.
They’re taking it one step at a time,” Meehan said.
“He said that while her face wasn’t familiar to him, her heart was familiar to him,” she
said. “He can’t remember his home, but he said their home felt like home to him.”
© 2006 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or
redistributed.
7. Running disorder is known as pivloktoq among Arctic indigenous

peoples. Women are well-known for it. It's known as frenzy witchcraft
among the Navajo tribe.
8. The typical dissociative symptoms, such as sudden personality

changes, are attributed to possession by a culturally significant spirit.

Phone No.: (082)300-5456/305-0647 Local 118
9. In India, Nigeria (where they are known as vinvusa), Thailand (phii

pob), and other Asian and African countries, dissociative trances are
common (van Duijil, Cardea, & de Jong, 2005). Dissociation is
commonly observed in African American prayer meetings, Native
American rituals, and Puerto Rican spiritist sessions in the United
States (Comas-Diaz, 1981).
C. Dissociative Identity Disorder

• People with dissociative identity disorder (DID) may have up to 100
different identities coexisting at the same time, but the average is closer
to 15.
• However, since the identities are only partly separate in certain

situations, only a few traits are distinct, so it is not true that there are
"multiple" full personalities. As a result, the condition's name was
changed from multiple personality disorder to DID in the most recent
version of the DSM, DSM-IV.
THE CASE OF “JONAH”: Bewildering Blackouts

Jonah, 27 years old and black, suffered from severe headaches that were unbearably painful
and lasted for increasingly longer periods. Furthermore, he couldn’t remember things that happened
while he had a headache, except that sometimes a great deal of time passed. Finally, after a
particularly bad night, when he could stand it no longer, he arranged for admission to the local
hospital. What prompted Jonah to come to the hospital, however, was that other people told him
what he did during his severe headaches. For example, he was told that the night before he had a
violent fight with another man and attempted to stab him. He $ed the scene and was shot at during
a high-speed chase by the police. His wife told him that during a previous headache he chased her
and his 3-year-old daughter out of the house, threatening them with a butcher knife. During his
headaches, and while he was violent, he called himself “Usoffa Abdulla, son of Omega.” Once he
attempted to drown a man in a river. The man survived, and Jonah escaped by swimming a quarter
of a mile upstream. He woke up the next morning in his own bed, soaking wet, with no memory of
the incident.
• In addition to Jonah, the workers identified three distinct
personalities or alters. (In DID, the word "alters" refers to the
various identities or personalities.)
o Sammy was the name of the first alter. Sammy seemed
to be logical, calm, and in command.
o The second alter, King Young, seemed to be in control

of all sexual activity, with a strong interest in as many
heterosexual encounters as possible.
o The third alter was Usoffa Abdulla, a violent and

dangerous man.
• Amnesia, such as dissociative amnesia, is one of the DSM-5

conditions for DID. However, identity has fragmented in DID. It

Phone No.: (082)300-5456/305-0647 Local 118
makes little difference how many personalities live inside one

body, whether there are three, four, or even 100.
2. Characteristics
• A "host" persona is someone who pretends to be a patient and
requests medication.
• A switch is the change from one personality to another. The

transition is usually instantaneous (although in movies and on
television it is often drawn out for dramatic effect). During
switches, physical transformations can occur. Posture, facial
expressions, wrinkling patterns on the face, and even
physical disabilities can appear (Putnam, Guroff, Silberman,
Barban, & Post, 1986).
3. Can DID Be Faked?

• This issue, like conversion disorders, is difficult to answer for a
variety of reasons (Kluft, 1999). First, research suggests that
people with DID are susceptible to suggestion (Giesbrecht et
al., 2008)

Phone No.: (082)300-5456/305-0647 Local 118
THE CASE OF “KENNETH”: The Hillside Strangler

During the late 1970s, Kenneth Bianchi brutally raped and murdered 10 young women in
the Los Angeles area and left their bodies naked and in full view on the sides of various
hills. Despite overwhelming evidence that Bianchi was the “Hillside Strangler,” he continued to
assert his innocence, prompting some professionals to think he might have DID. His lawyer
brought in a clinical psychologist, who hypnotized him and asked whether there was another
part of Ken with whom he could speak. Guess what? Somebody called “Steve” answered and
said he had done all the killing. Steve also said that Ken knew nothing about the murders. With
this evidence, the lawyer entered a plea of not guilty by reason of insanity.
The prosecution called on the late Martin Orne, a distinguished clinical psychologist and
psychiatrist who was one of the world’s leading experts on hypnosis and dissociative disorders
(Orne, Dinges, & Orne, 1984). Orne used procedures similar to those we described in the
context of conversion blindness to determine whether Bianchi was simulating DID or had a true
psychological disorder. For example, Orne suggested during an in-depth interview with Bianchi
that a true multiple personality disorder included at least three personalities. Bianchi soon
produced a third personality. By interviewing Bianchi’s friends and relatives, Orne established
that there was no independent corroboration of different personalities before Bianchi’s arrest.
Psychological tests also failed to show significant differences among the personalities; true
fragmented identities often score differently on personality tests. Several textbooks on
psychopathology were found in Bianchi’s room; therefore, he presumably had studied the
subject. Orne concluded that Bianchi responded like someone simulating hypnosis, not
someone deeply hypnotized. On the basis of Orne’s testimony, Bianchi was found guilty and
sentenced to life in prison.
• When cognitive science methodologies are used to evaluate
memory, especially implicit (unconscious) memory, patients
with DID's memory processes are found to be no different
than "normals" (Huntjens, Postma, Peters, Woertman, & van
der Hart, 2003).
• Based on these observations on faking and the impact of

hypnosis, Spanos (1996) proposed that therapists who
unwittingly implied the presence of alters to suggestible
individuals could account for the majority of DID symptoms, a
model known as the "sociocognitive model" since the
likelihood of identity fragments and early trauma is socially
reinforced by a therapist (Kihlstrom, 2005).
• According to some objective tests, many people with

fragmented identities are not consciously and willingly
simulating. The Three Faces of Eve were studied, and it was
discovered that one of the personalities (Eve Black) had a
transient microstrabismus (difference in joined lateral eye
movements) that was not present in the other personalities.
o Optical changes such as visual acuity, manifest
refraction, and eye muscle balance are difficult to fake,
according to S. D. Miller (1989).
o Subsequent research has confirmed that different alters

have different psychophysiological profiles (Cardea &
Gleaves, 2003).

Phone No.: (082)300-5456/305-0647 Local 118
4. Statistics
• The female-to-male ratio among people with DID can be as high
as 9:1, though these figures are based on case studies rather
than survey research (Maldonado, Butler, & Spiegel, 1998).
• The disorder appears almost always in childhood, often as

early as 4 years of age, though it is usually 7 years after the
symptoms appear before the disorder is recognized (Maldonado
et al., 1998).
• Although some evidence suggests that the frequency of

switching decreases with age, the form DID takes does not
appear to change significantly over a person's lifetime (Sackeim
& Devanand, 1991).
• A prevalence of 1.5 percent was found during the previous year

in the best survey to date in a nonclinical (community) setting
(Johnson et al., 2006).
• A large percentage of DID patients suffer from multiple

psychological disorders at the same time, such as anxiety,
substance abuse, depression, and personality disorders
(Giesbrecht et al., 2008).
• Despite the lack of systematic studies, DID appears to exist in

a variety of cultures around the world, particularly in terms of
possession, which is one manifestation of DID (Ross, 1997).
5. Causes
• Observations have led to widespread agreement that DID stems
from a natural desire to flee or "dissociate" from the unrelenting
negative affect associated with severe abuse (Kluft, 1984,
1991). Lack of social support during or after the abuse appears
to be a factor as well.
• Dissociative experiences were also influenced by individual

experiences and personality traits (Waller & Ross, 1997).
• It is quite common for otherwise normal people to seek relief

from emotional or physical pain in some way (Spiegel et al.,
2013).
• One theory suggests that DID is an extreme subtype of PTSD,

with a focus on the process of dissociation rather than anxiety
symptoms, despite the fact that both are present in each
disorder (Butler et al., 1996).
6. Suggestibility
• Suggestibility, like weight and height, is a personality trait that is
evenly distributed throughout the population.

Phone No.: (082)300-5456/305-0647 Local 118
• It also appears to be linked to being easily hypnotized or

suggestible (some people equate the terms suggestibility and
hypnotizability). Dissociation is similar to hypnotic trance
(Spiegel et al., 2013).
• There is also the self-hypnosis phenomenon, in which people

can dissociate from most of the world around them and
"suggest" to themselves that they won't feel pain in one of their
hands, for example.
• People who are suggestible, according to the autohypnotic

model, may be able to use dissociation as a defense against
extreme trauma (Putnam, 1991).
7. Biological Contributions
• Patients with DID have a smaller hippocampal and amygdala
volume than “normals,” similar to PTSD patients (Vermetten,
Schmahl, Lindner, Loewenstein, & Bremner, 2006).
• People who have certain neurological disorders, especially

seizure disorders, have a lot of dissociative symptoms (Bowman
& Coons, 2000).
• Finally, there is strong evidence that sleep deprivation causes

dissociative symptoms such as vivid hallucinations (van der
Kloet, Giesbrecht, Lynn, Merckelbach, & de Zutter, 2012).
8. Real Memories and False

• Retrospective case studies suggest that people with
dissociation, particularly those with DID, may have been
exposed to severe trauma as a child, such as sexual abuse, but
have dissociated themselves from it and "repressed" the
memory.
• On the one hand, if early sexual abuse did occur but was
forgotten due to dissociative amnesia, it is critical to relive
aspects of the trauma under the supervision of a skilled therapist
in order to alleviate current suffering.
• There is irrefutable evidence that false memories can be created

by psychological processes that are relatively well understood
(Bernstein & Loftus, 2009).
• Young children are notoriously unreliable when it comes to

reporting accurate details of events, especially emotional
ones (Toth et al., 2011).
• The findings suggest that memories are malleable and easily

distorted, especially in people with certain personality traits and

Phone No.: (082)300-5456/305-0647 Local 118
characteristics like vivid imaginal abilities (absorption) and an

openness to novel ideas (McNally, 2012).
• McNally and Geraerts (2009) also present evidence that some

people simply forget their early experiences after many years
and recall them when confronted with reminders outside of
therapy.
9. Treatment
• Therapy focuses on helping patients recall what happened
during their amnesic or fugue states, often with the help of
friends or family members who know what happened, so
that they can confront and integrate the information into their
conscious experience.
• Hypnosis or benzodiazepines (minor tranquilizers) have been

used in more difficult cases, with the therapist suggesting that
remembering the events is fine (Maldonado et al., 1998).
• Therapists' current DID treatment strategies are based on years

of clinical experience as well as procedures that have proven
effective with PTSD (Keane, Marx, Sloan & De Prince, 2011).
Hypnosis is frequently used to access hidden memories and
bring various alters to consciousness.
• The limited clinical evidence suggests that antidepressant

medications may be appropriate in some cases (Kluft, 1996).

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: somatic symptom disorder, dissociative disorder, illness anxiety disorder,
conversion disorder, malingering, factitious disorder, derealization, derealization-
depersonalization disorder, dissociative amnesia, generalize amnesia, localized or selective
amnesia, dissociative fugue, dissociative identity disorder (DID), dissociative trance disorder,
alters
lesson:

2. Bliss, E. L. (1980). Multiple personalities?: A report of 14 cases with implications for

schizophrenia and hysteria. Archives of General Psychiatry, 37, 1388-1397.
3. Chase, T. (1990). When rabbit howls. New York: Jove.
4. Ford, C. V. (1995). Dimensions of somatization and hypochondriasis. Special issue:

Malingering and conversion reactions. Neurological Clinics, 13, 241-253.
5. Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger.
6. Kellner, R. (1991). Psychosomatic syndromes and somatic symptoms. Washington,

DC: American Psychiatric Press.
7. Kluft, R. P. (1991). Multiple personality disorder. In A. Tasman & S. M. Goldfinger

(Eds.), American Psychiatric Press Review of Psychiatry, vol. 10. Washington,
DC: American Psychiatric Press.
8. Loewenstein, R. J. (1991). Psychogenic amnesia and psychogenic fugue: A

comprehensive review. In A. Tasman & S.M. Goldfinger (Eds.), American
Psychiatric Press Review of Psychiatry, vol. 10. Washington, DC: American
Psychiatric Press.
9. Lynn, S. J., & Rhue, J. W. (1994). Dissociation: Clinical and theoretical perspectives.
New York: Guilford.
10. Miller, M., & Bowers, K. S. (1993). Hypnotic analgesia: Dissociated experience or
dissociated control? Journal of Abnormal Psychology, 102, 29-38.
11. Putnam, Frank W., et al. (1986). The clinical phenomenology of multiple personality
disorder: A review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-
293.
12. Spanos, N. P. (1997). Multiple identities and false memories: A sociological

perspective. Washington, DC: American Psychological Association.
13. Thigpen, C. H., & Cleckley, H. M. (1957). The three faces of Eve. New York: McGraw-
Hill.

Phone No.: (082)300-5456/305-0647 Local 118
LESSON SIX: SUMMATIVE TEST

Let’s Check
Now that the student knows the essential knowledge under lesson six, which is all about
Somatic Symptoms and Related Disorders and Dissociative Disorders. Let us try to check the
student's understanding of these terms.
1. According to psychological theory, neuroses stem from

a. underlying unconscious conflicts.
b. the clash of conscious and unconscious therapy.
c. dream process.
d. identity concepts
2. An essential element of illness anxiety disorder is __________.

a. psychosis b. worry c. depression d. dissociation
3. Minor, physical complaints are common among ____________.

a. young children c. the middle aged
b. adolescents d. the elderly
4. Disorders such as koro and dhat that are similar to somatic symptom disorders
demonstrate the
a. influence of culture on psychopathology.
b. physical basis of many hypochondriacs' complaints.
c. difficulty of accurately diagnosing hypochondriasis.
d. influence of genetics on psychopathology.
5. A patient with somatic symptom disorder tends to generate higher healthcare costs
than an average patient due to.
a. an extensive medical and physical workup with every visit to a new physician.
b. the person's tendency to visit numerous medical specialists.
c. both a and b
d. neither a or b
6. George has completely lost his sight during the past year, but medical experts can find
no physical reason for his blindness. This could be an example of _______________.
a. somatization disorder c. conversion disorder
b. hypochondriasis d. dissociative disorder
7. Factitious disorder imposed on another is often characterized by

Phone No.: (082)300-5456/305-0647 Local 118
a. deliberate actions directed toward making a child sick.

b. a parent denying that a child has symptoms that have, in fact, been
observed.
c. a parent developing the same symptoms that their child has.
d. convincing a child to lie to a doctor about factitious symptoms.
8. Catharsis is
a. the process of placing a tube into the bladder to release urine.
b. a conscious behavioral process.
c. a purging of emotionally traumatic events.
d. none of these
9. The experience of dissociation occurs in

a. psychotic disorders only.
b. individuals with dissociative disorders only.
c. only in those individuals who have experienced great personal trauma.
d. certain psychological disorders as well as in non-disordered people at times.
10. While driving alone in her car, Sarah suddenly looks around and, for a moment, she
can't remember where she is, how she arrived at this point on the road, or even why
she is driving her car. Sarah is experiencing _______________.
a. derealization
b. depersonalization
c. the early stages of what will eventually become a severe psychotic disorder
d. symptoms of a mood disorder
11. In dissociative amnesia, the individual typically has no memory of

a. any events.
b. events prior to a trauma.
c. selective events, particularly those involving trauma.
d. events following a trauma, particularly those involving interpersonal issues.
12. An alter is
a. a separate identity experienced by someone with dissociative identity
disorder.
b. a new identity created by someone with dissociative fugue.
c. a new identity created by someone with generalized amnesia.
d. a physical symptom with no physical cause experienced by someone with
somatic symptom disorder.
13. Vanna, who is 40, apparently believes that she is a 20-year-old woman. Suddenly, she
starts to speak and behave very differently, and says she no longer thinks of herself
as "Vanna." Instead, she claims to be Elise, a 10-year-old child. It is likely that Vanna
has just experienced a _____.
a. switch c. conversion reaction
b. dissociative trance disorder d. schizophrenic moment
14. Comparisons of optical functioning in the various personalities of dissociative identity

disorder patients show changes that would be
a. easy to fake.
b. absolutely impossible to fake.
Phone No.: (082)300-5456/305-0647 Local 118
c. consistent with an individual who was trying to fake.

d. difficult to fake.
15. Some theorists suggest that dissociative identity disorder is an extreme subtype of
___________.
a. dissociative amnesia
b. obsessive-compulsive disorder
c. posttraumatic stress disorder
d. antisocial personality disorder
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson six is not enough; what
Case Four: Under Dissociative Disorder – THE CASE OF FRANCINE
“It feels like I’m losing my mind.” Francine Parfit was only 20 years old, but she had already
worked as a bank teller for nearly 2 years. Having received several raises during that time,
she felt that she was good at her job—conscientious, personable, and reliable. And healthy,
though she’d been increasingly troubled by her “out-of-body experiences,” as she called them.
“I’ll be standing behind my counter and, all of a sudden, I’m also standing a couple of
feet away. I seem to be looking over my own shoulder as I’m talking with my customer. And
in my head, I’m commenting to myself on my own actions, as if I were a different person I was
watching. Stuff like ‘Now she’ll have to call the assistant manager to get approval for this
transfer of funds.’ I came to the clinic because I saw something like this on television a few
nights ago, and the person got shock treatments. That’s when I began to worry something
really awful was wrong.”
Francine denied that she had ever had blackout spells, convulsions, blows to the head,
severe headaches, or dizziness. She had smoked pot a time or two in high school, but
otherwise she was drug- and alcohol-free. Her physical health had been excellent; her only
visits to physicians had been for immunizations, Pap smears, and a preemployment physical
exam 2 years ago.
Each episode began suddenly, without warning. First Francine would feel quite
anxious; then she’d notice that her head seemed to bob up and down slightly, out of her
control. Occasionally she felt a warm sensation on the top of her head, as if someone had
cracked a half-cooked egg that was dribbling yolk down through her hairline. The episodes
seldom lasted longer than a few minutes, but they were becoming more frequent—several
times a week now. If they occurred while she was at work, she could often take a break until
they passed. But several times it had happened when she was driving. She worried that she
might lose control of her car.
Francine had never heard voices or had hallucinations of other senses; she denied
ever feeling talked about or plotted against in any way. She had never had suicidal ideas and
didn’t really feel depressed.
“Just scared,” she concluded. “It’s so spooky to feel that you’ve sort of died.”

Phone No.: (082)300-5456/305-0647 Local 118
Question for CASE FOUR:

2. How would you manage this patient? Explain your answer thoroughly. (20 Points)
Case Five: Under Somatic Symptom and Related Disorders – THE CASE OF BISSELL
Ruby Bissell placed a hand on each chair arm and shifted uncomfortably. She had been talking
for nearly half an hour, and the dull, constant ache had worsened. Pushing up with both hands,
she hoisted herself to her feet. She winced as she pressed a fist into the small of her back;
the furrows on her face added a decade to her 45 years.
Although Ruby had had this problem for nearly 6 years, she wasn’t sure exactly when
it began. It could have started when she helped to move a patient from the operating table to
a gurney. But the first orthopedist she ever consulted explained that her pulled ligament was
mild, so she continued to work as an operating room nurse for nearly a year. Her back hurt
whether she was sitting or standing, so she’d had to resign With Predominant Pain Specifier
for Somatic Symptom Disorder 257 from her job; she couldn’t maintain any physical position
longer than a few minutes at a time.
“They let me do supervisory work for a while,” she said, “but I had to quit that, too. My
only choices were sitting or standing, and I have to spend part of each hour flat on my back.”
From her solidly blue-collar parents, Ruby had inherited a work ethic. She’d supported
herself from the age of 17, so her forced retirement had been a blow. But she couldn’t say she
felt depressed about it. In fact, she had never been very introspective about her feelings and
couldn’t really explain how she felt about many things. She did deny ever having hallucinations
or delusions; aside from her back pain, her physical health had been good. Although she
occasionally awakened at night with back pain, she had no real insomnia; appetite and weight
had been normal. When the interviewer asked whether she had ever had death wishes or
suicidal ideas, she was a little offended and strongly denied them. A variety of treatments had
made little difference in Ruby’s condition. Pain medication provided almost no relief at all, and
she had quit them all before she could get hooked. Physical therapy made her hurt all the
more, and an electrical stimulation unit seemed to burn her skin.
A neurosurgeon had found no anatomical pathology and explained to Ruby that a
laminectomy and spinal fusion were unlikely to improve matters. Her own husband’s
experience had caused her to distrust any surgical intervention. He had been injured in a
trucking accident a year before her own difficulty began; his subsequent laminectomy had left
him not only disabled for work, but impotent. With no children to support, the two lived in
reasonable comfort on their combined disability incomes.
“Mostly we just stay at home,” Ruby remarked. “We care a lot for each other. Our
relationship is the one part of my life that’s really good.”
The interviewer asked whether they were still able to have any sort of a sex life. Ruby
admitted that they did not. “We used to be very active, and I enjoyed it a lot. After his accident,
and he couldn’t perform, Gregory felt terribly guilty that he couldn’t satisfy me. Now my back
pain would keep me from having sex, regardless. It’s almost a relief that he doesn’t have to
bear all the responsibility.”
Question for CASE FIVE:

2. What factors will improve the likelihood of making the correct diagnosis? (20 Points)

Phone No.: (082)300-5456/305-0647 Local 118
In a Nutshell
Activity 1. In this lesson, we learned about Somatic Symptoms and Related Disorders and
Dissociative Disorders. In this section, I want you to write down what you had learned or
realized in this lesson. Provide at least 400 words.
Q&A List
lesson six. After being reviewed, questions related to the topics mentioned above will
1.
2.
3.
4.
5.
~End of Lesson Six~

Phone No.: (082)300-5456/305-0647 Local 118
Big Picture in Focus: ULOb. Illustrate the relationship of mood disorders and suicide.
LESSON SEVEN
Metalanguage
This lesson outlines the characteristic features of mood disorders (major

depressive disorder, persistent depressive disorder, double depression, bipolar
I disorder, bipolar II disorder, and cyclothymia). Specifically, the epidemiology,
etiology, and treatment of these conditions are described. Symptom feature modifiers,
or those additional factors that have implications for predicting course or response to
treatment, are also covered. This lesson is also devoted to the phenomenon of
suicide, including prevention and intervention of suicidal ideation and intent.
Various clinical examples are presented throughout the chapter. Extensive discussion
of the changes in mood disorders seen in the DSM-5 revision are discussed, along
with implications for how those changes will impact our understanding of these
disorders.
• Mood disorders are among the most common psychological disorders, and
the risk of developing them is increasing worldwide, particularly in younger
people.
• Major Depressive Disorder may be a single episode or recurrent, but it is

always time limited; in another form of depression, persistent depressive
disorder, the symptoms are somewhat milder but remain relatively
unchanged over long periods. In case of double depression, an individual
experiences symptom of a major depressive episode that is overlaid onto the
symptoms of persistent depressive disorder.
• Premenstrual Dysphoric Disorder (PMDD) is marked by severe and

sometimes incapacitating mood-related symptoms that precipitate a woman’s
menstrual period.
• Disruptive Dysregulation Disorder is marked by frequent temper outburst

that involve extreme verbal and/or physical acts of aggression, an absence of
indications of manic episodes that would indicate a bipolar- related illness.
• A variety of treatments, both biological and psychological which have proved

effective for mood disorders for at least in the short term. Such treatments are
Transcranial magnetic stimulation, Electroconvulsive Therapy, Cognitive
Therapy, and Interpersonal Therapy.
• Suicide is often associated with mood disorders but can occur in their absence
or in the presence of other disorders. Suicidal ideation refers to serious

Phone No.: (082)300-5456/305-0647 Local 118
thoughts about committing suicide, Suicidal plans refers to a detailed method

for killing oneself, and Suicidal attempts which are not successful.
Essential Knowledge
I. UNDERSTANDING AND DEFINING MOOD DISORDERS
THE CASE OF “KATIE”: Weathering Depression

Katie was an attractive but shy 16-year-old who came to our clinic with her parents. For
several years, Katie had seldom interacted with anybody outside her family because of her
considerable social anxiety. Going to school was difficult, and as her social contacts decreased,
her days became empty and dull. By the time she was 16, a deep, all-encompassing depression
blocked the sun from her life. Here is how she described it later:
“The experience of depression is like falling into a deep, dark hole that you cannot climb
out of. You scream as you fall, but it seems like no one hears you. Some days you $oat
upward without even trying; on other days, you wish that you would hit bottom so that
you would never fall again. Depression affects the way you interpret events. It influences
the way you see yourself and the way you see other people. I remember looking in the
mirror and thinking that was the ugliest creature in the world. Later in life, when some of
these ideas would come back, I learned to remind myself that I did not have those
thoughts yesterday and chances were that I would not have them tomorrow or the next
day. It is a little like waiting for a change in the weather.”
But at 16, in the depths of her despair, Katie had no such perspective. She often cried
for hours at the end of the day. She had begun drinking alcohol the year before, with the
blessing of her parents, strangely enough, because the pills prescribed by her family doctor did
no good. A glass of wine at dinner had a temporary soothing effect on Katie, and both she and
her parents, in their desperation, were willing to try anything that might make her a more
functional person. But one glass was not enough. She drank increasingly more often. She
began drinking herself to sleep. It was a means of escaping what she felt: “I had very little hope
of positive change. I do not think that anyone close to me was hopeful, either. I was angry,
cynical, and in a great deal of emotional pain.” Katie’s life continued to spiral downward.
For several years, Katie had thought about suicide as a solution to her unhappiness. At
13, in the presence of her parents, she reported these thoughts to a psychologist. Her parents
wept, and the sight of their tears deeply affected Katie. From that point on, she never expressed
her suicidal thoughts again, but they remained with her. By the time she was 16, her
preoccupation with her own death had increased.
“I think this was just exhaustion. I was tired of dealing with the anxiety and depression,
day in and day out. Soon I found myself trying to sever the few interpersonal connections
that I did have, with my closest friends, with my mother, and my oldest brother. I was
almost impossible to talk to. I was angry and frustrated all the time. One day I went over
the edge. My mother and I had a disagreement about some unimportant little thing. I went
to my bedroom where I kept a bottle of whiskey or vodka or whatever I was drinking at
the time. I drank as much as I could until I could pinch myself as hard as I could and feel

Phone No.: (082)300-5456/305-0647 Local 118
nothing. Then I got out a very sharp knife that I had been saving and slashed my wrist
deeply. I did not feel anything but the warmth of the blood running from my wrist.”
“The blood poured out onto the floor next to the bed that I was lying on. The sudden
thought hit me that I had failed, that this was not enough to cause my death. I got up
from the bed and began to laugh. I tried to stop the bleeding with some tissues. I stayed
calm and frighteningly pleasant. I walked to the kitchen and called my mother. I cannot
imagine how she felt when she saw my shirt and pants covered in blood. She was
amazingly calm. She asked to see the cut and said that it was not going to stop bleeding
on its own and that I needed to go to the doctor immediately. I remember as the doctor
shot Novocain into the cut he remarked that I must have used an anesthetic before
cutting myself. I never felt the shot or the stitches.”
“After that, thoughts of suicide became more frequent and more real. My father asked
me to promise that I would never do it again and I said I would not, but that promise
meant nothing to me. I knew it was to ease his pains and fears and not mine, and my
preoccupation with death continued.”
A. An Overview of Depression and Mania

1 Originally, these disorders were known as "depressive disorders,"
"affective disorders," or even "depressive neuroses." However, it
was reclassified as Mood Disorders in the DSM-III edition.
2. The most common type of depression is Major Depressive Episode,

which is defined as an extremely depressed mood state that lasts at
least 2 weeks and includes cognitive symptoms (such as feelings of
worthlessness and indecisiveness) as well as disrupted physical
functions (such as altered sleeping patterns, significant changes in
appetite and weight, or a noticeable loss of energy) according to DSM-
5 criteria (Bech, 2009).
• Anhedonia refers to a lack of energy and the inability to engage
in pleasurable activities or have any “fun,” which are all
symptoms of severe depression (Kasch et al., 2002). The
physical changes are the most important indicators of a full
major depressive episode (sometimes called somatic or
vegetative symptoms).
• The duration of a major depressive episode, if untreated, is

approximately 4 to 9 months (Kessler & Wang, 2009).
3. Mania episode refers to individuals who find extreme pleasure in

every activity; some patients compare their daily experience of mania
with a continuous sexual orgasm.
• DSM-5 highlights this feature by adding “persistently
increased goal-directed activity or energy” to the “A” criteria
(see DSM-5 Table 7.2; American Psychiatric Association,
2013).

Phone No.: (082)300-5456/305-0647 Local 118
• Due to the excitement of expressing all ideas at once, speech

became rapid and incoherent, which is a sign of flight of ideas.
• If the person was engaging in self-destructive behavior, he or

she might be admitted to the hospital. This only takes one week
of manic episodes. They frequently become irritated. An
untreated manic episode lasts about 3 to 4 months on average
(Solomon et al., 2010).
• A hypomanic episode is a milder form of manic depression that

does not impair social or occupational functioning and lasts only
four days rather than a full week.
B. The Structure of Mood Disorders

1. Individuals with unipolar mood disorders experience either
depression or mania, but their mood remains at one pole of the
depression-mania spectrum.
2. Although mania (unipolar mania) can occur on its own (Bech, 2009), it
appears to be uncommon, as most people with unipolar mood disorders
eventually develop depression.

Phone No.: (082)300-5456/305-0647 Local 118
3. Individuals with bipolar mood disorder alternate between depression

and mania, moving from one "pole" of the depression-elation
continuum to the other and back.
4. Mixed features on the other hand, refers to a person who may exhibit
manic symptoms while also feeling depressed or anxious, or who may
be depressed while exhibiting a few mania symptoms (Swann et al.,
2013).
• The term "mixed features" in DSM-5 refers to determining
whether a predominantly manic or predominantly depressive
episode is present, followed by determining whether enough
symptoms of the opposite polarity are present to meet the mixed
features criteria.
5. A patient in full remission has recovered completely for at least two

months between episodes. Partial Remission occurs when a person
recovers partially but still has some depressive symptoms.
C. Depressive Disorders
• The absence of manic or hypomanic episodes prior to or
during the onset of major depressive disorder is a defining
feature of the disorder (Angst, 2009).
• Recurrent major depressive disorder is defined as two or

more major depressive episodes separated by at least two
months during which the individual was not depressed.

Phone No.: (082)300-5456/305-0647 Local 118
• Based on follow-ups as long as 23 years, between 35 percent

and 85 percent of people with single-episode occurrences of
major depressive disorder later experience a second episode
(Angst, 2009).
• The median number of major depressive episodes in one's

lifetime is 4 to 7; in one large sample, 25% had six or more
episodes (Angst, 2009).
• Recurrent major depressive episodes last 4 to 5 months on

average (Boland & Keller, 2009), which is slightly less than the
average length of the first episode.
a. Persistent Depressive Disorder (Dysthymia) – shares many

symptoms of major depressive disorder but differs in its course.
• Although there may be fewer symptoms (as few as two in
DSM-5 Table 7.4), depression persists for long periods of
time, sometimes 20 or 30 years or more (Cristancho, Kocsis,
& Thase, 2012)
• A major depressive episode is defined as a period of

depressed mood that lasts at least two years and during
which the patient cannot be symptom-free for more than
two months at a time, even if they do not experience all of
the symptoms of a major depressive episode.
• About 20% of patients with a major depressive episode

report that it has been ongoing for at least two years,
indicating that they have persistent depressive disorder
(Klein, 2010).
b. Double Depression – individuals who suffer from both major

depressive episodes and persistent depression with fewer
symptoms.
• Typically, a few depressive symptoms appear first,
perhaps at a young age, followed by one or more major
depressive episodes, with the underlying pattern of
depression returning once the major depressive episode
has passed (Boland & Keller, 2009).
• In these cases, it is crucial to determine whether or not the

patient is experiencing a major depressive episode. Figure
7.1 depicts the various course configurations of depression
for both major depressive disorder and persistent
depressive disorder.

Phone No.: (082)300-5456/305-0647 Local 118

Phone No.: (082)300-5456/305-0647 Local 118
D. Additional Defining Criteria for Depressive Disorders

1. At DSM-5 Table 7.3, on the diagnostic criteria for major depressive
disorder; notice the section at the bottom that asks the clinician to
specify the features of the latest depressive episode.
• The following specifiers are the following: (1) with psychotic
features (mood-congruent or mood-incongruent), (2) with
psychotic features (mild to severe), (3) with mixed features,
(4) with melancholic features, (5) with atypical features, (6)
with catatonic features, (7) with peripartum onset, and (8)
with seasonal pattern.
i. Psychotic features specifiers - Psychotic symptoms,
such as hallucinations (seeing or hearing things that
aren't there) and delusions (strongly held but inaccurate
beliefs), can occur in people who are experiencing a
major depressive (or manic) episode (Rothschild, 2013).
a) Somatic (physical) Delusions -for example,
believing that their bodies are rotting internally
and deteriorating into nothingness.
b) Auditory Hallucinations – hearing voices telling

them how evil and sinful they are (mood
congruent).
c) Delusions of Grandeur – believing that they are

supernatural or supremely gifted (mood-
incongruent).

Phone No.: (082)300-5456/305-0647 Local 118
ii. Anxious distress specifier - The presence and severity

of accompanying anxiety, whether in the form of
comorbid anxiety disorders (anxiety symptoms that meet
all of the criteria for an anxiety disorder) or anxiety
symptoms that do not meet all of the criteria for disorders
(anxiety symptoms that do not meet all of the criteria for
disorders) (Goldberg & Fawcett, 2012).
iii. Mixed features specifier - This specifier applies to

major depressive episodes in both major depressive
disorder and persistent depressive disorder that are
predominantly depressive and have several (at least
three) symptoms of mania as described above.
iv. Melancholic features specifier - Early morning

awakenings, weight loss, loss of libido (sex drive),
excessive or inappropriate guilt, and anhedonia
(disinterest or pleasure in activities) are some of the
more severe somatic (physical) symptoms associated
with melancholy (Parker et al., 2013).
v. Catatonic features specifier - This serious condition is

characterized by a lack of movement (stupor) or
catalepsy, in which the muscles are waxy and semirigid,
allowing the patient's arms or legs to remain in any
position (Huang, Lin, Hung, & Huang, 2013).
vi. Atypical features specifier - This specifier applies to

both depressive episodes and persistent depressive
episodes, whether or not they are part of a persistent
depressive disorder.
vii. Peripartum onset specifier - Peri means

“surrounding”, in this case the period of time just before
and just after the birth. Between 13% and 19% of all
women giving birth (one in eight) meet criteria for a
diagnosis of depression, referred to as peripartum
depression.
viii. Seasonal pattern specifier - Recurrent major

depressive disorder is covered by this temporal specifier
(and also to bipolar disorders). It is used to accompany
episodes that take place during specific seasons (for
example, winter depression). Seasonal affective
disorder is the name for this condition (SAD).
2. Onset and Duration

• The risk of developing major depression is generally low until
the early adolescent years, when it begins to rise steadily
(linearly) (Rohde, Lewinsohn, Klein, Seeley, & Gau, 2013).

Phone No.: (082)300-5456/305-0647 Local 118
• According to a large (43,000) and representative sample of the

US population, the average age of onset for major depressive
disorder is 30 years, but 10% of all people who develop major
depression are 55 or older when they have their first episode
(Hasin et al., 2005).
• Kessler and colleagues (2003) compared four age groups, they

discovered that 25% of people aged 18 to 29 had already
experienced major depression, which was far higher than the
rate for older groups at that age.
• They found that in children ages 5 to 12, 5% had experienced

major depressive disorder.
• The corresponding figures in adolescence (ages 13 to 17) was

19%; in emerging adulthood (ages 18 to 23), 24%; and in
young adulthood (ages 24 to 30) 16%.
• Although 9 months is a long time to suffer with a severe

depressive episode, evidence indicates that, even in the most
severe cases, the probability of remission of the episode
within 1-year approaches 90% (Kessler & Wang, 2009).
• In this case, the likelihood of a subsequent episode with

another incomplete recovery is much higher (Judd 2012).
• Patients with early onset persistent depressive disorder have a

higher prevalence of concurrent personality disorders than
patients with major depressive disorder, according to research
(Klein, 2008).
• Kovacs, Akiskal, Gatsonis, and Parrone (1994) found that 76%

of a sample of children with persistent mild depressive
symptoms later developed major depressive disorder.
• The co-occurrence of major depressive episodes and dysthymia

(double depression) is fairly common (Boland & Keller, 2009).
3. From Grief to Depression

• If someone you care about has died, especially if the death was
unexpected and the person was a member of your immediate
family, you may have experienced a variety of depressive
symptoms, as well as anxiety, emotional numbness, and denial,
after your initial reaction to the trauma (Shear, 2012).
• Most of us experience acute grief, which eventually transforms

into integrated grief, in which the finality of death and its
consequences are acknowledged, and the individual adjusts to
the loss (Shear et al., 2011).

Phone No.: (082)300-5456/305-0647 Local 118
• Many of the psychological and social factors linked to mood

disorders in general, such as a history of previous depressive
episodes, can also predict the development of the syndrome of
complicated grief, though this reaction can occur without a
prior depressive state (Bonanno, Wortman, & Nesse, 2004).
E. Other Depressive Disorders

1. Premenstrual Dysphoric Disorder (PMDD)
• In general, clinicians discovered a small group of women,
ranging from 2% to 5%, who experienced severe and
sometimes incapacitating emotional reactions during the
premenstrual period (Epperson et al., 2012).
• In DSM-5 Table 7.5, the criteria for PMDD are listed. As can be
seen, incapacitation is linked to a combination of physical
symptoms, severe mood swings, and anxiety during this time
(Hartlage, Freels, Gotman & Yonkers, 2012).
2. Disruptive Mood Dysregulation Disorder

• Many clinicians are now using much broader diagnostic criteria
that do not correspond to the relatively ambiguous category of
bipolar disorder not otherwise specified (NOS), such as

Phone No.: (082)300-5456/305-0647 Local 118
children with chronic irritability, anger, aggression,

hyperarousal, and frequent temper tantrums that are not
limited to an occasional episode (as might be the case if the
child was cycling into a man) (Liebenluft, 2011).
F. Bipolar Disorders
• The tendency of manic episodes to alternate with major depressive
episodes in an unending roller-coaster ride from the peaks of elation to
the depths of despair is a key identifying feature of bipolar disorders.

Phone No.: (082)300-5456/305-0647 Local 118
THE CASE OF “JANE”: Funny, Smart, and Desperate

Jane was the wife of a well-known surgeon and the loving mother of three children. The
family lived in an old country house on the edge of town with plenty of room for family members
and pets. Jane was nearly 50; the older children had moved out; the youngest son, 16-year-old
Mike, was having substantial academic difficulties in school and seemed anxious. Jane brought
Mike to the clinic to find out why he was having problems.
As they entered the office, I observed that Jane was well dressed, neat, vivacious, and
personable; she had a bounce to her step. She began talking about her wonderful and
successful family before she and Mike even reached their seats. Mike, by contrast, was quiet
and reserved. He seemed resigned and perhaps relieved that he would have to say little during
the session. By the time Jane sat down, she had mentioned the personal virtues and material
achievement of her husband, and the brilliance and beauty of one of her older children, and
she was proceeding to describe the second child. But before she finished, she noticed a book
on anxiety disorders and, having read voraciously on the subject, began a litany of various
anxiety-related problems that might be troubling Mike.
In the meantime, Mike sat in the corner with a small smile on his lips that seemed to be
masking considerable distress and uncertainty over what his mother might do next. It became
clear as the interview progressed that Mike suffered from obsessive-compulsive disorder, which
disturbed his concentration both in and out of school. He was failing all his courses. It also
became clear that Jane herself was in the midst of a hypomanic episode, evident in her
unbridled enthusiasm, grandiose perceptions, “uninterruptable” speech, and report that she
needed little sleep these days. She was also easily distracted, as when she quickly switched
from describing her children to the book on the table. When asked about her own psychological
state, Jane readily admitted that she was a “manic depressive” (the old name for bipolar
disorder) and that she alternated rather rapidly between feeling on top of the world and feeling
depressed; she was taking medication for her condition. I immediately wondered if Mike’s
obsessions had anything to do with his mother’s condition.
Mike was treated intensively for his obsessions and compulsions but made little progress.
He said that life at home was difficult when his mother was depressed. She sometimes went to
bed and stayed there for 3 weeks. During this time, she seemed be in a depressive stupor,
essentially unable to move for days. It was up to the children to care for themselves and their
mother, whom they fed by hand. Because the older children had now le" home, much of the
burden had fallen on Mike. Jane’s profound depressive episodes would remit after about 3
weeks, and she would immediately enter a hypomanic episode that might last several months
or more. During hypomania, Jane was mostly funny, entertaining, and a delight to be with—if
you could get a word in edgewise. Consultation with her therapist, an expert in the area,
revealed that he had prescribed a number of medications but was so far unable to bring her
mood swings under control.
1. Bipolar II Disorder – When a person has major depressive episodes

followed by hypomanic episodes rather than full-blown manic episodes.
2. Bipolar I Disorder – Are the same, except the person goes through a
full manic episode. For the manic episodes to be considered separate,
there must be a symptom-free period of at least 2 months between
them, just as there must be a symptom-free period of at least 2 months
between them in the case of major depressive disorder.
3. Cyclothymic Disorder – Bipolar disorder that is milder but more

chronic. In many ways, it's similar to persistent depressive disorder
(Parker, McCraw, & Fletcher, 2012).
Phone No.: (082)300-5456/305-0647 Local 118
G. Additional Defining Criteria for Bipolar Disorders

1. Rapid-Cycling Specifier
• A rapid-cycling pattern is defined as a severe type of bipolar
disorder that does not respond well to standard treatments and
occurs when a person has at least four manic or depressive
episodes in a year (Angst, 2009).
• Rapid switching or rapid mood switching is a treatment-

resistant form of the disorder that occurs when this direct
transition from one mood state to another occurs (MacKinnon,
Zandi, Gershon, Nurnberger, & DePaulo, 2003).
2. Onset and Duration

• Although both bipolar I and bipolar II disorders can start in
childhood, the average age of onset for bipolar I disorder is 15
to 18 years old and for bipolar II disorder is 19 to 22 years old
(Angst, 2009).
• About a third of cases of bipolar disorder start in
adolescence, with minor mood swings or mild cyclothymic
mood swings often preceding the onset (Merikangas et al.,
2007).

Phone No.: (082)300-5456/305-0647 Local 118
• Between 10% and 25% of people with bipolar II disorder will

develop full-blown bipolar I disorder (Birmaher et al., 2009).
• Suicide attempts in people with bipolar disorder range from 12

percent to 48 percent over their lifetime, and this rate is roughly
20 times higher than in people without bipolar disorder
(Goodwin & Jamison, 2007).
• Cyclothymic mood swings progress to full-blown bipolar

disorder in about one-third to one-half of patients (Parker et al.,
2012).
II. PREVALENCE OF MOOD DISORDERS

A. Prevalence in Children, Adolescent, and Older Adults
1. Depressive disorders are less common in prepubescent children
than in adults, but they rise dramatically in adolescence, according to
the findings (Rohde et al., 2013).
2. Major depression is about 1.5 percent among children ages 2 to 5,

and slightly lower later in childhood (Garber et al., 2009), but up to 20
percent to 50 percent of children experience some depressive
symptoms that are not frequent or severe enough to meet diagnostic
criteria but are still impairing (Garber et al., 2009).
3. Adolescents are just as likely as adults to suffer from major depressive

disorder (Rohde et al., 2013).

Phone No.: (082)300-5456/305-0647 Local 118
4. The sex ratio for depressive disorders in children is roughly 50:50,

but this ratio shifts dramatically in adolescence. Major depressive
disorder is primarily a female disorder in adolescents, as it is in adults,
with puberty appearing to be the catalyst for this sex imbalance (Garber,
Clarke et al., 2009).
5. Major depressive disorder is about half as common in people over 65

as it is in the general population (Blazer & Hybels, 2009).
6. Bipolar disorder appears to affect children and adolescents at the same

rate (1%) as it does adults (Kessler et al., 2012).
B. Life Span Developmental Influences on Mood Disorders

1. There is evidence that three-month-old babies can develop depression!
Even when interacting with a nondepressed adult, infants of depressed
mothers exhibit depressive behaviors (sad faces, slow movement,
lack of responsiveness) (Garber et al., 2009).
2. The majority of researchers agree that mood disorders in children and

adults are fundamentally the same (Brent & Birmaher, 2009).
3. Even the core symptoms of anhedonia, hopelessness, excessive

sleeping, and social withdrawal appear to change with age,
becoming more severe in most cases (Garber & Carter, 2006).
4. Children may experience “emotional swing,” or oscillating manic

states that are less distinct than in adults, as well as brief or rapid-
cycling manic episodes lasting only a few hours (Youngstrom, 2009).
5. Childhood depression (and mania) are frequently associated with

and misdiagnosed as attention deficit hyperactivity disorder
(ADHD) or, more commonly, conduct disorder, which is marked by
aggression and even destructive behavior (Garber et al., 2009).

Phone No.: (082)300-5456/305-0647 Local 118
6. Bipolar adolescents may become aggressive, impulsive, sexually

provocative, and prone to accidents (Carlson, 1990).
7. In contrast to adolescents with major depressive disorder, these

prepubescent children were more likely to develop substance abuse or
other disorders as adults than to continue with their depression.
8. Age-Based Influences on Older Adults

• According to studies, 14% to 42% of nursing home residents
may experience major depressive episodes (Fiske et al., 2009).
• Depressed elderly patients aged 56 to 85 were followed for 6

years in one large study; approximately 80% did not remit but
continued to be depressed (or cycled in and out of depression)
despite their depressive symptoms not being severe enough to
meet diagnostic criteria for a disorder (Beekman et al., 2002).
• Sleep problems, illness anxiety disorder (anxiety about being

sick or injured in some way), and agitation are all linked to late-
onset depressions (Baldwin, 2009).
• Several studies have found that going through menopause

increases the risk of depression in women who have never been
depressed before (Cohen, Soares, Vitonis, Otto, & Harlow,
2006)
• According to Bruce (2002), the death of a spouse, the burden of

caring for an ill spouse, and the loss of independence due to
medical illness are all strong risk factors for depression in this
age group.
C. Across Cultures
1. Some cultures have their own idioms for depression; for example, the
Hopi, a Native American tribe, refers to themselves as "heartbroken,"
whereas depressed aboriginal men in central Australia attribute their
feelings to spiritual weakness or injury (Brown et al., 2012).
2. However, in cultures where individuals are tightly integrated into larger

groups, someone might say, "Our life has lost its meaning," referring
to the group in which the individual lives (Manson & Good, 1993).
3. Nonetheless, on many reservations, appalling social and economic

conditions meet all of the criteria for chronic major life stress,
which is so closely linked to the onset of mood disorders, particularly
major depressive disorder.
D. Among Creative Individuals

1. Many people mistakenly believe that intellectual ability or creativity are
synonymous with insanity.

Phone No.: (082)300-5456/305-0647 Local 118
2. Kay Redfield Jamison and Nancy Andreasen tried to figure it out. The
outcomes are unexpected. Table 7.3 lists a number of well-known
American poets, many of whom have received the prestigious Pulitzer
Prize.
• As you can see, every single one of them had bipolar disorder.
Many people took their own lives. These eight poets are among
the 36 poets born in the twentieth century who are featured in
the New Oxford Book of American Verse, a collection of the
country's most illustrious poets.
3. Perhaps something about manic episodes fosters creativity, and

recent research confirms that creativity is linked to manic episodes
rather than depressive episodes (Soeiro-de-Souza, et. al., 2011).
4. On the other hand, it is possible that a predisposition to creativity is

linked to a genetic vulnerability to mood disorders (Richards, et. al.,
1988).
5. These ideas need to be confirmed, but a better understanding of

"madness" could benefit the study of creativity and leadership, which
are highly valued in all cultures (Goodwin & Jamison, 2007).
III. CAUSES OF MOOD DISORDERS

A. Biological Dimensions
1. Familial and Genetic Influences
• In family studies, we look at the prevalence of a particular
disorder in first-degree relatives of someone who has the
disorder (the proband).
• Despite wide variation, we discovered that the rate in relatives

of probands with mood disorders is consistently 2 to 3

Phone No.: (082)300-5456/305-0647 Local 118
times higher than in relatives of controls without mood

disorders (Lau & Eley, 2010).
• The highest rates of depression in relatives are associated with

increasing severity, recurrence of major depression, and onset
at a younger age in the proband (Kendler, Gatz, Gardner, &
Pedersen, 2007).
• Twin Studies - we compare the frequency with which identical

twins (with identical genes) have the disorder to fraternal
twins, who only share 50% of their genes (as do all first-degree
relatives).
• Figure 7.3 depicts a compelling study (McGuffin et al., 2003). If

the first twin has a mood disorder, an identical twin is 2 to 3
times more likely than a fraternal twin to present with a mood
disorder (66.7 percent of identical twins compared with 18.9
percent of fraternal twins if the first twin has bipolar disorder;
45.6 percent versus 20.2 percent if the first twin has unipolar
disorder).
• If one identical twin is unipolar, the other identical twin is 80

percent likely to be unipolar as well. This finding suggests that
these disorders may be inherited separately and, as a result, are
distinct disorders (Nurnberger, 2012).
• In conclusion, the best estimates of genetic contributions to

depression for women are in the range of 40%, but appear to be
significantly lower for men (around 20 percent). Bipolar disorder
appears to have a higher genetic component. This means that
environmental factors account for 60 percent to 80 percent of
the causes of depression.
2. Depression and Anxiety: Same Genes?

• Evidence suggests that depression, anxiety, and panic have a
close relationship (as well as other emotional disorders). Data
from family studies, for example, show that the more anxiety and
depression signs and symptoms a patient has, the higher the
rate of anxiety, depression, or both in first-degree relatives and
children (Leyfer & Brown, 2011).
3. Neurotransmitter System
• Low levels of serotonin have been linked to mood disorders
in studies, but only in relation to other neurotransmitters like
norepinephrine and dopamine (Thase, 2005, 2009).
• When serotonin levels are low, other neurotransmitters are

"permitted" to range more widely, become dysregulated, and
contribute to mood irregularities, including depression,
according to the "permissive" hypothesis.

Phone No.: (082)300-5456/305-0647 Local 118
• There is continued interest in the role of dopamine in this

delicate balance, particularly in relation to manic episodes,
atypical depression, or depression with psychotic features
(Dunlop & Nemeroff, 2007).
4. The Endocrine System

• Researchers became interested in the endocrine system after
noticing that patients with diseases that affect it can become
depressed.
• Researchers have also discovered that hypothalamic

neurotransmitter activity controls the release of hormones that
affect the HPA axis.
• Cortisol is known as the stress hormone because it rises in

response to stressful life events.
• Dexamethasone is a glucocorticoid that inhibits cortisol

production in healthy people. However, when this substance
was given to depressed patients, there was much less
suppression than in normal participants, and what did occur did
not last long (Carroll et al., 1980).
• Evidence shows that healthy girls at risk for depression because

their mothers have recurrent depression have lower
hippocampal volume than girls whose mothers are not
depressed (Chen, Hamilton, & Gotlib, 2010). Low hippocampal
volume may precede and possibly contribute to the onset
of depression, according to this finding.
5. Sleep and Circadian Rhythm

• Most importantly, in depressed people, the time between falling
asleep and the onset of rapid eye movement (REM) sleep is
significantly shorter.
• Sleep pattern in depressed children are less pronounced

than in adults, possibly due to the fact that children sleep very
deeply, highlighting the importance of developmental stage in
psychopathology once again (Brent & Birmaher, 2009).
• Sleep disturbances are more common in bipolar patients, who

are characterized not only by decreased REM latency but also
by severe insomnia and hypersomnia (sleeping excessively)
(Harvey, Talbot, & Gershon, 2009).
• Sleep disruptions predicted negative mood, and negative mood

resulted from sleep disruptions.

Phone No.: (082)300-5456/305-0647 Local 118
• In any case, because sleep patterns are a reflection of biological

rhythms, there could be a link between SAD, sleep disturbances
in depressed patients, and a more general disruption in
biological rhythms (Soreca, Frank, & Kupfer, 2009).
B. Additional Studies of Brain Structure and Function

1. Depressed people have more right-sided anterior activation of
their brains, particularly in the prefrontal cortex (and less left-sided
activation and, correspondingly, less alpha wave activity) than
nondepressed people, according to Davidson (1993) and Heller and
Nitschke (1997).
C. Psychological Dimensions
1. Stressful Life Events
• We usually look for a stressful or traumatic life event to see what
activates this vulnerability (diathesis).
2. Stress and Depression

• The majority of people who develop depression say they lost
their job, got divorced, had a child, or graduated from
school and started a career. However, as with most issues in
psychopathology, determining the significance of a major event
is difficult (Carter & Garber, 2011).
• The context of the life event, as well as its meaning, are critical.
Figure 7.4 depicts the approach to studying life events
developed by George W. Brown (1989b) and associates in
England.
• Stressful life events are strongly related to the onset of

mood disorders, according to a large body of research
(Kendler & Gardner, 2010).
• According to Kendler and colleagues (1999a), about one-third

of the link between stressful life events and depression is due to
individuals vulnerable to depression who put themselves in
high-risk stressful environments, such as difficult relationships
or other high-risk situations with a high likelihood of negative
outcomes.
• It is interesting to note that when mothers are asked about their

depressed adolescents, they tend to blame them, whereas
adolescents blame the stressful event itself (Eley, 2011). The
truth, according to the reciprocal model, is somewhere in
between these two points of view.
3. Stress and Bipolar Disorder

• While negative stressful life events typically cause
depression, a different, more positive set of stressful life events
appears to cause mania (Alloy et al., 2012).

Phone No.: (082)300-5456/305-0647 Local 118
o Experiences associated with pursuing important goals,

such as acceptance into graduate school, obtaining a
new job or promotion, getting married, or any other goal-
oriented activity aimed at gaining popularity or financial
success, can lead to mania in vulnerable people (Alloy
et al., 2012).
• Mania and depression appear to be triggered by stress at

first, but as the disorder progresses, these episodes appear
to take on a life of their own. To put it another way, once the
cycle starts, a psychological or pathophysiological process
takes over, ensuring that the disorder will continue (Post, 1992).
• Loss of sleep, such as in the postpartum period (Soreca et

al., 2009) or as a result of jet lag, which disrupts circadian
rhythms, appears to be a trigger for manic episodes.
• Let's go back to Katie for an example. Attending a new school

was a stressful life event for her. Another important
psychological factor in depression is learned helplessness,
which Katie experiences as a result of her sense of loss of
control.
THE CASE OF “KATIE”: No Easy Transition

“I was a serious and sensitive 11-year-old at the edge of puberty and at the edge of
an adventure that many teens and preteens embark on—the transition from elementary
to junior high school. A new school, new people, new responsibilities, new pressures.
Academically, I was a good student up to this point, but I didn’t feel good about myself
and generally lacked self-confidence.”
Katie began to experience severe anxiety reactions. Then she became quite ill with the
flu. After recovering and attempting to return to school, Katie discovered that her anxieties were
worse than ever. More important, she began to feel she was losing control.
“As I look back, I can identify events that precipitated my anxieties and fears, but then
everything seemed to happen suddenly and without cause. I was reacting emotionally
and physically in a way that I didn’t understand. I felt out of control of my emotions and
body. Day after day I wished, as a child does, that whatever was happening to me would
magically end. I wished that I would awake one day to find that I was the person I was
several months before.”
4. Learned Helplessness
• According to Seligman, we do, but only under one condition:
when people believe they have no control over the stress in
their lives, they become anxious and depressed (Miller &
Norman, 1979).
• Seligman's point that anxiety is the first response to a stressful

situation is frequently overlooked. Depression can occur as a

Phone No.: (082)300-5456/305-0647 Local 118
result of a sense of hopelessness about coping with

difficult life events (Barlow, 2002).
• The depressive attributional style is (1) internal, in that the

individual attributes negative events to personal failings (“it is all
my fault”); (2) stable, in that, even after a particular negative
event passes, the attribution that “additional bad things will
always be my fault” remains; and (3) global, in that the
attributions extend across a variety of issues.
• According to Nolen-Hoeksema and colleagues, significant

negative events in childhood may lead to negative
attributional styles, making these children more susceptible to
depressive episodes in the future when stressful events occur.
• Evidence suggests that negative attributional styles are

common in people with anxiety as well as depression (Barlow
et al., 2013).
5. Negative Cognitive Styles

• In 1967, Aaron T. Beck suggested that depression may result
from a tendency to interpret everyday events in a negative
way.
• Arbitrary Inferences - When a depressed person focuses on

the negative rather than the positive aspects of a situation, this
is evident. For example, a high school teacher may believe
he is a bad teacher because two of his students fell asleep
in class. He fails to consider other possible reasons for their
lack of sleep (such as staying up all night partying) and instead
“infers” that his teaching style is to blame.
• Overgeneralization – For example, despite a long string of

positive comments and good grades on other papers, you
assume you will fail the class if your professor makes one critical
remark on your paper. You're making broad generalizations
based on a single remark.
• They make cognitive errors when they think negatively about

themselves, their immediate environment, and their future,
which are referred to as the depressive cognitive triad (see
Figure 7.5).
• Beck theorized, after a series of negative events in

childhood, individuals may develop a deep-seated negative
schema, an enduring negative cognitive belief system about
some aspect of life (Alloy et al., 2012).
6. Cognitive Vulnerability for Depression: An Integration

Phone No.: (082)300-5456/305-0647 Local 118
• Seligman and Beck each developed their theories

independently, and evidence suggests that their models are
distinct in that some people have a negative outlook
(dysfunctional attitudes), while others explain things
negatively (hopeless attributes) (Spangler, Simons, Monroe,
& Thase, 1997).
D. Social and Cultural Dimensions

1. Marital Relations
• During the study, approximately 21% of women who reported
a marital split experienced severe depression, which was
three times higher than the rate for women who remained
married. Nearly one-fifth of men who reported a divorce
suffered from severe depression, a rate nine times higher
than men who remained married (Davila, Stroud, & Starr, 2009).
• However, when the researchers looked only at men and women

who had separated or divorced during the study period and had
no history of severe depression, they found that 14% of men
and 5% of women had severe depression.
o In other words, only the men faced a heightened risk
of developing a mood disorder for the first time
immediately following a marital split.
• Because emotions are contagious, the spouse is likely to

become depressed as well. These interactions can lead to fights
or, worse, make the nondepressed spouse want to leave (Joiner
& Timmons, 2009).
2. Mood Disorders in Women

• Although men and women are equally affected by bipolar
disorder, women account for nearly 70% of those suffering
from major depressive disorder and dysthymia (Kessler &
Bromet, 2013).
• It is possible that perceptions of uncontrollability play a big role

in gender differences in the development of emotional disorders
(Barlow et al., 2013).
• The sex roles assigned to men and women in our society

are the source of these differences. Males are urged to be
self-sufficient, masterful, and assertive; females, on the other
hand, are expected to be more passive, sensitive to others, and,
perhaps, to rely on others more than males (needs for affiliation)
(Hankin & Abramson, 2001).
3. Social Support
• Brown and Harris (1978) proposed the importance of social
support in the onset of depression in a seminal study.

Phone No.: (082)300-5456/305-0647 Local 118
• In China (Wang, & Shen, 2006) and every other country where
it has been studied, the importance of social support in
preventing depression holds true.
• While a socially supportive network of friends and family aided

recovery from depressive episodes, it did not help with recovery
from manic episodes. This finding emphasizes the distinct
nature of manic episodes (McGuffin et al., 2003).
E. An Integrative Theory
1. Essentially, depression and anxiety may share a genetically determined
biological vulnerability (Barlow, 2002) that is defined as an overactive
neurobiological response to stressful life events.
2. We must look at psychological vulnerabilities as well as life experiences

that interact with genetic vulnerabilities to understand the causes of
depression.
3. The pessimistic "giving up" process appears to be critical in the

development of depression when vulnerabilities are triggered (Alloy &
Abramson, 2006).
4. There is also good evidence that stressful life events, particularly initial
episodes, trigger the onset of depression in these vulnerable individuals
in the majority of cases (Jenness, Hankin, Abela, Young, & Smollen,
2011).
5. According to Booij and Van der Does (2007), this biological challenge
was effective in temporarily inducing a variety of depressive symptoms
in some of these people, but the symptoms were more pronounced in
those who also had evidence of the cognitive vulnerability marker.
6. Scientists are beginning to believe that, in addition to the factors

mentioned thus far, people with bipolar disorder are particularly
sensitive to life events associated with achieving important goals,
possibly due to an overactive brain circuit known as the behavioral
approach system (BAS) (Alloy & Abramson, 2010).
IV. TREATMENT OF MOOD DISORDERS

A. Medications
1. Antidepressants
• Selective serotonin reuptake inhibitors (SSRIs), mixed
reuptake inhibitors (MRIs), tricyclic antidepressants, and
monoamine oxidase (MAO) inhibitors are the four basic types
of antidepressant medications used to treat depressive
disorders.
a. These selective-serotonin reuptake inhibitors (SSRIs)

specifically block the presynaptic reuptake of serotonin.

Phone No.: (082)300-5456/305-0647 Local 118
• This temporarily raises serotonin levels at the receptor site,

but the long-term mechanism of action is unknown, even
though serotonin levels eventually rise (Gitlin, 2009).
• Fluoxetine is probably the most well-known drug in this

category (Prozac).
• Then reports surfaced that it could lead to suicidal

obsession, paranoid reactions, and, on rare occasions,
violence (see, for example, Mandalos & Szarek, 1990).
• One possible conclusion is that SSRIs increase suicidal

thoughts in some adolescents in the first few weeks, but that
once they begin to work after a month or more, they may
prevent depression from leading to suicide (Berman, 2009).
b. Antidepressants (sometimes termed mixed reuptake inhibitors)

seem to have somewhat different mechanisms of neurobiological
action.
• Venlafaxine (Effexor), the most well-known, is related to
tricyclic antidepressants but works in a slightly different way,
blocking both norepinephrine and serotonin reuptake.
c. MAO Inhibitors block the enzyme MAO that breaks down such
neurotransmitters as norepinephrine and serotonin.
• The MAO inhibitors appear to be as effective as tricyclic
antidepressants, but with fewer side effects. According to
some evidence, they are more effective for depression with
atypical symptoms (American Psychiatric Association,
2010).
d. Tricyclic antidepressant was the most widely used treatments for

depression before the introduction of SSRIs, but are now used less
commonly (Gitlin, 2009).
• Imipramine (Tofranil) and amitriptyline (Elavil) are
probably the most well-known variants.
• At first, they block the reuptake of certain neurotransmitters,

allowing them to pool in the synapse and, according to
theory, desensitize or down-regulate that
neurotransmitter's transmission (so less of the
neurochemical is transmitted).
• Blurred vision, dry mouth, constipation, difficulty

urinating, drowsiness, weight gain (at least 13 pounds on
average), and sexual dysfunction are all possible side
effects.
• What should clinicians do if a patient's depression does not

respond well to medication, a condition known as treatment

Phone No.: (082)300-5456/305-0647 Local 118
resistant depression? The Sequenced Treatment

Alternatives to Relieve Depression (STAR*D) study
looked at whether giving people who didn't achieve
remission the option of adding a second drug or switching to
a second drug was beneficial.
• According to recent research, drug treatments that work for

adults do not always work for kids (American Psychiatric
Association, 2010).
2. Lithium
• Lithium carbonate is a common salt that can be found in the
natural world (Nemeroff, 2006). It is found in trace amounts in
our drinking water, far too small to have any effect. The side
effects of therapeutic doses of lithium, on the other hand, are
potentially more serious than those of other antidepressants.
• Lithium, on the other hand, has one significant advantage over

other antidepressants: it is frequently effective in preventing and
treating manic episodes. As a result, it's commonly referred to
as a mood-stabilizing medication. Even in healthy people,
antidepressants can cause manic episodes.
• Patients who don't respond to lithium can try anticonvulsants like

carbamazepine and valproate (Divalproex), as well as calcium
channel blockers like verapamil, which have antimanic
properties (Thase & Denko, 2008).
o Valproate has recently surpassed lithium as the most
commonly prescribed mood stabilizer for bipolar
disorder, and it is just as effective, even in patients
who experience rapid-cycling symptoms (Calabrese et
al., 2005).
B. Electroconvulsive Therapy and Transcranial Magnetic Stimulation

1. Electroconvulsive Therapy (ECG)
• Despite many unfortunate abuses along the way, ECT is
considerably changed today. It is now a safe and reasonably
effective treatment for those cases of severe depression that do
not improve with other treatments (American Psychiatric
Association, 2010).
• In current administrations, patients are anesthetized to reduce

discomfort and given muscle-relaxing drugs to prevent bone
breakage from convulsions during seizures. Electric shock is
administered directly through the brain for less than a second,
producing a seizure and a series of brief convulsions that
usually lasts for several minutes.

Phone No.: (082)300-5456/305-0647 Local 118
• The most common side effects are short-term memory loss

and confusion, which go away after a week or two, though
some patients may experience long-term memory problems.
• There is evidence that ECT boosts serotonin levels, reduces

stress hormones, and boosts neurogenesis in the hippocampus.
2. Transcranial Magnetic Stimulation

• A method for modifying brain electrical activity by creating a
strong magnetic field has been developed.
• It works by generating a precisely localized electromagnetic

pulse by placing a magnetic coil over the individual's head.
Anesthesia is not required, and the most common side effects
are headaches.
• TMS showed promise in treating depression in early reports, as

it does with most new procedures, and recent observations and
reviews have confirmed that it can be effective (Mantovani et al.,
2012).
• It is possible that TMS is more comparable to antidepressant

medication than ECT, and one recent study found that
combining TMS and medication had a slight advantage over
either treatment alone (Brunoni et al., 2013).
C. Psychological Treatments for Depression

1. Cognitive-Behavioral Therapy
• Treatment entails correcting cognitive errors and replacing
depressing thoughts and appraisals with less depressing
and (possibly) more realistic ones. Later in therapy, the
underlying negative cognitive schemas (typical ways of looking
at the world) that cause specific cognitive errors are targeted,
not only in the clinic but also in the client's daily life.
• The therapist takes a Socratic approach (teaching by asking

questions; see dialogue below), emphasizing that the therapist
and the client are working together to uncover faulty thinking
patterns and the underlying schemas that cause them.
• This exemplifies the hopelessness about the future that most

depressed patients experience. Another benefit of this line of
inquiry is that the therapist introduced Irene to the concept of
looking at her own thoughts, which is a key component of
cognitive therapy (Young et al., in press).

Phone No.: (082)300-5456/305-0647 Local 118
BECK AND IRENE: A Dialogue

Because an intake interview had already been completed by another therapist, Beck did
not spend time reviewing Irene’s symptoms in detail or taking a history. Irene began by
describing her “sad states.” Beck almost immediately started to elicit her automatic thoughts
during these periods.
Therapist: What kind of thoughts go through your mind when you’ve had these sad feelings
this past week?
Patient: Well . . . I guess I’m thinking what’s the point of all this. My life is over. It’s just not the
same. . .. I have thoughts like, “What am I going to do? . . . Sometimes I feel mad at him, you
know my husband. How could he leave me? Isn’t that terrible of me? What’s wrong with me?
How can I be mad at him? He didn’t want to die a horrible death. . .. I should have done more.
I should have made him go to the doctor when he first started getting headaches. . .. Oh, what’s
the use. . ..”
T: It sounds like you are feeling quite bad right now. Is that right?
P: Yes.
T: Keep telling me what’s going through your mind right now.
P: I can’t change anything. . .. It’s over. . .. I don’t know. . .. It all seems so bleak and hopeless.
. .. What do I have to look forward to . . . sickness and then death. . ..
T: So, one of the thoughts is that you can’t change things and that it’s not going to get any
better?
P: Yes.
T: And sometimes you believe that completely?
P: Yeah, I believe it, sometimes.
T: Right now, do you believe it?
P: I believe it—yes.
T: Right now, you believe that you can’t change things and it’s not going to get better?
P: Well, there is a glimmer of hope but it’s mostly. . ..
T: Is there anything in your life that you kind of look forward to in terms of your own life from
here on?
P: Well, what I look forward to—I enjoy seeing my kids but they are so busy right now. My son
is a lawyer and my daughter is in medical school. . .. So, they are very busy. . .. They don’t
have time to spend with me.
2. Interpersonal Psychotherapy
• We have seen that major disruptions in our interpersonal
relationships are a common source of stress that can lead to
depression (Joiner & Timmons, 2009).
• Interpersonal psychotherapy (IPT) (Weissman, 1995) is a

type of psychotherapy that focuses on resolving problems in
existing relationships as well as learning to form important new
interpersonal relationships.
• IPT is well-structured and rarely lasts more than 15 to 20

sessions, which are usually held once a week (Cuijpers et al.,
2011).
• The therapist and patient work collaboratively on the patient’s

current interpersonal problems. Typically, these include one or

Phone No.: (082)300-5456/305-0647 Local 118
more of four interpersonal issues: dealing with

interpersonal role disputes, such as marital conflict;
adjusting to the loss of a relationship, such as grief over the
death of a loved one; acquiring new relationships, such as
getting married or establishing professional relationships; and
identifying and correcting deficits in social skills that
prevent the person from initiating or maintaining important
relationships.
• After helping identify the dispute, the next step is to bring it to a

resolution. First, the therapist helps the patient determine the
stage of the dispute.
a) Negotiation stage. Both partners are aware it is a
dispute, and they are trying to renegotiate it.
b) Impasse stage. The dispute smolders beneath the

surface and results in low-level resentment, but no
attempts are made to resolve it.
c) Resolution stage. The partners are taking some action,

such as divorce, separation, or recommitting to the
marriage
3. Prevention
• The Institute of Medicine (IOM) defined three types of programs:
universal programs, which apply to everyone; selected
interventions, which target individuals at risk for depression
due to factors such as divorce, family alcoholism, and so on;
and indicated interventions, which target individuals who have
mild symptoms of depression.
D. Combined Treatments for Depression

1. The consensus is that combined treatment does provide some
advantage.
2. However, because combining two treatments is costly, many

experts believe it is better to use a sequential strategy, in which you
start with one treatment (perhaps the one the patient prefers or the one
that is most convenient) and only switch to the other if the first isn't
completely satisfactory (Lynch et al., 2011).
E. Preventing Relapse of Depression

1. Combining treatments may thus take advantage of the drugs' rapid
action as well as the psychosocial protection against recurrence or
relapse, allowing the medications to be tapered off over time.
2. Given the high rate of recurrence in depression, it's not surprising that
more than half of antidepressant patients who stop taking their
medication within four months of their last depressive episode relapse
(Thase, 1990).

Phone No.: (082)300-5456/305-0647 Local 118
3. As a result, one crucial question concerns long-term maintenance

treatment to prevent relapse or recurrence. In several studies,
cognitive therapy reduced the rate of relapse in depressed patients by
more than half when compared to groups treated with antidepressants
(Hollon et al., 2006).
F. Psychological Treatments for Bipolar Disorder

1. Taking drugs off the shelf between episodes or skipping doses during
an episode jeopardizes treatment. As a result, increasing drug
treatment compliance is critical (Goodwin & Jamison, 2007).
2. Clarkin, Carpenter, Hull, Wilner, and Glick (1998) investigated the

benefits of combining a psychological treatment with medication
in inpatients and discovered that it increased medication
adherence for all patients and resulted in better overall outcomes for
the most severe patients when compared to medication alone.
3. In a study comparing patients who received interpersonal and social

rhythm therapy (IPSRT) to patients who received standard, intensive
clinical management, patients who received IPSRT survived longer
without a new manic or depressive episode. The preliminary findings
with teenagers are also positive (Hlastala, Kotler, McClellan, &
McCauley, 2010).
V. SUICIDE
A. Statistics
1. Consider a group of 1000 people chosen at random from the global
population. Four of these people will kill themselves each year, seven
will plan to kill themselves, and twenty will seriously consider it (Borges
et al., 2010).
2. Suicide is the 11th leading cause of death in the United States (Cha,
et al., 2008), and most epidemiologists believe the true number of
suicides is 2 to 3 times higher than what is reported.
3. Suicide attempts are not limited to adolescents and adults. There have
been several reports of children aged 2 to 5 attempting suicide at
least once, with many of them injuring themselves severely, and
suicide is the fifth leading cause of death among children aged 5 to 14.
(Minino et al., 2002).
4. Males are more likely to use violent methods such as guns and
hanging, whereas females are more likely to use less violent
methods such as drug overdose. Men commit suicide at a higher rate
in their later years than women, owing to the fact that most older
women's suicide attempts fail (Berman, 2009).
5. Suicidal ideation (thinking seriously about suicide), suicidal plans

(forming a specific method for killing oneself), and suicidal attempts
(the person survives) are three other important indices of suicidal
behavior in addition to completed suicides (Nock et al., 2011).
Phone No.: (082)300-5456/305-0647 Local 118
B. Causes
1. Past Conceptions
• The great sociologist Emile Durkheim (1951) defined a number
of suicide types, based on the social or cultural conditions in
which they occurred.
o Hara-kiri - “formalized” suicides that were approved of
in Japan, in which an individual who brought dishonor to
himself or his family was expected to impale himself on
a sword.
• Altruistic Suicide – which refers to the type of suicide like hara-
kiri.
• Egoistic Suicide – loss of social support as an important

provocation for suicide.
• Anomic Suicide – results of marked disruptions, such as the

sudden loss of a high prestige job.
• Fatalistic Suicide – result from a loss of control over one’s own

destiny.
• Sigmund Freud (1917/1957) believed that suicide (and

depression, to some extent) indicated unconscious
hostility directed inward to the self rather than outward to the
person or situation causing the anger.
C. Risk Factors
• Psychological Autopsy - Extensive interviews with friends and
family members who are likely to know what the individual was
thinking and doing in the days leading up to death are used to
reconstruct the psychological profile of the person who committed
suicide.
1. Family History
• There is a higher chance that someone else in the family will
commit suicide if a family member has committed suicide
(Hantouche, Angst & Azorin, 2010).
• A recent study found that having a family history of suicide was

the strongest predictor of suicidal behavior among depressed
patients (Hantouche et al., 2010).
• Individuals with an early onset of their mood disorder, as well as

aggressive or impulsive traits, have a higher risk of suicidal
behavior in their families (Mann et al., 2005).
2. Neurobiology
• It is possible, then, that low serotonin levels contribute to a
proclivity for impulsive behavior. This could include self-
mutilation, which is sometimes a rash decision.

Phone No.: (082)300-5456/305-0647 Local 118
3. Existing Psychological Disorders and Other Psychological Risk

Factors
• More than 80% of people who commit suicide have a mental
illness, most commonly a mood, substance abuse, or impulse
control disorder (Berman, 2009).
• Alcohol use and abuse are linked to 25 to 50 percent of

suicides, with a higher prevalence among college students and
adolescents (Pompili et al., 2012).
• Combinations of disorders, such as substance abuse and mood

disorders in adults or mood disorders and conduct disorder in
children and adolescents, appear to increase vulnerability more
than any single disorder (Hwang, et al., 2010).
4. Stressful Life Events

• A severe, stressful event that is perceived as shameful or
humiliating, such as a failure (real or imagined) in school or at
work, an unexpected arrest, or rejection by a loved one, is
perhaps the most important risk factor for suicide (Conwell et
al., 2002).
• Abuse, both physical and sexual, is a major source of stress.

Natural disasters cause stress and disruption, which increases
the risk of suicide, according to research (Stratta et al., 2012).
D. Is Suicide Contagious?
1. A recent review found a positive relationship between suicidal behavior
and exposure to suicide-related media coverage. Gould (1990)
reported an increase in suicides during a 9-day period after widespread
publicity about a suicide.
2. Why would someone want to imitate a suicide attempt? To begin

with, suicides are frequently romanticized in the media: an attractive
young person under unbearable pressure commits suicide and
becomes a martyr to friends and peers by avenging the (adult) world for
putting them in such a difficult situation.
3. However, it is unclear whether suicide is contagious in the sense of an

infectious disease. Rather, the stress of a friend's suicide or another
major stressor may affect a group of people who are already
vulnerable due to psychological disorders (Blasco-Fontecilla,
2012).

Phone No.: (082)300-5456/305-0647 Local 118
E. Treatment
1. Mental health professionals are thoroughly trained in assessing for
possible suicidal ideation (Fowler, 2012).
2. The mental health professional will also check for possible recent
humiliations and determine whether any of the factors are present that
might indicate a high probability of suicide.
3. In short, the clinician must assess for (1) suicidal desire (ideation,
hopelessness, burdensomeness, feeling trapped); (2) suicidal
capability (past attempts, high anxiety and/or rage, available means);
and (3) suicidal intent (available plan, expressed intent to die,
preparatory behavior) (Joiner et al., 2007). If all three conditions are
present, immediate action is required.
4. Friends and relatives of victims should be able to access services

right away, according to the Institute of Medicine (2002). Limiting
access to lethal weapons for anyone at risk of suicide is an important
first step. According to a recent study, this may be the most effective
component of a suicide prevention program.

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: mood disorders, major depressive episode, mania, hypomanic episode, mixed
features, major depressive disorder, recurrent, persistent depressive disorder, double
depression, hallucinations, delusion, delusion, catalepsy, seasonal affective disorder,
integrated grief, complicated grief, premenstrual dysphoric disorder, disruptive mood
dysregulation disorder, bipolar II disorder, bipolar I disorder, cyclothymic disorder,
neurohormones, learned helplessness theory of depression, depressive cognitive triad,
moods-stabilizing drugs, electroconvulsive therapy, cognitive therapy, interpersonal therapy,
maintenance treatment, suicidal ideation, suicidal plans, suicidal attempts, psychological
autopsy
lesson:

2. Barnett, P. A., & Gotlib, I. H. (1988). Psychosocial functioning and depression:

Distinguishing among antecedents, concomitants, and consequences.
Psychological Bulletin, 104, 97–126.
3. Beck, A. T. (1987). Cognitive therapy of depression. New York: Guilford.
4. Bernard, M. E., & DiGuiseppe, R. (Eds.) (1989). Inside rational-emotive therapy. New
York: Academic Press.
5. Burns, D. D. (1989). The feeling good handbook. New York: Plume.
6. Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory and
therapy of depression. Philadelphia: Wiley.
7. Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA:
Houghton Mifflin Company. Chapter 5, Major Depressive Disorder. Chapter 6,
Bipolar Disorder.
8. Copeland, M. E. (1994). Living without depression and manic depression: A workbook

for maintaining mood stability. New York: New Harbinger.
9. Coyne, J. C., & Gotlib, I. H. (1983). The role of cognition in depression: A critical
appraisal. Psychological Bulletin, 94, 472–505.
10. Dobson, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for

depression. Journal of Consulting and Clinical Psychology, 57, 414–419.
11. Faedda, G., Tondo, L., & Ross, J. (1993). Seasonal mood disorders: Patterns of
seasonal recurrence in mania and depression. Archives of General
Psychiatry, 50, 17-23.

Phone No.: (082)300-5456/305-0647 Local 118
LESSON SEVEN: SUMMATIVE TEST

Let’s Check
Now that the student knows the essential knowledge under lesson seven, which is all about
Mood Disorders and Suicide. Let us try to check the student's understanding of these terms.
1. The physical symptoms of a major depressive disorder include

a. changes in appetite or weight. c. increased energy
b. decreased ability to concentrate. d. decreased self-esteem
2. One of the symptoms of a mood disorder is called anhedonia, which means

a. a feeling of worthlessness.
b. an altered pattern of sleep.
c. indecisiveness.
d. an inability to engage in pleasurable activities.
3. When used in connection with mood disorders, "flight of ideas" means

a. anxiety about airplane travel.
b. rapid speech expressing many exciting ideas at once.
c. limited imagination reflected in a slow way of speaking.
d. repression of all creative ideas.
4. A 35-year-old individual named Manny has recently formulated an elaborate plan to

cure AIDS with vitamin therapy. To provide funding for this cause, he has withdrawn
all the money from his bank account and purchased thousands of jars of vitamins and
small boxes in which to put them. When he appeared at a hospital emergency room
loudly demanding names of patients with AIDS, he himself was hospitalized for
psychiatric observation. What is your diagnosis of Manny?
a. Major depressive episode c. Manic episode
b. Hypomanic episode d. Postpartum psychosis
5. Persistent depressive disorder (formerly called dysthymia) differs from major

depressive disorder because people diagnosed with dysthymia have symptoms of
depression that are ________.
a. more severe b. longer-lasting c. episodic d. temporary
6. Katie has been diagnosed with major depressive disorder. Most recently, she has been
lying immobile for long periods. If someone moves one of her arms to a different
position, it just stays there. Katie has stopped speaking and does not appear to hear

Phone No.: (082)300-5456/305-0647 Local 118
what is being said to her. What specifier would you apply to her diagnosis of major
depressive disorder?
a. Chronic c. With atypical presentation
b. With catatonic features d. Melancholic
7. Morning light is thought to help with seasonal affective disorder because it

a. produces phase advances of the melatonin rhythm.
b. reverses melatonin release.
c. increases the amount of melatonin released.
d. eliminates melatonin release.
8. Andy is currently completing a chemical formula that he knows will cure cancer. Shortly
before, he had submitted a book to a publisher and was sure that it would become a
bestseller. For several weeks prior to this, he was bedridden, morose, had no energy,
and lacked any spontaneity. He never left his bed and had to be cared for by his family.
Andy's diagnosis is ________________.
a. major depressive disorder c. bipolar I disorder
b. persistent depressive disorder d. bipolar II disorder
9. The less severe but more chronic version of bipolar disorder is called __________
disorder.
a. dysphoric c. bipolar III
b. seasonal affective d. cyclothymic
10. A child raised by depressed parents is likely to

a. struggle with depression as well.
b. learns how to avoid depression.
c. be inoculated against depression.
d. denies stress symptoms.
11. When individuals who are biologically vulnerable to depression place themselves in
high-risk stressful environments, it is called
a. humoral theory.
b. the cognitive-behavioral model.
c. the gene-environment correlation model.
d. a stress-depression linkage effect.
12. In Aaron Beck's depressive cognitive triad, individuals think negatively about all of the
following EXCEPT ________.
a. themselves c. their past
b. their immediate world d. their future
13. Which of the following factors contribute to the integrative theory of depression?
a. Stressful life events c. Neurotransmitter systems
b. Stress hormones d. All of these
14. Which of the following is perhaps the best-known and widely used SSRI medication?
a. Prozac b. Valium c. Hypericum d. Thorazine

Phone No.: (082)300-5456/305-0647 Local 118
15. A relative of yours has been diagnosed with bipolar disorder. Your family is impressed
when you mention that the preferred drug for this condition is ________.
a. Prozac c. an anticonvulsant
b. St. John's Wort d. lithium
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson seven is not enough;
what matters is that the student should also be able to evaluate some criterions found in the
DSM-5. Now, the CF will require the student to EVALUATE THE GIVEN CASE by providing
WHAT THE PATIENT IS EXPERIENCING (what kind of disorder) using the DSM-5 found
in the COURSE RESOURCES Section.
Case Six: Under Mood Disorder – THE CASE OF BRIAN
Brian Murphy had inherited a small business from his father and built it into a large one. When
he sold out a few years later, he invested most of his money; with the rest, he bought a small
almond farm in northern California. With his tractor, he handled most of the farm chores
himself. Most years the farm earned a few hundred dollars, but as Brian was fond of pointing
out, it really didn’t make much difference. If he never made a dime, he felt he got “full value
from keeping busy and fit.”
When Brian was 55, his mood, which had always been normal, slid into depression.
Farm chores seemed increasingly to be a burden; his tractor sat idle in its shed. As his mood
blackened, Brian’s body functioning seemed to deteriorate. Although he was constantly
fatigued, often falling into bed by 9 p.m., he would invariably awaken at 2 or 3 a.m. Then
obsessive worrying kept him awake until sunrise. Mornings were worst for him. The prospect
of “another damn day to get through” seemed overwhelming. In the evenings he usually felt
somewhat better, though he’d sit around working out sums on a magazine cover to see how
much money they’d have if he “couldn’t work the farm” and they had to live on their savings.
His appetite deserted him. Although he never weighed himself, he had to buckle his belt two
notches smaller than he had several months before.
“Brian just seemed to lose interest,” his wife, Rachel, reported the day he was admitted
to the hospital. “He doesn’t enjoy anything any more. He spends all his time sitting around and
worrying about being in debt. We owe a few hundred dollars on our credit card, but we pay it
off every month!”
During the previous week or two, Brian had begun to ruminate about his health. “At
first it was his blood pressure,” Rachel said. “He’d ask me to take it several times a day. I still
work part-time as a nurse. Several times he thought he was having a stroke. Then yesterday
he became convinced that his heart was going to stop. He’d get up, feel his pulse, pace around
the room, lie down, put his feet above his head, do everything he could to ‘keep it going.’
That’s when I decided to bring him here.”
“We’ll have to sell the farm.” That was the first thing Brian said to the mental health
clinician when they met. Brian was casually dressed and rather rumpled. He had prominent
worry lines on his forehead, and he kept feeling for his pulse. Several times during the
interview, he seemed unable to sit still; he would get up from the bed where he was sitting and
pace over to the window. His speech was slow but coherent. He talked mostly about his
feelings of being poverty-stricken and his fears that the farm would have to go on the block.
He denied having hallucinations, but admitted to feeling tired and “all washed up— not good
for anything any more.” He was fully oriented, had a full fund of information, and scored a
perfect 30 on the MMSE. He admitted that he was depressed, but he denied having thoughts
about death. Somewhat reluctantly, he agreed that he might need treatment.
Phone No.: (082)300-5456/305-0647 Local 118
Rachel pointed out that with his generous disability policy, his investments, and his
pension from his former company, they had more money coming in than when he was healthy.
“But still we have to sell the farm,” Brian replied.
Question for CASE SIX:

2. What are the treatment options for Brian? Explain your answer thoroughly. (20 Points)
Case Seven: Under Dissociative Disorders – THE CASE OF JOHN
When the man first walked into the homeless shelter, he hadn’t a thing to his name, including
a name. He’d been referred from a hospital emergency room, but he told the clinician on duty
that he’d only gone there for a place to stay. As far as he was aware, his physical health was
good. His problem was that he didn’t remember a thing about his life prior to waking up on a
park bench at dawn that morning. Later, when filling out the paperwork, the clinician had
penciled in “John Doe” as the patient’s name.
Aside from the fact that he could give a history spanning only about 8 hours, John
Doe’s mental status exam was remarkably normal. He appeared to be in his early 40s. He
was dressed casually in slacks, a pink dress shirt, and a nicely fitting corduroy sports jacket
with leather patches on the elbows. His speech was clear and coherent; his affect was
generally pleasant, though he was obviously troubled at his loss of memory. He denied having
hallucinations or delusions (“as far as I know”), though he pointed out logically enough that he
“couldn’t vouch for what kind of crazy ideas I might have had yesterday.”
John Doe appeared intelligent, and his fund of information was good. He could name
five recent presidents in order, and he could discuss recent national and international events.
He could repeat eight digits forward and six backwards. He scored 29 out of 30 on the MMSE,
failing only to identify the county in which the shelter was located. Although he surmised (he
wore a wedding ring) that he must be married, after half an hour’s conversation he could
remember nothing pertaining to his family, occupation, place of residence, or personal identity.
“Let me look inside your sports jacket,” the clinician said.
John Doe looked perplexed, but unbuttoned his jacket and held it open. The label gave
the name of a men’s clothing store in Cincinnati, some 500 miles away.
“Let’s try there,” suggested the clinician. Several telephone calls later, the Cincinnati
Police Department identified John Doe as an attorney whose wife had reported him missing 2
days earlier.
The following morning John Doe was on a bus for home, but it was days before the
clinician heard the rest of the story. A 43-year-old specialist in wills and probate, John Doe
had been accused of mingling the bank accounts of clients with his own. He had protested his
innocence and hired his own attorney, but the Ohio State Bar Association stood ready to
proceed against him. The pressure to straighten out his books, maintain his law practice, and
defend himself in court and against his own state bar had been enormous. Two days before
he disappeared, he had told his wife, “I don’t know if I can take much more of this without
losing my mind.”
Question for CASE Seven:

2. How would you investigate and manage this patient? (20 Points)
Phone No.: (082)300-5456/305-0647 Local 118
In a Nutshell
Activity 1. In this lesson, we learned about Mood Disorders and Suicide. In this section, I want
you to write down what you had learned or realized in this lesson. Provide at least 400 words.
Q&A List
lesson seven. After being reviewed, questions related to the topics mentioned above will
1.
2.
3.
4.
5.
\
~End of Lesson Seven~

Phone No.: (082)300-5456/305-0647 Local 118
Big Picture
to
a. Classify eating and sleep-wake disorders.

b. Formulating Case Conceptualization, Diagnosis, and Treatment Planning
Big Picture in Focus: ULOa. Classify eating and sleep-wake disorders
LESSON EIGHT
Metalanguage
This lesson outlines the major characteristics of eating disorders (bulimia

nervosa, anorexia nervosa, and binge-eating disorder) as well as obesity.
Etiological, developmental, and cultural factors that impact these problems are
described. In addition, treatment procedures are discussed, including cognitive-
behavioral approaches, family and interpersonal therapy, and pharmacotherapy.
This lesson also provides an overview of the key features of sleep-wake disorders,
with primary emphasis on the dyssomnias (insomnia disorder, hypersomnolence
disorder, narcolepsy, circadian rhythm sleep-wake disorder, and breathing-
related sleep disorders), and lesser emphasis on some of the parasomnias
(nightmare disorder, sleep terrors, and sleep walking [somnambulism] and
related situations). Assessment of these conditions is addressed, as well as
discussion of available medical and psychological treatments. Biological,
psychological, and cultural influences on sleep and sleep behavior are discussed.
• Bulimia Nervosa is an eating disorder in which dieting leads to out-of-control

binge-eating episodes, which are often followed by compensating for the intake
by purging the food through vomiting or other means, or by exercising and/or
fasting to "make up" for the intake.
• Anorexia Nervosa is another eating disorder in which a person's food intake

is drastically reduced, resulting in significant weight loss and, in some cases,
dangerously low body weight.
• Binge-eating Disorder refers to a pattern of chronic and repeated binge

eating, but it differs from bulimia nervosa in that it is not accompanied by
compensatory behaviors.
• Obesity is not a DSM disorder, but it is one of the world's most dangerous
epidemics today. Obesity, which is difficult to treat, is caused by cultures that
encourage eating high-fat foods in combination with genetic and other factors.

Phone No.: (082)300-5456/305-0647 Local 118
• Insomnia disorder is characterized by an inability to fall asleep, difficulties

staying asleep, or a failure to feel refreshed after a full night's sleep.
• Other dyssomnias include narcolepsy (sudden and irresistible sleep attacks),

circadian rhythm sleep disorders (sleepiness or insomnia caused by the
body’s inability to synchronize its sleep patterns with day and night), breathing-
related sleep disorders (disruptions that have a physical origin, such as sleep
apnea, that leads to excessive sleepiness or insomnia).
Essential Knowledge
I. MAJOR TYPES OF EATING DISORDERS
THE CASE OF “PHOEBE”: Apparently Perfect

Phoebe was a classic all-American girl: popular, attractive, intelligent, and talented. By the time she
was a senior in high school, she had accomplished a great deal. She was a class officer throughout high
school, homecoming princess her sophomore year, and junior prom queen. She dated the captain of the
football team. Phoebe had many talents, among them a beautiful singing voice and marked ability in ballet.
Each year at Christmastime, her ballet company performed the Nutcracker Suite, and Phoebe attracted
much attention with her poised performance in a lead role. She played on several school athletic teams.
Phoebe maintained an A-minus average, was considered a model student, and was headed for a top-ranked
university.

Phone No.: (082)300-5456/305-0647 Local 118
But Phoebe had a secret: She was haunted by her belief that she was fat and ugly. Every single bite
of food that she put in her mouth was, in her mind, another step down the inexorable path that led to the end
of her success and popularity. Phoebe had been concerned about her weight since she was 11. Ever the
perfectionist, she began regulating her eating in junior high school. She would skip breakfast (over the
protestations of her mother), eat a small bowl of pretzels at noon, and allow herself one half of whatever she
was served for dinner.
This behavior continued into high school, but as Phoebe struggled to restrict her eating, occasionally
she would binge on junk food. Sometimes she stuck her fingers down her throat after a binge (she even tried
a toothbrush once), but this tactic was unsuccessful. During her sophomore year in high school, Phoebe
reached her full adult height of 5 feet 2 inches and weighed 110 pounds; she continued to fluctuate between
105 and 110 pounds throughout high school. By the time she was a senior, Phoebe was obsessed with what
she would eat and when. She used every bit of her willpower attempting to restrict her eating, but
occasionally she failed. One day during the fall of her senior year, she came home after school and, alone
in front of the television, she ate two big boxes of candy. Depressed, guilty, and desperate, she went to the
bathroom and stuck her fingers farther down her throat than she had ever before dared. She vomited. And
she kept vomiting. Although so physically exhausted that she had to lie down for half an hour, Phoebe had
never in her life felt such an overwhelming sense of relief from the anxiety, guilt, and tension that always
accompanied her binges. She realized that she had gotten to eat all that candy and now her stomach was
empty. It was the perfect solution to her problems.
Phoebe learned quickly what foods she could easily vomit. And she always drank lots of water. She
began to restrict her eating even more and her bingeing increased.
This routine went on for about 6 months, until April of her senior year in high school. By this time,
Phoebe had lost much of her energy, and her schoolwork was deteriorating. Her teachers noticed this and
saw that she looked bad. She was continually tired, her skin was broken out, and her face pulled up,
particularly around her mouth. Her teachers and mother suspected that she might have an eating problem.
When they confronted her, she was relieved her problem was Finally, out in the open, and stopped binging
for a while, but mortally afraid of gaining weight and losing her popularity, Phoebe resumed her pattern, but
she was now much better at hiding it. For 6 months, Phoebe binged and purged approximately 15 times a
week.
When Phoebe went away to college that fall, things became more difficult. Now she had a roommate
to contend with, and she was more determined than ever to keep her problem a secret. Although the student
health service offered workshops and seminars on eating disorders for the freshman women, Phoebe knew
that she could not break her cycle without the risk of gaining weight. To avoid the communal bathroom, she
went to a deserted place behind a nearby building to vomit. She kept her secret until the beginning of her
sophomore year, when her world fell apart. One night, after drinking beer and eating fried chicken at a party
she attempted to cope with her guilt anxiety and tension in the usual manner, but when she tried to vomit,
her gag reflex seemed to be gone. Breaking into hysterics, she called her boyfriend and told him she was
ready to kill herself. Her loud sobbing and crying attracted the attention of her friends in her dormitory, who
attempted to comfort her. She confessed her problem to them. She also called her parents. At this point,
Phoebe realized that her life was out of control and that she needed professional help.
A. Bulimia Nervosa
• Bulimia nervosa is characterized by consuming more food,
usually junk food rather than fruits and vegetables, than other
people would consume under similar circumstances (Fairburn &
Cooper, 1993).
• The feeling of eating as out of control (Sysko & Wilson, 2011),

a criterion that is an integral part of the concept of binge eating,

Phone No.: (082)300-5456/305-0647 Local 118
is just as important as the amount of food consumed. Phoebe

met all of these conditions.
• Another important criterion is that the person uses purging

strategies to compensate for the binge eating and potential
weight gain.
o Techniques includes self-induced vomiting, using
laxatives, and exercise excessively.
• Davis et al., 1997, found that 57% of a group of patients with

bulimia nervosa exercised excessively while 81% of a group
with anorexia did).
• Bulimia nervosa was subtyped in DSM-IV-TR into

o purging type (e.g., vomiting, laxatives, or diuretics)
o nonpurging type (e.g., exercise and/or fasting).
2. Medical Consequences
• One is enlargement of the salivary glands as a result of
excessive vomiting, which gives the face a chubby look. This
was particularly evident in Phoebe's case.
• Vomiting on a regular basis will erode the dental enamel on

the inner surface of the front teeth and tear the esophagus.
• If left untreated, electrolyte imbalance can lead to severe
medical problems such as cardiac arrhythmia (abnormal

Phone No.: (082)300-5456/305-0647 Local 118
heartbeat), seizures, and renal (kidney) failure, all of which can

be fatal (Ludescher et al., 2009).
• Some bulimics develop calluses on their fingers or the backs

of their hands as a result of the friction of their fingers against
their teeth and throat when they repeatedly stick their fingers
down their throat to stimulate the gag reflex.
3. Associated Psychological Disorders

• According to a comprehensive national survey on the
prevalence of eating disorders and related psychological
disorders, 80.6 percent of people with bulimia had an anxiety
disorder at some point in their lives, and 66 percent of
bulimia-affected adolescents had a co-occurring anxiety
disorder when interviewed (Swanson et al., 2011).
• Mood disorders, particularly depression, are common co-

occurring disorders with bulimia, with approximately 20% of
bulimic patients meeting criteria for a mood disorder when
interviewed, and between 50% and 70% meeting criteria at
some point during their disorder (Swanson et al., 2011).
THE CASE OF “JULIE”: The Thinner, the Better

Julie was 17 years old when she first came for help. If you looked hard enough past her sunken
eyes and pasty skin, you could see that she had once been attractive. But at present, she looked emaciated
and unwell. Eighteen months earlier she had been overweight, weighing
140 pounds at 5 feet 1 inch. Her mother, a well-meaning but overbearing and demanding woman, nagged
Julie incessantly about her appearance. Her friends were kinder but no less relentless. Julie, who had
never had a date, was told by a friend she was cute and would have no trouble getting dates if she lost
some weight. So, she did! After many previous unsuccessful attempts, she was determined to succeed
this time.
After several weeks on a strict diet, Julie noticed she was losing weight. She felt a control and
mastery that she had never known before. It wasn’t long before she received positive comments, not only
from her friends but also from her mother. Julie began to feel good about herself. The difficulty was that
she was losing weight too fast. She stopped menstruating. But now nothing could stop her from dieting.
By the time she reached our clinic, she weighed 75 pounds but she thought she looked fine and, perhaps,
could even stand to lose a bit more weight. Her parents had just begun to worry about her. Julie did not
initially seek treatment for her eating behavior. Rather, she had developed a numbness in her left lower
leg and a left foot drop—an inability to lift up the front part of the foot—that a neurologist determined was
caused by peritoneal nerve paralysis believed to be related to inadequate nutrition. The neurologist
referred her to our clinic.
Like most people with anorexia, Julie said she probably should put on a little weight, but she didn’t
mean it. She thought she looked fine, but she had “lost all taste for food,” a report that may not have been
true because most people with anorexia crave food at least some of the time but control their cravings.
Nevertheless, she was participating in most of her usual activities and continued to do extremely well in
school and in her extracurricular pursuits. Her parents were happy to buy her most of the workout
videotapes available, and she began doing one every day, and then two. When her parents suggested she
was exercising enough, perhaps too much, she worked out when no one was around. After every meal,
she exercised with a workout tape until, in her mind, she burned up all the calories she had just taken in.

Phone No.: (082)300-5456/305-0647 Local 118
B. Anorexia Nervosa
• Although anorexia nervosa is less common than bulimia, the two
disorders have a lot in common. Many people with bulimia, for
example, have a history of anorexia, in which they used
fasting to reduce their body weight to below desirable levels
(Fairburn, et al., 1997).
• While many people lose weight as a result of a medical

condition, anorexics have a strong fear of obesity and strive
to be as thin as possible (Russell, 2009).
• DSM-5 specifies two subtypes of anorexia nervosa:

o restricting type – the individual’s diet to limit calorie
intake.
o binge-eating–purging type - they rely on purging.
• DSM-5 criteria specify that subtyping refer only to the last 3

months (Peat, Mitchell, Hoek, & Wonderlich, 2009).
• Anorexics never seem to be satisfied with their weight loss.

Staying the same weight or gaining weight from one day to the
next is likely to cause panic, anxiety, and depression.
• DSM-5 Only “significantly low” body weight (15 percent below

expected) is defined by DSM-5 criteria; the average is between
25 and 30 percent.
• Individuals with anorexia seldom seek treatment on their

own. Usually, pressure from somebody in the family leads to the
initial visit (Agras, 1987; Fairburn & Cooper, in press), as in
Julie’s case.
2. Medical Conditions
• Menstrual irregularity (amenorrhea) is a common medical
complication of anorexia nervosa, which also occurs frequently
in bulimia (Crow, Fluras, Keel, & Mitchell, 2002).
• Dry skin, brittle hair or nails, and sensitivity to or intolerance of

cold temperatures are other medical signs and symptoms of
anorexia.
• Lanugo is a downy hair that grows on the limbs and cheeks.
• Electrolyte imbalance and resulting cardiac and kidney

problems, as in bulimia, can occur if vomiting is a part of the
anorexia (Mehler et al., 2010).

Phone No.: (082)300-5456/305-0647 Local 118
3. Associated Psychological Disorders

• Individuals with anorexia are more likely to have anxiety and
mood disorders, with up to 71% of cases experiencing
depression at some point during their lives (Godart et al.,
2007).
• Substance abuse is also common in people with anorexia

nervosa (Swanson et al., 2011), and it is a strong predictor of
mortality, particularly by suicide, when combined with anorexia.
C. Binge-Eating Disorder
1. Beginning in the 1990s, researchers focused on a subset of people who
are distressed by binge eating but do not engage in extreme
compensatory behaviors and thus are not diagnosed with bulimia
(Fairburn et al., 1998).
2. When compared to other eating disorders, BED has a higher chance of

remission and a better response to treatment (Wonderlich et al., 2009).
3. It is widely assumed that about 20% of obese people in weight-loss

programs binge eat, with the number rising to around 50% among
bariatric surgery candidates (surgery to correct severe or morbid
obesity).

Phone No.: (082)300-5456/305-0647 Local 118
4. About half of people with BED try to diet before bingeing, and the other
half binge first and then try to diet (Abbott et al., 1998).
5. It appears that approximately 33% of people with BED binge to get rid
of their "bad moods" or negative feelings (Grilo, Masheb, & Wilson,
2001).
D. Statistics
1. The overwhelming majority of people with bulimia who seek treatment
are women (90 percent to 95 percent). Bulimia affects men at a slightly
later age, and a large minority of them are gay or bisexual men
(Rothblum, 2002).
2. Male athletes in weight-regulatory sports, such as wrestling, make up

another large group of men with eating disorders (Ricciardelli &
McCabe, 2004).
3. The case was listed under "Any binge eating" if binge eating occurred
at least twice a week for three months, even if it was just a symptom of
one of the four other disorders listed in Table 8.2. This last category
gives you a general idea of how common binge eating is. Table 8.2
summarizes all of the information.

Phone No.: (082)300-5456/305-0647 Local 118
4. The median age of onset for all eating disorders was between the ages
of 18 and 21 years (Hudson et al., 2007).
5. Fairburn, Stice, et al. (2003) found that a history of childhood obesity

and a continuing overemphasis on the importance of being thin were
the strongest predictors of persistent bulimia.
6. Cross-Cultural Considerations
• One particularly striking finding is that these disorders develop
in recent immigrants to Western countries (Anderson-Fye,
2009).
• Most North American minority populations, including African

Americans, Hispanics, Native Americans, and Asians, have
varying levels of eating disorders.
• Greenberg and LaPorte (1996) found in an experiment that

young white males preferred thinner female figures than African
American males, which could explain why African American
women have a lower rate of eating disorders.
7. Developmental Considerations
• Eating disorders, particularly anorexia nervosa, can affect
children as young as 11 years old (Walsh, 2010).
• Both bulimia and anorexia can strike in later life, especially after
55. According to Hsu and Zimmer (1988), the majority of these
people had been suffering from an eating disorder for decades,
with little change in their behavior.
II. CAUSES OF EATING DISORDERS

A. Social Dimensions
1. For many young women, looking good takes precedence over staying
healthy. Self-worth, happiness, and success for young females in
competitive environments are largely determined by body
measurements and body fat percentages, factors that have little or no
long-term correlation with personal happiness and success.
2. In magazines and on television, Levine and Smolak (1996) refer to "the

glorification of slenderness," where most females are thinner than
the average American woman.
3. In a review of 77 studies, Grabe, Ward, and Hyde (2008) found a strong

link between exposure to media images depicting the thin-ideal
body and body image concerns in women.
4. The problem with today's standards is that they are becoming

increasingly difficult to meet, as the average woman's size and weight
have increased over time as nutrition has improved; there has also been
a general increase in size throughout history (Brownell & Rodin, 1994).

Phone No.: (082)300-5456/305-0647 Local 118
5. In a case study of male and female undergraduates, Fallon and Rozin

(1985) discovered that men rated their current size, ideal size, and the
size they thought would be most attractive to the opposite sex as
roughly equal; indeed, they rated their ideal body weight as heavier than
the weight females thought would be most attractive in men (see Figure
8.2).
6. Men generally want to be bigger and stronger than they are, according
to Pope and colleagues (2000). They asked the men to choose the body
image that best represented (1) their own body, (2) the body they
wished they had, (3) the body of an average man their age, and (4) the
male body they believed women preferred.
7. You are more likely to use extreme dieting or other weight-loss

techniques if your friends do (Hutchinson & Rapee, 2007).
8. Stice and colleagues (1999) demonstrated that one of the reasons

weight loss efforts in adolescent girls are more likely to result in weight
gain than weight loss, which could lead to eating disorders.
9. Like other addictive substances, repeated cycles of "dieting" appear to

cause stress-related withdrawal symptoms in the brain, resulting in
more eating than would have occurred without dieting.
10. Olivardia, Pope, and Hudson (2000) first coined the term "reverse
anorexia nervosa" to describe a syndrome in men, particularly male
weight lifters. Even though they were muscular, men with this syndrome
expressed extreme concern about appearing small.
11. Growing evidence suggests that body size has a strong genetic
component; that is, some of us are born heavier than others, and we
are all shaped differently.
12. Dietary Restraint

• Dieting is one factor that can contribute to eating disorders, and
it is a primary risk factor for later eating disorders, along with
body dissatisfaction (Stice, Ng, & Shaw, 2010).

Phone No.: (082)300-5456/305-0647 Local 118
13. Family Influences

• According to a number of clinicians and researchers (Attie &
Brooks Gunn, 1995), the “typical” anorexia family is successful,
hardworking, concerned about outward appearances, and
eager to maintain harmony.
• At least initially, mothers of girls with disordered eating

appeared to act as "society's messengers" in wanting their
daughters to be thin (Steinberg & Phares, 2001).
B. Biological Dimensions
1. According to studies, relatives of patients with eating disorders are 4 to
5 times more likely than the general population to develop eating
disorders themselves, with female relatives of anorexic patients having
a higher risk (Strober, Freeman, Lampert, Diamond, & Kaye, 2000).
2. Both twins had bulimia in 23 percent of identical twin pairs, compared

to 9 percent of fraternal twin pairs. Strong sociocultural influences
cannot be ruled out because no adoption studies have been reported,
and other studies have produced mixed results (Fairburn, Cowen, &
Harrison, 1999).
3. A person's tendency to be emotionally reactive to stressful life

events may be inherited, and as a result, he or she may eat
impulsively in an attempt to relieve stress and anxiety (Kaye, 2008).
4. Low levels of serotonergic activity, the system most often linked to

eating disorders (Steiger, Bruce, & Groleau, 2011), is linked to eating
disorders.
C. Psychological Dimensions
1. Many young women with eating disorders have a diminished sense of
personal control and confidence in their own abilities and talents,
according to clinical observations over the years (Walters & Kendler,
1995).
2. They also exhibit more perfectionistic attitudes, which may reflect

attempts to exert control over important events in their lives and may
have been learned or inherited from their families (Joiner et al., 1997).
3. Women who suffer from eating disorders are obsessed with how
they appear to others (Smith et al., 2007).
4. According to Striegel-Moore and colleagues (1993), as a result of the

eating disorder, these social self-deficits are likely to worsen, further
isolating the woman from the larger social world.
5. Rosen and Leitenberg (1985) found significant anxiety before and

during snacks, which they believe is alleviated by purging. They claimed
that the feeling of relief reinforces the purging because we tend to
repeat behaviors that bring us pleasure or provide relief from anxiety.
Phone No.: (082)300-5456/305-0647 Local 118
D. An Integrative Model
1. Individuals with eating disorders may share some of the same biological
vulnerabilities as people with anxiety disorders (such as being
hypersensitive to stressful life events) (Bermudez, & Livianos, 2006).
2. Anxiety and mood disorders are common in eating disorder families

(Steiger et al., 2013), and negative emotions, as well as "mood
intolerance," appear to trigger binge eating in many patients.
3. It is undeniable that social and cultural pressures to be thin drive

significant dietary restriction, usually through extreme dieting.
4. A strong emphasis on appearance and achievement in these families,

as well as perfectionistic tendencies, may help establish strong
attitudes about the overriding importance of physical appearance to
popularity and success, which are reinforced in peer groups.
III. TREATMENT OF EATING DISORDERS

A. Drug Treatments
1. Antidepressant medications that have been shown to be effective for
mood disorders and anxiety disorders are commonly used to treat
bulimia (Broft, Berner, & Walsh, 2010).
2. Prozac was approved by the Food and Drug Administration (FDA) in

1996 as an effective treatment for eating disorders. Effectiveness is
typically measured by reductions in binge eating frequency, as well as

Phone No.: (082)300-5456/305-0647 Local 118
the percentage of patients who stop binge eating and purging entirely,
at least temporarily.
3. Researchers found that the average reduction in binge eating and

purging was 47 percent and 65 percent in two studies, one using
several tricyclic antidepressant drugs and the other using Prozac
(Walsh, 1991).
B. Psychological Treatments
1. Short-term cognitive-behavioral treatments target problem eating
behavior and associated attitudes about the overarching importance
and significance of body weight and shape, and they've become the go-
to treatment for bulimia (Sysko & Wilson, 2011).
C. Preventing Eating Disorders

1. Following a review of prevention programs, Stice, Shaw, and Marti
(2007) concluded that selecting girls aged 15 or older and focusing
on eliminating an exaggerated focus on body shape or weight, as
well as encouraging acceptance of one's body, had the best chance of
preventing eating disorders.
2. The researchers created the "student bodies program" (Winzelberg

et al., 1998), an Internet-based structured, interactive health education
program aimed at improving body image satisfaction.
3. The Body Project, a shorter and more efficient program, has now been
adapted as a stand-alone intervention delivered over the Internet
(eBody Project; Stice, Rohde, Durant, and Shaw, 2012), with no need
for a clinician.
IV. OBESITY
A. Statistics
1. Obesity (BMI 30 or greater) affected fully 30.5 percent of adults in the
United States in 2000, rising to 30.6 percent in 2002, 32.2 percent in
2004, 33.8 percent in 2008, and 35.7 percent in 2010, with no difference
in prevalence between men and women (Flegal et al., 2012).
2. This condition is linked to significantly higher mortality in the general

population (Flegal, Kit, Orpana, & Graubard, 2013).).
3. Obesity rates for children ages 2–19 (defined as above the 95th
percentile for sex-specific BMI for that age) have risen steadily over the
last decade, from 13.9 percent in 2000 to 17.1 percent in 2004 (Ogden
et al., 2006), but now appear to be leveling off, with a 16.9% rate in
2008 and 2010 (Ogden et al., 2006).
4. Ethnicity plays a role in obesity rates. Obesity affects 58 percent of

African American women and 41% of Hispanic American women in the
United States, compared to 32 percent of Caucasian women (Flegal et
al., 2012).

Phone No.: (082)300-5456/305-0647 Local 118
B. Disordered Eating Patterns in Cases of Obesity

1. Obese people have two types of maladaptive eating patterns: the first
is binge eating, and the second is night eating syndrome (Lundgren,
Allison, & Stunkard, 2012).
2. Even more intriguing is the pattern of night eating syndrome, which

affects between 6% and 16% of obese people seeking weight-loss
treatment, but up to 55% of those with extreme obesity seeking bariatric
surgery (Colles & Dixon, 2012).
C. Causes
1. According to Henderson and Brownell (2004), the obesity epidemic is
inextricably linked to the spread of modernization. To put it another way,
as technology advances, we become fatter.
2. The most significant single contributor to the obesity epidemic is the

promotion of an inactive, sedentary lifestyle and the consumption of
a high-fat, energy-dense diet (Caballero, 2007).
3. Genes are thought to account for about 30% of the equation in obesity
causation (Bouchard, 2002), but this is misleading because these
genes are turned on by a "toxic" environment.
4. Physiological processes, particularly hormonal appetite regulation,

play a big role in the start and stop of eating, and they differ a lot from
person to person (Friedman, 2009).
5. Unhealthy eating and drinking in readily available fast-food outlets

appear to reduce stress in some lower-income groups, particularly
African-American communities, but with harmful physical
consequences (Jackson, Knight, & Rafferty, 2010).
D. Treatment
1. The treatment of obesity is only moderately successful at the individual
level, with somewhat greater long-term evidence for effectiveness in
children compared to adults (Sarwer et al., 2004). Treatments like self-
directed weight-loss program and exercise.
Phone No.: (082)300-5456/305-0647 Local 118
2. Several studies have compared the most popular diet programs, such
as the Atkins (carbohydrate restriction), Ornish (fat restriction),
Zone (macronutrients balance), and Weight Watchers (calorie
restriction) diets.
3. The most successful programs are professionally directed behavior

modification programs, particularly if patients attend group
maintenance sessions periodically in the year following initial weight
reduction (Bray, 2012).
4. Drug treatments that reduce internal cues signaling hunger may

have some effect, particularly if combined with a behavioral approach
targeting lifestyle change, but concerns about cardiovascular side
effects have plagued these medications (Morrato & Allison, 2012).
5. The surgical approach to extreme obesity called bariatric surgery is

an increasingly popular approach for individuals with a BMI of at least
40 (Adams et al., 2012).
V. SLEEP-WAKE DISORDERS: THE MAJOR DYSSOMNIAS

A. An Overview of Sleep Disorders
1. Moral treatment for people with severe mental illness in the nineteenth
century included encouraging patients to get enough sleep as part of
their therapy (Charland, 2008).
2. The link between sleep disturbances and mental health, on the other
hand, is more complicated. People's problems in everyday life may be
caused by sleep problems (e.g., McKenna & Eyler, 2012).
3. Inadequate sleep, for example, can encourage overeating and

contribute to the obesity epidemic (Hanlon & Van Cauter, 2011).
4. Sleep–wake disorders are divided into two major categories:

dyssomnias and parasomnias (see Table 8.4).
a. Dyssomnias are sleep problems that include insufficient sleep,
difficulty sleeping when you want to, and complaints about sleep
quality.
b. Parasomnias are sleep disorders marked by abnormal

behavioral or physiological events such as nightmares and
sleepwalking.
5. Polysomnographic (PSG) Evaluation is a method to see the clearest

and most comprehensive picture of your sleep habits (Morin, Savard, &
Ouellet, 2012).
a. Electroencephalogram – measure the brain activity
b. Electrooculogram – measure the eye movement
c. Electromyogram – measure the muscle movements
d. Electrocardiogram – measure the heart activity

Phone No.: (082)300-5456/305-0647 Local 118
6. Actigraph is an alternative device for comprehensive assessment of

sleep. It is a wristwatch-size that is being worn all the time.
7. Clinicians and researchers benefit from knowing an individual's average

number of hours of sleep per day, as well as their sleep efficiency
(SE), which is the percentage of time spent sleeping rather than lying in
bed trying to sleep.
B. Insomnia Disorder
1. After one or two nights of being awake, a person begins to have
microsleeps that last several seconds or longer. Total lack of sleep
eventually leads to death in the rare cases of fatal familial insomnia (a
degenerative brain disorder) (Parchi, Capellari, & Gambetti, 2012).
THE CASE OF “SONJA”: School on Her Mind

Sonja was a 23-year-old law student with a history of sleep problems. She reported that she
never really slept well, both having trouble falling asleep at night and usually awakening again in the
early morning. She had been using the nighttime cold medication Nyquil several times per week over
the past few years to help her fall asleep. Unfortunately, since she started law school last year, her
sleep problems had grown even worse. She would lie in bed awake until the early morning hours thinking
about school, getting only 3–4 hours of sleep on a typical night. In the morning, she had a great deal of
difficulty getting out of bed and was frequently late for her early morning class.
Phone No.: (082)300-5456/305-0647 Local 118
Sonja’s sleep problems and their interference with her schoolwork was causing her to experience
increasingly severe depression. In addition, she recently reported having a severe anxiety attack that
woke her in the middle of the night. All of these difficulties caused her to be increasingly isolated from
family and friends, who finally convinced her to seek help.
We return to Sonja later in this chapter.
• Sonja’s sleep problems were not related to any other medical or
psychiatric issues, so her symptoms fit the DSM-5 criteria for
insomnia disorder (also referred to as primary insomnia).
• Sonja’s is a classic example of insomnia. She had trouble falling

asleep and staying asleep. Others sleep all night but wake up
feeling like they've been awake for hours.

Phone No.: (082)300-5456/305-0647 Local 118
3. Statistics
• Around 35% of older adults report excessive daytime
sleepiness, with older black men having the most issues (Green,
Ndao-Brumblay, & Hart-Johnson, 2009).
• The link between alcohol use and sleep disorders can be

especially concerning. Alcohol is frequently used to help
people fall asleep (Morin et al., 2012).
• Women are more likely than men to have trouble falling

asleep, which could be due to hormonal differences or to
different reporting of sleep problems, with women being more
negatively affected by poor sleep (Jaussent et al., 2011).
• Estimates of insomnia among young children range from 20%

to more than 40% (Price, Wake, Ukoumunne, & Hiscock,
2012).
• As people get older, the number of people who complain about

sleeping problems rises. According to a national sleep poll, 26%
of adults aged 55 to 64 have sleep problems, while 21% of
those aged 65 to 84 have sleep problems (National Sleep
Foundation, 2009).
4. Causes
• Many medical and psychological disorders, such as pain and
physical discomfort, physical inactivity during the day, and
respiratory problems, are associated with insomnia. Insomnia is
sometimes linked to issues with the biological clock and its
temperature regulation.
• Drug use and a variety of environmental influences such as

changes in light, noise, or temperature can also make it difficult
to sleep.
• Sleep apnea (an obstructed nighttime breathing disorder) and

periodic limb movement disorder (excessive jerky leg
movements) can disrupt sleep and appear to be the same as
insomnia.
• People with insomnia may have unrealistic expectations

about how much sleep they need (Morin & Benca, 2012).
• Infants are expected to sleep on their own in a separate bed

and, if possible, in a separate room in the United States'
dominant culture (see Table 8.5). However, in other cultures,
such as rural Guatemala, Korea, and urban Japan, the child
spends the first few years of life in the same room and, in some
cases, the same bed as the mother (Burnham & Gaylor, 2011).

Phone No.: (082)300-5456/305-0647 Local 118
C. Hypersomnolence Disorders
1. Hypersomnolence disorders are characterized by excessive sleeping
(hyper means "in great quantity" or "abnormal excess"). Many people
who sleep through the night find themselves falling asleep multiple
times the following day.
THE CASE OF “ANN”: Sleeping in Public

Ann, a college student, came to my office to discuss her progress in class. We talked about
several questions that she got wrong on the last exam, and as she was about to leave she said that she
never fell asleep during my class. This seemed like faint praise, but I thanked her for the feedback. “No,”
she said, “you don’t understand. I usually fall asleep in all of my classes, but not in yours.” Again, I didn’t
quite understand what she was trying to tell me and joked that she must pick her professors more
carefully. She laughed. “That’s probably true. But I also have this problem with sleeping too much.”

Phone No.: (082)300-5456/305-0647 Local 118
As we talked more seriously, Ann told me that excessive sleeping had been a problem since her
teenage years. In situations that were monotonous or boring, or when she couldn’t be active, she fell
asleep. This could happen several times a day, depending on what she was doing. Recently, large lecture
classes had become a problem unless the lecturer was particularly interesting or animated. Watching
television and driving long distances were also problematic.
Ann reported that her father had a similar problem. He had recently been diagnosed with
narcolepsy (which we discuss next) and was now getting help at a clinic. Both she and her brother had
been diagnosed with hypersomnolence disorder. Ann had been prescribed Ritalin (a stimulant
medication) about 4 years ago and said that it was only somewhat effective in keeping her awake during
the day. She said the drug helped reduce the sleep attacks but did not eliminate them altogether.
2. The DSM-5 diagnostic criteria for hypersomnolence include not only

Ann's description of excessive sleepiness, but also her subjective
impression of the problem (American Psychiatric Association, 2013).

Phone No.: (082)300-5456/305-0647 Local 118
3. People with hypersomnolence sleep all night and appear rested when
they wake up, but they still complain of being tired all day.
4. Sleep apnea, a breathing-related sleep disorder, is another sleep

problem that can cause excessive sleepiness.
• People with this condition have trouble breathing at night. They
snore loudly, pause between breaths, and have a dry mouth and
headache in the morning.
5. In some cases, genetic factors appear to play a role, with individuals

having a higher likelihood of having certain genetic factors (HLA-Cw2
and HLA-DR11) (Buysse et al., 2008).
D. Narcolepsy
1. Cataplexy is a sudden loss of muscle tone that some people with
narcolepsy experience during the day.
2. Cataplexy is a condition that occurs while a person is awake and can

range from minor facial muscle weakness to complete physical
collapse.
3. People with narcolepsy have two additional characteristics (Ahmed &

Thorpy, 2012).
a. Sleep Paralysis – a brief period following awakening in which
the person is unable to move or speak, which is often frightening
for those who experience it.
b. Hypnagogic Hallucinations - vivid and often frightening

experiences that begin at the start of sleep and are described
as "unbelievably realistic" because they include not only visual
aspects but also touch, hearing, and even the sensation of body
movement

Phone No.: (082)300-5456/305-0647 Local 118
4. When sleep paralysis occurs in the presence of anxiety disorders, the

condition is known as isolated sleep paralysis.
5. Narcolepsy patients appear to have a significant loss of a specific type

of nerve cell (hypocretin neurons). These neurons produce peptides
that appear to be important in waking up (Burgess & Scammell, 2012).
E. Breathing-Related Sleep Disorders

1. People who have their breathing interrupted while sleeping have
numerous brief arousals throughout the night and do not feel rested
even after sleeping for 8 or 9 hours (Overeem & Reading, 2010).
2. Sleep Apnea is a condition in which breathing is severely restricted and

may be labored (hypoventilation) or, in the extreme, where they stop
breathing completely (10 to 30 seconds).
a. Obstructive Sleep Apnea Hypopnea Syndrome occurs when
airflow stops despite continued activity by the respiratory system
(Mbata & Chukwuka, 2012).
b. Central Sleep Apnea is characterized by a complete cessation

of respiratory activity for brief periods of time, and it is frequently
linked to central nervous system disorders like cerebral vascular
disease, head trauma, and degenerative disorders (Badr, 2012).
c. A decrease in airflow without a complete pause in breathing is

known as sleep-related hypoventilation. Because insufficient
air is exchanged with the environment, this tends to result in an
increase in carbon dioxide (CO2) levels.
3. When heavy sweating, morning headaches, and episodes of falling

asleep during the day occur with no resulting feeling of being rested,
this is referred to as Sleep Attacks (Overeem & Reading, 2010).
F. Circadian Rhythm Sleep Disorders

1. The inability of the brain to synchronize its sleep patterns with the
current day and night patterns causes this disorder, which is
characterized by disturbed sleep (insomnia or excessive sleepiness
during the day).
2. These rhythms are known as circadian (from circa meaning "about" and
dian meaning "day") because they don't exactly match our 24-hour day.
3. The suprachiasmatic nucleus of the hypothalamus houses our

biological clock. A pathway leading from our eyes connects to the
suprachiasmatic nucleus. Each day, the increasing light in the morning
and decreasing light at night signal the brain to reset the biological
clock.
4. Jet Lag Type is, as its name implies, caused by rapidly crossing
multiple time zones (Kolla, Auger, & Morgenthaler, 2012).

Phone No.: (082)300-5456/305-0647 Local 118
5. Shift work type sleep problems are associated with work schedules
(Åkerstedt & Wright Jr., 2009).
6. Working (and thus staying awake) at odd hours can cause problems
beyond sleep, such as cardiovascular disease, ulcers, and breast
cancer in women (Richardson, 2006).
7. People who are extreme night owls, staying up late and sleeping late,
may suffer from a condition known as delayed sleep phase type. “Early
to bed and early to rise” is a phrase used by people with an advanced
sleep phase type of circadian rhythm disorder.
8. There are two more types: irregular sleep–wake type (people who
have highly varied sleep cycles) and non-24-hour sleep–wake type
(people who do not sleep for 24 hours) (e.g., sleeping on a 25- or 26-
hour cycle with later and later bedtimes ultimately going throughout the
day).
9. Melatonin, a hormone, is thought to play a role in the setting of our

biological clocks, which tell us when to sleep. The pineal gland, located
in the center of the brain, produces this hormone (Kolla et al., 2012).

Phone No.: (082)300-5456/305-0647 Local 118
VI. TREATMENT OF SLEEP DISORDERS

A. Medical Treatments
1. People who visit a doctor with insomnia are likely to be prescribed one
of several benzodiazepine or related medications (see Table 8.6),
including short-acting drugs like triazolam (Halcion), zaleplon (Sonata),
and zolpidem (Ambien), as well as long-acting drugs like flurazepam
(Dalmane).
2. Medical insomnia treatments have a number of disadvantages. For

starters, benzodiazepine medications can make you sleepy. Second,
people can easily become reliant on them and, whether intentionally or
unintentionally, misuse them. Third, these medications are intended for
short-term use and should not be used for more than four weeks.
Longer use can lead to addiction and insomnia.

Phone No.: (082)300-5456/305-0647 Local 118
3. To treat hypersomnolence or narcolepsy, doctors typically prescribe

a stimulant such as methylphenidate (Ritalin, Ann's medication) or
modafinil (Nevsimalova, 2009).
4. As we saw earlier in this chapter, voluntary weight loss is rarely

successful in the long run; as a result, this treatment for breathing-
related sleep disorders has not been successful (Sanders & Givelber,
2006).
5. Continuous positive air pressure (CPAP) machine is a device that

helps people with sleep apnea. Patients sleep with a mask on their
faces that provides slightly pressurized air, allowing them to breathe
more normally throughout the night.
B. Environmental Treatments
1. One general principle in the treatment of circadian rhythm disorders is
that phase delays (moving bedtime later) are easier than phase
advances (moving bedtime earlier).
2. People can best readjust their sleep patterns by going to bed several
hours later each night until bedtime is at the desired hour (Sack et al.,
2007).
3. Another method for assisting people with sleep issues is to use bright
light to fool the brain into resetting the biological clock. Research
indicates that bright light (also referred to as phototherapy) may help
people with circadian rhythm problems readjust their sleep patterns
(Kolla et al., 2012).

Phone No.: (082)300-5456/305-0647 Local 118
C. Psychological Treatments
1. The limitations of using medication to help people sleep better have led
to the development of psychological treatments. Some psychological
approaches to insomnia are briefly described in Table 8.7.
2. Siddiqui & D'Ambrosio (2012) found that cognitive-behavioral

therapy (CBT) may be more effective than a medical (drug)
intervention in treating sleep disorders in older adults when using a
randomized placebo control design.
3. Some cognitive treatments may not be possible for young children.

Instead, bedtime routines such as a bath followed by a parent reading
a story are frequently used to help children fall asleep at night.
Graduated extinction (described in Table 8.8) has been used
successfully for bedtime issues as well as waking up in the middle of
the night (Durand, 2008).

Phone No.: (082)300-5456/305-0647 Local 118
D. Preventing Sleep Disorders

1. Sleep Hygiene refers to the fact that many of the sleep problems
people face on a daily basis can be avoided by taking a few simple
steps during the day (Goodman & Scott, 2012).
2. Avoiding stimulants like caffeine and nicotine, which are both

stimulants, can help you avoid issues like nighttime awakening. A
number of the sleep hygiene steps recommended for preventing sleep
problems are shown in Table 8.8.
E. Parasomnias and Their Treatment

1. Parasomnias are abnormal events that occur during sleep or in the
twilight period between sleeping and waking. They are not sleep
disorders.
2. Nightmares (or nightmare disorder) happen during REM (rapid eye

movement) or dream sleep. Approximately 10% to 50% of children and
9% to 30% of adults are exposed to them on a regular basis (Schredl,
2010).
• These experiences must be so distressing that they impair a
person's ability to carry on normal activities, according to DSM-
5 criteria, to qualify as a nightmare disorder (such as making a
person too anxious to try to sleep at night).
• Nightmares are linked to some psychological disorders (e.g.,

substance abuse, anxiety, borderline personality disorder, and
schizophrenia spectrum disorders) and are thought to be
influenced by genetics, trauma, and medication use (Augedal et
al., 2013).

Phone No.: (082)300-5456/305-0647 Local 118
• Studies on the treatment of nightmares suggest that both

psychological (e.g., cognitive behavior therapy) and
pharmacological (e.g., prazosin) interventions can help reduce
these dreadful sleep events (Augedal et al., 2013).
3. A piercing scream usually precedes sleep terrors, which most commonly

affect children. Sleep terrors resemble nightmares in that the child cries
and appears terrified, but they occur during NREM sleep and are thus
unrelated to frightening dreams.
• Children cannot be easily awakened and comforted during sleep
terrors, as they can during a nightmare. Despite their often-
dramatic effect on the observer, children do not remember sleep
terrors (Durand, 2008).
• We do not know much about sleep terrors, despite the fact that
several theories have been proposed, including the possibility of a
genetic component, given that the disorder tends to run in families
(Durand, 2008).

Phone No.: (082)300-5456/305-0647 Local 118
• One of the treatments for chronic sleep terrors is scheduled

awakening. Parents of children who had almost nightly sleep
terrors were advised by Durand and Mindell (1999) to briefly
awaken their child about 30 minutes before a typical episode
(these usually occur around the same time each evening).
4. Sleepwalking (somnambulism) occurs during NREM sleep (Shatkin &

Ivanenko, 2009). This means that when people walk in their sleep, they
are probably not acting out a dream.
• Sleepwalking is defined by the DSM-5 as a person getting out of
bed, though fewer active episodes can involve small motor
behaviors like sitting up in bed and picking at the blanket or
gesturing.
• Sleepwalking is primarily a problem in children, though it affects a

small percentage of adults. A large percentage of children,
between 15% and 30%, experience at least one episode of
sleepwalking, with about 2% reporting multiple incidents (Neylan et
al., 2003).
• Sleepwalking episodes have been linked to violent behavior in the

past, including homicide and suicide (Cartwright, 2006).
5. Nocturnal Eating Syndrome occurs when people get out of bed and eat
while still sleeping (Striegel-Moore et al., 2010).
6. Sexsomnia is defined as the act of performing sexual acts such as

masturbation and sexual intercourse while having no recollection of the
event (Béjot et al., 2010).

Phone No.: (082)300-5456/305-0647 Local 118
Key Terms: bulimia nervosa, insomnia disorder, anorexia nervosa, binge-eating disorder,
obesity, purging techniques, night eating syndrome, bariatric surgery, rapid eye movement
(REM) sleep, dyssomnias, parasomnias, polysomnographic (PSG), evaluation, actigraph,
sleep efficiency (SE), microsleeps, binge, primary insomnia, rebound insomnia,
hypersomnolence disorder, sleep apnea, narcolepsy, breathing-related sleep disorders,
circadian rhythm sleep disorders, nightmares, disorder of arousal, sleep terrors, sleepwalking
(somnambulism)
lesson:

2. Anderson, G. H., & Kennedy, S. H. (Eds.) (1992). The biology of feast and famine:
Relevance to eating disorders. New York: Academic.
3. Bruno, F. (1997) Get a good night’s sleep. New York: Macmillan.
4. Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA:
Houghton Mifflin Company. Chapter 15, Bulimia Nervosa: The Self-Destructive
Diet.
5. Cooper, R. (Ed.) (1994). Sleep. New York: Chapman and Hall Medical.
6. Durand, V. M. (1998). Sleep better!: A guide to improving sleep for children with special
needs. Baltimore, MD: Paul H. Brookes Publishing.
7. Fairburn, C. G., & Wilson, G. T. (Eds.) (1993). Binge eating: Nature, assessment, and
treatment. New York: Guilford.
8. Fichter, M. M. (Ed.) (1993). Bulimia nervosa: Basic research, diagnosis and therapy.
Chichester, England: Wiley.
9. Garner, D. M., & Garfinkel, P. E. (Eds.) (1985). Handbook of psychotherapy for

anorexia nervosa and bulimia. New York: Guilford.
10. Hall, L., & Ostroff, M. (1998). Anorexia nervosa: A guide to recovery. Gurze Designs &
Books.
11. Kazdin, A. E. (1990). Psychotherapy for children and adolescents. Annual Review of
Psychology, 41, 21–54.
12. Kryger, M. H., Roth, T., & Dement, W. C. (Eds.) (1989). Principles and practice of sleep
medicine. Philadelphia: Saunders.
13. Maas, J. (1998). Power sleep. New York: Villard.

Phone No.: (082)300-5456/305-0647 Local 118
LESSON EIGHT: SUMMATIVE TEST

Let’s Check
Now that the student knows the essential knowledge under lesson eight, which is all about
Eating and Sleep-Wake Disorders. Let us try to check the student's understanding of these
terms.
1. The chief motivating factor in both anorexia nervosa and bulimia nervosa is
a. a desire to purge.
b. an overwhelming drive to eat.
c. an overwhelming urge to be thin.
d. a desire to starve oneself.
2. The strongest contributions to etiology of eating disorders seem to be _________.

a. genetic b. psychological c. somatogenic d. sociocultural
3. Susan, a woman of relatively normal weight, sometimes eats huge quantities of junk
food with no ability to stop herself. She follows this with long periods of complete
fasting. Based on this information, Susan
a. might be diagnosed with bulimia nervosa.
b. should be diagnosed with anorexia nervosa.
c. will not be diagnosed with any disorder because she is of normal weight.
d. cannot be diagnosed with bulimia nervosa because she is not purging.
4. Which of the following might help to explain the vast differences in the incidence of
eating disorders among men and women?
a. The influence of behavioral genetics
b. The fact that boys are encouraged to play sports and girls to be active in
social functions
c. The fact that puberty brings boys' bodies closer to the societal ideal and girls'
bodies further from the societal ideal
d. The differences in the way boys and girls tend to gain weight from overeating
5. Studies suggest that young males would often prefer to be ____________ than they
are.
a. thinner b. heavier c. taller d. shorter
6. Dietary restraint studies suggest that people who are starved

a. stop caring about food.
b. may become preoccupied with food and eating.

Phone No.: (082)300-5456/305-0647 Local 118
c. lose interest in food over time.

d. gradually adjusts to starvation diets.
7. Genetic influences on eating disorders most likely involve

a. a specific gene for each actual eating disorder.
b. inherited personality traits that may make development of an eating disorder
more likely.
c. multiple genes interacting in ways not yet determined that directly produce
eating disordered behavior.
d. recessive genes.
8. An early stage of Phoebe's cognitive-behavioral treatment for bulimia nervosa will likely
involve
a. antidepressant medication. c. small, frequent meals
b. family therapy. d. in-patient treatment.
9. Individuals with night eating syndrome
a. consumes a third of their daily intake after their evening meal.
b. binge during the night.
c. does not wake up while eating during the night.
d. often purges after eating.
10. Seriously obese adolescents are most likely to lose weight with
a. the use of medications.
b. the use of behavioral treatments.
c. the combination of medications and behavioral treatments.
d. the use of surgery
11. Individuals who feel tired and cranky all day despite falling asleep at a normal hour and
awakening at their usual time are most likely suffering from a(n) _____________.
a. parasomnia c. type of REM sleep deprivation
b. dyssomnia d. anxiety problem
12. Individuals suffering from primary insomnia

a. does not sleep at all.
b. has difficulty initiating or maintaining sleep.
c. wakes up during their sleep cycle with severe nightmares.
d. frequently sleepwalks.
13. Samantha started having difficulty falling asleep during final exam week. Although
exams are over, she now starts to worry about sleep right after dinner. Even the sight
of her bed makes her very anxious. The fact that Samantha's insomnia continues long
after the stress of exams is over points to the role of ___________in the maintenance
of sleep disorders.
a. biology c. learning
b. other medical conditions d. unknown factors
14. While suddenly and unexpectedly falling asleep during normal waking hours, Sarah
experiences vivid hallucinations of being in a horrible car crash. The experience is so
realistic that she actually feels physical sensations as if the hallucination were real.
Sarah's most likely diagnosis is _______.
a. sleep apnea b. hypersomnia c. schizophrenia d. narcolepsy

Phone No.: (082)300-5456/305-0647 Local 118
15. All of the following are examples of causes of circadian rhythm sleep disorder EXCEPT
____________
a. jet lag b. shift work c. delayed sleep phase d. sleep rebound
Let’s Analyze
Activity 1. Getting acquainted with the essential terms in the lesson eight is not enough; what
Case Eight: Under Eating Disorder – THE CASE OF MONICA
“I know I’m obese by anyone’s standards,” Monica Hudgens told her internist, “and I’m doing
it to myself.”
Even as a child, Monica was overweight. Now, at 5 feet 3 inches, she weighed 210
pounds. “I’m 37 now; for years, my BMI has been tracking with my age.”
Monica’s bingeing started years ago, on the heels of a busted relationship. Now, at
least twice a week, she would cook supper—she especially loved pasta with hazelnuts. She’d
devour one helping, then gobble down another, then another. Even if she wasn’t still hungry,
she’d then have ice cream (“At least two servings—I just scarf it down, no thinking involved”)
and cookies. Though she felt stuffed (“with nosh and remorse”), she never vomited up what
she had eaten; she’d never used laxatives or other drugs to purge. Washing the dishes
afterwards, she was often surprised to realize that only 30 minutes had elapsed.
“I’ve always been large. But until the last couple of years, I’ve dieted pretty hard. Now
I just seem to have given up,” Monica said as she touched the bran muffin hidden in her purse.
She denied any history of substance misuse; other than the obesity, the internist pronounced
her healthy.
Born and reared on the West Coast, Monica had been married and divorced; she now
lived with her 15-year-old son, Roland, whose weight was normal. She tended to binge on
weekends, when she wasn’t working. It had worsened since Roland developed his own set of
friends and was “off doing his own thing.”
Monica’s self-image was mixed: “I have a terrific sense of humor and a really pretty
face, but I know I’m huge. My ex-husband loved hiking in the mountains, but in the end, he
decided he didn’t want to be married to one.”
Monica worked as a radio announcer for her local public broadcasting affiliate. Her
“final straw” moment occurred when she was almost offered a better job. “A producer for cable
TV heard me on the radio and liked my voice. But when we met for coffee, he lost interest.”
She looked sad, but then, with just a hint of a smile, she added, “Can’t you just see me on TV?
It’d have to be wide-screen.”
Question for CASE EIGHT:

2. What are the treatment options? Explain your answer thoroughly. (20 Points)

Phone No.: (082)300-5456/305-0647 Local 118
Case Nine: Under Sleep-Wake Disorders – THE CASE OF USHER

“It’s almost spooky. It doesn’t seem to make any difference what time I go to bed—9:30,
10:00, 10:30. Whatever, my eyes click open at 2:00 in the morning, and that’s it for the rest of
the night.”
Curtis Usher had had this problem off and on for years. Recently, it was more often
on. “Actually, I guess it’s usually the worst during the week. Whenever I lie there, I’m worrying
about work.”
Curtis was a project manager at an advertising agency. It was a wonderful job when
times were flush, which they hadn’t been for several years. Curtis’s boss was a bit of a tyrant,
who enjoyed saying that he didn’t have headaches; he caused them. Curtis didn’t have
headaches, but he didn’t get much sleep, either.
At age 53, Curtis was a healthy man of regular habits. He had lived alone since his
wife divorced him 3 years earlier, with the complaint that he was dull. Occasionally his current
girlfriend stayed overnight in his studio apartment, but most evenings he spent lying on his
bed watching public television until he couldn’t stay awake any longer. He never drank or used
drugs, and his mood was good; neither he nor anyone else in his family had ever had any
mental health problems.
“I don’t take naps during the day,” Curtis summed up, “but I might as well. I’m sure not
getting much done at work.”
Question for CASE NINE:
2. What are the treatment options? Explain your answer thoroughly. (20 Points)
In a Nutshell
Activity 1. In this lesson, we learned about Eating and Sleep-Wake Disorders. In this section,
I want you to write down what you had learned or realized in this lesson. Provide at least 400
words.
Q&A List
lesson eight. After being reviewed, questions related to the topics mentioned above will
1.
2.
3.
4.
5.
~End of Lesson Eight~

Phone No.: (082)300-5456/305-0647 Local 118
Big Picture in Focus: ULOb. Formulating Case Conceptualization, Diagnosis,

and Treatment Planning
a.
b. LESSON NINE
Metalanguage
Individuals who choose careers as mental health professionals—including

counselors, psychotherapists, social workers, counseling and clinical psychologists,
psychiatrists, and those in similar career paths—often enter the counseling field
because earlier in their lives, in their families of origin, in their schools and
neighborhoods, and among their friends and peers, they previously found themselves
in the role of good listener, intelligent analyzer, or effective problem-solver when
those around them encountered life’s difficulties (Neukrug & Schwitzer, 2006). In other
words, many people already are “natural helpers” when they decide to become
professionals (Neukrug & Schwitzer, 2006, p. 5). As natural helpers for friends and
family, they have relied on their intuition, personal opinions, and natural
inclinations as they spontaneously listen, support, analyze, encourage, push, or
make hopeful suggestions.
However, the demands of professional counseling work go beyond the qualities
needed by natural helpers. Compared with the spontaneous nature of natural helping,
professional counseling requires us to rely on purposeful skills and to
systematically guide the counseling relationship through a sequence of
organized stages, intentionally aiming to achieve specific client outcome goals
(Neukrug & Schwitzer). That is, professional counseling requires us to become
competent at using clinical thinking skills “to facilitate [the] provision of mental
health treatment” (Seligman, 1996, p. 23). These skills include diagnosis, case
conceptualization, and treatment planning.
Consider the following essential terms before we formulate a case

conceptualization:
• Diagnosis refers to identify and describe clinically significant patterns

associated with the clients’ distress or impairment or risk.
• Case Conceptualization refers to a tool for observing, understanding,

and conceptually integrating client behaviors, thoughts, feelings, and
physiology from a clinical perspective (Neukrug & Schwitzer, 2006).
• Treatment Planning is built that integrates the information from the

diagnosis and case conceptualization into a coherent plan of action. It
is a vital aspect of today’s mental healthcare delivery (Jongsma &
Peterson, 2006).

Phone No.: (082)300-5456/305-0647 Local 118
I. What are the primary parts of Case Formulation (With Diagnosis and
Treatment Plan)
A. Demographic Profile
• In this part, the profile should consist of the Name, Age, Civil
Status, Job, No. of Children (if applicable), Civil Status, Religion,
and another necessary demographic of the Client.
• You must note that not all profile is given in the case. With this,
focus only on what is indicated in the case's context and not give
any assumptions.
For example: (From the Case of JANET)
B. Background
• The background may refer to the client's important turning points
that possibly affect his or her cognition, behavior, and social
aspects.
• Using the Mental Status Examination, which is attached to the

Course Resources section, can also help point out other
significant events that contributed to the development of a
disorder or mental illness.

Phone No.: (082)300-5456/305-0647 Local 118

Phone No.: (082)300-5456/305-0647 Local 118
C. Reason for Referral

• In this section, you will discuss the reason for your referral of the
client. Why did you decide to refer the client for professional
help? Is it the decision of the client or the significant individuals
around the client? Does the experience of the client is already
destructive or harmful to others?
• In here, you will most likely root for his or her background to
entirely refer to the client.
D. Diagnosis and Justification

• This section needed to detailed for you are going to use the
DSM-5, looking for the criteria that manifest in the client’s
presenting problem, look for the justification in each criterion
found in the context of the given case, and also consider looking
for comorbidity or differential diagnosis (if applicable).
• You need to note that in the table, just like in the given an
example, you may change the font color to blue if it is present to
the client. If the criterion is not present, you may change the font
color to red. This is just for distinguishing how the client meets
many criteria.
• Take note, in the justification, only stick to what is given in the

context. No more adding or having assumptions.
• As you can also see in the example, the student's diagnosis

is MAJOR DEPRESSIVE DISORDER 296.33 (F33.22), severe,
recurrent episode, with melancholic features.
o So, where can we get this diagnosis? In the
COURSE RESOURCES SECTION, I also
uploaded the DSM – 5 (Diagnostic Statistical
Manual), a reference for diagnosis symptoms.
o In each disorder and specifier, it has

accompanied with ICD – 10 (the first code

Phone No.: (082)300-5456/305-0647 Local 118
number, e.g., 296.33) and ICD – 9 (the code

number found inside the parenthesis).
o ICD stands for International Classification of

Disease, which has been used for many
decades for helping professionals for accurate
identification, retrieval of information for
research, and other informational purposes.

Phone No.: (082)300-5456/305-0647 Local 118

Phone No.: (082)300-5456/305-0647 Local 118
E. Treatment
• Always bear in mind that a treatment plan is always required in
the field of counseling a client.
• The treatment plan always looks for cognitive and behavior

modification. It makes psychopharmacology the last resort if the
modifications are not entirely convincing.
• In this section, you will see in the given example that the student
provided the possible behavioral problems which require
interventions.
• You must note that the treatment plan is not universal to all
clients. There are instances that one treatment plan will only last
for several weeks, and other clients last for at least a year of
sessions.
• In this section, you will provide Long-Term Goals for your client
and Short-Term Goals for weekly sessions. In each short-term
goal, there should be detailed Therapeutic Interventions. (For
those students who are not so familiar with other interventions,
you can always search about it on the internet. Other
discussions will be provided before this week)
• The example provided will be a glimpse. The rest of the

intervetions will be uploaded in the course resources sections.

Phone No.: (082)300-5456/305-0647 Local 118
F. Insight (For Educational Purposes only)

• In this part, you will share some thoughts about the case you
have conceptualize or formulated.
• Ensure that the insight is coming from you and not from the
internet because it will defeat the purpose of the INSIGHT.
• You are required with a minimum of 400 words.

Phone No.: (082)300-5456/305-0647 Local 118
II. Referencing
A. APA Citation
• The latest APA citation format is 7th edition. Please, refer to the
sample below.
~End of Lesson Nine~

Psy 222 Sim - Week 1 - 9

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Psy 222 Sim - Week 1 - 9

Uploaded by

Copyright:

Available Formats

College of Arts and Sciences Education

PART 1: QUALITY ASSURANCE POLICY

Course Outline: PSY 222 – Abnormal Psychology

Course Facilitator: Joannie Villareal Intong, MPsy.

Course Outline Policy

Areas of Concern Details

If the assessment task is done in real time through the

Plagiarism Check To ensure honesty and authenticity, all assessment tasks

PSY 222 – ABNORMAL PSYCHOLOGY 1

output/paper that goes beyond 30%, the students will

In addition, if the paper has reached more than 30%

Please note that academic dishonesty such as cheating

However, if the late submission of assessment paper has

For group assessment tasks, the course coordinator will

Assignment Resubmission You should request in writing addressed to the course

Re-marking of Assessment You should request in writing addressed to the program

PSY 222 – ABNORMAL PSYCHOLOGY 2

program coordinator shall communicate with the students

If disapproved by the course coordinator, you can elevate

Grading System All culled from Blackboard sessions and submissions of

Preferred Referencing APA 7th Edition

Student Communication You are required to create a umindanao email account

For students who have not created their student email,

Contact Details of the Dean KHRISTINE MARIE D. CONCEPCION, Ph.D.

Contact Details of the SHEENA MAY A. LACUESTA

PSY 222 – ABNORMAL PSYCHOLOGY 3

may provide alternative assessment tasks or extension

Online Tutorial Students who need tutorial will be identified by the

To enroll in the tutorial classes, please send an email to

Instructional Help Desk JOANNIE VILLAREAL INTONG, MPSY.

SHEENA MAY A. LACUESTA

Well-being Welfare Guidance Services and Testing Center

CASE Guidance Facilitator

Library Contact Details BRIGIDA E. BACANI

PSY 222 – ABNORMAL PSYCHOLOGY 4

Course Information – see/download course syllabus in the Black Board LMS

According to the American Psychological Association, abnormal psychology is

PSY 222 – ABNORMAL PSYCHOLOGY 5

PART 2: INSTRUCTION PROPER

a. Demonstrate the basic history content of Abnormal Behavior.

Consider the following essential terms:

• A psychological disorder is characterized by an irregular pattern of

• Abnormal psychology, on the other hand, is a field of psychology dealing

PSY 222 – ABNORMAL PSYCHOLOGY 6

2. The three criteria on looking Psychological disorder are the following:

• As a result, these problems are often thought of as being

PSY 222 – ABNORMAL PSYCHOLOGY 7

b. Personal Distress or Impairment - The behavior must be

The concept of impairment is useful, although not entirely

c. Atypical or Not Culturally Expected - Anything may be

• An informative example of this view is provided by

PSY 222 – ABNORMAL PSYCHOLOGY 8

who, during his studies, worked closely with the Masai

• Jerome Wakefield (1999, 2009), informative example of

3. Finally, defining “normal” and “abnormal” is difficult (Lilienfeld &

B. The Science of Psychopathology

Some Fields that are Specially Trained Professionals

PSY 222 – ABNORMAL PSYCHOLOGY 9

Typically earn a master’s degree in social work as they develop expertise in

2. The Scientist Practitioner – The mental health professionals that take

3. Clinical Description - The term "presents" refers to a traditional

b. Incidence – refers to the statistics on how many new cases

c. Course – refers to the pattern. (For example, some disorders,